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CT Neck A Practical Approach: Dr. Hazem Abu Zeid Yousef (MD) May 2007
CT Neck A Practical Approach: Dr. Hazem Abu Zeid Yousef (MD) May 2007
A PRACTICAL APPROACH
Dr. Hazem Abu Zeid Yousef (MD)
May 2007
STANDARD TECHNIQUE
Scanning protocol
NORMAL ANATOMY
Cervical triangles.
Cervical spaces.
Lymph nodes
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Submandibular Space
The submandibular space is posterolateral to the sublingual space and contains
the superficial lobe of the submandibular salivary gland and lymph nodes. The
submandibular space communicates freely with the sublingual. Congenital
lesions such as cystic hygromas, branchial cleft cysts, dermoids, epidermoids,
and thyroglossal duct cysts may occur in the submandibular space. Abscesses
are associated with skin thickening, edema of the fat, and gas in over 50% of
cases. Calculi commonly occur in the submandibular glands. Tumors of the
submandibular gland, present as soft-tissue masses within the gland. The
submandibular lymph nodes are important sentinels in the spread of floor of
mouth infections and malignancies and may be involved with lymphom
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Buccal Space
The buccal space is a small region anterior to
the masseter and lateral to the buccinator
muscle. This space contains the buccal fat pad
and is most commonly involved with infection.
Deeply invasive skin cancers also may involve
this space.. Infections and neoplasms from
adjacent spaces, such as the parotid and
masticator space, also may secondarily involve
the buccal space
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Parotid Space
The parotid space is located posterior to the masseter
muscle. This space extends from the external auditory
canal and the mastoid tip superiorly to the angle of the
mandible below. It contains the parotid gland, intraand extra-parotid lymph nodes. The gland contains
about 20 intraglandular lymph nodes which are
considered normal if their transverse diameter is less
than 8 mm. The gland also contains extracranial
branches of the facial nerve, and vessels: the external
carotid artery and the retromandibular vein just
behind the mandibular ramus
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Parapharyngeal Space
The parapharyngeal space is shaped like an inverted
pyramid and extends from the skull base to the hyoid bone.
This space is triangular on transaxial images with the apex
pointing towards the nasopharynx. Anterolaterally, it is
bounded by the medial pterygoid fascia, which separates it
from the masticator space. Medially, the parapharyngeal
space is bordered by the pharyngobasilar fascia. At the level
of the nasopharynx, this space is subdivided into prestyloid
and poststyloid compartments. The prestyloid compartment
contains branches of the internal maxillary and ascending
pharyngeal arteries, fat, salivary rests, and minor salivary
glands. The poststyloid compartment is also known as the
carotid space as it extends below the hyoid bone.
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Carotid Space
The cylindrical carotid space extends from the base of the skull to the
aortic arch. The suprahyoid portion of the carotid space is bordered
anteromedially by the pharynx, posteriorly by the prevertebral fascia,
and anterolaterally by the prestyloid parapharyngeal space. In the
infrahyoid region, this space is surrounded by the visceral and
retropharyngeal spaces medially, the prevertebral and posterior
cervical spaces posteriorly, and the sternocleidomastoid muscle
anterolaterally.
The carotid space contains the carotid artery, internal jugular vein,
glossopharyngeal nerve, vagus nerve, spinal accessory nerve,
hypoglossal nerve, sympathetic chain, and the internal jugular nodes
of the deep cervical chain.
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Masticator Space
This space contains the mandible, the muscles of mastication, and the
mandibular division of the trigeminal nerve. Lesions derived from
these tissues include nerve sheath tumors, mandibular and soft tissue
sarcomas, dental tumors, cysts and abscesses, osteomyelitis,
hemangiomas, lymphangiomas, and lipomas..
The mandibular branch of the trigeminal nerve exits the skull through
the foramen ovale, which is located above the masticator space and has
been termed the "chimney of the masticator space". Lesions within the
masticator space can invade the middle cranial fossa by this route and
intracranial processes, such as meningiomas, can descend into the
masticator space and become extracranial. Signs of perineural spread
along the mandibular division of the trigeminal nerve include:
expansion of the foramen ovale, mass within Meckel's cave, lateral
bulging of the cavernous sinus, and atrophy of the muscles of
mastication.
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Visceral Space
The midline visceral space is enclosed by the middle layer of
deep cervical fascia and extends from the hyoid bone to the
mediastinum. It contains the larynx and hypopharynx, the
thyroid and parathyroid glands, the trachea and esophagus,
paratracheal lymph nodes, and the recurrent laryngeal nerves.
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Retropharyngeal Space
The retropharyngeal space lies posterior to the visceral space. The
retropharyngeal space extends from the base of the skull to the
mediastinum and serves as a potential conduit for spread of neck
pathology into the chest. The retropharyngeal space is divided into
suprahyoid and infrahyoid compartments. The suprahyoid
compartment contains lymph nodes and fat, whereas the infrahyoid
compartment only contains fat. Therefore, retropharyngeal
lymphadenopathy only occurs above the hyoid and tends to remain
unilateral or bilateral, sparing the midline. In contradistinction,
infections and direct invasion of cancer may involve both the
suprahyoid and infrahyoid portions and the midline "danger space.
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The sublingual nodes are found in the sublingual space and drain
the tongue and floor of mouth. A lateral group follows the course of
the lingual artery and a median group lies between the genioglossus
muscles
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The lateral cervical chain is subdivided into the superficial and deep
lateral cervical nodes. The superficial group follows the course of the
external jugular vein, is easily palpable, and therefore is not usually
examined by imaging. The important deep group is further divided into
the spinal accessory, transverse cervical, and internal jugular groups.
The spinal accessory nodes are found within the fat of the posterior
cervical triangle and posterior cervical space lateral and posterior to
the spinal accessory nerve between the trapezius and the
sternocleidomastoid muscles. The transverse cervical group are seen in
the supraclavicular region.
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Thank you
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