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 cervical fascia

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 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 to Manubrium(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.

Middle Layer of Deep Cervical Fascia - A derivative of investing layer

Visceral Layer of Deep Cervical Fascia

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 layers 2. 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 Cause70-85% have odontogenic origin First molar and anterior Second and third molars Sialadenitis, lymphadenitis, lacerations of the floor of mouth, mandible fractures

Presentation/Origin

Ludwigs 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 its 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

Superiorskull base Inferiorhyoid Anterior ptyergomandibular raphe Posteriorprevertebral fascia Medial buccopharyngeal fascia Lateralsuperficial layer of deep fascia

Suprahyoid: Parapharyngeal Space

Prestyloid Medialtonsillar fossa Lateralmedial pterygoid Contains fat, connective tissue, nodes Poststyloid Carotid sheath Cranial nerves IX, X, XII

Suprahyoid: Peritonsillar Space

Medialcapsule of palatine tonsil Lateralsuperior pharyngeal constrictor Superioranterior tonsil pillar Inferiorposterior tonsil pillar

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)

Masticator space clinical implications

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.

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 Causeparotitis, sialolithiasis, Sjogrens 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 SCMs, the inferior ends of the anterior jugular veins, the jugular venous arch, fat and a few lymph nodes Clinical: Trauma and bleedingbulging above the manubrium and may decend down into the superior mediastinum.

Retropharyngeal Space

Posterior to pharynx and esophagus Anterior to alar layer of deep fascia Extends from skull base to T1-T2

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 Causesuppurative process in lymph nodes Nose, adenoids, nasopharynx, sinuses Adults Causetrauma, 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 Causeextension 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 CausePotts abscess, trauma, osteomyelitis, extension from retropharyngeal and danger spaces

Visceral Vascular Space

Carotid Sheath Lincolns 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 Causeintravenous 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 Causeforeign 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 Causeinfection 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 Causeextension 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(fourniers 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 bhemolytic 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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