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2. medicine
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THE _ARRA:NG_mJYLE1JNT, OF 'l'BE DEEP CERVICAl
FASCIA
By
E. S. MEYI<jRS, lVLB.
Senior
Honorar-y
Lecturer
(Sydney), F.RA.C.S.,
S-urgeon,
Brisbane
Hospita-l;
in Anatomy, Unive?'sity of Q�wensland;
AND
R K. MACPIJJ<jRSON, lVI.Sc.
Sen-ior
(Queensland),
Dmnonstrator,
Department of Biology, Un-iversity of Q!t- eenslanil.
[Reprinted from 1'he Medical Jrn1-rnal of fhistralia, November
pagL;
12,
10B8,
813.1
Fryer
QLBOl
.us
V.l no.l
(Reprinted from
'!'he
November
Mcdica.l Jou,rnal of A_ustralia.,
1�. 1938, page 813.)
THI<J ARRANGI•}MEN'l' OF THI<J
DEEP
UERVIC'�\L FASCIA.
By K H. MEYERS,
M.B. ( Sydney), F.R.A.C.S.,
Senior Honorary S�trgeon, Brisbane Hospital;
Lecturer in A_natom.y, University o.f Queensland;
AND
R. K. MACPHERSON,
M.Sc. (Queensland),
Senior
Demonstrator, Department of
Univ e'fsity of Queensland.
Biology,
SYDNEY
AUSTRALASIAN MEDICAL PUBLISHING CO., LTD.
SEAMER STREET, GLEBE
1939
THE AHRANGRMENT
OF
'l'Hl<J
DEI<JP
CEHVICAL FASCIA.
By E. S. MEYERS,
M.B. (Sydney), F.R.A.C.S.,
Senior Honorary B-urgeon, Brisbane Hospital.;
Lecturer in Anatomy, Univenity of Queensland;
AND
H. K. MACPHIDilSON,
M.Sc. (Queensland),
8enior
VemonstratoT,
Department
UnfveTsity of Queensland.
TrLLAUX(4) has remarked on
the
of
Biology,
ProtetJ.s-like n ature
of the deep fascia of the neck, and another French­
man, Sebilau (quoted by Testut ) has ob served with
typi c al Gallic insight, that, in defining its l a yers ,
the wish is father to the plane and the scalpel is
directed accordi ngly. Some have gone so far as to
say that the pla nes described as e x ist i ng in this
fascia are artifacts pure and s imple , and that no
such struct ures o ccur during life. But, as ap ology
for yet another account of the arrangements of the
fascia of th e neck, we would state that t he facts to
be recorded here are largely the resul t of observa­
tions
on
the living.
O bservat i ons have been made
d issecting room, post mortem r o o m and
operating t h e atre ; but it is in the last -name d pl ace
that the reader may most profitably veri fy t he
descript ion for himself.
in
the
It
is
maintained
govern ing the
that
the
arrangement of
general
the
principles
fascia
in
this
region in no wise differ from those which determine
its a r ran gement in any other pa rt of the body. It
is our o pinio n that sufficient attentio n has not been
given to these general p rinci p les , because on them
dep end the understanding of the fascial arrange­
ment in the neck and, as a co rollar y, t he un der 8t anding also of the various surgic al affections
eneonntered in
practice .
6
E. S. MF.YEHS AND R. K. MACPHERSON.
mastoid, roofs over the posterior triangle, encloses
the trapezius and is attached to the ligamentum
nucha; in the mid-line posteriorly. In short, every­
one is agreed on the existence and disposition of
this layer.
'rhe second layer is one of great importance-a
fact which, in our opinion, has not been sufficiently
stressed by the Ihajority of observers. Tt is derived
from the fascial sheaths of the sterho-hyoid and
omo-hyoid muscles, which are considered as being
in the same morphological plane. Beginning at the
mid-line, it passes laterally, im-esting in turn the
sterno-hyoid and the omo-hyoid, and passing fnrtheT
laterally comes into relation with the internal
jugular vein, turning round the latet·al aspect of
this vessel to become continuous with the pre­
vertebral layer of fascia.
'l'he next layer to
laterally from
the
qe
considered is th�;tt comiilg off
sterno-thyreoid
muscle.
This
layer is also of great importance lri1t. of innch
greater strength than the preceding one.
At the
lateral border of the sterho�thyreoid 1rtusele the
fascial sheaths covering its anterior and posterior
surfaces fuse to form the third laye1: Of the deep
fascia.
This layer passes postero-laterally to join
the retrov1sceral layer, which lies on the po'sterior
surface of the constrictor muscle. In its course it
passes between the great vessels a11d the thyreoid
gland, and provides a sheath for the lattei·. Passing
it does medial to the carotid artery, it co1itributes
to the formation or the carotid sheath, constituting
its medial wall. It also gives off, just anterioi· to
as
the artery, a thin layer of fascia, which passes
between the carotid artery and the internal j1igular
vein, forming a partition between these two vessels.
Consideration of :U'igure I shows how all the layers
enumerated above haYe become continuous.
In
addition, the mode of formation of the following
structures is indicated:
The Carotid Sheath.�An investing layer of the great
the neck, the so-called carotid sheath; may be
vessels of
considered as consisting of three components:
(a) one from
AHRANGFJMEN'l' OF
the
(b)
and
'.I'I-IF; DEEP CERVICAL FASCIA.
7
fascia
ove r the sterno-hyoid and omo-hyoid muscles,
one from the fascia over the sterno-thyreoid muscle,
(c)
one
from
the prevertebral
fascia.
The Sheath for the Thyreoid Gland.-A sheath for the
thyreoid gland is formed by the fascia coming off from
both surfaces of the sterno-thyreoid muscle.
'l'he Retropharyngeal Space.-A retrophatyngeal space is
formed anteriorly by the retrovisceral fascia, posteriorly
by the prevertebral fascia, and laterally by the medial
portion of the carotid sheath.
FIGURE I.
Schematic transverse section of the anterior
part .of the left half of the neck at the
level of the sixth cervical vertebra, to show
the arrangement of the fascia at that leveL
(e ,co common carotid, IJ = internal jugular,
Le = longus ce·r·vicis, LSc � levator scapulre,
OE = resophagus, OH = omo-hyoid, SeA =
scalenus ante·ri01', sea = semispinalis capitis,
ScM = scalenus medius, See = semispinalis
cervicis, SH = sterno-hyoid, SM = sterno­
mastoid, Sp = splenius, ST = sterno-thyreoid,
T = trapezius, TG = thyreoid gland, Tr =
trachea, l' = sixth cervical vertebra, l'A ·=
vertebral artery.)
The fascial planes are
indicated by broken lines.
If a section is taken at a higher level, say just
below the upper border of the thyre o id cartilage, as
shown
in Figure II, similar
conditions
are
found
8
E.
to prevail.
S. MEYERS
AND
R. K. MACPHEUSON.
It is to be noted , however, that: (i) the
thyreoid gland has disappeared from the section;
(ii) the thyre o-hyoid muscle rep.l aces the stern o ­
thyreoid muscle ;
(iii)
the retrovisceral layer may
now be de scrib e d as t he aponeurmds of the inferior
constrictor of the ph arynx .
If we examine a prep a ration from which the sterno­
mastoid muscle has been removed , we can observe
the whole extent of the fascial l ayer c overi ng· the
FIGURE
II.
Schematic transverse section at the level of
the upp er part of the thyreoid cartilage.
(AJ = anterior jugular, C = inferior con­
strictor, CA = ·carotid artery, .EJ = external
jugular, IJ = internal jugular, L = cavity of
the larynx, LC = longus cervicis, OH = omo­
hyoid, SM = sterno-mastoid, TC = thyreoid
cartilage, TH = thyreo-hyoid, V = body of
fifth
cervical
vertebra,
VA
=
vertebra.!
artery.)
sterno-hyoid and omo-hyoid muscles.
At the level
at which the omo - hyoid crosses the internal j ugula r
vein it is obvious that the
a rr an
g ement
described
above for this laye r can no longer hold good, as the
fascia is d ra wn outwards by the omo - hyoid
muscle.
·There remains now to be c onsidered the attach ­
ment of these layers at the root of the neck. The
attachment of the investing layer is exactly as
AURANGFlMENT OF THE DEEP
CERVICAL
FASCIA.
9
deseribed in the standard text-books: it e ncloses the
space of Burns above the sternum and the supra­
clavicular space as it passes laterally and gains
attachment to the clavicle. The attacllment of the
sterno-omo-hyoid layer iR along the upper border
of the sternum and clavicle, merging with the attach­
ment of the inner lamella of the investing layer.
The layer on the anterior surface of the sterno­
thyreoid (which is common to it and the sterno­
hyoid) will, of course, gain an attachment to the
sternum. 'l'he layer of fascia on the deep surface
of the sterno-thyreoid passes down into the thorax
to blend "\vith the fibrous pericardium over the great
vessels in the superior mediastinum in front of the
trachea.
We would call attention here to the caudal extent
the
retropharyngeal
space.
According
to
Barlow, <ll this space reaches the level of the aorta,
although its lateral limits there are uncertain.
of
In an upward direction this space extends to the
base of the skull.
The layer of fascia which we
have previously called the retropharyngeal layer
now becomes the pharyngeal aponeurosis.
Its
lateral limit anteriorly is the pterygo-mandibular
raphe. These facts are mentioned here for the sake
of convenience, hut will be dealt with more fully
in the second part of the description. It should be
noted here, however, that the retrovisceral layer
of the fascia, the prevertebral layer and the medial
wall of the carotid sheath maintain a constant
relationship to one another throughout the whole
extent of the nee�!;.
The Arrangement Above the Level of the Hyoid Bone.
At the level of the hyoid bone all three layers,
namely, the investing layer, the sterno-omo-hyoid
layer and the continuation upwards of the sterno­
thyreoid layer, fuse and are inserted along the
body and greater cornu of the bone.
Above this
point the fate of the various layers is best described
s�para tely.
'J'hc Invest·ing Layer.
'l'he investing layei' sweeps upwards to gain an
attachment along
a
line extending along the lower
10
E. S. MEDJH� ANll IL K. MACPJ-LEltHON.
border of tile mandible, the zygomatic arch, the
external acoustic meatus and the mastoid process.
This layer forms tile external fascial covering for
both the submaxillary and parotid glands. Laterally
It also
it encloses the sterno-mastoid as before.
gains
a
special attachment to the angle of the jaw
by a connexion passing from the sheath of the
Aterno-mastoid to the angle of the jaw and the hyoid
bone. 'l'his is sometimes called the stylo-mandibular
ligament.1
'l'he
Stenw-Omo-Hyoiil and tlie Sterno-Thy-reoid
Laye1·s.
and
the sterno­
The sterno-omo-hyoid layer
thyreoid layer fuse at the level of the hyoid bone,
and thereafter constitute a single layer. This layer
is best considered first in relation to its more
anterior attachments and then in relation to its
more posterior attachments.
Antero-medial to the angle of the mandible t his
layer, leaving the hyoid bone, sweeps upwards, gives
an investment to the anterior belly of the digastric
and the mylo-hyoid muscle, and gains an attach·
In
ment to the mylo-hyoid line. of the mandible.
this way the deep layer of the capsule of the sub­
mandibular gland is formed (see Figure III).
At
level of the digastric the fascia is
times above the ------------- ----very thin and its continuity is easily destroyed. A t
confusion has arisen on this subject, and it would
1 Much
There
appear that two distinct s tructures have been confused,
some man1mals, for exan1ple the horse, a distinct
in
exists
muscle which extends from the tip of the paramastoid process
(arising in common with the posterior belly of the digastric)
to the ang'le of the mandible, and which is known as the
stylo-mandilmlaris or stylo-maxillaris muscle."'
This is repre­
sented in man by a fascial thickening (or ligament, if you
will) which extends from th·e base of the sty loid process to
'
the ang'le of the mandible, and this constitutes the stylo­
mandibular Jig'ament in senstt. . stricto.
It is thus figm;ed. in
and
c
"Practi al Anatomy", edited bY.- Stibbe.
But this structure,
f unction.
rig·htly called the stylo-mandibular- !ig'ament, does not separate
submandibular glands.
Another.· structure
the parotid
perform's this
It is the layer of ·fascia alread y
mentioned, which..stretches from the sheath o f 'the_ sterno­
mas toid to the angle of the jaw.
It would seem _that this
represents a mandibular head of the sterno"mastoid comparable
with the mnscnltts ste,·noccephalious in the horse,
It is on
account of the varying attachment,. of this muscle in the lower
mammals that, in veterlnary anatomy, it i� usually referred
,
to by the non-committal name of the sterno-cephalieus.
It is
interesting to note that the authorR, after arriving at this
conclusion, had occasion to <'orisult 'l'estut,'"' and fout!d that
he had advanced an identical view.
AIUIAl\<iEM�DIT O.F 'J'HE DEFJP CERVICAL
FASCIA.
11
the angle of the mandible the fascia is continuous
with the layer of fascia uniting the sheath of the
sterno-mastoid to the angle of the mandible.
More posteriorly the fascia obtains
a
very firm
attachment along the posterior belly of the digastric,
which extends
temporal bone.
continuous
as
far as the mastoid portion of the
Posterior to this the fascia becomes
with
the
fascia
covering
the
muscles
which fonn the floor of the posterior triangle.
PIGu!m
Schematic.
through
III.
�oronal
section
mandible and sub­
mandibular g-land to show the
arrangmnent of the 'fascia above
the
level
of the hyoid bone.
(D = digastric, ll = hyoid bone,
M = mandible,
1l:Ul
=
mylo­
hyoid,
SMG = submandibular
gland.)
be
the
'L'he arrangement abo�-e described will not be seen
in the usual course of dissection described in the
various manuals. It is best seen in the post rnortern
or operating
room,
after the sterno-mastoid has
been turned down from its insertion. It will then
observed· �ls a continuous sheath firmly attached
12
�j. S. MID YEllS AND IL K. M ACPHFJRSON.
along
the
length
whole
of
both
bellies
the
of
digastric muscle and connecting the sheath of the
sterno-mastoid musc le with the angle of the jaw.
'l'his
arrangement is illustrated in l!'igure IV A,
whieh is a diagrammatic cross-section at the level
Rhown in ]<'ignre IVB.
,
®, ��;· �
p�j;lflu
-<�·�:�E���� ��!_-�<-:::��:-:::�
0
·
-----
-----#
.":•.,s. --------
..... .. _
.. -... .. , � ... �.-::.--":. . �
-�
FIGURE IVA.
Schematic section along the plane XY in Figure IVB to
show the connexion between the sheath of ·the sterno­
mastoid and the angle of the jaw,
(D = digastric, M =
mandible, Ms = mnsseter, · SII = stylo-hyoid, S1li � sterno-
mastoid.)
Above
digastric
the
the
level
of
fascia
the
is
posterior
continued
belly
of
upwards
the
as
a
It successively ensheaths the mm;cles
which arise from the styloid process.
thinner layer.
�'IGUREl
IVB.
Thumbnail sketch to show the plane of section
(M = masseter, Mn = body of
of F'igure IVA.
mandible, OH = omo-hyoid, P = parotid gland,
SH = sterno-hyoid, S.M = sterno-mastoid, XY =
plane of section.)
As the great vessels pass beneath the digastric
rnuscle they carry wi th them a sheath derived from
the
fascial
sheath
under
consideration.
This
arrangement iR exactly comparable with th e con­
dition of affairs f ou n d in the infrahyoid region,
AitHA:'\UI<;MFJNT
OF 'l'HIG DFJI!lP
CJomVICAL FASCIA.
13
where the great vessels pass beneath, the omo-hyoid
muscle.
It is impo rta nt to no te that the vessel s
and the muscles are co mplete ly separated from one
a noth er by their s h eaths .
to
As stated before, the relation of the prevertebral
the
retrovisceral
layer
of
fascia
rem ains
unchanged. Their li ne of fusion continues righ t up
to the base of the skull,
In intimate association
with t hi s line of fusion we have the sheath of the
In the su perior portion of
its extent the p rev ert ebr al space, or retrovisceral
internal carotid ar tery .
space of IIacnke as it is sometimes called , is d ivided
into two parts by a vertical p arti tion in the mid­
line formed by a f usion between th e retrovisceral
and prev ertebr a l lay ers , a fact remarked upon by
I.ee McGregor iu his "Surgical Anatomy". <2l
'!'he
authors have been u nable to iden tify
aponeurosis
as
described
stylo-pharyngeal
the
by
Barlow Y > Pei·h ap s it is th e fused prevertebral and
re tro v isc eral la yers .
In point of fact , we have
noticed that Barlow's captio n "stylo-pharyngeal
aponeurosis" in Pla�e IV il lustrating his ar ticle ,
actually repre se nt s the line of fusion between the
two aponeuroses (see Figure V).
The Lateral Pharyngeal Space.
The back ward inclination of the vert ebr al column
and the p osition of. the styloid process, with its
nttached muscles and fascia, resnlt in the forma­
tion of a fa sc i a -cove red, chink-like space into wh ic h
the p aro tid g land fits.
Laterally there is a strong layer of fascia derived
from th e i nves ting lay er ; infe riorly there are, a
s tro ng lay er over the po s t erior belly of the digastric
mmlCle and a strong lay er attached to th e angle of
the mandible.
The result of this arrangement is
tha t the on ly way in w hic h the glan d may ea sily
extend is to war ds the weaker medial area, whe1•e
it may push the ph aryngeal wall before it.
'[:lpints
Barlow has devoted considerable a tt ention to the
lateral pharyngeal space, and while w e agree in t he
greater part with, his d esc rip tio n, there are certain
with which we do not agree.
The first iA in
14
E. S. MEYEUS
AND R.
K. MACPHERSON.
regard to the stylo-mandibular ligament.
It is not
considered by us that this structure separates the
parotid from the submandibular gland. This point
has been dealt with earlier in this paper.
Again, it is considered that this space is easy of
surgical access.
All that one has to do is to incise
the fascia along the posterior belly of the digastric,
and, by insertion of the finger, the fascial sheaths
FIGURE V.
Schematic transverse section at the level
of the atlas.
(A = atlas, B = buccinator,
C = internal carotid, D = digastrk, E =
external carotid, F' = fat, G = lymph
gland, J = internal jugular, C = long·Hs
capitis, 1li = masseter, Mn = mandible,
0 = .odontoid peg, PG = parotid gland,
PT = me dia l pterygoid, So = spinal �ord,
SC = superior constrictor, SM = sterno­
mastoid,
V = vertebra.! artery, SP =
soft palat e , St = s t yl o process.)
The
�tylo-hyoid
and
stylo-pharyngeus
are
elsa
shown, but not labelled.
I..
of the styloid muscles are easily broken down, and
the finger can be. rapidly passed to the pharyngeal
wall and
a
drain inserted in cases of suppuration.
'l'he third point of difference is the question of the
stylo-pharyngeal aponeurosis already noted.
'l'he S.heath ot the Internal J.1tg1tla1· Vein.
If the sterno-mastoid muscle is removed in its
entirety the sheath of the internal jugular vein will
be seen tbroughont the greater part of its extent.
AltllANGEMENT OF
THE DEEP CERVICAL
FASCIA.
15
l<'rom a consideration of its method of formation,
describ ed above,
as
it
is
natural outlets from it are
obvious
along
that
the
only
the sheaths of its
tributary veins.
In our
ex perience
infections
of
the
infrahyoid
region provide greater probl e ms in treat m en t than
those in the suprahyoid region.
there
are
more
laye r s
of
The reason is that
fascia;
and this
fact,
tog eth er with that of the altered position of the
sterno-mastoid
muscle
in
the
presence of
patho
­
logic al processes, leads to the formation of cu,ls-de­
wc
which are difficult of dr ainag e
.
Summary.
1. A
of
new
the deep
acc ount
is given of the arrangement
c er v i eal
fascia in the
anterior
com­
partment of the neck, based largely on observations
on the living and the recently dead.
2. An attempt is made to show that t he arrange­
ment
is
in
ac cordance
with
certain
general
principles.
3. The composition of the sheath of the thyreoid
gland and the carotid sheath is discussed.
4. The fascia is described in relation to the sub­
mandibular a n d parotid glands, tog ether with the
stylo-mandibular l i gament.
5. A
means
of
s ur g i c al
access
to
the
lateral
pharyng eal space is outlined.
6. C e rt ain of the views expressed are eomp:u·ed
with those of Barlow.
References.
'1' D. Barlow: "Surgical Anatomy of the :-<eck in Helation to
Septie
LeRions",
JoiM'nal of
Anatomy, Volume LXX, 1936,
pag·e 584.
<2) A. L. McGregor: 4'A Synopsis of Su rgi ca l Anatomy", Third
Edition, 19�6. pageR 179 to 185.
<<:l S. Sisson: "�rhe Anatomy of Dornestic Animals", Second
Edition, 19:>5. uages 262 and 266.
w P. Tillanx: "TTaite d'anatornie topoiJTaphiqne",
Eleventh
·
Edition, 1914, pages 4 7 1 to 480.
<i'i) Testut: "T1·ait8 d'rtnato,mi.e htr,rnainen.· Volume I, 1928, pages
859 to 9 63.