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ppt describing the anatomy of facial spaces
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Anatomy of fascial spaces-applied an surgical
Dr.Vaibhav N.Post graduate Dept of OMFS,
Overview of surgical anatomy of the neck
Fascia of the neck
First described by Burns in 1811
Succinctly elaborated by Grodinsky and Holyoke (1938)
Present confusion regarding nomenclature
?different for anatomists, surgeons and radiologists?
Need for consensus
Superficial Fascia Extends from the head to
the thorax, shoulders and axilla.
Envelops the platysma muscle and the muscles of facial expression.
Completely encircles the neck.
Superficial cervical fascia
Superficial layer of deep cervical fascia-the investing layer
Enveloping layer, completely surrounds the neck. Extends from the zygoma to the pectoral and
axillary regions. Envelops the parotid and submandibular glands
and the trapezius and SCM muscles. The space of Burns
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 toManubrium(g) Clavicles(h) Acromion(i)
Middle layer of deep cervical fascia
Divided into a muscular division and visceral division.
The Muscular division surrounds the strap muscles It extends from the hyoid bone to the sternum, clavicle and scapula. The visceral division surrounds the thyroid, trachea and oesophagus. Posteriosuperiorly -extends from the skull base Anteriosuperiorly -extends from the hyoid bone. Continuous with the fibrous pericardium continues as the covering
of the esophagus and trachea.
Visceral Layer of Deep Cervical Fascia
Middle Layer of Deep Cervical Fascia - A derivative of investing layer
Deep layer of the deep cervical fascia
Divided into a prevertebral and alar layer. Prevertebral layer - from the base of the skull to the coccyx. From the transverse process around the deep muscles of the neck and
anterior vertebral bodies to re-insert on the spinous processes. Alar layer - from the base of the skull to T-2 and laterally from transverse
spinous process to transverse spinous process. Lies between the prevertebral fascia and the posterior visceral fascia to
which it fuses to at T-2.
Visceral and Pharyngeal Layers of Deep Cervical Fascia
Alar fascia anterior subdivision of prevertebral fascia
Carotid sheath
Derived from all three layers of the deep cervical fascia
"Lincon Highway" of the neck – Mosher Extends from the base of the skull to the chest. Blends in front with the pretracheal and investing
layers of deep fascia Continuous behind with the prevertebral layer of
deep fascia Internal jugular vein, common carotid artery, the
vagus nerve, and lymph nodes.
clinical: It can be involved in any neck infection because it is made of those three
layers: investing, pretracheal and prevertebral fascia. Infections tend to be localized within the cervical region because the
sheath is closely adherent to vessels · Infection usually arises from thrombosis of the internal jugular vein or
from infection of those deep cervical lymph nodes that lie within the sheath ·
Thrombosis of IJV from a deep infection of the neck is probably not due to direct infection sheath, but that infectious material follows tributaries of the vein to reach the sheath. ·
DANGER SPACE 4
An area of delicate loose connective tissue that lies between the alar and prevertebral fascia
Extends from the base of the skull to the mediastinum
Infection from posterior wall of the oropharynx and oral cavity decends to the thorax by traveling from the Retropharyngeal Space, and passing downward to the Retrovisceral space.
It can then pierce thru the weak alar fascia - into Danger Space #4
"Dangerous" because an infection can travel to the thoracic cage and mediastinum.
Abscess in the mediastinum can spread to pericardial area and affect the manubrium, sternum, etc..
SMAS
Superficial muscular aponeurotic system is fascia that covers or invests the neck face and scalp
Discrete fibromuscular layer that envelops and interlinks the muscles of facial expression
Fascial plane: Galea---> Temporoparietal Fascia --->SMAS----> Superfical layer of DCF
Delineates the dissection planes for the extensive undermining necessary in facial rejuvenation procedures
Of late doubts have been cast on its very existence. (Plast Reconstr Surg. 2003 Feb;111(2):664-72)
SMAS
Fascial spaces The supra hyoid spaces
The spaces may be divided into three categories: 1. Blind or Intrafascial spaces: formed by splitting
of fascial layers2. Intercommunicating spaces: surrounding the
pharynx and lying between fascial laminae and the pharyngeal walls
3. Blind "spaces": potential only, within the pharyngeal wall deep to the buccopharyngeal fascia.
Space of the body of the mandible
Potential cleavage plane between the fascia and the bone. Limited anteriorly by superfical investing fascia and the
attachment of the anterior belly of the digastric Limited posteriorly by investing fadscia and the
attachment of the medial pterygoid to the jaw Inferiorly closed by the continuity of the fascial layers Superiorly closed by the attachment of fascial layers to
the inferior border of the body of the mandible.
Formed by the attachment of the SCFA to both inner and outer aspects of the mandible
Attachment to the outer surface is at the lower border of the mandible
Attachment to the inner surface can be elevated from the mandible up to the origin of the mylohyoid muscle
Clinical: an infection here may remain localized or may spread to the masticator space.
Submandibular space
Anterior element of the peripharyngeal fascial spaces (Continuous with the lateral pharyngeal space.
Infection under the tongue and the floor of the mouth can fill the submandibular space, and pass posterior to the lateral pharyngeal space)
Limited above by oral mucous membrane and the tongue (lingual mucosa)
Inferior boundary is the superficial layer of cervical fascia (suprahyoid deep investing fascia) as it extends from the hyoid bone to the mandible
Posteriorly – continuous with the lateral pharyngeal space
Sublingual space Contains - sublingual gland, duct for the
submandibular gland, accessory submandibular gland, Lingual Nerve, hypoglossal nerve
Loose connective tissue, lingual and hypoglossal nerves, part of the submandibular gland and its duct.
Paired Clinical: Infection will pass down to the submandibular space or can pass directly through the mylohyoid muscle
Submaxillary space
Divided into subsidiary submental and submaxillary spaces by attachment of the superficial layer of fascia to the anterior belly of the digastric muscle.
Contains Submandibular Gland with its
fascial covering Facial Artery and Vein, Hypoglossal Nerve Vena hypoglossi commitantes
Submaxillary(submandibular) space
Clinical : Line of cleavage between fascia and muscles The roots of molars are all below the level of the
mylohyoid. Infection passes directly into the submandibular space and then to the lateral pharyngeal space.
Potential airway problems. Injecting into this area drives the infection deeper.
Fascial relationship to the submandibular gland The investing layer to form a capsule around it Associated lymph nodes are embedded in and fused with the
fascial capsule. The outer layer of the capsule is strong The inner layer is thinner and is perforated by the duct of the
gland
Clinical: Infections arising in the region of the gland generally break
inward Any lymph node involvement implies removal of entire gland.
Infections of the submandibular space
Submandibular Space Pain, drooling, dysphagia, neck stiffness Anterior neck swelling, floor of mouth edema Cause—70-85% have odontogenic origin
First molar and anterior Second and third molars
Sialadenitis, lymphadenitis, lacerations of the floor of mouth, mandible fractures
Presentation/Origin Ludwig’s angina
1. Cellulitis, not abscess 2. Limited to SM space 3. Foul serosanguinous fluid, no frank purulence 4. Fascia, muscle, connective tissue involvement,
sparing glands 5. Direct spread rather than lymphatic spread
Tender, firm anterior neck edema without fluctuance “Hot potato” voice, drooling Tachypnea, dyspnea, stridor
Lateral pharyngeal space
Bounded posteriorly by the carotid sheath which separates it from the retropharyngeal space
Deep to medial pterygoid Medial to the masticator space Lateral to where pharynx attaches to mandible Bounded medially by the pharyngeal fascia
covering the fascia of the pharynx itself Laterally by the pterygoid muscles and the sheath
of the parotid gland.
Extends upward to the base of the skull. Limited by the sheath of the submandibular gland it’s
attachments to the sheaths of the stylohyoid muscle and posterior belly of the digastric.
Traversed by the styloglossus and stylopharyngeus muscles Opens medially into the retropharyngeal space Anterosuperiorly extends to the pterygomandibular raphe Anteriorly is continuous with the submandibular space Clinical: subject to infection from several sources
Infections of lateral pharyngeal space
Through its connection with the spaces about the tongue (sublingual space), may receive and transmit to the retropharyngeal space infections originating here.
Masticator space and the parotid gland border the lateral pharyngeal space, and infections that perforate deeply necessarily invade the lateral pharyngeal space.
Tonsillar region is the medial and infections may involve this space. Infections within the petrous temporal bone may rupture directly
into the lateral pharyngeal space Mastoiditis may follow the mastoid groove and extend along the
styloid and digastric muscles to this space
Suprahyoid: Parapharyngeal Space
Superior—skull base Inferior—hyoid Anterior—
ptyergomandibular raphe Posterior—prevertebral
fascia Medial—
buccopharyngeal fascia Lateral—superficial layer
of deep fascia
Suprahyoid: Parapharyngeal Space
Prestyloid Medial—tonsillar fossa Lateral—medial
pterygoid Contains fat, connective
tissue, nodes Poststyloid
Carotid sheath Cranial nerves IX, X,
XII
Medial—capsule of palatine tonsil
Lateral—superior pharyngeal constrictor
Superior—anterior tonsil pillar
Inferior—posterior tonsil pillar
Suprahyoid: Peritonsillar Space
Masticator space
Formed by the splitting of the superficial layer of cervical fascia to enclose the ramus of the mandible, the masseter, the medial pterygoid, and the lower portion of the temporal muscle.
Filled by the buccal fat pad, pterygoid plexus of veins, and its extends posteriorly, upward, and medially
It is traversed by the mandibular nerve (v3) and the internal maxillary vessel
Relations
Posteriorly, the fascial walls come together behind the ramus.
Anteriorly, a part of masseteric fascia attaches to the mandible in front of the masseter and to the insertion of the temporalis along the anterior border of the ramus,
Superiorly, Inferior temporal ridges and lines. Superficially, it is limited by temporal fascia. Deep, anterior to the lateral pterygoid plate it extends into
the pterygopalatine fossa. (Superior Temporal Line)
Infections of the zygomatic or temporal bones may pass to the masticator space
Odontogenic infections cleave into this space Abscesses may point at the anterior aspect of the
masseter muscle, either into the cheek or the mouth, or they may point posteriorly below the parotid gland.
Masticator space clinical implications
Space of the parotid
Encloses the parotid gland and its associated lymph nodes and the facial nerve and great vessels traversing it.
Attached to its surrounding fascia
Parotid Space
Pain, trismus Medial bulge of posterior lateral pharyngeal
wall Cause—parotitis, sialolithiasis, Sjogren’s
syndrome Fluctuation may not be present-unyielding
parotidomasseteric fascia
Clinical: Though the deep surface of the parotid gland is
strong, infections (usually of the glands or the nodes) may pass deeply into the important lateral pharyngeal space deep to the parotid.
The deep fascia around the parotid gland is weaker medially than laterally .
Infection can evidence itself as a bulge that sticks out medially into the oral cavity.
Temporomasseteric recess
Temporalis is covered by both superficial layer of deep investing fascia and by the masseteric fascia.
Bounded laterally and medially by deep investing fascia Directly inferior it is open and communicates with the
masticator space Clinical: Infections can pass outward to the cheek, but
can also pass medial to the medial pterygoid muscle or to the parotid gland
Suprasternal space(of Burns)
Formed by the investing layer dividing to attach into anterior and posterior aspects of manubrium
Encloses the sternal heads of the SCM’s, the inferior ends of the anterior jugular veins, the jugular venous arch, fat and a few lymph nodes
Clinical: Trauma and bleeding- bulging above the manubrium and may decend down into the superior mediastinum.
Posterior to pharynx and esophagus
Anterior to alar layer of deep fascia
Extends from skull base to T1-T2
Retropharyngeal Space
Retropharyngeal Abscess 50% occur in patients 6-12 months
of age 96% occur before 6 years of age Children--fever, irritability,
lymphadenopathy, torticollis, poor oral intake, sore throat, drooling
Adults--pain, dysphagia, anorexia, snoring, nasal obstruction, nasal regurgitation
Dyspnea and respiratory distress Lateral posterior oropharyngeal
wall bulge
Presentation
Pediatrics Cause—suppurative
process in lymph nodes Nose, adenoids,
nasopharynx, sinuses Adults
Cause—trauma, instrumentation, extension from adjoining deep neck space
Danger Space(Grodinsky and Holyoke space 4)
Entire Length of Neck: Anterior border is
alar layer of deep fascia
Posterior border is prevertebral layer
Extends from skull base to diaphragm
Presentation
Danger Space Presentation and exam nearly identical to
retropharyngeal space infection Cause—extension from retropharyngeal,
prevertebral or parapharyngeal space
Prevertebral Space
Anterior border is prevertebral fascia
Posterior border is vertebral bodies and deep neck muscle
Extends along entire length of vertebral column
Prevertebral Space infection
Back, shoulder, neck pain made worse by deglutition Dysphagia or dyspnea Cause—Pott’s abscess,
trauma, osteomyelitis, extension
from retropharyngeal and danger
spaces
Visceral Vascular Space
Carotid Sheath “Lincoln’s Highway”
Can become secondarily involved with any other deep neck space infection by direct spread
Presentation
Visceral Vascular Space Induration and tenderness over SCM Torticollis toward opposite side Spiking fevers, sepsis Cause—intravenous drug abuse, extension from
other deep neck spaces
Pretracheal fascia
Surrounding the trachea and lying against the anterior wall of the esophagus
Bounded anteriorly by the investing layer Bounded posteriorly by visceral cervical layer Limited above by the attachments of the infra-hyoid muscles Below, continues into the anterior portion of the superior
mediastinum Bounded inferiorly by the sternum and scalene fascia Extends to approximately the arch of the aorta to about the
level of the T4 vertebrae
Clinical: Can be infected directly by anterior perforations or
rupture of the esophagus Indirectly by spread from the retrovisceral portion,
around the sides of the esophagus and thyroid gland
Both pretracheal and retrovisceral spaces descend into the superior mediastinum.
Presentation
Anterior Visceral Space Hoarseness, dyspnea, dysphagia, odynophagia Erythema, edema of hypopharynx, may extend
to include glottis and supraglottis Anterior neck edema, pain, erythema, crepitus Cause—foreign body, instrumentation,
extension of infection in thyroid
Spread of odontogenic infections
Parapharyngeal Space
Fever, chills, malaise Pain, dysphagia, trismus Medial bulge of lateral
pharyngeal wall Cause—infection of pharynx,
tonsil, adenoids, dentition, parotid, mastoid, suppurative lymphadenitis, extension from other deep neck spaces
Peritonsillar Space
Fever, malaise Dysphagia, odynophagia “Hot-potato” voice,
trismus, bulging of superior tonsil pole and soft palate, deviation of uvula
Cause—extension from tonsillitis
Necrotizing fasciitis Life-threatening, progressive, polymicrobial soft
tissue infection of the neck characterized by gas formation and extensive tissue necrosis
Skin and muscle spared in the initial stages Groin(fournier’s gangrene), abdomen and
extremities - most frequent sites involved Relatively rare in the head and neck
Types of cervical fasciitis
Affecting scalp and eyelids Caused by trauma followed by infection Anatomic barriers limit the spread of infection
outside the orbit Path of least resistance- across the nasal bridge
Opposite orbit is frequently involved Organism most commonly isolated - group A b-
hemolytic strep alone or in combination with S aureus.
No fatalities reported
Affecting head and neck: Dental infections are the most common etiology Trauma, peritonsillar and pharyngeal abscesses,
and osteoradionecrosis –other causes Rapidly progressive course Bacteriology consists of anaerobes, gram negative
rods, group A b-hemolytic strep, and staph species.
Presentation
Onset of symptoms is usually 2 to 4 days after the insult
Skin develops a dusky discoloration with poorly defined borders.
Localized necrosis of skin (secondary to thrombosis of nutrient vessels passing through fascia)
Clinically can be mistaken for cellulitis or erysipelas Soft tissue crepitance is common from gas formation
Management
Routine blood work Culture and sensitivity Broad spectrum antibiotics after cultures have
been obtained Debridement - most important aspect in the
treatment
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