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Anatomy of facial spaces --Yash Chadha

Fascial Space infection

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Page 1: Fascial Space infection

Anatomy of facial spaces

--Yash Chadha

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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

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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.

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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.

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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.

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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.

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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.

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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..

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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.

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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

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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”)

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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

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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

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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.

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Deep cervical fascia

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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

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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

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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)

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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

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It forms the superficial border of the submandibular

space and splits to form the capsule of the

submandibular gland.

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Over the ascending ramus of the mandible it splits to

surround the muscles of mastication, thus forming the

masticator space.

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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.

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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.

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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.

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Investing fascia (of the neck)

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Deep Cervical Fascia-anterior

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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

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Fasciae of head & neck

Deep cervical fascia

Middle layer

Sternohyoid – omohyoid division

Sternothyroid – thyrohyoid division

Visceral division

• Buccopharyngeal

• Petracheal

• Retropharyngeal

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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.

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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.

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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

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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.

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Deep Cervical Fascia-middle

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Often broken down into

Retropharyngeal, Lateral

Pharyngeal and Buccopharyngeal

components as it posteriorly to

anteriorly envelops the pharynx.

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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

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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

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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.

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Posterior Layer of the Deep Cervical Fascia

Posterior layer

Alar division

Prevertebral division

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Posterior Layer of the Deep Cervical Fascia

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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)

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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

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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

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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.

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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.

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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.

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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”

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“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.

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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.

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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

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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

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Numbered Spaces of Grodinsky & Holyoke (1938)

Space 1

Space 2

Space 3 & 3A

Space 4 & 4A

Space 5 & 5A

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Numbered Spaces of Grodinsky & Holyoke (1938)

Space 1

Lies superficial to

Superficial fascia

Also k/a Subcutaneous

Space.

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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.

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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

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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.

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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

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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

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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.

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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.

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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

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Thank you

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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

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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

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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

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Contents

Angular artery and vein

Infraorbital nerve

Likely Causes

Upper canine

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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.

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Contents

Submandibular gland

Facial artery and vein

Lymph nodes

Likely Causes

Lower molars