What is the anatomy of the parapharyngeal space relevant to deep neck infections?

Updated: Apr 30, 2020
  • Author: Alan D Murray, MD; Chief Editor: Arlen D Meyers, MD, MBA  more...
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Answer

Within the deep neck are 11 spaces created by planes of greater and lesser resistance between the fascial layers. These spaces may be real or potential and may expand when pus separates layers of fascia. The deep neck spaces communicate with each other, forming avenues by which infections may spread. These spaces are described briefly.

  • Parapharyngeal space

    • The parapharyngeal space (ie, lateral pharyngeal space, pharyngomaxillary space, pterygomaxillary space, pterygopharyngeal space) occupies an inverted pyramidal area bounded by multiple components of the fascial system. The inferior limitation of this space is the lesser cornua of the hyoid bone; the entire space is situated superiorly with respect to the hyoid. The superior margin of the space is the skull base. Its medial boundary is the visceral division of the middle layer of deep cervical fascia around the pharyngeal constrictor and the fascia of the tensor and levator muscles of the velum palatini and the styloglossus. Laterally, the space is defined by the superficial layer of the deep cervical fascia that overlies the mandible, medial pterygoids, and parotid.

    • The posterior border is formed by the prevertebral division of the deep layer and by the posterior aspect of the carotid sheath at the posterolateral corner. The anterior boundary is the interpterygoid fascia and the pterygomandibular raphe. The parapharyngeal space can be subdivided into compartments by a line extending from the medial aspect of the medial pterygoid plate to the styloid process.

    • The internal maxillary artery, inferior alveolar nerve, lingual nerve, and auriculotemporal nerve comprise the anterior (ie, prestyloid) compartment. Infections in this compartment often give significant trismus.

    • The posterior (ie, poststyloid) compartment contains the carotid sheath (ie, carotid artery, internal jugular vein, vagus nerve) and the glossopharyngeal and hypoglossal nerves, sympathetic chain, and lymphatics. It also contains the accessory nerve, which is somewhat protected from pathologic processes in this region by its position behind the sternocleidomastoid muscle.

    • The parapharyngeal space connects posteromedially with the retropharyngeal space and inferiorly with the submandibular space. Laterally, it connects with the masticator space. The carotid sheath courses through this space into the chest. This space provides a central connection for all other deep neck spaces. It is directly involved by lateral extension of peritonsillar abscesses and was the most commonly affected space before the advent of modern antibiotics.

    • Infections can arise from the tonsils, pharynx, dentition, salivary glands, nasal infections, or Bezold abscess (ie, mastoid abscess).

    • Medial displacement of the lateral pharyngeal wall and tonsil is a hallmark of a parapharyngeal space infection. Trismus, drooling, dysphagia, and odynophagia are also commonly observed.


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