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a flap below the superficial layer of deep cervical fascia, and care must be taken not to dissect deeper to investing fascia [15]. Moving on, the deep cervical fascia consists of three fascial layers or sheaths called the investing, pretracheal and prevertebral fascia. Trace the attachments of investing, pre-tracheal, carotid sheath and Identify various modifications and neck spaces formed by fascial Comprehend the. FREE INDIKATOR FOREX PROFIT

The alar fascia is a distinct facial layer that is attached to and lies anteriorly to the prevertebral fascia. It is attached laterally to the prevertebral fascia, where they both attach to the transverse vertebral processes. The alar fascia spans the midline, anterior to the prevertebral fascia and posterior to the buccopharyngeal fascia.

Posterior to the buccopharyngeal fascia and anterior to the alar fascia lies the retropharyngeal space. Posterior to the alar fascia and anterior to the prevertebral fascia lies the danger space of the neck. The alar fascia attaches to the base of the skull, like the prevertebral fascia which it overlies anteriorly.

Inferiorly the alar fascia joins the buccopharyngeal fascia at about the level of the first or second thoracic vertebra. Fibers from all three deep cervical fascial layers - the investing, pretracheal and prevertebral - give fibers that blend with the carotid sheath. Some sources consider the carotid sheath to be a distinct division of the deep cervical fascia, while others consider it to be a "facial sheath," separate from the true deep cervical fascia. Deep Spaces of the Neck The spaces in reality they are compartments, not true spaces bound by these fasciae represent important clinical correlates of this basic anatomy topic and have been addressed previously by several authors.

The hyoid bone represents an essential boundary for anterior deep spaces of the neck, dividing these spaces into sub- and suprahyoid regions. Other spaces, more posterior, are not interrupted by the hyoid bone and extend the entire length of the neck. Importantly, many of these spaces extend into the mediastinum.

The spaces that span the entire length of the neck further subdivide into superficial and deep. The superficial full-length space is the superficial space. There are four deep spaces of the neck that span the entire length of the neck. These are the retropharyngeal space, the danger space, the prevertebral space and the space within the carotid sheath. The spaces bound inferiorly by the hyoid bone include the submandibular, pharyngomaxillary, masticator, parotid and peritonsillar spaces.

The anterior visceral space is the only space that is bound superiorly by the hyoid bone. The retropharyngeal space lies in the space bound by the alar fascia and buccopharyngeal fascia and consists of loose areolar tissue and lymph nodes. This space is bound superiorly by the base of the skull, laterally by the attachment sites of these fasciae to the transverse vertebral processes and inferiorly where these layers join at about T1 or T2.

The danger space lies between the alar and prevertebral fascia. It is bound superiorly by the base of the skull and laterally by the attachment site of the alar fascia to the prevertebral fascia at the transverse vertebral processes.

Inferiorly, the danger space is in free communication with the posterior mediastinum, which extends to the diaphragm. An infection of this space can thus spread to involve the vital organs of the thorax. The submandibular space is bound, in part by the superficial layer of the deep cervical fascia. Laterally and anteriorly is bound by the mandible, inferiorly and posteriorly it is bound by the hyoid bone. Superficially, its boundary is the superficial layer of the deep cervical fascia, and its superior border is the mucosa of the oral cavity.

This space is the area that is involved in Ludwig angina, an infectious process of the floor of the oral cavity often associated with dental infections. These fasciae also serve, in some cases, as attachment sites for some parts of these muscles. The fasciae which are in close associating with viscera act as structural support and are separate from the organ capsule or the adventitia of the blood vessels which they enclose.

Embryology The fasciae that are closely associated with the muscles of the neck, as described above, are derived from fibro-muscular laminae during ontogenesis. For example, one fetal anatomy study discovered that the prevertebral lamina develops as an aponeurosis for the longus colli muscles. Arguably more important than blood supply is the relation of the main vessels of the neck to these fasciae. As previously mentioned, the carotid sheath contains the common carotid and internal carotid arteries as well as the internal jugular vein.

The vertebral arteries travel through the transverse foramina of the cervical vertebrae which are themselves surrounded by the prevertebral fascia. The major groups of lymph nodes that drain the mucosal surfaces of the oropharynx and nasopharynx are located deep to the investing fascia and superficial to the pretracheal and prevertebral fasciae and tend to lie in proximity to nerves or vessels that course through this space.

The retropharyngeal space contains deeper nodes whereas the danger space does not contain any organized lymph tissue. The anatomic relationship of such nerves to the deep cervical fascia is essential. The vagus nerve CN X , travels, for the most part, within the carotid sheath.

Sympathetic chain ganglia are deep to the prevertebral fascia, anterolateral to the cervical vertebral bodies. The nerves of the brachial plexus are contained within the prevertebral fascia as they leave the intervertebral foramina. More laterally the brachial plexus are still contained within the same fascia in the form of the axillary sheath: the axillary sheath being continuous with the prevertebral fascia. The recurrent laryngeal nerve, a branch of the vagus nerve, exists within the visceral division of the pretracheal layer, lying on the posterior aspect of the lateral lobes of the thyroid gland.

The cervical plexus, like the brachial plexus, leaves the spinal column and enters the space bound by the prevertebral fascia and then extends out laterally, piercing through all three deep cervical layers to innervate the skin. Innervation of the fasciae is likely significant in the pathophysiology of myofascial pain. In this context, nociceptive fibers that travel with the motor fibers which innervate a particular muscle are possibly involved in pain sensation of the involved muscle and its associated fascia.

Clinical Significance The clinical significance that the deep fascia had until part way through the previous century primarily revolved around the spread of infection, but with the advent and widespread use of antibiotics, knowledge of the anatomy of these structures has become less important. However, knowledge of the deep spaces of the neck, in particular, the retropharyngeal and danger spaces, are of still of potential clinical significance, particularly in areas of international medicine where vaccine rates and antibiotic use may be lower than in the United States.

Based on previous cadaver dissection studies, the course of MMN anterior to the facial artery is above the lower mandibular margin. However, Wang et al. We suggest the use of pterygo-masseteric sling approach for surgeries involving the ramus of mandible, as the nerve anatomically courses underneath masseteric fascia and above the masseter muscle Figs.

Relation to perifacial lymph nodes A common instance for MMN palsy is during surgical approaches to submandibular region [ 12 , 22 , 23 , 24 , 25 , 26 , 27 , 28 ]. The MMN is more often jointly found with perifacial lymph nodes in the submandibular triangle Fig.

It is imperative to remove these nodes as they are primary lymphatic draining sites for oral carcinomas and show an increased risk of metastasis [ 29 ]. Oncological safety of the nerve during surgical neck dissection maneuvers has been discussed in several studies [ 25 , 31 , 32 , 33 ].

The Hayes-Martin technique is a long-established nerve preservation technique used during surgical neck dissections. Tirelli et al. These observations are in line with our recommendation for the use of classic Hayes-Martin maneuver to identify and preserve the MMN in cases of node-negative neck dissections Figs. They argued that the contrasting results could be attributed to the differences in nerve location in fresh cadaver specimens and clinical practice, in comparison to embalmed cadaver specimens.

Savary et al. They also proposed that incision placed about 3—4 cm below mandible is safer to avoid nerve damage. Baker and Conley [ 37 ] concluded based on clinical observations during parotidectomies, that the MMN is 1—2 cm below the lower border in almost all the cases and up to 3—4 cm below the lower border in patients with atrophic and lax tissues.

They explained this disparity based on the extension of fascia during the rotation of the head to the contralateral side in surgical dissections. This observation is supported by Nason et al. Based on this concept and considering that the nerve mostly passes below the mandible and is always in the subplatysmal plane, we recommend supra-platysmal dissection of flap till the mandibular lower border and creating a pouch by opening the platysma-SMAS in the area of interest to decrease the chance of nerve injury Figs.

Classical description by Dingman and Grabb [ 20 ] implies nerve injury can be avoided by placing incisions 2 cm below inferior mandibular margin but on the contrast abovementioned clinical dissection, studies [ 4 , 37 ] concluded that nerve is at greater risk when the incision is placed 2 cm below the inferior mandibular margin. Marcuzzo et al.

We recommend placing the incision in the submandibular crease with caution, considering that the position of nerve inevitably changes with rotation of the neck and pull of the deep cervical fascia. During surgeries above inferior mandibular margin anterior to the facial vessels, the dissection is advanced from the margin of mandible beneath the platysma supra-periosteally, to avoid the MMN as it lies within the platysma muscle immediately anterior to facial vessels [ 31 ].

The MMN lies beneath the deep fascia in this region and hence the dissection plane is established in subplatysmal tissue, reflecting the platysma away from the deep cervical fascia till the inferior mandibular margin, thus maintaining a tissue bridge that protects the nerve from iatrogenic injuries [ 15 ].

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These layers act like a shirt collar, supporting the structures and vessels of the neck. We shall now look at the layers of the deep cervical fascia in more detail superficial to deep : Investing Layer The investing layer is the most superficial of the deep cervical fascia. It surrounds all the structures in the neck. Where it meets the trapezius and sternocleidomastoid muscles, it splits into two, completely surrounding them. The investing fascia can be thought of as a tube; with superior, inferior, anterior and posterior attachments: Superior - attaches to the external occipital protuberance and the superior nuchal line of the skull.

Anteriorly - attaches to the hyoid bone. Inferiorly - attaches to the spine and acromion of the scapula, the clavicle, and the manubrium of the sternum. It spans between the hyoid bone superiorly and the thorax inferiorly where it fuses with the pericardium. The trachea, oesophagus , thyroid gland and infrahyoid muscles are enclosed by the pretracheal fascia.

Anatomically, it can be divided into two parts: Muscular part — encloses the infrahyoid muscles. Visceral part — encloses the thyroid gland, trachea and oesophagus. The posterior aspect of the visceral fascia is formed by contributions from the buccopharyngeal fascia a fascial covering of the pharynx. It has attachments along the antero-posterior and supero-inferior axes: Superior attachment - base of the skull. Anterior attachment - transverse processes and vertebral bodies of the vertebral column.

Posterior attachment - along the nuchal ligament of the vertebral column Inferior attachment - fusion with the endothoracic fascia of the ribcage. The anterolateral portion of prevertebral fascia forms the floor of the posterior triangle of the neck. It also surrounds the brachial plexus as it leaves the neck and subclavian artery as it passes through the lower neck region — in doing so, it forms the axillary sheath.

The contents of the carotid sheath are: Common carotid artery Vagus nerve. Accompanying cervical lymph nodes. The fascia of the carotid sheath is formed by contributions from the pretracheal, prevertebral, and investing fascia layers. Posteriorly: It is attached to the ligamentum nuchae and spine of seventh cervical vertebra. Anteriorly: It is attached to the symphysis menti, hyoid bone and is continuous with the fascia of the opposite side. Structures enclosed: It encloses the following structures: Two muscles — sternocleidomastoid and trapezius Two glands — parotid and submandibular Two spaces — suprasternal and supraclvicular Describe the attachment of Pretracheal Fascia.

It covers the front and sides of trachea and splits to enclose the thyroid gland and forms its false capsule. Attachments: Superiorly: It is attached to the hyoid bone, oblique line of thyroid cartilage and cricoid cartilage. Inferiorly: It blends with the adventitia of arch of aorta and fibrous pericardium. Laterally: It merges with the carotid sheath A fibrous band termed ligament of Berry is the extension of this fascia which attaches the capsule of the lobe of the thyroid gland to the cricoid cartilage.

Applied Anatomy Thyroid gland moves up and down during deglutition The pretracheal fascia which forms the false capsule of thyroid gland Is thickened posteriorly to form the suspensory ligament of Berry. The ligament connects the medial surface of lateral lobes of thyroid gland to cricoid cartilage. Therefore, the gland moves up and down with larynx during deglutition.

Describe attachment of Prevertebral Fascia It lies in front of the cervical and upper three thoracic vertebrae and prevertebral muscles. It forms the floor of posterior triangle. Attachments: Superiorly: It is attached to the base of skull in front of foramen magnum. Inferiorly: It is attached to the anterior longitudinal ligament and body of T3 vertebra. It covers the muscles forming floor of the posterior triangle.

Cervical and brachial plexus lie deep to it. The trunks of brachial plexus and the subclavian artery emerge between the scalenus anterior and medius muscles covered by per-vertebral fascia and carry a sheath axillary sheath of this fascia along with them to the axilla. The space behind it and in front of vertebrae is prevertebral space.

The space in front of it and behind the pharynx is retropharyngeal space.

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Deep Cervical Fascia - I (Investing Layer)/ Anatomy / Simplified/ Fascia colli

Surgical anatomy and related considerations Relation to parotid gland The marginal mandibular nerve MMN leaves from anterior caudal margin of the parotid gland underneath the parotid-masseteric and deep cervical neck fascia just below the angle of the mandible and is anatomically protected by a thick superficial musculo-aponeurotic system SMAS after it exits the parotid gland [ 9 ] Fig.

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Investing layer of deep cervical fascia attachments international	The instance of lower lip paralysis is limited due to the variability in branching and anastomosis pattern of MMN with other nerves or its own branches [ 1236 ] Table 1. Posterior to the alar fascia and anterior to the prevertebral fascia lies the danger space of the neck. Further, Hazani et al. The MMN is more often jointly found with perifacial lymph nodes in the submandibular triangle Fig. The muscles that lie within the prevertebral fascial layer can be thought of in terms of their location respective to the cervical vertebrae. The prominence of the mandibular body and fibrous adhesions of masseteric ligaments in this region can make the plane of dissection enigmatic [ 19 ].
Forextime indonesia airlines	The vagus nerve CN Xtravels, for the most part, within the carotid sheath. These are the retropharyngeal space, the danger space, the prevertebral space and the space within the carotid sheath. They argued that the contrasting results could be attributed to the differences in nerve location in fresh cadaver specimens and clinical practice, in comparison to embalmed cadaver specimens. Some sources report that the prevertebral fascia is continuous with the muscular division of the pretracheal layer and that posteriorly the inferior aspect of this singular fascia is continuous with the fascia of the rhomboid major, rhomboid minor and the serratus posterior muscles with boney attachment to the scapulae. It extends superiorly to cover the pharyngeal constrictor muscles and runs anteriorly at this level from the pharynx to link the buccinators muscle of the face. The spaces that span the entire length of the neck further subdivide into superficial and deep.
Investing layer of deep cervical fascia attachments international	298
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