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Parapharyngeal and Adjacent Spaces: • 1 Content PARAPHARYNGEAL SPACE Parapharyngeal and adjacent spaces: • 1. Anatomical considerations • 2. Primary pathology of the parapharyngeal space anatomy and spectrum of pathologies • 3. Secondary pathology Sofie Van Cauter, MD PhD RETROPHARYNGEAL SPACE • 1. Anatomical considerations Friday 26th March 2021 • 2. Primary pathology of the retropharyngeal space European Course in Head & Neck Neuroradiology 1st cycle module 2 MASTICATOR SPACE • 1. Anatomical considerations • 2. Primary pathology of the masticator space • Neck spaces Æ concept by surgeons and anatomists 19th century Content infection spread • Fascia: Supporting structure PARAPHARYNGEAL SPACE Compartimentalization • 1. Anatomical considerations • 2. Primary pathology of the parapharyngeal space Barriers for disease spread • 3. Secondary pathology RETROPHARYNGEAL SPACE • 1. Anatomical considerations • 2. Primary pathology of the retropharyngeal space MASTICATOR SPACE • 1. Anatomical considerations • 2. Primary pathology of the masticator space Pharyngobasilar fascia Buccopharyngeal fascia` Prevertebral fascia Carotid sheat Journal of Anatomy, Volume: 237, Issue: 1, Pages: 197-207, First published: 20 February 2020, DOI: (10.1111/joa.13175) Superficial fascia (between dermis and deep layer): superficial musculo-aponeurotic system • Hyoid bone: anterior neck spaces Deep fascia: Superficial layer Middle layer • Suprahyoid region: from skull base (BOS) to hyoid bone Deep layer • Infrahyoid region: from hyoid bone to clavicles Fascial layers cannot be seen on imaging Æ definition by fat planes • Excluding orbit (O), sinunasal cavity (S/N) and oral cavity (OC) COMPARTIMENTALIZATION OF THE NECK ALLOWS TO COMMUNICATE TWO, MOST IMPORTANT RESULTS -Location -Likely pathology MULTIPLE SPACES MULTIPLE SPACES SUPRAHYOID INFRAHYOID Courtesy of Dr Jeffrey Hocking, Radiopaedia.org, rID: 43811 Courtesy of Dr Jeffrey Hocking, Radiopaedia.org, rID: 43811 MULTIPLE SPACES Inverted pyramid PARAPHARYNGEAL SPACE SUPRAHYOID INFRAHYOID Anterior • Pharyngeal mucosal space (oro- /nasopharynx) • Visceral space Medial Skull base • Parapharyngeal space (prestyloid parapharyngeal space) • Carotid space Lateral • Carotid space (poststyloid parapharyngeal space) Posterior • Masticator space (infratemporal fossa) • Parotid space Prestyloid PPS PPS proper • Submandibular Each compartment specific pathology Hyoid bone • Sublingual • Buccal Poststyloid PPS Carotid space • Retropharyngeal space (proper / danger space) • Retropharyngeal space (proper / danger space) • Perivertebral space (prevertebral/paraspinal) • Perivertebral space (prevertebral/paraspinal) Musculofascial sheat associated with the 1 principal space stylopharyngeaus, styloglossus and 5 principal spaces 3 spaces continuous with the SHN stylohyoid muscle 2 posterior midline spaces Of which 2 posterior midline spaces Grant’s Atlas of Human Anatomy PARAPHARYNGEAL SPACE - SCHEMATIC PARAPHARYNGEAL SPACE Inverted pyramid – anatomy of the surrounding structures Oval foramen Pterygoid plates Posterior maxilla Anterior tonsillar pillar Pharyngeal constrictor muscles Palatal muscles Anterior Medial nV3 Skull base Middle layer deep cervical fascia Superficial layer Posterior deep cervical fascia Tensor Prestyloid parapharyngeal space Retropharyngeal lymph nodes palatini m. Lateral PP Cervical sympathetic trunc Stylomandibular tunnel Carotid artery Medial Deep portion parotid gland pterygoid jugular vein muscle PM Submandibular space Palatine tonsil Hyoid bone RPN SMT Submandibular RPN: retropharyngeal lymph node gland C: carotid artery J: jugular vein SYM: sympathetic chain CORONAL TRANSVERSE – LEVEL NASOPHARYNX CN: cranial nerve SMT: stylomandibular tunnel PP: pterygoid plate PM: palatal muscles PARAPHARYNGEAL SPACE PARAPHARYNGEAL SPACE Inverted pyramid – anatomy of the surrounding structures PP PM RPN Lighter blue: Parapharyngeal space RPN: retropharyngeal lymph node Deep purple: Pharyngeal mucosal space C: carotid artery Red: Carotid space J: jugular vein Yellow: Posterior cervical space SYM: sympathetic chain Green: Masticator space CN: cranial nerve Light purple: parotid space SMT: stylomandibular tunnel Darker blue: perivertibral space (prevertebral/parapsinal part PP: pterygoid plate Pink line: Rettropharyngeal space PM: palatal muscles Yellow line: Danger space PARAPHARYNGEAL SPACE - contents PARAPHARYNGEAL SPACE fat (main component) Prestyloid PPS vessels ലŝŶƚĞƌŶĂůŵĂdžŝůůĂƌLJĂƌƚĞƌLJ Extent: Skull base to hyoid bone ascending pharyngeal artery Connection to submandibular space inferiorly pterygoid venous plexus, in its portion surrounded by fat Contents: Fat, V3 branches (main branch MS), arteries, nerve minor salivary glands small branch of cranial nerve V3 supplying the tensor veli palatini muscle Importance: salivary tissue Swallowing movements - pharyngeal expansion minor or ectopic salivary gland/rests Easily identified Displacement helps define location of larger SHN lesions Lymph nodes and muscle are not included in the radiological definition of the parapharyngeal space. Infection conduit Content Primary pathology of the parapharyngeal space PARAPHARYNGEAL SPACE Pseudomasses • 1. Anatomical considerations Pterygoid venous plexus • 2. Primary pathology of the parapharyngeal space Primary • 3. Secondary pathology Lipomas Minor salivary gland tumours Brachial cleft cysts RETROPHARYNGEAL SPACE Teratomas • 1. Anatomical considerations Venolymphatic malformations • 2. Primary pathology of the retropharyngeal space Schwannomas MASTICATOR SPACE • 1. Anatomical considerations • 2. Primary pathology of the masticator space Pseudomass: asymmetry in the pterygoid venous plexus Primary Px: minor salivary gland tumour Supraorbital vein Between temporal muscles and pterygoid muscles (medial and lateral) Ectopic rests of salivary tissue Superior ophtalmic vein Partly in de PPS (surrounded by fat) > 90% Benign mixed tumours (pleiomorphic adenoma) Cavernous sinus Drains the palate, nasal cavity, sinuses, nasopharynx, infratemporal face, DDx: deep lobe parotid: stylomandibular tunnel! Fat planes! superficial and deep face Thin section T1 with no fat suppression Inferior Facial vein ophtalmic Intracranial connection Æ cavernous sinus thrombosis! vein Pterygoid venous plexus Asymmetry 1. normal 2. cavernous sinus thrombosis - dAVF! IM v: internal maxullary vein ST v: superior temporal vein Primary Px: 2nd branchial cleft cyst Primary Px: Lipoma 2nd BCC: remnant embryological BCC – 10-40y Rare! tonsillar fossa Æ supraclavicular area Case 1 Fat density/intensity Typical location: anterior SCM, mandibular angle, near ICA and IJV Case 2 Atypical location: PPS (“Type IV Bailey classification”) Sharply demarcated lesion, fluid density/intensity, T1 variable (protein content) Case 3 Case 1 Case 2 Primary Px: Content Teratoma Venolymphatic malformation Schwannoma PARAPHARYNGEAL SPACE • 1. Anatomical considerations • 2. Primary pathology of the parapharyngeal space • 3. Secondary pathology RETROPHARYNGEAL SPACE • 1. Anatomical considerations • 2. Primary pathology of the retropharyngeal space MASTICATOR SPACE • 1. Anatomical considerations • 2. Primary pathology of the masticator space (courtesy A. Mancuso) (J Surg Case Rep, Volume 2020, Issue 3, March 2020) Radiological Analysis Suprahyoid Neck Space-specific differential diagnosis Mass center? Lateral Posterior Locate the mass versus the parapharyngeal space Locate the mass versus the prevertebral muscles Anterior Posterior Lighter blue: Parapharyngeal space Secondary lesions: displacement patterns Deep purple: Pharyngeal mucosal space Red: Carotid space Retropharyngeal space Perivertebral space Masticator space postermedially Yellow: Posterior cervical space Green: Masticator space Parotid space anteromedially Light purple: parotid space Pharyngeal mucosal space posterolaterally Darker blue: perivertibral space (prevertebral/paraspinal part Pink line: Retropharyngeal space Space specific DDx Carotid space anteriorly Yellow line: Danger space Retropharyngeal space anterolaterally 26/03 - Session I Prof. dr. M. de Win WORKSHOP Lighter blue: Parapharyngeal space 26/03 - Session II Prof. dr. C. Tramontini Deep purple: Pharyngeal mucosal space Displacemen t from the parotid space Red: Carotid space Light purple: Parotid space Green: Masticator space 25/03 - Session I Pink line: Retropharyngeal space Prof. dr. J. Casselman Yellow line: Danger space Prof. dr. T. Nunes Displacement from the PMS Courtesy A. Mancuso Displacement from the carotid space Content PARAPHARYNGEAL SPACE Lighter blue: Parapharyngeal space • 1. Anatomical considerations • 2. Primary pathology of the parapharyngeal space Deep purple: Pharyngeal mucosal space Red: Carotid space • 3. Secondary pathology Light purple: Parotid space Pink line: Retropharyngeal space RETROPHARYNGEAL SPACE Yellow line: Danger space Green: Masticator space • 1. Anatomical considerations • 2. Primary pathology of the retropharyngeal space MASTICATOR SPACE • 1. Anatomical considerations • 2. Primary pathology of the masticator space Flattened tube RETROPHARYNGEAL SPACE Flattened tube RETROPHARYNGEALTROPHARYNGEAL SPACESPACE Upper cervical spine (vertbral bodies and discs) Pre- and paravertebral muscles and fascia Extent: skull base to mediastinum Anterior longitudinal ligament Posterior Skull base (clival region) Posterior Two compartments: Retropharyngeal proper (Th1-Th6 - hilum) Lateral Danger space terminates at the diafragm Carotid space Lateral Anterior Retropharyngeal space “proper” Parapharyngeal space Possible conduit for infections Perivertebral space Carotid
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