fascial space infection
TRANSCRIPT
Anatomy of facial spaces
--Yash Chadha
INDEX History Introduction Definition Classification Fasciae of head & neck Clinical anatomy of the deep fascial space of head &
neck. Deep space associated with Odontogenic infection
Deep space associated with mandibular Odontogenicinfection
Deep space associated with maxillary Odontogenic infection
Summary Conclusion Reference
History
In 1939 ASHBEL WILIAMS in the NEW ENGLAND
JOURNAL OF MEDICINE reported a case series of 31
patients with Ludwig’s angina in which 54% of patients lost
their lives
In 1979 Hough et al. reported several cases of Ludwigs
angina and in their review mortality rate had dropped to
4%
In 1930 the anatomical studies of GORDINSKY and
HOLOYKE established the modern understanding Of
facial layers and the potential anatomical spaces through
which infections can spread in the head and neck region.
Introduction
Soft tissue infections of head and neck are commonly
encountered in routine practice of oral and maxillofacial
surgery.
In most of the clinical situations it is easy to determine whether
the patient has an infection. Locally, the classic signs and
symptoms of
pain,
swelling,
surface erythema,
and lymphadenopathy ,
and systemically , fever , malaise, toxic appearance ,and an
elevated white blood cell count is found.
Pus tends to accumulate in the specific regions,
referred to as tissue spaces.
Normally these structures are surrounded by deep
connective tissue.
Pus destroys the loose connective tissue and
separates the anatomical boundaries of the
compartment.
The management of oral and maxillofacial infection
requires a series of diagnostic and therapeutic
maneuvers.
The oral and maxillofacial surgeon who manages
these infections must have knowledge in the
anatomy applied to the progression of the infectious
process and its surgical intervention.
Potential Spaces
Shapiro defined fascial spaces as potential
spaces b/w the layer of fascia. These spaces are
normally filled with loose connective tissues and
various structures like veins, arteries, glands,
lymph nodes, etc.
Space is a misnomer. There are no voids in the
tissues in actual reality.
Odontogenic infections generally pass through three
stages
During the first 1 to 3 days the swelling is soft, mildly
tender, and doughy in consistency.
Between days 2 and 5 the swelling becomes hard,
red, and exquisitely tender. Its borders are diffuse
and spreading.
Between the fifth and seventh days the center of the
cellulitis begins to soften and the underlying abscess
undermines the skin or mucosa, making it
compressible and shiny.
The yellow color of the underlying pus may be seen
through the thin epithelial layers..
At this stage the term fluctuance is appropriately
applied. Fluctuance implies the palpation of a fluid
wave by one hand as the abscess is compressed by
the other hand.
The final stage of odontogenic infection is resolution,
which generally occurs after spontaneous or surgical
drainage of an abscess cavity.
Fascia
This term describes broad sheets of dense CT.
Form the boundaries of compartments.
Fascial spaces can communicate infection or fluid to
other regions of the body
Used as a guide to surgical dissection
FasciaFascia Superficial fascia
Is a layer of dense CT that courses deep to the SC tissue throughout the body
SC space is defined as tissues lying superficial to superficial fascia
Also known as tela subcutanea
or hypodermis
Deep fascia Formed by dense, organized connective tissue
“Invests” (i.e., surrounds) deep structures such as muscles
Creates compartments that contain/direct spread of infection
Limits outward expansion of muscles so that veins are compressed, moving blood toward heart (“musculovenous pump”)
Fasciae of head & neck Superficial fascia
Deep cervical fascia Anterior layer
Investing fascia
Parotideomasseteric
Temporal
Middle layer Sternohyoid – omohyoid division
Sternothyroid – thyrohyoid division
Visceral division
• Buccopharyngeal
• Petracheal
• Retropharyngeal
Posterior layer Alar division
Prevertebral division
Superficial fascia
The Superficial fascia is a layer of dense
connective tissue that courses deep to the
subcutaneous tissue through out the entire body.
SC space is defined as tissues lying superficial to
superficial fascia
Below the mouth , the muscle of facial expression lie
deep to the superficial fascia , whereas in the upper
face the muscle of facial expression are positioned
superficial to this layer
This very thin, delicate fascia is found just deep to
the skin.
It extends from the epicranium above to the axillae
and upper chest below and includes the superficial
musculo-aponeurotic system/SMAS.
Abscesses located either superficial to or within the
tissue space immediately deep to the superficial
cervical fascia are treated by simple incision and
drainage.
Deep cervical fascia
Fasciae of head & neck Superficial fascia
Deep cervical fascia Anterior layer
Investing fascia
Parotideomasseteric
Temporal
Middle layer Sternohyoid – omohyoid division
Sternothyroid – thyrohyoid division
Visceral division
• Buccopharyngeal
• Petracheal
• Retropharyngeal
Posterior layer Alar division
Prevertebral division
Fasciae of head & neck
Deep cervical fascia
Anterior layer
Investing fascia (of the neck)
Parotideomasseteric
Temporal
The anterior layer of the deep cervical fascia is
also called the superficial or investing layer.
The anterior layer encircles the neck, splits to
surround the sternocleidomastoid and trapezius
muscles, and attaches posteriorly to the spinous
processes of the cervical vertebrae.
Covers the posterior as well as the anterior
triangle of the neck
Superiorly it attaches to
Superior nuchal line of
occipital bone (a)
Spinous processes of
cervical vertebrae and
nuchal ligament(b)
Mastoid processes of
temporal bones(c)
Zygomatic arches(d)
Inferior border of
mandible(e)
Hyoid bone(f)
Inferiorly it attaches to
Manubrium(g)
Clavicles(h)
Acromion(i)
Just above the
sternum this layer
splits around the
anterior and posterior
surfaces of the
manubrium forming the
Suprasternal Space
It forms the superficial border of the submandibular
space and splits to form the capsule of the
submandibular gland.
Over the ascending ramus of the mandible it splits to
surround the muscles of mastication, thus forming the
masticator space.
Superficially the anterior layer is called the
parotideomasseteric fascia in this region because it
covers the superficial surface of the masseter
muscle anteriorly and splits to surround the parotid
gland posteriorly.
At the zygomatic arch the anterior
layer of the deep cervical fascia
fuses with the periosteum of the
arch and then rises superiorly to
cover the superficial surface of the
temporalis muscle.
It attaches to the cranium,
terminating at the superficial
temporal crest.
Above the zygomatic arch the anterior layer is called
the temporal fascia.
For a distance of approximately 2 cm superior to the
zygomatic arch, the temporal fascia divides into two
layers, between which is the temporal fat pad, an
extension of the buccal fat pad.
Investing fascia (of the neck)
Deep Cervical Fascia-anterior
Superficial Layer of the Deep Cervical Fascia
Completely surrounds the neck.
Arises from spinous processes.
Superior border – nuchal line, skull base, zygoma, mandible.
Inferior border – chest and axilla
Splits at mandible and covers the masseter laterally and the medial surface of the medial pterygoid.
Envelopes
Sternocleidomastoid
Trapezius
Submandibular
Parotid
Forms floor of submandibular space
Fasciae of head & neck
Deep cervical fascia
Middle layer
Sternohyoid – omohyoid division
Sternothyroid – thyrohyoid division
Visceral division
• Buccopharyngeal
• Petracheal
• Retropharyngeal
The middle layer of the
deep cervical fascia can
be divided into three
divisions. The first two are
the sternohyoid-omohyoid
and the sternothyroid-
thyrohyoid divisions.
These two divisions
surround the
corresponding strap
muscles of the neck
between the hyoid bone
and the clavicle.
The primary surgical significance of these layers is
that they must be divided in the midline in a surgical
approach to the trachea or thyroid gland
They usually are not directly involved in head and
neck infections because they do not lie on the
major routes that an orofacial infection may follow
to the mediastinum or chest wall.
The third division of the middle layer of the deep
cervical fascia is clinically significant.
Visceral Layer of Deep Cervical Fascia Lies deep to the infrahyoid
muscles, following them to their
origin behind the sternum, and
splits to enclose the thyroid,
trachea, pharynx, and
esophagus
Attached superiorly to the
cricoid cartilage(e), thyroid
cartilage(d), and hyoid bone(f)
Attached posteriorly to the
(Pre)Vertebral Fascia
Blends laterally with the carotid sheath and inferiorly with
the pericardium
Blends posteriorly and superiorly with pharyngeal fascia
of the pharynx
Continuous with Investing Fascia at lateral borders of
infrahyoid muscles
Is refered to pretracheal anteriorly(a) and retrovisceral(c)
posteriorly.
Deep Cervical Fascia-middle
Often broken down into
Retropharyngeal, Lateral
Pharyngeal and Buccopharyngeal
components as it posteriorly to
anteriorly envelops the pharynx.
Above the hyoid bone the visceral fascia wraps
around the lateral and posterior sides of the pharynx,
lying on the superficial (toward the skin) side of the
pharyngeal constrictor muscles. In this region it is also
called buccopharyngeal fascia
The important deep neck spaces (i.e., the
retropharyngeal, lateral pharyngeal, and pretracheal
spaces) all lie on the superficial side of the visceral
division of the middle layer of the deep cervical fascia
Middle Layer of the Deep Cervical Fascia
Envelopes
Thyroid
Trachea
Esophagus
Pharynx
Larynx
Muscular Division
Superior border – hyoid and thyroid cartilage
Inferior border – sternum, clavicle and scapula
Envelopes infrahyoid strap muscles
Visceral Division
Superior border
Anterior – hyoid and thyroid cartilage
Posterior – skull base
Inferior border –continuous with fibrous pericardium in the upper mediastinum.
Buccopharyngeal fascia
Name for portion that covers the pharyngeal constrictors and buccinator.
Posterior Layer of the Deep Cervical Fascia
Posterior layer
Alar division
Prevertebral division
Posterior Layer of the Deep Cervical Fascia
Vertebral Layer of Deep Cervical Fascia
Forms a tubular sheath for the
vertebral column and the
muscles associated with it
extending from the base of the
skull to T3 vertebra
Extends laterally as the axillary
sheath
Begins from cervical spinous
processes(a) and the
ligamentum nuchae(b). (Similar
to the Investing Layer of Deep
Cervical Fascia)
It is immediately deep to the
trapezius muscle and its
surrounding superficial layer of
fascia.
Covers the floor of the posterior
triangle of the neck.
Is refered to as prevertebral
anteriorly.
The prevertebral layer of fascia
attaches to the tranverse
processes(c) and divides into
twolayers/laminae as it passes
behind the esophagus
Alar fascia
Alar fascia is the anterior
subdivision of prevertebral fascia
that bridges between the
transverse processes(a).
It blends with the (retro)Visceral
fascia (posterior fascia of the
esophagus) at the level of T2
vertebral body. This seals
inferiorly the (retro)Pharyngeal
space.
It runs from the base of the skull
to the superior mediastinum
The posterior layer of the deep cervical fascia has
two divisions, the alar and the prevertebral.
The alar fascia passes through the transverse
processes of the vertebrae on either side, posterior
to the retropharyngeal fascia.
Infections of the retropharyngeal space may
rupture the alar fascia, thus entering the danger
space, which is continuous with the posterior
mediastinum.
The prevertebral fascia surrounds the vertebrae
and lies just anterior to the periosteum of the
vertebrae.
Infections of the vertebrae, such as tuberculous
osteomyelitis, may enter the prevertebral space.
The prevertebral fascia usually is not invaded by
infections arising in the maxillofacial regions.
Deep Layer of Deep Cervical Fascia
Arises from spinous processes and ligamentum nuchae.
Splits into two layers at the transverse processes:
Alar layer
Superior border – skull base
Inferior border – upper mediastinum at T1-T2
Prevertebral layer
Superior border – skull base
Inferior border – coccyx
Envelopes vertebral bodies and deep muscles of the neck.
Extends laterally as the axillary sheath.
Carotid Sheath Formed by all three
layers of deep fascia
Anatomically separate from all layers.
Contains carotid artery, internal jugular vein, and vagus nerve
“Lincoln’s Highway”
“Lincoln’s Highway”
A viscerovascular space coined by mosher - is the carotid sheath from the jugular
foramen & carotid canal at the base of the skull to the middle mediastinum.
Carotid Sheath (contd.)
- Coller and Yglesias (1935) pointed out that infection from visceral space readily spreads to the potential cavity within carotid sheath, later also being a pathway for the spread of infections from upper to the lower part of the neck and into the mediastinum.
According to Pearse (1938), 21% of mediastinal suppurations originating in neck spread along this pathway .
Infections in this space are usually associated with internal jugular vein thrombophlebitis or caroid artery erosion.
CLASSIFICATION OF FASCIAL SPACES
A. Based on mode of involvement
I. Direct involvement
Primary spaces:
a. Maxillary Spaces:- canine, buccal, and infratemporal spaces
b. Mandibular Spaces:- submental, buccal, submandibular, and sublingual
II. Indirect involvement:
Secondary spaces: -
massetric, pterygomandibular, superficial and deep temporal, lateral pharyngeal, retropharyngeal, and prevertibral, parotid spaces
B. Based on clinical significance
I. Face:- buccal, canine, masticatory, parotid
II. Suprahyoid:- sublingual, submandibular,
submental, Lateral pharyngeal
III. Infrahyoid:- Pretracheal
IV. Spaces of total neck:- retropharyngeal, danger,
carotid and prevertebral
CLASSIFICATION OF FASCIAL SPACES
Numbered Spaces of Grodinsky & Holyoke (1938)
Space 1
Space 2
Space 3 & 3A
Space 4 & 4A
Space 5 & 5A
Numbered Spaces of Grodinsky & Holyoke (1938)
Space 1
Lies superficial to
Superficial fascia
Also k/a Subcutaneous
Space.
Numbered Spaces of Grodinsky & Holyoke (1938)
Space 2
Group of spaces
surrounding cervical strap
muscles.
Superficial to the
sternothyroid-thyrohyoid
div.of Middle layer of DCF.
Between sternothyroid-
thyrohyoid div. and
sternohyoid-omohyoid div.
Numbered Spaces of Grodinsky & Holyoke (1938)
Space 3
Superficial to visceral div. of
Middle layer of DCF.
It contain 3 spaces-
Pretracheal
Retropharyngeal
Lateral pharyngeal
Space 3A
Carotid sheath
Numbered Spaces of Grodinsky & Holyoke (1938)
Space 4 (DANGER space)
Lies between Alar and Prevertebral div. of Posterior Layer of DCF.
Space 4A
Lies in Posterior Triangle of neck, posterior to Carotid sheath.
Numbered Spaces of Grodinsky & Holyoke (1938)
Space 4
( Danger Space)
Anterior border is alar layer of deep
fascia
Posterior border is prevertebral
layer
Extends from skull base to
diaphragm
Numbered Spaces of Grodinsky & Holyoke (1938)
Danger Space
The danger space is immediately posterior to the
retropharyngeal space and immediately anterior to the
prevertebral space
present between the alar and prevertebral divisions of the
deep layer of the deep cervical fascia.
It extends from the skull base to the posterior mediastinum
and diaphragm.
Laterally, it is limited by the fusion of the alar and prevertebral
division with the transverse processes of the vertebrae
Numbered Spaces of Grodinsky & Holyoke (1938)
Danger space
Spread within the danger space tends to occur rapidly
because of the loose areolar tissue that occupies this region.
This spread can lead to mediastinitis, empyema, and sepsis.
Numbered Spaces of Grodinsky & Holyoke (1938)
Space 5
Prevertebral space
Space 5A
Enclosed by prevertebral
fascia, posterior to the
transverse process of
vertebrae.
It surrounds Scalene and
spinal postural muscles.
Numbered Spaces of Grodinsky & Holyoke (1938)
Prevertebral Space
Anterior border is
prevertebral fascia
Posterior border is
vertebral bodies and
deep neck muscles
Extends along entire
length of vertebral
column
Thank you
BUCCAL SPACE
Boundaries
v Anteriorly – Corner of mouth
v Posteriorly – Masseter
muscle, pterygomandibular space.
v Superiorly – Maxilla,
infraorbital space
v Inferiorly – Mandible
v Superficial or Medial –
Subcutaneous tissue and skin
v Deep or lateral – Buccinator
muscle
Contents
vv Parotid duct
vv Anterior facial artery and vein
vv Transverse facial artery and vein
Likely Causes
vv Upper premolars
vv Upper molars
vv Lower premolars
INFRAORBITAL SPACE
Boundaries
Anteriorly – Nasal cartilages
Posteriorly – Buccal space
Superiorly – Quadratus labbi superioris muscle
Inferiorly – Oral musoca
Superficial or Medial – Quadratus labii superioris
muscle
Deep or lateral – Levator anguli oris muscle
Contents
vv Angular artery and vein
vv Infraorbital nerve
Likely Causes
Contents
Angular artery and vein
Infraorbital nerve
Likely Causes
Upper canine
SUBMANDIBULAR SPACE
Boundaries
Anteriorly – Anterior belly of digastric muscle
Posteriorly – posterior belly of digastric muscle,
stylohyoid muscle and stylopharyngeus muscle
Superiorly – Inferior and medial surface of mandible
Inferiorly – Digastric tendon
Superficial or Medial – Platysma muscle, investing
fascia
Deep or lateral – Mylohyoid, hypoglossus, superior
constricting muscle.
Contents
Submandibular gland
Facial artery and vein
Lymph nodes
Likely Causes
Lower molars