Fascial Spaces of the Head and Neck
Fascial Spaces of the Head and Neck
Fascial spaces also termed fascial tissue spaces or tissue spaces are potential spaces that exist between the fasciae and underlying organs and other tissues. In health, these spaces do not exist; they are only created by pathology, e.g. the spread of pus or cellulitis in an infection. The fascial spaces can also be opened during the dissection of a cadaver. The fascial spaces are different from the fasciae themselves, which are bands of connective tissue that surround structures, e.g. muscles. The opening of fascial spaces may be facilitated by pathogenic bacterial release of enzymes which cause tissue lysis (e.g. hyaluronidase and collagenase). The spaces filled with loose areolar connective tissue may also be termed clefts. Other contents such as salivary glands, blood vessels, nerves and lymph nodes are dependent upon the location of the space. Those containing neurovascular tissue (nerves and blood vessels) may also be termed compartments.
Generally, the spread of infection is determined by barriers such as muscle, bone and fasciae. Pus moves by the path of least resistance, e.g. the fluid will more readily dissect apart loosely connected tissue planes, such the fascial spaces, than erode through bone or muscles. In the head and neck, potential spaces are primarily defined by the complex attachment of muscles, especially mylohyoid, buccinator, masseter, medial pterygoid, superior constrictor and orbicularis oris.
Infections involving fascial spaces of the head and neck may give varying signs and symptoms depending upon the spaces involved. Trismus (difficulty opening the mouth) is a sign that the muscles of mastication (the muscles that move the jaw) are involved. Dysphagia (difficulty swallowing) and dyspnoea (difficulty breathing) may be a sign that the airway is being compressed by the swelling.
Superficial Fascia
The superficial fascia of the head and neck
lies just under the skin, as it does in the entire body, invests the
superficially situated mimetic muscles (platysma, orbicularis oculi, and
zygomaticus major and minor), and is located in distinct anatomic areas. It is
composed of two layers, an outer fatty ( areolar cleavage plane) layer
and a thin inner membrane with a large number of elastic fibers ( superficial musculoaponeurotic system [SMAS] ).
The superficial fascia attaches the skin to the deep fascia, which covers and
invests the structures lying deep to the skin while maintaining the movability
of the skin, with the two layers allowing for separation during blunt
dissection. The areolar cleavage plane overlies the lower masseter, is
rhomboidal in shape, and is important in cosmetic surgery (such as lower
[cervicofacial] facelifts), because dissection is bloodless and provides safety
for all facial nerve branches, as they are located outside this plane.
The SMAS is a fibromuscular fanlike fascial extension of the platysma
muscle that arises superiorly from the fascia over the zygomatic arch. The
facial nerve lies deep to the SMAS and innervates the mimetic muscles of the
forehead and midface from the ventral aspect of the muscles. The SMAS is
continuous with the platysma muscle inferiorly and the superficial temporal
fascia superiorly, superficial to the parotideomasseteric fascia, and it
connects to the fascial musculature in the nasolabial, perioral, and
periorbital regions. Location and anatomic identification of this layer are
important in surgical manipulation for both reconstructive and cosmetic
procedures
Deep Fascia
The deep fascia begins at the anterior border
of the masseter muscle, attaches to the superior temporal and nuchal lines, and
posterior and inferior to these margins it continues cranially as the
pericranium. The deep facial fascia represents a continuation of the deep
cervical fascia cephalad into the face and, more posterior, invests the muscles
of mastication, the surgical importance of which lies in the fact that the
facial nerve branches within the cheek lie deep to this fascial layer.
Fascial Spaces of the
Face
The fascial spaces of the
face are subdivided into five spaces: the canine space, the buccal space, the
masticatory space (further divided into the masseteric, pterygomandibular, and
temporal spaces), the parotid space, and the infratemporal space
Canine
Space
 |
| Diagram showing muscles of the infra-orbital region. Levator anguli oris is colored red. The canine space is situated between the levator anguli oris muscle and the levator labii superioris muscle. |
The canine space is located
between the levator anguli oris and the levator labii superioris muscles.
Infection spreads to this space through the root apices of the maxillary teeth,
usually the canine. Direct surgical access is achieved through incision through
the maxillary vestibular mucosa above the mucogingival junction.
Buccal Space
 |
| The buccal space is located superficial to buccinator muscle. |
The buccal space is bounded
anterior to the masticatory space and lateral to the buccinator muscle, with no
true superior or inferior boundary, and consists of adipose tissue (the buccal
fat pad that fills the greater part of the space), Stensen’s duct, the facial
artery and vein, lymphatic vessels, minor salivary glands, and branches of
cranial nerves VII and IX. The buccal space frequently communicates posteriorly
with the masticatory space because the parotideomasseteric fascia is sometimes
incomplete along its medial course where it joins the buccopharyngeal fascia.
The parotid duct separates the buccal space into two equal-sized anterior and
posterior compartments, with the facial vein located along the lateral margin
of the buccinator muscle just anterior to transversely coursing Stensen’s duct.
 |
| An abscess originating from a tooth which has spread to involve the buccal space. Above, deformation of the cheek on the second day. Below, deformation on the third day. |
The buccal space may serve as a
conduit as there is a lack of fascial compartmentalization in the superior,
inferior, and posterior directions, which permits the spread of pathology both
to and from the buccal space. Surgical access to the buccal space infections
may be easily accomplished through the intraoral approach. However, more
complicated infections or masses, directed by location within the buccal space
and suspicion of malignancy, may require a preauricular or submandibular
approach.
Parotid
Space
The parotid space is formed by
splitting fascia of the investing layer of the deep cervical fascia and
contains the parotid gland with associated extraglandular and intraglandular
lymph gland, the parotid portion of cranial nerve VII, the external carotid,
internal maxillary, and superficial temporal arteries, and the retromandibular
vein. Infection in this space may spread to the lateral pharyngeal spaces, as
they communicate posteriorly and the fascia of the deep parotid space is thin
and easily breached. However, primary infection in this is rare and is
generally blood-borne or retrograde through the parotid duct.
Masticatory Spaces
 |
| The four compartents of the right masticator space. A Temporalis muscle, B Masseter muscle, C Lateral pterygoid muscle, D Medial ptaerygoid muscle, E Superficial temporal space, F Deep temporal space, G Submasseteric space, H Pterygomandibular space, I Approximate location of infratemporal space. |
Masseteric
Space (and Submasseteric Space)
The fascia that forms the borders
of the masseteric space is a well-defined fibrous tissue that surrounds the
muscles of mastication and contains the internal maxillary artery and the
inferior alveolar nerve. It is bounded anteriorly by the mandible, posteriorly
by the parotid gland, medially by the lateral pharyngeal space, and superiorly
by the temporal space.
Most masseteric space infections
are of odontogenic origin (e.g., molar teeth), with trismus being the most
pronounced clinical feature, and often preclude intraoral examination. Computed
tomography (CT) or magnetic resonance imaging (MRI) may be an invaluable
resource in the assessment of masseteric space infections, as it can often
influence the surgical approach and distinguish abscess from cellulitis. The
submasseteric space is bounded laterally by the masseter muscle, medially by
the mandible ramus, and posteriorly by the parotid gland. Infections are mostly
of odontogenic origin (usually a mandibular third molar) and are often
misdiagnosed as a parotid abscesses or parotitis. Intraoral surgical access to
this space for simple, isolated abscesses is generally adequate to allow for
drainage, but with extension into adjacent spaces, an extraoral submandibular
approach may be required.
Pterygomandibular
Space
The pterygomandibular space is
bounded by the mandible laterally and medially and inferiorly by the medial
pterygoid muscle. The posterior border is formed by the parotid gland as it
curves medially around the posterior mandibular ramus and anteriorly by the
pterygomandibular raphe, the fibrous junction of the buccinator and superior
constrictor muscles. The inferior alveolar and lingual nerves, other structures
in this space, are of particular importance in the administration of local
anesthesia, including the inferior alveolar vessels, the sphenomandibular
ligament, and the interpterygoid fascia. Surgical access to this space may be
achieved intraorally in the case of simple infections, but may require
extraoral access when multiple adjacent spaces are involved.
Temporal
Space
The temporal fascia surrounds the
temporalis muscle in a strong fibrous sheet that is divided into clearly
distinguishable superficial and deep layers that originate from the same region
with the muscle fibers of the two layers intermingled in the superior part of
the muscle. It attaches to the superior temporal line and passes inferiorly to
the zygomatic arch. Superiorly, the temporal fascia and fibers of origin of the
temporalis muscle blend into a firm aponeurosis, a flat fan of extremely dense
and firm fibrous connective tissue. Communicating facial-zygomaticotemporal
nerve branches piercing through the fascial and muscular planes of the
intermingled superficial and deep layers of the temporal fascia in the superior
part of the muscle are important from a surgical perspective to prevent
temporal hollowing that may occur due to surgical access procedures.
submandibular spaces
The submandibular space is a fascial space of the head and
neck (sometimes also termed fascial spaces or tissue spaces). It is a potential
space, and is paired on either side, located on the superficial surface of the
mylohyoid muscle between the anterior and posterior bellies of the digastric
muscle.The space corresponds to the anatomic region termed the
submandibular triangle, part of the anterior triangle of the neck.
Anatomic boundaries
The anatomic boundaries of each submandibular space are:
the mylohyoid muscle superiorly,
the skin, superficial fascia, platysma muscle and
superficial layer of the deep cervical fascia inferiorly and laterally,
the medial surface of the mandible anteriorly and laterally,
the hyoid bone posteriorly,
the anterior belly of the digastric muscle medially.
Communications
The communications of the submandibular space are:
medially and anteriorly to the submental space (located
medial to the paired submandibular spaces, separated from them by the anterior
bellies of the digastric muscles).
posteriorly and superiorly to the sublingual space (located
above the mylohyoid muscle)
inferiorly to the lateral pharyngeal space
Contains
In health, the contents of the space are:
the submandibular gland, which largely fills the space,
branches of the facial artery
lymph nodes.
Clinical relevance
Infections may spread into the submandibular space, e.g.
odontogenic infections, often related to the mandibular molar teeth. This is
due to the fact that the attachment of mylohyoid (the mylohoid line) becomes
more superior towards the posterior of the mandible, meaning that the roots of
the posterior teeth are more likely to be below mylohyoid than above.
Signs and symptoms of a submandibular space infection might
include trismus (difficulty opening the mouth), inability to palpate (feel) the
inferior border of the mandible and swelling of the face over the submandibular
region.
If the space contains pus, the usual treatment is by
incision and drainage. The site of the incision is extra-oral, and usually made
2–3 cm below, and parallel to, the inferior border of the mandible.
Ludwig's angina is a serious infection involving the
submandibular, sublingual and submental spaces bilaterally. Ludwig's angina
may extend into the pharyngeal and cervical spaces, and the swelling can
compress the airway and cause dyspnoea (difficulty breathing).
sublingual spaces
The sublingual space is a fascial space of the head and neck
(sometimes also termed fascial spaces or tissue spaces). It is a potential
space located below the mouth and above the mylohyoid muscle, and is part of
the suprahyoid group of fascial spaces.
Anatomic boundaries
The sublingual space is V-shaped, with the apex pointing to
the anterior. Its boundaries are:
the mucosa of the floor of mouth and the tongue superiorly
the mylohyoid muscle inferiorly
the medial surface of the mandible anterolaterally
the muscles along the base of the tongue (geniohyoid and
genioglossus muscles) posteriorly
medially, the intrinsic muscles of the tongue and
genioglossus separate the two halves of the sublingual space.
Communications
The sublingual space communicates posteriorly around the
posterior free border of the mylohyoid muscle with the submandibular space. Infections of the sublingual space may also erode through the mylohyoid, or
spread via the lymphatics to the submandibular and submental spaces.
Contents
The sublingual space contains:
a number of blood vessels and nerves, e.g. the lingual
artery and nerve, the hypoglossal nerve and the glossopharyngeal nerve.
the sublingual salivary gland. Saliva from the sublingual
gland drains through several small excretory ducts in the floor of the mouth.
Sometimes a more distinctive duct can be recognized, known as Bartholin's duct.
the deep part of the submandibular gland and the
submandibular duct (Wharton's duct)
some extrinsic tongue muscle fibers.
Clinical relevance
This space may be created by pathology, such as the spread
of pus in an infection, e.g. odontogenic infections. A periapical abscess may
spread into the sublingual space if the apex of the tooth is above the level of
attachment of mylohyoid, and the infection erodes through the lingual cortical
plate of the mandible.
Signs and symptoms of a sublingual space infection might
include a firm, painful swelling in the anterior part of the floor of the
mouth. A sublingual abscess may elevate the tongue and cause drooling or
dysphagia (difficulty swallowing). There is usually little swelling visible on
the face outside the mouth.
If the space contains pus, the usual treatment is by
incision and drainage. The site of the incision is intra-oral, made lateral to
sublingual plica. Incision of the plica itself can result in a ranula, or an
incision placed medial to the plica can damage Wharton's duct, the sublingual
artery and veins and the lingual nerve.
Pathology arising from the sublingual gland is rare,
however, sublingual gland neoplasms are predominantly malignant and thus
important to recognize.
Ludwig's angina is a serious infection involving the
submandibular, sublingual and submental spaces bilaterally. Ludwig's angina
may extend into the pharyngeal and cervical spaces, and the swelling can
compress the airway and cause dyspnoea (difficulty breathing). Collectively,
the submandibular, sublingual and submental spaces are sometimes termed the
perimandibular spaces, or the submaxillary space.
submental spaces
The submental space is a fascial space of the head and neck
(sometimes also termed fascial spaces or tissue spaces). It is a potential
space located between the mylohyoid muscle superiorly, the platysma muscle
inferiorly, under the chin in the midline. The space coincides with the
anatomic region termed the submental triangle, part of the anterior triangle of
the neck.
Anatomic boundaries
The boundaries of the submental space are:
the mylohyoid muscle superiorly
the investing layer of deep cervical fascia (and this in
turn is covered by the platysma muscle) inferiorly
the inferior border of the mandible anteriorly
the hyoid bone posteriorly
the anterior bellies of the digastric muscles laterally.
Communications
The communications of the submental space are:
the submandibular spaces posterolaterally.
the sublingual space superiorly (via erosion through the
mylohyoid).
Contents
Its contents are submental lymph nodes, areolar connective
tissue and the anterior jugular veins.
Clinical relevance
This space may be created by pathology, such as the spread
of pus in an infection. Odontogenic infection of the mandibular anterior teeth
may erode through the lingual cortical plate of the mandible. If the level at
which the infection breaks out of the mandible is below the attachment of the
mylohyoid, then it will spread into the submental space. However, it is more
usual for odontogenic infections to spread into the submental space via first
involving the submandibular space. Cutaneous infections or
symphyseal/parasymphyseal mandibular fractures may also give rise to a
submental space infection. Signs and symptoms of a severe submental abscess
include a firm swelling below the chin and dysphagia (difficulty swallowing).
Treatment is by surgical incision and drainage, with the incision running
transversely in a skin crease behind the chin.
Ludwig's angina is a progressive cellulitis involving the
submandibular, sublingual and submental spaces bilaterally. Ludwig's angina may
extend into the pharyngeal and cervical spaces, and the swelling can compress
the airway and cause dyspnoea (difficulty breathing)
Hilton’s Method of Incision and Drainage
Hilton’s Method of Incision and Drainage
Hilton’s Method of Incision and Drainage
What is Hilton’s Method of Incision and Drainage?The method of opening an abscess ensures that no blood vessel or nerve in the viscinity is damaged and is called Hilton’s method.
What are the Steps of Hilton’s Method of Incision and Drainage?
There are total 10 Steps of Hilton’s Method of Incision and Drainage. These are as follows.
1. Topical anaesthesia: Topical anaesthesia is achieved with the help of ethyl chloride spray.
2. Stab incision: made over a point of maximum fluctuation in the most dependent area along the skin creases, through skin and subcutaneous tissue.
3. If pus is not encountered, further deepening of surgical site is achieved with sinus forceps (to avoid damage to vital structures).
4. Closed forceps are pushed through the tough deep fascia and advanced towards the pus collection.
5. Abscess cavity is entered and forceps opened in a direction parallel to vital structures.
6. Pus flows along sides of the beaks.
7. Explore the entire cavity for additional loculi.
8. Placement of drain: A soft yeat’s or corrugated rubber drain is inserted into the depth of the abscess cavity; and external part is secured to the wound margin with the help of suture9. Drain left for at least 24 hours.
10. Dressing: dressing is applied over the site of incision taken extraorally without pressure.
What is The Purpose of keeping the drain?The purpose of drain is
To allow the discharge of tissue fluids and pus from the wound by keeping it patent.The drain allows for debridement of the abscess cavity by irrigation.Tissue fluids flow along the external surface of a latex drain.
Can you send me the link of the original source ir the picture on the top (suprahyoid fascial spaces)
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