Fascial spaces

Seminar
by
S.Srirangarajan
What is a compartment?
 Fascial Spaces
“The facial spaces or compartments are regions
of loose C.T. that fill the areas between facial
layers”.
The concept of fascial ‘spaces’ is based on
anatomists knowledge that all ‘spaces’, exist
only potentially, until fasciae are separated by
pus, blood, drains or a surgeon’s finger.
Basic plan of the neck
 How did the concept of facial
spaces arise?
“If I have seen further, it is by standing on the
shoulder of Gaints”.
Issac
Newton”
• In the 1930s the classic anatomical studies of
Grodinsky and Holyoke established the modern
understanding of the fascial layers and the
potential anatomical spaces through which
infection can spread in head and neck.
What is fascia and its functions?
• It is a sheet or layer of more / less
condensed connective tissue.
• Fascial layers are like tissue paper
surrounding each item of clothing within a
garment box, which allows them to pass
over each other without their becoming
unfolded.
 Functions of the fascia
• Acts as a musculovenous pump-
• Limits outward expansion of muscles as they contract.
• Contraction of muscles compress the intramuscular veins
(push the blood towards the heart).
• Prevent penetrating objects eg knife & low velocity
bullets from vital structures
• They also afford the slipperiness that allows the structures
in the neck to move & pass over one another esply during
swallowing & turning the neck.
• Determine the direction of spread of infection
 CLASSIFICATION

FASCIAE IN THE NECK

SUPERFICIAL DEEP

(SCF) (DCF)
 Superficial fascia
Superficial fascia is not a fascial sheet in the classic sense, but
rather a fatty loose connective tissue in which are embedded the
voluntary muscles of facial expression and the platysma muscle.
 Superficial fascia
Skin
+ Superficial
Complex musculo-
Superficial fascia morphological aponeurotic
+ unit system
Platysma muscle (SMAS)

Clinical considerations:
1. Surgeons consider SMAS most important component of
rhytidectomy / face-lift surgery / plastic surgery of the face.
2. Necrotizing fascitis – Infection of this fascia causes necrosis
of the tissues in the subcutaneous space leading to necrotizing
fascitis.
 Deep fascia

Superficial layer Middle layer of Deep layer of

of deep fascia deep fascia deep fascia
Superficial layer of deep cervical fascia
Superficial layer of deep cervical fascia
Middle layer of deep cervical fascia
Buccopharyngeal fascia
Deep layer of deep cervical fascia
Deep layer of deep cervical fascia
Carotid sheath
Schematic diagram showing the arrangement
of deep neck spaces
Schematic diagram showing the arrangement
of deep neck spaces
• The greatest clinical implication of cervical
fascia is that it divides the neck into potential
spaces that function as a unit but are
anatomically separate.
• Hyoid bone is considered the most important
structure limiting the spread of infection.
• For this reason infection are classified by
dividing the potential spaces into 3 general
divisions:
1. Space of entire neck.
2. Supra hyoid spaces.
3. Infra hyoid spaces.
 Classification of the spaces of Face & Neck
I Spaces of the Face
A. Maxillary spaces
1. Buccal space.
2. Canine space.
B. Mental space.
II Spaces of neck
A. Spaces involving the entire length of the neck.
1. Superficial space
2. Deep neck spaces (all involve only the posterior side of the neck)
a) Retropharyngeal space (Space 3).
b) Danger space (Space 4)
c) Prevertebral space (Space 5)
d) Visceral vascular space (within carotid sheath).
B. Suprahyoid spaces:
1) Mandibular space
• Submandibular space.
• Submental space.
• Sublingual space.
• Space of the body of the mandible.
2) Masticatory space.
3) Lateral pharyngeal space (Pharyngomaxillary,
peripharyngeal / parapharyngeal).
4) Peritonsillar space.
5) Parotid space.
C. Infrahyoid space (involves anterior side of the
neck only).
1. Pretracheal space.
 Concepts about space infections
• The spaces are not empty they contain various
organs, nerves, blood vessels, salivary glands,
lymph nodes and fat surrounded by loose fibrous
connective tissue.
• The spaces of head and neck are not perfectly
enclosed they are pathways around the muscles
through which infection can spread.
 Concepts about space infections
• Infections within each space has its own
diagnostic signs and tends to spread in an
orderly, anatomic fashion from one space to
another by continuous extension.
• If the surgeon understands this process, he
can anticipate the spread of infection into
dangerous spaces and abort the process by
timely incision and drainage.
What are primary spaces?
What are secondary spaces?
 Pathways of spread of dental infection

Spread of infection from erupted and

Pericoronitis of third molar area
infected third molar area
General pathways of spread of maxillary and mandibular
infection
 Predisposing factors
• Primary predisposing factors leading to deep
infection of the neck were:
1. Local dental disease like dental caries or diseases of
the gums.
2. Lowered body resistance due to result of conditions
such as tuberculosis, diabetes mellitus, syphiles,
scurvy.
Primary signs & symptoms of these infections:
- Cellulitis / phlegmons.
- Localized pain.
- Tenderness.
- Redness.
- Edema of the overlying tissue.
 Relationship of point of bone perforation to
spread of infection

Infection enters soft tissue through

thinnest bone

In respect to buccinator muscle

Relationship of point of bone perforation to
muscle attachment
 Stages of infections
• Stage I – Inoculation
• Stage II – Cellulitis
• Stage III – Abscess
• Stage IV – Resolution
Surgical anatomy of deep facial
spaces of head and neck
 Buccal space

Clinical evaluation: Examination of the patient with the buccal space infection
demonstrate swelling confined to the cheek with abscess forming beneath the
buccal mucosa and bulging into the mouth.
• Haemophilus influenzae cellulitis with the marked buccal swelling.
 Canine space / Infraorbital space

• Clinical evaluation: Patient exhibits swelling lateral to the nose

obliterating the nasolabial fold, grouping at the corner of the
mouth and swelling of the upper lip, edema occurs in the
upper and lower lid that may close the eye.
 Differential diagnosis of upper face
infections

Dacrocystitis with Odontogenic cellulitis.

minimal involvement The nasolabial fold is
of nasolabial fold. effaced.
 Suprahyoid spaces
1) Mandibular space
• Submandibular space.
• Submental space.
• Sublingual space.
• Space of the body of the mandible.
 Mandibular spaces
Submandibular space

Clinical Evaluation:
Infection mostly arises from 2nd or third molar.
Induration and erythema in the submandibular area obliterating the
mandibular line and extending to the level of hyoid bone.
No trismus.
Submandibular space

Relationship of Sublingual.S
with submandibular.S
 Submandibular space abscess
A.Contrast enhanced
axial CT section
demonstrating
decreased myositis
A and fasciitis of RT
submandibular
space
B. Contrast enhanced
axial CT
demonstrating
deep and
B superficial portion
of right
submandibular
space.
 Sublingual space

Clinical evaluation: Edema and induration of the floor of the mouth on the
affected side displacing tongue medially and superiorly.
Hot potato voice.
Elevation of tongue to palate causing airway compromise.
Prevents patient from extending tongue beyond the vermilion border of upper lip.
Sublingual space
 Submental space

Boundary
Clinical evaluation
Management
Complications
 Ludwig’s Angina

Ludwig’s angina is a firm, acute, toxic cellulitis of the submandibular

and sublingual spaces bilaterally and of the submental space.
Three ‘fs’ of Ludwig’s Angina
-feared
-rarely fluctuant
-often fatal
 Ludwig’s Angina
• The original description of the disease was given by Wilhelm
Friedrich von Ludwig.
• Ludwig’s original description he emphasized that the angina
1. Is characterized by rapidly spreading gangrenous cellulitis.
2. Originates in the region of submandibular gland but never
involves one single space and
3. Arises from extension by continuity and not by lymphatics
and
4. Produces gangrene with serosanguinous, putrid infiltration
but very little or no frank pus.
 Ludwig’s Angina
Clinical evaluation:
- It is characteristically aggressive and rapidly spreading.
- Patient will appear toxic with elevation of WBC count, fever,
chills.
- Airway compromise occurring quickly and with little fore
warning.
- Drooling, dysphagia, mouth pain and neck stiffness are not
uncommon.
- Physical examination.
- Anteriorly protruding tongue, induration and erythema of
the floor of the mouth and indentation of the tongue by the
teeth.
- Indentation of the tongue by the teeth.
- A woody induration in the suprahyoid region of neck.
- Trismus is usually absent.
 Management of Ludwig’s Angina
• Hospitalization.
• Airway control – tracheostomy.
• Early I.v. antibiotics.
• External surgical exploration with division of mylohyoid
muscle and drainage.
• Blind or nasotracheal intubation is unsafe.
• Drainage: ‘Classic’ horizontal incision midway between
chin and hyoid bone is no longer advocated.
• Bilateral through and through drainage of submandibular
space with simultaneous exploration of submental and
sublingual space is recommended.
Incision for surgical drainage of Ludwig’s Angina

X
 Masticator space

The masticatory spaces are called secondary spaces and are combination of
four smaller spaces.
Clinically if one space is involved with infection, this usually implies that all
spaces are involved.
These are known as secondary spaces because they are usually involved with
infection via spread from one of the primary spaces like buccal, sublingual or
submandibular.
 Clinical examination
• Difficulty in swallowing.
• Severe pain.
• Swelling extending over the ramus of the mandible
with obliteration of subungular depression.
• Marked trismus.
• Posterior portion of tongue is impossible to depress.
• No fluctuance
• Parotid secretions are clear.
• Patient is not acutely illed.
 MASTICATOR SPACE- APPLIED
ASPECTS.
• Lesions which could present in
this space-
Nerve sheath tumours
Mandibular & soft tissue

sarcomas
Dental tumours
Cysts & abscesses
Osteomyelitis
Drainage of parotid and Masseter space
infection
Infratemporal space
Lateral pharyngeal space
infection
Drainage of lateral pharyngeal space
Lateral pharyngeal space infections
• It lies immediately posterior and lateral to the
pharynx and extend forward into the sublingual
region so that together they form a ring about the
pharynx.
• Anatomically the lateral pharyngeal space may be
thought of as an inverted pyramid-the base of the
pyramid being the skull base and the apex the
hyoid bone.
• In 1929 Mosher called this potential avenue of
infection the “Lincoln highway” of the body.
 Lateral pharyngeal space infections
This space is further divided by the
styloid process and the surrounding
musculature into a prestyloid and post
styloid compartment.
The prestyloid compartment contains
fat, lymph nodes and internal maxillary
artery.
The post styloid compartment contains
the carotid artery, internal jugular vein,
cervical sympathetic chain and cranial
nerves IX, X, XI, XII
 Clinical evaluation
• Firm induration with surrounding erythema lateral and
anterior to sternocleidomastoid muscle between angle of
mandible and hyoid bone.
• Difficulty of flexing and turning of neck.
• Trismus secondary pterygoid muscle involvement.
• Dysphagia.
• Dyspnea.
• Extended into mediastenum along the carotid sheath
(surgical emergency and prompt intervention with
thoracic surgery indicated).
• Diagnostic evaluation
• Chest CT scan, Gram stain, Chest radiographs
 Management
• Hospitalization with I.v. antibiotics.
• Airway protection.
• Rapid surgical drainage.
• Surgical approach always through neck not
through oral cavity.
• Incision is made at the level of hyoid bone across
the sternocleidomastoid muscle.
• If abscess not present that means the infection
material had no time to form an abscess.
 Complications
• Suppurative jugular venous thrombosis.
• Patient will have shaking chills, spiking
fevers, prostration.
• Tenderness at the mandibular angle and
along sternocleidomastoid muscle.
• Carotid artery rupture.
• Internal carotid artery most commonly
involved than external.
 Peritonsillar space infection
• Peritonsillar space consists of
an area of loose CT between the
fibrous capsule of the palatine
tonsil medially and superior
constrictor laterally.
Clinical evaluation:
• 3-7 day H/o pharyngitis that has
been Rx with antibiotics
without resolution.
• Severe sore throat, dysphagia,
Odyonophagia and referred
otalgia.
• The speech is muffled and
classically described as hot
potato voice.
• Trismus is not present
• Management
 Parotid space infection
• The parotid space infection is the name applied to the closed space
occupied by the parotid gland fascial nerve, lymph nodes ECA and
the posterior fascial vein. Its walls are formed by split of superficial
layer of deep cervical fascia.
• Clinical evaluation: Symptoms of the infection in the parotid space
include marked swelling of the angle of the jaw without associated
trismus or pharyngeal swelling.
• The symptoms of parotitis include pain and induration over the
involved gland. Purulent secretions may sometimes be expressed
after massage from the parotid depth.
• The symptoms of patients with parotid gland abscess will manifest
in much the same way as those of patients with parotitis but very
characteristics pitting edema of the gland is the pathognamic for
parotid gland abscess.
• Management:
Differential diagnosis
 Relationship showing lateral pharyngeal,
peritonsillar and pterygomandibular spaces
Pterygomandibular space
Differential diagnosis
 Deep neck infections
• All involve only posterior side of neck.
a)Retropharyngeal space (space 3, posterior
visceral space).
b)Danger space (space 4).
c)Prevertebral space (space 5).
d)Visceral vascular space (within the carotid
sheath)
Principles for Rx of the deep neck spaces

• Benjamin J. Gans, in his Atlas of oral surgery,

articulated these principles:
1. Drain all significant deep space infections.
2. Do not wait for fluctuance. Fluctuance is a late sign.
3. Determine incision placement, incisions designed to
avoid important anatomical structures, provide
dependent drainage and leave cosmetically acceptable
scar.
4. Institute definitive treatment as soon as possible,
Offending tooth to be removed.
5. Check for systemic disease.
 Retropharyngeal space
Retropharyngeal space is the potential space sandwiched between alar
and prevertebral layers of deep layer of the deep investing fascia.

Extension Base of the skull

Mediastinum

Most dangerous of all types of deep neck

infections

Sagittal section of retropharyngeal space

Two compartments:
Suprahyoid Infrahyoid
1. Lymph nodes and fat. 1. Only fat
 Clinical Evaluation
• Children less than 4 yrs commonly affected.
• In adults it manifests as cold abscess.
• Sore throat, dysphagia, odynophagia, difficulty handling
secretions.
• Hot potato voice.

Early signs: Late signs

•Refusal to take food. •Neck tilts towards involved side.
•Cervical lymphadenopathy. •Hyperextended complete inability
•Slight neck rigidity. to flex the neck.

•Noisy breathing due to laryngeal •Respiratory embarssment may

edema. occur if abscess not ruptured or
drained.
Oblique section of retropharyngeal space
Mediastinits, occurring 9 days after drainage of
the retropharyngeal space

CT Scan

A-P view
 Diagnosis of the soft tissue radiograph
for retropharyngeal space infection
Step I:
• Look at the prevertebral or
retropharyngeal soft tissue shadow.
• In the area of 2nd and 3rd CV, RP soft
tissue shadow should be less than 7mm
wide.
• In the area of 6 cervical vertebra soft
tissue shadow is behind the trachea and
includes the thickness of esophagus
making it approx.
Children – 14mm wide
adults – 22mm wide
Step II.
The second feature that should be looked
for in this radiograph is the presence of
gas.

Anaerobic bacteria will produce gas that

can be seen as emphysema in the soft
tissues of the neck

Areas of Emphysema in the

submandibular and lateral
pharyngeal space region
Step III.
- Finally, the lateral soft tissue radiograph will show the curve of the cervical spine
- Loss of the lordotic curve is a strong indication of retropharyngeal space infection.
- Tipping of the head forward in sniffing position to maintain an open airway.
Management of Retropharyngeal
space infection
 Danger space

• Danger space or space for cannot be reliably differentiated

from the retropharyngeal space on imaging and is therefore
combined with retropharyngeal space for discussion.
 Prevertebral space
• Is found by the deep cervical fascia.
• Facia attaches to the transverse process of the cervical
vertebra dividing this space into anterior and posterior
compartments.
Anterior compartment contains:
-Vertebral bodies.
-Spinal cord.
-Vertebral arteries.
-Phrenic nerve.
-Prevertebral and scalene muscles

Posterior compartment contains:

-Posterior vertebral elements.
-Paraspinous muscles.
 Lesions in prevertebral space
• Arise in the vertebral body,
intervertebral disc spaces Or
Prevertebral / paraspinous
muscles. E.g. vertebral
osteomyelitis and metastatic rare
lesions chondroma and nerve
sheath tumors.
Imaging:
• Prevertebral lesions anteriorly
displace the retropharyngeal
space and anterior border of the
prevertebral muscles.
• Posteriorly displace the posterior Retropharyngeal tuberculous abscess
triangle fat.
CT demonstrates hypodense fluid
collection involving the
retropharyngeal space (Asterisks)
 Carotid space / Visceral vascular space
• The cylindrical space
extends from base of
the skull to the aortic
arch.
• It is invested with all
three layers of the
deep cervical fascia
Thrombosed internal jugular vein
Left IJV fails to fill with contrast.
The lumen is hypodense

Vascular complications:
1. Artery rupture – 20 to 40% mortality
2. Venous thrombosis – Life threatening problem
 Complications of space infection
Frontal view of the patient with right cavernous sinus
thrombosis

• Venous congestion of the fundus of the left eye.

• the same patient two weeks later.
Clinically
One eye experiences early involvement than the other.
Cranial nerve most likely to be involved is abducens.
 Diagnosis of cavernous sinus
thrombosis
• Eagleton’s six features.
– Known site of infection.
– Evidence of blood stream
infection.
– Early sign of venous obstruction
in retina, conjunctiva or eyelids.
– Paresis of III, IV, VI cranial
nerves resulting from
inflammatory edema.
– Abscess forms and neighboring
tissues and
– Evidence of meningeal
irritation.
• Venous drainage of the head including the dural
sinuses.
 Mediastinitis

• Extension of infection from deep neck spaces into the mediastinum is heralded by
– chest pain
– severe dyspnea
– Unremitting fever,
– Radiographic demonstration of mediastinal widening.
Surgical incisions used to approach deep neck
infections
 Diagnostic Imaging of Fascial & Neck
Spaces

Plain film. CT. MRI Ultrasound

 Plain Film
AP view
• Diagnostic imaging of a patient with a known or
suspected fascial space infection often starts with a plain
film study of pharyngeal or cervical airways.
• Views taken
– AP view
– Lateral view
• Plain film findings:
- In the AP view the normal cervical airway should appear
symmetrical over the middle third of the cervical spine.
- It should have distinct shoulders in the proximal segment Lateral view
of the trachea.
- Lateral view – In the adult the width of the prevertebral
soft tissue should not exceed 7mm at the C3 level and
20mm at C7 level.
 Ultrasound US of submandibular region
demonstrating a branchial cleft cyst

• Not been used extensively in the

evaluation of inflammatory lesions
involving the H & N.
• Major limitation is it cannot
penetrate osseous structures such as
maxilla/mandible.
• Useful in differentiating between
solid and cystic masses and in
demonstrating the relationships of
these masses to various structures.
• An echomorphological classification
of soft tissue head and neck swelling,
consisting of edema, infiltrate,
preabscess echo-poor and echo-free
abscess, has been reported. US of Rt parotid showing an
echogenic shadowing sialolith in hilus
of Rt parotid
 Principles of incision and drainage
• Incise in healthy skin and mucosa when possible.
• Incision placed at the site of maximum fluctuance
results in a puckered, unesthetic scar.
• Place the incision in an esthetically acceptable
area.
• When possible place the incision in a dependent
position to encourage drainage by gravity.
• Dissect bluntly with closed surgical clamp or
finger, through deeper tissues.
• Place a drain and stabilize it with sutures.
 Principles of incision and drainage
• Consider use of through and through drains in
bilateral submandibular space infections.
• Do not leave drains in place for an overly
extended period.
• Remove them when drainage becomes minimal.
• Clean wound margins daily under sterile
conditions to remove clots and debris.
• Another approach to drainage is the use of
computed tomographic (CT) guided catheter.
 Computed Tomography – Guided Percutaneous
Drainage of a Head and Neck Infection – JOMS 1992

Left Radiopaque
submandibular markers on the
space abscess skin

Percutaneous
Aspiration to
needle being
evacuate the
guided into the
abscess
abscess