Journal of Ultrasound (2010) 13, 85e89

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Ultrasound anatomy of the neck:

The infrahyoid region
A. Gervasio a,*, I. Mujahed a, A. Biasio a, S. Alessi b

a
Radiology Department, Clinical Institute City of Brescia, San Donato Hospital Group, Brescia, Italy
b
Institute of Radiology, Fondazione IRCCS, Policlinico S. Matteo, Pavia, Italy

KEYWORDS Abstract The infrahyoid region of the neck includes the visceral, anterior cervical, posterior
Ultrasound; cervical, carotid, retropharyngeal, and perivertebral spaces. The visceral space contains the
Anatomy; thyroid, parathyroid glands, larynx, hypopharynx, the cervical trachea, and esophagus, the
Neck. recurrent laryngeal nerve. The carotid space contains two parts, which extend from the skull
base to the aortic arch and are delimited by the three layers of the deep cervical fascia (super-
ficial, middle, and deep). It contains the internal carotid artery, the internal jugular vein,
cranial nerves (IXeXII), the sympathetic plexus (suprahyoid compartment), the common
carotid artery, the internal jugular vein, vagus nerve (infrahyoid compartment). The retro-
pharyngeal space is a midlinespace containing adipose tissue that extends from the skull base
to the upper mediastinum. It is located posterior to the pharynx and cervical esophagus, ante-
rior to the danger area and the perivertebral space.
The perivertebral space extends from the skull base to the clavicles and includes two parts:
prevertebral and paraspinal. The prevertebral space includes the prevertebral muscles (long
muscles of the neck and head), the scalene muscles (anterior, middle, and posterior), the roots
of the brachial plexus, the phrenic nerve, the vertebral arteries and veins, and the vertebral
bodies. The paraspinal space contains the paraspinal muscles and the posterior elements of
the cervical spine.
The posterior cervical space is a deep space located posterior to the sternocleidomastoid
muscle. It contains the accessory nerve, the accessory chain lymph nodes, the pre-axillary
component of the brachial plexus, and the dorsal scapular nerve. The anterior cervical space
is located deep to the strap muscles and sternocleidomastoid muscle. It surrounds the front
and sides of the visceral space and is related posteriorly to the carotid space. This article
reviews the ultrasound features of the structures located in the infrahyoid region of the neck.

Sommario Gli spazi viscerale, cervicale anteriore, cervicale posteriore, carotideo, retrofa-
ringeo e perivertebrale, localizzati al di sotto dell’osso ioide, costituiscono la regione infraioi-
dea.
Lo spazio viscerale contiene tiroide, paratiroidi, linfonodi, laringe, ipofaringe, il tratto cer-
vicale della trachea e dell’esofago, il nervo laringeo ricorrente.

* Corresponding author. Radiology Department, Istituto Clinico Città di Brescia, Hospital Group San Donato, Brescia, Italy.
E-mail address: heart2@libero.it (A. Gervasio).

1971-3495/$ - see front matter ª 2010 Published by Elsevier Srl.

doi:10.1016/j.jus.2010.09.006
86 A. Gervasio et al.

Lo spazio carotideo è costituito da due parti che si estendono dalla base cranica all’arco aor-
tico, delimitati dai tre strati della fascia cervicale profonda (foglietti superficiale, medio e pro-
fondo). Contiene: arteria carotide interna, vena giugulare interna, nervi cranici (9e12), plesso
simpatico (collo sopraioideo), arteria carotide comune, vena giugulare interna, nervo vago
(collo sottoiodeo).
Lo spazio retrofaringeo è uno spazio adiposo mediano che si estende dalla base cranica al
mediastino superiore, localizzato posteriormente alla faringe e all’esofago cervicale, anterior-
mente allo spazio pericoloso e allo spazio perivertebrale.
Lo spazio perivertebrale è esteso dalla base cranica alle clavicole, comprende due parti:
prevertebrale e paraspinale. Lo spazio prevertebrale comprende i muscoli prevertebrali (lun-
ghi del collo e della testa), i muscoli scaleni (anteriore, medio e posteriore), le radici del ples-
so brachiale, il nervo frenico, le arterie e vene vertebrali, i somi vertebrali. Lo spazio
paraspinale comprende i muscoli paraspinali e le costituenti posteriori del rachide cervicale.
Lo spazio cervicale posteriore è uno spazio adiposo situato in profondità e posteriormente al
muscolo sternocleidomastoideo; contiene il nervo accessorio, linfonodi della catena accesso-
ria, la componente pre-ascellare del plesso brachiale e il nervo scapolare dorsale.
Lo spazio cervicale anteriore è uno spazio adiposo situato in profondità ai muscoli sottoioidei
ed al muscolo sternocleidomastoideo; circonda anteriormente e sui lati lo spazio viscerale,
posteriormente ha rapporti con lo spazio carotideo.
Nell’articolo vengono presentati gli aspetti ecografici delle strutture situate nella regione
infraioidea del collo.
ª 2010 Published by Elsevier Srl.

Introduction the inferior thyroid artery (a branch of the thyrocervical

trunk, which originates from the subclavian artery), and in
The infrahyoid region of the neck is located below the hyoid rare cases (3%) also by the thyroid ima artery (branch of the
bone and contains the visceral, anterior cervical, posterior anonymous artery or of the aortic arch) [3]. The area is
cervical, carotid, retropharyngeal, and perivertebral drained by three veins: the upper and middle veins empty
spaces. Some of these spaces are confined to the infrahyoid into the internal jugular vein, and the lower one drains into
region; others continue into the suprahyoid region of the the brachiocephalic vein [3]. Lymphatic drainage occurs
neck and the mediastinum. primarily through the prelaryngeal, pretracheal, and para-
tracheal lymph nodes (level 6, the paratracheal nodes along
the recurrent laryngeal nerve also drain the mediastinum).
Visceral space
Drainage is also provided laterally by the internal jugular
(levels 2e4) and the accessory chains (level 5) and, in the
The visceral space is a cylindrical space bounded by the
middle layer of the deep cervical fascia, which extends
from the hyoid bone to the upper mediastinum. It is
delimited anterolaterally by the anterior cervical space,
posterolaterally by the carotid space, and posteriorly by
the retropharyngeal space [1,2]. It includes the thyroid and
parathyroid glands, the larynx, the hypopharynx, the
cervical segments of the trachea and esophagus, and the
recurrent laryngeal nerve.
The thyroid gland is composed of two lobes connected by
a median isthmus (which may be absent in some cases); 40%
of all patients have an accessory lobedthe pyramidal lobe,
which is more or less developed. It extends from the isthmus
toward the hyoid bone, in front of the thyroid cartilage
(Fig. 1) [3]. The thyroid lies in front of and on the sides of the
trachea. It is bounded posterolaterally by the carotid space,
and its anterior and lateral aspects are covered by the strap
muscles and the sternocleidomastoid muscles. Its poster-
omedial border is near the tracheoesophageal groove, which
contains the recurrent laryngeal nerve, the parathyroid Fig. 1 Axial scan at the level of the thyroid showing the right
glands, and lymph nodes (Fig. 3A and 4) [1,2]. lobe (1), isthmus (2) and left lobe (3) of the thyroid, the
The posterior surfaces of the lobes are adjacent to trachea (4), esophagus (5), common carotid artery (6), internal
the perivertebral space and on the left to the esophagus. jugular vein (7), the sternocleidomastoid (8), sternothyroid
The blood supply is provided by the superior thyroid artery (10), sternohyoid (11), long cervical muscles (12), and the
(the first anterior branch of the external carotid artery), cervical vertebrae (13).
Ultrasound anatomy of the neck 87

to the anterior mediastinum. The most common sites are

right below the lower pole of the thyroid or thymus; ret-
ropharyngealeretroesophageal and posterior mediastinal
locations are rarer [1e3]. The superior parathyroids are
vascularized by the superior thyroid artery; the inferior
glands by the inferior thyroid artery. Under physiological
conditions, the parathyroid glands cannot be assessed by
ultrasound [4,5].
The trachea extends from the larynx (which lies
approximately at the level of the sixth cervical vertebra) to
the carina (fifth dorsal vertebra). It is composed of carti-
laginous rings anterolaterally and posteriorly by a fibro-
muscular membrane [3]. Anteriorly, the trachea has
relations with the strap muscles and the isthmus of the
thyroid (at the level of the IIeIV cartilaginous rings). On
either side are the lobes of the thyroid and the structures
found in the tracheoesophageal groove (recurrent laryngeal
nerve, parathyroids, lymph nodes), and behind it lies the
esophagus (Fig. 1,2,5) [1,2]. The cervical trachea is vascu-
Fig. 2 Axial scan cranial to the thyroid isthmus showing the
larized by the inferior thyroid artery and drained by the
sternothyroid (10), sternohyoid (11), and thyrohyoid muscles
pretracheal and paratracheal lymph nodes (level VI) [3].
(18), the larynx (16), and the hypopharynx (17).
Sonographically the trachea is characterized by alternating
suprahyoid portion of the neck, along the internal jugular hypo- and hyperechoic bands representing the cartilaginous
vein [3]. During embryogenesis, the thyroid descends from rings and annular ligaments, respectively (Fig. 5) [4,5].
the foramen cecum (base of the tongue) along the thyro- The esophagus extends from the hypopharynx (at the
glossal duct, which runs in front of the hyoid bone and level of the sixth cervical vertebra) to the abdomen (at the
laryngeal cartilage [3]. The gland is characterized by fine, eleventh dorsal vertebra). It lies behind the thyroid and
uniform internal echoes, hyperechogenicity with respect to trachea and in front of the last cervical and first few dorsal
the surrounding muscles, and a thin hyperechoic capsule vertebrae. The cervical segment is shifted somewhat to the
(Fig. 1,3A, 4). With advancing age, the thyroid frequently left of the midline. The anterolateral walls are adjacent to
undergoes fibrosis and/or calcification manifested by the the structures of the tracheoesophageal groove and the
presence of hyperechoic linear or ring-shaped streaks [4,5]. thyroid. On either side are the carotid spaces, and behind are
There are usually four parathyroid glands, two upper the retropharyngeal and perivertebral spaces (Fig. 1,4A)
and two lower. They are generally located in the visceral [1,2]. The cervical esophagus is vascularized by the inferior
space posterior to the thyroid, adjacent to the trache- thyroid artery and drained by the paratracheal lymph nodes
oesophageal groove. The presence of supernumerary (level VI) [3]. On ultrasound, the esophagus has a stratified
glands, up to 12, is common. Fewer than 2% of the ectopic appearance. The innermost of the three layers is hyper-
glands are superior parathyroids; they are located behind echoic and corresponds to the mucosa and submucosa; the
the pharynx or esophagus. Approximately 50% are inferior middle layer, hypoechoic, is the muscle layer (which
parathyroids, and 15% of these are located within 1 cm from constitutes about 50% of the thickness); and the outer
the lower pole of the thyroid. In 35% of the cases, the adventitial layer is hyperechoic. The lumen is virtual and is
ectopic gland is located anywhere from the angle of the jaw visualized as a thin hyperechoic line (Fig. 4A) [4,5].

Fig. 3 A. Axial scans of the lateral cervical spaces showing A: the left lobe of the thyroid (3), the common carotid artery (6),
internal jugular vein (7), the sternocleidomastoid (8), omohyoid (9) and sternothyroid (10) muscles. B. The common carotid artery
(6), the sternocleidomastoid muscle (8), the omohyoid muscle (9), the long muscle of the neck (12), the scalene muscles (14), and
the vertebral artery (15).
88 A. Gervasio et al.

Fig. 4 A Longitudinal scan of the thyroid lobes A: the left thyroid lobe (3), esophagus (5), sternothyroid muscle (10), and cervical
vertebrae (13). B The right thyroid lobe (1)and the long muscle of the neck (12).

Carotid space The internal jugular veins originate from the jugular
foramen at the base of the skull (as direct continuations of
The carotid space consists of two cylindrical areas that the transverse sinuses). They descend within the neck along
extend from the base of the skull (jugular foramen-carotid the lateral wall of the pharynx, posterior to the internal
canal) to the aortic arch (supra- and infrahyoid portions of carotid artery, continue laterally to the common carotid,
the neck and the mediastinum). It is delimited by the three beneath the sternocleidomastoid muscle, and finally merge
layers of the deep cervical fascia (superficial, medial, with the subclavian veins, forming the brachiocephalic
deep). It contains the internal carotid artery, internal venous trunks [3].
jugular vein, cranial nerves (IXeXII), sympathetic plexus,
supra- and infrahyoid cervical lymph nodes, the common Retropharyngeal space
carotid artery, and the vagus nerve (Fig. 1 and 3) [1,2]. In
the suprahyoid region of the neck, the carotid space is The retropharyngeal space is a midline area of adipose tissue
surrounded by the retropharyngeal space (medially), the extending from the skull base to the upper mediastinum. It is
perivertebral space (posteriorly), the parotid space (later- located posterior to the pharynx and cervical esophagus,
ally), and the parapharyngeal space (anteriorly). anterior to the danger space and the perivertebral space
In the infrahyoid neck, it is surrounded by the anterior (Fig. 1,2) [1,2]. The suprahyoid part contains lymph nodes,
cervical space (anteriorly), by the visceral and retro- which are absent in the infrahyoid portion of this space.
pharyngeal spaces (medially), and by the perivertebral and The danger space, which is located between the retro-
posterior cervical spaces (posteriorly) [1,2]. pharyngeal and perivertebral spaces, is an area containing
The right common carotid artery originates from the adipose tissue. Its name reflects the fact that it provides
brachiocephalic trunk, behind the joint sternoclavicular a route for the diffusion of inflammatory or neoplastic
joint. The left common carotid artery originates directly lesions from the retropharyngeal space to the posterior
from the aortic arch. mediastinum [1].
Both ascend within the neck to the upper edge of the
thyroid cartilage of the larynx, where each divides to form
an internal and external carotid artery. Each of the The perivertebral space
common carotids presents a dilatation at the bifurcation,
the carotid sinus, which usually extends into the initial The perivertebral space extends from the skull base to the
segment of the internal carotid artery. The common clavicles and includes prevertebral and paraspinal portions.
carotids run behind the sternocleidomastoid muscles and The prevertebral space is located posterior to the pharynx
medial to the internal jugular veins. About halfway up the and cervical esophagus. Anterolaterally, it is related to the
neck, they intersect the superior bellies of the omohyoid carotid space and laterally to the anterior portion of the
muscles. The vagus nervesrun behind the two vessels [3]. posterior cervical space. It contains the prevertebral
muscles (long muscles of the head and neck), the scalene
muscles (anterior, middle, and posterior), the roots of the
brachial plexus, the phrenic nerve, the vertebral arteries
and veins, and the bodies and pedicles of the vertebrae
(Fig. 1,3,4). The paraspinal space is surrounded on the sides
by the posterior cervical space. It lies posterior to the
transverse processes and lateral to the posterior arches and
the spinous processes of the cervical vertebrae and
contains the paraspinal muscles and posterior components
of the cervical spine [1,2,6].

Posterior cervical space

Fig. 5 Longitudinal scan at the level of the trachea shows
the trachea (4), the isthmus of the thyroid (2), the sternohyoid The posterior cervical space is an adipose-tissue space
muscle (11), and the larynx (16). located deep and posterior to the sternocleidomastoid
Ultrasound anatomy of the neck 89

muscle. Anteriorly, it is related to the carotid space. It increasingly important for a correct diagnosis and treatment.
surrounds the sides of the perivertebral space and contains For this reason, a thorough knowledge of the anatomy of this
the accessory nerve (XI cranial nerve), accessory chain region is essential for the completeness of the examination.
lymph nodes (level 5), the pre-axillary component of the
brachial plexus, and the dorsal scapular nerve [1,6].
Conflict of interest statement
Anterior cervical area
The authors have no conflict of interest.
The anterior cervical space is located deep to the sterno-
cleidomastoid muscle and infrahyoid muscles. It surrounds
the front and sides of the visceral space and posteriorly it is
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