147

Pictorial

Essay

Differential Diagnosis Their Space of Origin.

H. Ric Harnsberger1 and Anne G. Osborn

of Head and Neck 1. The Suprahyoid

Lesions Based on Part of the Neck

This

pictorial

essay

reviews

the

spaces

of

the

suprahyoid

portion of the head and neck, focusing on the normal spatial anatomy as defined by the deep cervical fascia, the appearance of a generic mass in each of the spaces defined, and the unique differential diagnoses involved in each individual space.

The cylindrical soft-tissue core of the extracranial of the head and neck, excluding the more anterior

portion parts of

and infrahyoid portions. The three layers of deep cervical fascia that cleave this area of the body into functional spaces converge on the hyoid bone, dividing the neck into these two parts (Fig. 1) [i , 2]. The suprahyoid area encompasses the deep spaces between the skull base and hyoid bone, and the infrahyoid portion lies inferiorly between the hyoid bone and the clavicles.

the orbit, sinonasal region, and oral cavity, can be subdivided at the hyoid bone into two distinct regions: the suprahyoid

In the suprahyoid area, the three layers of deep cervical fascia delineate the individual spaces of the deep part of the
face (Figs. i -4). As the contents of these spaces are some-

Fig. 1.-A and B, Axial drawing (A) and corresponding MR image (B) of normal anatomy of mid nasopharynx. Left side of drawing shows critical normal anatomy of region. Right side shows three layers of deep cervical fascia and spaces they define. See key on page 148. (Reprinted with permission from Harnsberger [2].)

A
Received
1

B
December 1 7, 1990. Center, 50 N. Medical Dr., Salt Lake City, UT 841 32. Address

October authors:

1 5, 1 990; accepted Department

after revision University

Both

of Radiology,

of Utah Medical

reprint requests to H. A.

Harnsberger. AJR 157:147-154, July 1991 0361-803x/91/1571-0147 American Roentgen Ray Society

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HARNSBERGER

AND

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AJR:157,

July 1991

Key

to Abbreviations

and

Symbols

Used

in Figures

i
5
6

buccinator

muscle

hyoglossus muscle intrinsic muscles of tongue lateral pterygoid muscle

49 50 Si
53

soft palate
uvula hyoid bone ramus of the mandible mandibular canal styloid process temporalis muscle

8 9
i0

masseter muscle medial pterygoid muscle

mylohyoid muscle

54 57 58
59

ii i2
13 14 15

palatoglossus muscle (anterior tonsillar pillar) palatopharyngeus muscle (posterior tonsillar pillar)
paraspinal platysma muscles muscle

tensor veli palatini muscle

levator veli palatini muscle

60

61 62 63
a
65

spinal accessory
torus tubarius lateral pharyngeal artery buccal space carotid space danger space

nerve
recess (fossa of Rosenm#{252}ller)

prevertebral
styloglossus

muscles muscle
muscle

16
17 18

19
20 21 22 23 24

superior pharyngeal trapezius muscle

constrictor

muscle
of V3)

CS DS
m
MS

inferior alveolar nerve (branch lingual nerve (branch of V3) facial nerve (VII)

muscle masticator node

space

25
26

glossopharyngeal nerve (IX) vagus nerve (X) hypoglossal nerve (XII)

sympathetic plexus

30 31
32

external
internal

carotid
carotid

artery
artery

internal
lingual jugular

maxillary
artery vein

artery

PCS PMS PPS PS PVS RPS SLS SMS

TS

posterior cervical space pharyngeal mucosal space

parapharyngeal

space

parotid space prevertebral space

retropharyngeal

space

33
34

sublingual space submandibular space temporal space (suprazygomatic

masticator

facial vein
v

space)
vein

35 36 37 40
41

pharyngeal venous plexus retromandibular vein adenoids

faucial tonsil

heavy black line outlines

pharyngobasilar
superficial

fascia
layer of cervical

_____medium
------

black

line outlines

deep cervical

fascia
middle layer of deep

43
45

46 48

parotid gland submandibular gland submandibular gland duct cartilaginous eustachian tube

dotted line outlines fascia

broken line outlines fascia

deep layer of deep cervical

what

unique,

differential

diagnostic

possibilities

can be sug-

with

complex

fascial

margins

that

lies in a central

location

in

gested when a lesion is identified within a given space (Table 1). A simple method of assigning a suprahyoid lesion to a specific space of origin is accomplished by establishing the center of the lesion and assessing its displacement of the parapharyngeal space fat (Figs. 5-8) [2, 4]. This method is particularly effective in lesions involving the four spaces surrounding the parapharyngeal space: the pharyngeal mucosal

the deep face (Figs. 1-3). It extends from the skull base to the hyoid bone, containing only fat, branches of the trigemmnal nerve, and the pterygoid venous plexus. In order to definitely ascribe a lesion as primary to the parapharyngeal space, fat
must be identified surrounding the whole circumference of

the lesion [5]. The pharyngeal

ryngeal cervical

mucosal

space is medial

to the parapha-

(Fig. 5), masticator (Fig. 6), parotid (Fig. 7), and carotid (Fig. 8) spaces. Lesions involving the two midline spaces, the retropharyngeal and prevertebral spaces, are best evaluated by noting the relationship of the lesion to the prevertebral muscles. A
retropharyngeal space lesion displaces the prevertebral mus-

space. It is delimited by the middle layer of deep fascia (Fig. 5). Its major contents include the mucosa,

des posteriorly (Fig. 9), whereas a prevertebral space lesion displaces the muscles anteriorly (Fig. i 0) [4]. The parapharyngeal space is an area of fatty areolar tissue

lymphoid tissues of Waldeyer ring, minor salivary glands, cartilaginous eustachian tube, superior and middle constrictor muscles, pharyngobasilar fascia, and levator palatini muscles. A mass in the pharyngeal mucosal space is centered medial to the parapharyngeal space, displacing it laterally (Fig. 5A)
[2,4].

Anterior

to the parapharyngeal

space

is the masticator

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Fig. 2.-A and B, Axial drawing (A) and corresponding MR image (B) of normal anatomy of mid oropharynx. Critical contents of spaces are on left three layers of deep cervical fascia are on right. See key on page 148. (Reprinted with permission from Hamsber-

ger [2].)

..

/
A
Fig. 3.-A of suprahyoid and B, Coronal part of neck.

B
drawing (A) with corresponding MR image (B) of normal anatomy of spaces Note craniocaudal extent of these spaces, especially parapharyngeal and Critical contents of spaces on left three layers of deep cervical fascia on right. See Fig. 4.-Axialdrawing of skull base shows relationship of spaces of suprahyoid part of neck to skull base apertures. Foramen ovale (FO), through which passes mandibular division of trigeminal nerve, empties into masticator space, whereas stylomastold foremen (SF) transmits facial nerve directly into parotid space. Carotid space receives cranial

masticator spaces. key on page 148. (Reprinted

with permission from Harnsberger

[2].)

nerves lX-Xl

from jugular foramen

(J) and

cranial nerve XII from hypoglossal canal (HC). FL = foramen lacerum, FS = foramen spinosum, C = carotid canal. See key on

page 148. (Reprinted Osborn et al [3].)

with permission

from

space. The superficial layer of deep cervical fascia splits to envelop this space. It has a suprazygomatic component (Fig. 3A) and extends mnferiorly to the inferior margin of the mandible. Principal components tion, ramus and posterior

masticator and inferior alveolar nerves, and inferior alveolar vein and artery. A mass is said to originate from the masticator space
when its center is anterior to the parapharyngeal space, displacing the fat from anterior to posterior (Fig. 6A). Masti-

include the muscles body of the mandible,

of mastica-

Lateral to the parapharyngeal space is the parotid space. by the superficial layer of deep cervical fascia (Fig. 7A). The superior margin of the parotid space abuts the external auditory canal, whereas the parotid tail often extends mnferiorly below the inferior mandibular margin. Important contents include the parotid gland, intraparotid
It

too is circumscribed

facial nerve, space when

retromandibular it is centered

vein, external within

carotid gland

artery, lateral

and to

lymph nodes. A mass is described the parapharyngeal

as originating
the parotid

in the parotid

cator

space

malignancy

may spread

permneurally
nerve into

along
the

the

space and displaces

the parapharyngeal

mandibular division of the trigeminal cranial fossa (Fig. 6C).

middle

fat from lateral to medial. Associated widening of the stylomandibular notch (Fig. 7A) is usually seen. Parotid space

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TABLE

1:

Differential

Diagnosis Space/Type

of Deep

Facial

Lesions

Based

on Their

Space

of Origin

of

Abnormality Parapharyngeal Pseudomass

Congenital
inflammatory

P ssible 0

D agnosis

Asymmetric
Second
Infection

pterygoid
from

venous plexus
atypical
spaces adjacent

branchial
spreading

cleft cyst,

Benign

tumor

Pleomorphic

adenoma

of salivary

gland

rest; lipoma;

Malignancy
Pharyngeal mucosal

nerve sheath tumors Malignant tumor of salivary gland rest; direct spread of
tumor from adjacent spaces

Pseudomass Inflammatory
Benign tumor Malignancy

Asymmetric
(pharyngitis calcification

fossa of RosenmUller;
or radiation)

mucosal

inflammation

Tonsil hypertrophy,

tonsillitis,
cyst

abscess;

postinflammatory

or retention

Benign mixed tumor of minor salivary gland origin Squamous cell carcinoma; non-Hodgkin lymphoma; nor salivary gland malignancy; metastases

mi-

Miscellaneous Masticator Pseudomass Congenital

Inflammatory Benign tumor Malignancy

Thornwaldt

cyst hypertrophy;
(mandibular

Benign masseteric
denervation

accessory
division

parotid gland;
V)

atrophy

Hemangioma/lymphangioma
Odontogenic abscess, mandibular osteomyelitis Leiomyoma; nerve sheath tumor Sarcoma (soft tissue, chondrosarcoma, osteosarcoma); malignant schwannoma; non-Hodgkin lymphoma; mandibular metastases; squamous cell carcinoma from oropharynx

Parotid Congenital Inflammatory Benign tumor

Malignancy

First branchial cleft cyst; hemangioma/lymphangioma Abscess/cellulitis/reactive adenopathy; benign lymphoepithelial cysts (AIDS); autoimmune/SjOgren syndrome

Benign mixed tumor (pleomorphic

mor; lipoma
Mucoepidermoid carcinoma; adenoid

adenoma);
cystic

Warthin
carcinoma;

tu-

non-Hodgkin lymphoma; malignant mixed tumor; other: acinar cell carcinoma, adenocarcinoma, squamous cell carcinoma

Metastases Carotid Pseudomass Inflammatory Vascular

Skin squamous
lung carcinoma;

cell carcinoma
nodal

or melanoma;

breast or

non-Hodgkin

lymphoma

Ectatic common
internal jugular

or internal carotid artery; asymmetric

vein

Carotid space cellulitis or abscess Jugular vein thrombosis or thrombophlebitis; internal carotid artery mural thrombus, aneurysm; internal carotid artery dissection
Paraganglioma; nerve sheath tumor (schwannoma, neu-

Benign

tumor

Malignancy

rofibroma) Squamous cell carcinoma nodal metastasis; sion by primary squamous cell carcinoma; kin lymphoma; metastases

direct invanon-Hodg-

Retropharyngeal

Pseudomass Congenital inflammatory Benign tumor Malignancy

Tortuous

carotid

artery; edema secondary

to deep ye-

nous obstruction

Hemangioma Reactive adenopathy/cellulitis/abscess Lipoma Nodal metastases from squamous cell carcinoma, melanoma, thyroid carcinoma, non-Hodgkin lymphoma; direct invasion from primary squamous cell carcinoma

Prevertebral

Pseudomass Vascular Inflammatory

Benign tumor

Vertebral Vertebral Vertebral

body osteophyte/anterior disk herniation artery aneurysm, pseudoaneurysm, ectasia body osteomyelitis

Malignancy

Chordoma; schwannoma, neurofibroma (brachial plexus); vertebral body benign bony tumors Vertebral body/epidural metastasis; non-Hodgkin lymphoma; vertebral body primary malignant tumor

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Fig. 5.-A, Axial drawing through low nasopharynx shows contents and fascial boundaries of pharyngeal mucosal space (PMS) on left and pharyngeal mucosal space mass on right. Middlelayer of deep cervicalfascia (dotted line) encompasses posterolateral margin of superior constrictor muscle, dofining pharyngeal mucosal space. Center of pharyngeal mucosal space mass (black dot) is medial to laterally displaced parapharyngeal space (black area), invading parapharyngeal space from medial to lateral. m = muscle. (Reprinted with permission from Harnsberger [4].) B, Axial density-weighted MR image in patient with early nasopharyngeal carcinoma (N) in lateral pharyngeal re-

cess of nasopharyngeal space. p = parapharyngeal

mucosal space.

Fig. 6.-A, Axial drawing through low nasopharynx shows contents and fascial boundaries of masticator space on left and appearance of masticator space mass (MS) on right. Superficial layer of deep cervical fascia surrounds muscles of mastication and mandible, defining masticator space. Center of masticator space mass (black dot) is anterior to posteriorly displaced parapharyngeal space (black area), invading parapharyngeal space from anterior to posterior. See key on page 148. (Reprinted with permission from Harnsberger [4].) B, Axial Ti-weighted unenhanced MR image of masticator space chondrosarcoma (C). Tumor involves muscles of mastication and mandible. C, Coronal MR image of masticator space malignant schwannoma (5) with perineural tumor spread along mandibular division of trigemmel nerve (arrows) to skull base and through foramen ovale. p = parapharyngeal space.

malignancy

may follow

the facial nerve

into the temporal

bone

sheath

that

circumscribes

this

space

(Fig.

8A).

This

space

(Fig. 7C). Posterior to the parapharyngeal space is the carotid space. All three layers of deep cervical fascia contribute to the carotid

extends from the skull base to the aortic arch. Its suprahyoid contents include the internal carotid artery, jugular vein, cranial nerves IX-Xll, and deep cervical lymph node chain. A

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Fig. 7.-A, Axial drawing through low nasopharynx shows contents and fascial boundaries of parotid space on left and appearance of a parotid space mass (PS) on right. Superficial layer of deep cervical fascia surrounds parotid gland and its contents, defining parotid space. Center of mass (black dot) is lateral to medially displaced parapharyngeal space (black area), invading parapharyngeal space from lateral to medial. See key on page 148. (Reprinted with permission from Harnsberger [4].) B, Ti-weighted axial MR image in a patient with a large benign mixed tumor (BMT) of parotid space that widens stylomandibular notch (dotted llne) and impinges on fatty parapharyngeal space from lateral to medial (open arrow). Note lack of identifiable fat plane between remaining normal parotid gland and mass (solid arrows). C, Mucoepidermoid carcinoma of parotid space with penneural tumor following mastoid segment of facial nerve. Coronal Ti-weighted MR image shows an intraparotid tumor (T) with a long tail extending to posterior genu of facial nerve canal within adjacent temporal bone along mastoid segment of facial nerve (arrows).

Fig. 8.-A,

Axial

drawing

through

low nasopharynx shows contents and fascial boundaries of carotid space on left and appearance of a carotid space mass (CS) on right. All three layers of deep cervical fascia contribute to ca-

rotid sheath, which circumscribes carotid artery, jugular vein, and associated cranial nerve and lymph nodes,

defining

carotid space. Center of mass (blackdot) is posteriorto anteriorly dis-

placed parapharyngeal space (black area), invading it from posterior to anterior. a = artery, v = vein. (Reprinted with permission from Harnsberger [4].) B, Glomus vagale paraganglioma of

nasopharyngeal

carotid

space.

Axial

TI-weighted MR image of a right carotid space paraganglioma (PG) shows anterior displacement of parapharyngoal space fat (P). Plethora of serpiginous vascular flow voids within tumor signals its vascular nature and probable histology. Right internal carotid artory is thrombosed. j = internal jugular

vein.

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Fig. 9.-A,

Axial

drawing

of extra-

nodal mass lesion of retropharyngeal space (RPS) at level of oropharynx causing posterior displacement of prevertebral muscles (arrows) within prevertebral space proper (PVS) and anterior displacement of pharyngeal mucosal space (PMS). Note somewhat bow tie shape of retropharyngeal space mass. See key on page 148. (Reprinted with permission from Harnsberger [4].) B, Squamous cell carcinoma of postenor wall of oropharynx invading adjacent retropharyngeal space. Enhanced axial CT scan shows tumor (T)

within

oropharyngeal

retropharyngeal

space. Pharyngeal mucosal space (broken line) is displaced anteriorly, whereas prevertebral muscles (p) are flattened along their anterior surface. C, Axial drawing through low naso-

pharynx shows appearance of nodal mass lesion of retropharyngeal space

(RPS), which has its center (black dot) posteromedial to parapharyngeal space (black area) and displaces it anterolaterally (compare with Fig. 8A). Carotid space masses can be confused with lateral retropharyngeal space lesions unless there is awareness of their unique characteristics. Key differential feature is direction of displacement of carotid space contents, especially ca-

rotid artery. In lateral retropharyngeal space masses, internal carotid artery is displaced laterally. (Reprinted with
permission from Harnsberger D, Malignant squamous of retropharyngeal weighted MR image space. through [4].) cell carciDensitylow naso-

noma node within lateral nodal chain pharynx reveals a lateral retropharyngoal space malignant node (N) that
displaces internal carotid artery (c) posterolaterally, parapharyngeal space fat (black p) anterolaterally, and provertebral muscle (white p) posteriorly.

Fig. 10.-A,

Axial drawing

at level of

low oropharynx

shows a mass lesion

originating within prevertebral space (PVS) proper with anterior displacement of prevertebral muscles (arrows),

retropharyngeal

space (RPS), and pha-

ryngeal mucosal space (PMS). As is commonly the case in infection and malignancy of the prevertebral space, vertebral body is partially destroyed by lesion. See key on page 148. (Reprinted with permission from Harnsberger [4]. B, Colonic metastasis to lower clivus with extension into adjacent prevertebral space. Axial Ti-weighted MR im-

age shows clival colonic metastatic deposit (CM) extending into adjacent
prevertebral space (asterisks). Prevertebral muscles (m) are displaced anteriorly.

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mass lesion

is primary

to the carotid

space

when

it is centered

posterior

to the parapharyngeal

space and displaces

it ante-

(Fig. 1 OA). This space vertebral body, artery,

contains the prevertebral and vein; and the spinal

muscles; the cord. A lesion

riorly (Fig. 8B).

originates
places

from the prevertebral

muscles

space
anteriorly

proper

when

it dis-

The retropharyngeal space is a posterior midline space that has the middle layer of deep cervical fascia as its anterior margin and the deep layer of deep cervical fascia as its posterior and lateral margins (Fig. 9A). It extends from the
skull hyoid base to the level of the T3 vertebral retropharyngeal space contains only body. The supra-

the prevertebral

(Fig. 1 OB).

REFERENCES
1 . Grodlinsky M, Holyoke E. The fascia and fascial spaces neck and adjacent regions. Am J Anat 1938;63:367-407 of the head and

fat. When disease affects the prevertebral muscles

(Fig. 9B). When the mass

lymph nodes and the retropharyngeal space diffusely, are seen to be displaced posteriorly
occurs in the laterally placed nodes,

it will impinge on the parapharyngeal (Figs. 9C and 9D).

space

posteromedially

HR. CT and MRI of masses of the deep face. Curr Probl Diagn Radiol i987;i6:147-173 3. Osborn AG, Harnsberger HA, Smoker WAK. Base of skull imaging. Semin Ultrasound CTMR i986;7:91-106 4. Harnsberger HR. Handbooks in radiology. Head and neck radiology volume. St. Louis: Mosby-Year Book Medical, 1990 5. Som PM, Sacher M, Stollman AL, Biller HF, Lawson of the parapharyngeal space: refined imaging W. Common diagnosis. tumors Radiology

2. Hamsberger

The prevertebral

space proper is defined

by the deep layer

of deep cervical fascia as it passes superficial to the prevertebral muscles to attach to the cervical transverse processes

1988:169:81-85