Fascias and fascial space infections of head and neck 1.ppt

good

1. FASCIAS AND FASCIAL FASCIAS AND FASCIAL
SPACES OF THE HEAD SPACES OF THE HEAD
AND NECKAND NECK

3. •The term fascias is used to describe broad
sheets of dense CT whose function is to
separate structures that must pass over each
other during movement, muscles and gland,and
serves as a pathway for the course of vascular
and neural structures
•These types of tissue is easily destroyed by the
hyaluronidase and collagenase elaborated by
bacteria, thus opening the potential spaces
surrounding the muscles

4. •IN 1930s –GRODINSKY AND HOLYOKE
The following outline provides a conceptual
view of the organisation of fascias
Superficial fascia
Deep cervical fascia
A.anterior layer
1. investing fascia
2. parotideomassetric
3. temporal

5. B. Middle layer
1.Sternohyoid- omohyoid division
2.Sternothyroid-thyrohyoid
3.Visceral division
a.buccopharyngeal
b.pre-tracheal
c.retropharyngeal

6. C.Posterior division
1.Alar division
2.prevertebral division

7. Superficial cervical fascia
is a thin layer of CT that lies
between the dermis of the skin and the investing
layer of deep cervical fascia
it contains cutaneous nerves,blood vesselsand
lymphatics and variable amount of
fat.anterolateraly containts platysma

9. •Numbered spaces of Grodinsky and holyoke
space1-lies superficial to the superficial
fascia
space2-is a group of spaces surrouding the cervical
strap muscle
space 3- is the potential space lying superficially to
the visceral division of the middle layer of deep
cervical fascia
space3a-is carotid sheath
space 4 - is the potential space that lies between
the alar and pre vertebral division of the posterior
layer of the deep cervical fascia
space 4a- posterior triangle of the neck

11. Deep cervical fasciaDeep cervical fascia
The investing layer of deep cervical fascia, the
most superficial of this surrounds the entire
neck deep to the skin and subcutaneous tissues.
It splits into two sheets to enclose the SCM and
trapezius muscle and attaches post to the
spinous process of cervical vertebrae

12. Parotideomassetric fascia
superficially the anterior layer is called so
in this region because it covers the superficial
surfaces of anterior muscle and splits to enclose the
parotid gland posteriorly
Temporal fascia
above the zygomatic arch the anterior
layer is called so.from the zygomatic arch it rises
superiorly to cover the superficial surface of
temporal muscle

14. –Suprasternal space
– following the SCM
muscle the fascia attached to
both ant and post surfaces of
the manubrium sterni and
medial one third of the clavicle.

– the seperation of the ant
and post laminae is prolonged
upward above the manubrium
strni for about 3 cm between
the convergent medial borders
of the SCM muscle the
interfascial space thus formed
largely fills with fat but
accomodatingthe transverse
link between the two ant
jugular vein

15. Middle layer of deep cervical fascia
the superficial layer of fascia encloses the
sternohyoid and thyrohyoidmuscles of the two sides and
attaches above the hyoid bone. This layer is carried
along the omohyoid muscle behind the SCM where it
fuses with the superficial cervical fascia on deep ascpect
superiorly extend to the lateral border of the
omohyoid muscle
below it follows the inferior attachment of the
sternohyoid medially and covers the omohyoid laterally

17. The deeper lamina of the fascia encloses the
strenothyroid and thyrohyoid muscle and ends
superiorly at the hyoid bone
laterally it extends to the carotid sheath
where it blends with IJV
Inferiorly the layer follow strnothyroid to its
attachment to the back of the sternum
both the layers are prolonged behind the
sternum onto the left brachiocephalic vein and to
the fibrous pericardiumm

19. The primary surgical significance of the
layers is that it must be divided in the
midline in a surgical approach to the
trachea or thyroid gland
They usually are not directly involved in
the head and neck infections because they
do not lie on the major routes that an
orofacial infection may follow to the
mediastianium or chest wall

20. The cervical visceral fasciaThe cervical visceral fascia
Lies in the central part of the neck enclosed the
cervical visceras with in a cylindrical fascial
covering
consist of two fascias pre-tracheal layer ant and
buccopharyngeal post
these two fascias blend together along the
attachment of the pharyngeal constrictors to the
hyoid bone and thyroid cartilage at the
postromedial border of the thyroid gland

22. Pre-tracheal fasciaPre-tracheal fascia
It closes covers the larynx and trachea and splits to
enclose and form a sheath for the thyroid gland
superiorly attaches to the hyoid bone
laterally it blends with the buccopharyngeal fascia
covering the insertion of middle constrictor to the lesser
and greater horns of hyoid bone and to the stylohyoid
ligament
below it attaches to the oblique line of thyroid
cartilage ,where it also bends with the buccopharngeal
fascia

24. The sheath of the thyroid gland is a well
differentiated portion of this fascia and encloses
the gland on all the sides
below the gland,the fascia covres the trachea
and is continous behind the sternum with the
fascial sheathof the aorta and with the fibrous
pericardium in the thorax

25. Buccopharyngeal fasciaBuccopharyngeal fascia
It covers the buccinator muscle and the pharynx and its
prolonged downwards over the posterior surface of the
oesophagus.
superiorly it attaches to the occipital bone and then
extends laterally over the pharyngobasilar fascia to the
medial pterygoid plate.
as an external covering of the superior constrictor
nuscle the fascia attaches to the pterygomandibular
raphe and then extends forward over the buccinator
muscle

26. Inferiorly the fascia covers the middle and
inferior constrictor and blends with the
pretracheal fascia.
At the level of the thyroid gland the
fascia of the lower pharynx and
oesophagus blends with the sheath of the
gland at its posteromedial border

27. CAROTID SHEATHCAROTID SHEATH
•It’s a tubular investment of the internal and
common carotid artery,IJV and vagus nerve.
•Sympathetic trunk lies behind the sheath.
•The fibers adhere to and blend with the sheath
of thyroid gland anteromedially and with the
fascia of the deep surface of the SCM
anterolaterally.
•Posterially CS is attached to the prevertebral
fascia along the tips of the transverse process of
vertebra

29. •In the upper part of the neck the CS fuses with
the fascia of the stylohyoid and posterior belly of
digastric.
•In the base of the skull, the fascia attaches to
the jugular foramen and the carotid canal.

30. PREVERTEBRALPREVERTEBRAL FASCIAFASCIA
•This fascia is also cylindrical in form and encloses the
vertebral coloumn and its associated musculature
• the prevertebral fascia crosses the midline anterior
to the prevertebral muscles and is then attached to the
tips of the transverse process.
•Continuing laterally this fascia covers the scalene
muscles, levator scapulae, splenius and the other deep
cervical muscles at the side of the neck.
•Posteriorly it attches to the external occipital
protruberance, the ligamentum nuchae and the spine of
the seventh cervical vertebra.

33. ALAR FASCIAALAR FASCIA

36. Deep space infectionDeep space infection assosiated with odontogenic assosiated with odontogenic
infectioninfection
Vestibular space
is the potential
space between the oral
vestibular mucosa and
the nearby muscles of
facial expression
dento alveolar abcess
occupy a portio of
vestibular space
this space is filled
with submucosal &aerolar
CT is crossed by the long
buccal and mental nerves

37. Sub cutaneous space Sub cutaneous space
•This space occupies the
potential space between
the superficial fascia
along with the muscles of
facial expression
• Necrotising fascitis ,a
rapidly spreading
infection causes necrosis
of the tissue in the
subcutaneous space by
the thrombosis of the
vessel that supply the
superficial muscle & skin

38. Buccal space Buccal space
•This space is formed
antromedially- by
buccinator muscle
posteromedially- by the
masseter overlying the ant: border
of the ramus of the mandible
laterally: covered by a
forward xetension of the deep
fascia from the capsule of the
parotid gland
limited below by the
attachment of the deep fascia in
the mandible and by the depressor
anguli oris
above by the zygomatic process
of maxilla and by the zygomaticus
major &minor

39. This space contains buccal pad of
fat.

communication :superficiallywit
h submassetric space
on medial side with the
pterygomandibular space
inferiorly and the infratemporal
space superior to lateral
pterygoid
posteriorly with lateral
pharyngeal space
extension of buccal pad of fat
allows allows infection to
spread superficial temporal
space

41. DEEPSPACES ASSOSIATED WITH MAND DEEPSPACES ASSOSIATED WITH MAND
ODONTOGENIC INFECTION ODONTOGENIC INFECTION
•SUB LINGUAL SPACE
superiorly ;by the mucosa
of thefloor of the mouth
inferiorly: mylohyoid
muscle
medially:intrinsic muscle of
the tongue and genioglossus
ant& late: the lingual surface
of the mandible
poste border is formed by
the superior, posterior and
medial portion of the sub
mandi gland
buccopharyngeal gap

43. Sub mandibular spaceSub mandibular space
Formed by
ante& post borde: ante&post
belly of digastric
posterior border of this
space also include the
stylohyoid and the superior
&middle constrictor at the
superior,middle and the
posterior corner the space
the sub mandibular gland
largely fills the space . Five
branches of facial artery in the
space are ascending
palatine,tonsillar,sublingual,gla
ndularand submental

47. SUBMENTAL SPACESUBMENTAL SPACE
Laterally : anterior belly of
digastric
Superficial border : investing
layer of deep cervical
fascia, skin and inferior
border of the mandible.
it contain areolar
connective tissue,
submental lymph nodes
and anterior jugular vein.

50. SUBMASSETRIC SPACESUBMASSETRIC SPACE
This space lies between the
parotideomassetric fascia (ant.
Layer of deep cervical fascia)
The inferior border is the
ptyergomassetric sling
Superior border is the dense
attachment of the fascia to the
lateral surface of the zygomatic
arch, inferior border of the
zygomatic arch, and the bottom
of the superficial temporal space
medial to the arch.
This space communicates with the
ptyegomandibular space through
the sigmoid notch

52. Ludwigs anginaLudwigs angina
Is a clinical diagnosis and is the name given to a massive
firm cellulits affecting simultaneosly the sub-
mandiobular,sub mental and sublingual space bilaterally
Aetiology
complication usually follows a sub mandibular
infection to sub lingual (same side sidearound the deep
part of thegland)
From there it pasess to the opposite sub lingual space to
sub mandibular region

53. •Sub mental is involved by lymphatic
spread
• from the sub lingual space infection
may spread backwards in the substance of
the tongue in the cleft between the
hypoglossus and genioglossus muscle
and along the course of sublingual artery
• it is this route the infection reaches the
epiglottis and so produces swelling around
the laryngeal inlet

56. PTERYGOMANDIBULAR SPACEPTERYGOMANDIBULAR SPACE
-Infection of the P.S correlates highly with the
pericoronitis of the mandibular third molar.
-Trismus (caused by the edema and the
inflammation of the medial pterygoid muscle)
hinders the view of the swollen anterior tonsillar
pillar and the deviation of the uvula to the
opposite sude that are charecteristic of infection
of this space

57. Laterally: ascending ramus
of the mandible
Medially: medial pterygoid
muscle
Anteriorly: buccinator $
superior constrictor
muscle as they meet at
the raphe.
Superiorly: lateral pterygoid
inferiorly: the
pterygomassetric sling
BordersBorders

58. •Infections may spread into the infratemporal
portion of the deep temporal space by passing
superiorly around the lateral pterygoid muscle
which runs from the mandibular condylar neck to
the medial pterygoid plate.
•This space infections spreads to the lateral
pharyngeal space by passing around the medial
pterygoid plate following the posterolateral
surface of the superior constrictor muscle.

60. SUPERFICIAL TEMPORAL SUPERFICIAL TEMPORAL
SPACESPACE
It lies between the temporal fascia
(parotideomassetric fascia) and the
temporalis muscle.
Anterior border: posterior surface of the
lateral orbital rim.
Posterior border: is the fusion of the
temporal fascia with the pericranium at the
posterior edge of the temporalis muscle.
Inferiorly: the zygomatic arch.

61. At 2 cm above the zygomatic arch fascia
split into 2 layers that passes laterally and
medial to the arch. This contain a leaflet of
buccal fat pad and 3 small veins that
drains the temporal region.

62. DEEP TEMPORAL SPACEDEEP TEMPORAL SPACE
Lateral border: temporalis muscle
Medial border: squamous temporal bone and skull
base.
(the infratemporal space is the portion of the deep
temporal space that lies inferior to the
infratemporal crest of the sphenoid bone)
Inferiorly: superior surface of the lateral pterygoid
muscle
Superior, posterior border is formed by the
attachment of the temporalis muscle to the
cranium at the temporal crestm

63. The anterior border of the temporal space is
composed of the posterior wall of the
maxillary sinus, pterygomaxillary fissure
and the posterior surface of the orbit
including the inferior orbital fissure.
Contents :Contents : terminal division of the internal
maxillary artery and mandibular division of
the trigeminal nerve

64. LATERAL PHARYNGEAL SPACELATERAL PHARYNGEAL SPACE
It is shaped like an inverted
pyramid with its base at
the base of the skull and
apex at the hyoid bone.
Pharyngeal constictor
muscle forms its medial
border(also the fascia
covering it)
Lateral border : superiorly
medial pterygoid muscle
and inferiorly anterior
layer of the deep cervical
fascia

65. Anterior border : palatal muscle superiorly,
buccinator and suoperior constrictor and the
stylohyoid and posterior belly of digastric
inferiorly
Posterior border : carotid sheath posterolaterally
and retropharyngeal space posteromedially.
(fascial condensation called the aponeurosis of
zuckerkandl and testut which divides this space
into anterior and posterior division(prestyloid and
poststyloid)

66. Anterior division contains loose areolar C.T.
Posterior division : it contains 9
th
, 10
th
, 11
th

and 12
th
nerves, carotid sheath and it
contents and sympathetic chain

67. RETROPHARYNGEAL SPACERETROPHARYNGEAL SPACE
This space extends vertically from
the base of the skull to the
fusion of the retropharyngeal
fascia (a local name for the
visceral division of the middle
layer of the deep cervical
fascia with alar fascia)
These 2 fascial layers unite at a
variable level between the 6
th

cervical and T4 vertebrae so
the 2 fascial layers compose
the anterior, posterior and
inferior border of the
retropharyngeal space.
Lateral border : lateral pharyngeal
space and carotid sheath

68. The space contains areolar C.T and lymph nodes
that drains the adenoidal tissue of the posterior
pharyngeal wall
The adenoid and the tonsil encircle the oropharynx
in structure reffered to as the waldeyers ring
The lateral and retropharyngeal space contain a
rich supply of lymph nodes that drain waldeyers
ring
Infection of this space is ominous because of the
ability to impinge on the airway directly and
potential involvement of the danger space.

69. VISCERAL SPACEVISCERAL SPACE
It contains the pharynx, larynx, oesophagus and
trachea
Anteriorly : it begins at the thyroid cartilage and
follows the trachea, oesophagus into the
mediastinum
Posterior: starts from the base of the skull. Above
the hyoid bone its the space occupied by the
buccopharyngeal fascia.
Below the hyoid bone the fascia encloses larynx,
trachea, thyroid gland and oesophagus in a
tubular sheath that descends into the
mediastinum

70. The visceral space encloses the peritonsillar space
Peritonsillar space lies between the oropharyngeal
mucosa and the suprior constrictor muscle. It
contains and surrounds the palatine tonsil
Peritonsillar infection may drain through the
mucosa into the oropharynx or may perforate
the superior constrictor and the visceral fascia to
enter the lateral pharyngeal space
Rather then spreading laterally the infection
spreads vertically

71. DANGER SPACEDANGER SPACE
Extends from the base of the skull
superiorly to the diaphragm
inferiorly
Its lateral extension is at the fusion of
the alar and the prevertebral
fascia at the transverse process of
the cervical and the thoracic
vertebra
Contents: areolar C.T
In the chest the danger space is
continous with the posterior
mediastinum which contains vena
cava, thoracic duct, trachea and
oesophagus
So infections that pass through the
danger space into the
mediastinum can erode into or
compress major vessels

72. Spaces involved in odontogenic Spaces involved in odontogenic
infectionsinfections
Primary maxillary
spaces
Canine
Buccal
Infratemporal
Primary mandibular
spaces
Submental
Buccal
Submandibular
Sublingual
Secondary fascial spaces
Masseteric
Pteygomandibular
Superficaial and deep temporal
Lateral phryngeal
Retrophryngeal
prevertebral

73. Spread of pathways of infectionSpread of pathways of infection

76. Infections assosiated with the maxillary Infections assosiated with the maxillary
odontogenic infectionodontogenic infection
•Palatal space:
infection that
begin in the lateral incisor
or the palatal roots of the
upper posterior teeth tend
to cause infection of the
palatal space ,because
their roots are located
closer to the palatal
space

77. Infraorbital space(Canine space)Infraorbital space(Canine space)
•Infection that begin in the maxi
ant teeth and in the pre molar
can affect the infraorbital
space because of the length of
the roots, dental infection of
the max canine may perforate
the facial cortical plate of the
maxilla at a point superior to
the attachment of the levator
anguli oris
• the infection may
spread directly into the
infraorbital space because it
forms the space between the
levator labi superioris and
levator anguli oris muscle

78. •Spontaneous i/o drainage
of the IOS may be
delayed because an
abcess in the region must
pass through or around
the levator anguli to reach
vestibular space and oral
mucosa altrnatively this
infection burrows towards
the skin on either side of
the quadratus laabi
superiors muscle thus the
abcess may point through
the medial or lateral
aspect of lower eye lid

81. Peri orbital spacePeri orbital space
•It lies bewteen the orbicularis muscle and the
orbital septum, which is a leaflet arising from the
rim extending and attaching to the tarsal plates
• the space is divided into the upper and
lower compartments by the medial and lateral
canthal ligaments
•Contents: fat and loose areolar CT fills the space
very loosely , which accomodates for the
propensity of the eye lid to accommodate
oedema fluid

82. Orbital spaceOrbital space
•This space is bounded by the bony walls of the orbit
laterally and posteriorly. The anterior border of the
orbital space is the orbital septum which divides from the
periorbital space
this space is a cone shaped with its base at the septum
and its apex posteromedially at the optic foramen
Thin layers of bone seperates from the orbital space
from the maxi sinus inferiorly and ethmoid sinus medially
Infections may spread unto the space by these bony
layers or through the tiny emissary vein that perforates
the bone

83. MediastinumMediastinum
The mediastinum can visualized as
the façade of greek temple, with
superior mediastinum sitting a top
the three columns formed by the
anterior, middle, and posterior
mediastiunum. All of the cervical
structures that pass into the
mediastinum traverse the superior
mediastinum that begins at the first
rib and the manubrium of the
sternum. The inferior border is an
imaginary line drawn from the
bottom of the fourth thoracic
vertebra (T4) to the angel of
Louis (the manubriosternal junction).

84. •The anterior mediastinum is
potential space filled with areolar
connective tissue, a few small
lymph nodes and vessels that lie
between the pericardium and the
posterior surface of the sternum,
superior to the anterior
mediastinum lies the superior
mediastinum and the pretracheal
space is above. The inferior
margin of the anterior
mediastinum is the diaphragm. It
is bounded laterally by the visceral
pleura on either side. The middle
mediastinum contains the heart,
pericardium, and the phrenic
nerves. Which course inferiorly on
either side of the heart to the
diaphragm.

85. •The posterior mediastinum
contains all of the noncardiac
major stuctures of the
mediastinum, including the
thoracic aorta, supeior and inferior
vena cava, azygos vein, thoracic
duct, vagus nervers, trachea,
esophagus and the splanchnic
nerves in the inferior portion. The
posterior mediastinum is bounded
anteiorly by the pericadium,
posteriorly by the alar fascia, and
laterally by the visceral pleura on
either side. The inferior border is
the diaphragm; superorly it is
bounded by the superior
medistinum with the danger space
above.