SPACES OF HEAD AND NECK

ABOUT THE SPACES PRESENT AND HOW INFECTION SPREAD

1. Dr nikil jain Dept . of Oral and Maxillofacial Surgery SPACES OF HEAD AND NECK

2. INTRODUCTION ANATOMY DEFINITION FASCIA CLASSIFICATION OF SPACES CONCLUSION Contents

3. The infection in orofacial region does not spread haphazardly through the loose connective tissue, but tends to accumulate in these potential spaces around the head and neck. Many of these spaces communicate with each other . Introduction

4. THE CONCEPT OF FASCIAL “SPACES” IS BASED ON ANATOMIST’S KNOWLEDGE THAT ALL “SPACES” EXIST POTENTIALLY, UNTIL FASCIAE ARE SEPARATED BY PUS, BLOOD, DRAINS OR SURGEONS FINGER .

5. WHEN DENTAL INFECTIONS SPREAD DEEPLY INTO SOFT TISSUE RATHER THAN EXITING THROUGH ORAL OR CUTANEOUS ROUTES,FASCIAL SPACES MAY BECOME INVOLVED FOLLOWING PATH OF LEAST RESISTANCE .

6. Anatomy of face Facial muscles are subcutaneous muscles Embryologically ,they develop from the mesoderm of the second brachial arch , therfore supplied by facial nerve Morphologically ,they represents the best remnants of panniculus carnosus,a continuous muscle sheet seen in some animals

7. SUPRAMANDIBULAR INFRAMANDIBULAR INFRAHYOID NECK MOUTH AND NOSE EYELIDS AND EYEBRO SCALP MUSCLES

8. MASSETER TEMPORALIS MEDIAL PTERYGOID LATERAL PTERYGOID SUPRAMANDIBULAR

9. MASSETER MASSETER SUPERFICIAL , MIDDLE,DEEP-ANT2/3 RD ,POST1/3 RD ,DEEP SURFACE OF ZYGOMATIC ARCH -SUPERFICIAL,MIDDLE,DEEP LAYER RAMUS+CORONOID PROCESS =2 ND PART OF MAXILLARY ARTERY

10. TEMPORALIS TEMPORALIS -TEMPORAL FOSSA AND FASCIA -CORONOID PROCESS AND RAMUS OF MANDIBLE =2 ND PART OF MAXILLARY ARTERY

11. MEDIAL PTERYGOID MEDIAL PTERYGOID -SUPERFICIAL-MAXILLARY TUBEROSITY -DEEP-MED SURFACE OF LATERAL PTERYGOID TO ANGLE AND ADJOINING RAMUS OF MANDIBLE =2 ND PART OF MAXILLARY ARTERY

12. LATERAL PTERYGOID LATERAL PTERYGOID -UPPER -INFRATEMPORAL SURFACE +CREST OF GREATER WING OF SPHENOID TO PTERYGOID FOVEA OF NECK OF MANDIBLE -LOWER-LAT SURFACE OF LATERAL PTERYGOID PLATE TO ARTICULAR DISC AND CAPSULE OF TMJ =2 ND PART OF MAXILLARY ARTERY

13. DIGASTRIC GENIOHYOID MYLOHYOID STYLOHYOID INFRAMANDIBULAR

14. DIGASTRIC DIGASTRIC -ANTERIOR BELLY-DIGASTRIC FOSSA OF MANDIBLE -POST BELLY-MASTOID NOTCH OF TEMPORAL BONE TO HYOID BONE BY A FIBROUS PULLEY -ant-facial artery, post-occipital artery

15. GENIOHYOID GENIOHYOID -INF MENTAL SPINE(GENIAL TUBERCLE) TO ANT SURFACE OF BODY OF HYOID -hyoid branch of lingual artery

16. MYLOHYOID MYLOHYOID -MYLOHYOID LINE OF MANDIBLE TO BODY OF HYOID -hyoid branch of lingual artery

17. STYLOHYOID STYLOHYOID -POSTERIOR SURFACE OF STYLOHYOID TO JUNCTION OF BODY AND GREATER CORNU OF HYOID -hyoid branch of lingual artery

18. STERNOHYOID OMOHYOID STERNOTHYROID THYROHYOID INFRAHYOID

19. STERNOHYOID STERNOHYOID -POST BORDER OF MANUBRIUM STERNI,CLAVICLE,POST STERNOCLAVICULAR LIGAMENT TO MEDIAL PART OF LOWER BORDER OF HYOID BONE -hyoid branch of lingual artery

20. OMOHYOID OMOHYOID -UPPER BORDER OF SCAPULA NEAR SUPRASTERNAL NOTCH,SUPRASCAPULAR LIGAMENT TO LOWER BORDER OF BODY OF HYOID -hyoid branch of lingual artery

21. STERNOTHYROID STERNOTHYROID -POST SURFACE OF MANUBRIUM STERNI,1 ST COSTAL CARTILAGE TO OBLIQUE LINE ON THE LAMINA OF THYROID CARTILAGE -hyoid branch of lingual artery

22. THYROHYOID THYROHYOID -OBLIQUE LINE OF THYROID CARTILAGE TO LOWER BORDER OF THE BODY AND GREATER CORNUA OF THYROID CARTILAGE -hyoid branch of lingual artery

23. PLATYSMA NECK PLATYSMA -UPPER PARTS OF PECTORAL AND DELTOID FASCIAE TO BASE OF MANDIBLE,SKIN OF LOWER FACE AND LIP,CONTINUOUS WITH RISORIUS -BRANCHES OF SUBMENTAL (FACIAL) AND SUPRASCAPULAR ARTERY (THYROCERVICAL TRUNK- SUBCLAVIAN)

24. COMPRESSOR NARIS (nasalis) DILATOR NARIS DEPRESSOR SEPTI NOSE

25. DILATOR NARIS DILATOR NARIS -from margin of nasal notch of maxilla and lesser alar cartilages -to the skin near margin of nostril

26. DEPRESSOR SEPTI DEPRESSOR SEPTI -from incisive fossa of maxilla -to the nasal septum

27. NASALIS COMPRESSOR NARIS(NASALIS) -alveolar eminences of lateral incisor and canine of upper jaw at the base of alveolar process -to the wing of the nose

28. TRANSVERSUS MENTI LEVATOR LABII SUPERIORIS ZYGOMATICUS MAJOR & MINOR RISORIUS LEVATOR ANGULI ORIS DEPRESSOR ANGULI ORIS MOUTH AND NOSE

29. DEPRESSOR LABII INFERIORIS MENTALIS BUCCINATOR ORBICULARIS ORIS INCISIVUS

30. LEVATOR LABII SUPERIORIS LEVATOR LABII SUPERIORIS -angular head-from the frontal processs of the maxilla -infraorbital head-below the infraorbital margin parallel to it to the zygomatic process -zygomatic head-most prominent part of the zygomatic bone -FACIAL ARTERY

31. ZYGOMATICUS MAJOR & MINOR ZYGOMATICUS MAJOR -from temporal process of zygomatic bone -to the corner of the mouth divided by the levator anguli oris into superficial & deep head -FACIAL ARTERY

32. RISORIUS RISORIUS -from the fascia of the masseter muscle -to the corner of the mouth -FACIAL ARTERY

33. LEVATOR ANGULI ORIS LEVATOR ANGULI ORIS -from the canine fossa and passes downward and lateral -divides the zygomatic major muscle -FACIAL ARTERY

34. DEPRESSOR ANGULI ORIS DEPRESSOR ANGULI ORIS -outer surface and above the lower border of the mandible -to the corner of the mouth -FACIAL ARTERY

35. DEPRESSOR LABII INFERIORIS DEPRESSOR LABII INFERIORIS -upward and medially to the lower lip -FACIAL ARTERY

36. MENTALIS MENTALIS -oval area in the depth of the mental fossa interlace with the muscle of the opposite side of chin

37. BUCCINATOR BUCCINATOR -alveolar process from 1 st molar distally to the suture between maxilla and palatine bone - alveolar process from 1 st molar till the lower end of retromolar fossa -BUCCAL ARTERY (MAXILLARY ARTERY 2 ND PART)

38. ORBICULARIS ORIS ORBICULARIS ORIS -occupies the entire width of the lips with no direct attachment to the skeleton -upper and lower fibres crossing each other at the corner of the mouth

39. ORBICULARIS OCULI DEPRESSOR SUPERCILII PROCERUS NASII CORRUGATOR SUPERCILII EYELIDS AND EYEBROWS

40. DEPRESSOR SUPERCILII DEPRESSOR SUPERCILII -from lacrimal crest of frontal maxillary process -skin of the head of the eyebrow -OPHTHALMIC ARTERY

41. PROCERUS NASI PROCERUS NASII -from the nasal bone -to the skin of the brow and of forehead in the glabellar region between the eyebrows

42. CORRUGATOR SUPERCILII CORRUGATOR SUPERCILII -from frontal bone at the medial end of the superciliary arch -to the outer part of the eyebrow and skin of forehead immed above it -OPHTHALMIC ARTERY

43. FRONTALIS OCCIPITALIS SCALP

44. FRONTALIS FRONTALIS -from anterior border of galea aponeurotica -to skin of eyebrow and root of nose -OPHTHALMIC ARTERY

45. OCCIPITALIS OCCIPITALIS -Supreme nuchal line from base of mastoid process -to the midline and into the fibres of the aponeurotic cap -OCCIPITAL ARTERY

46. The face is supplied by branches of the external carotid and the internal carotid artery Two main branches of the external carotid Facial artery and superficial temporal artery Main branches of the internal carotid that supplies the medial upper face and scalp is the ophthalmic artery Arterial Supply

47. Most veins in the face run parallel with their corresponding arteries These veins lack valves and therefore allow bidirectional blood flow The facial vein can communicate with the cavernous sinus through the ophthalmic vein or the pterygoid plexus (which drain the paranasal area and the upper lip). Wound infections in this area have the potential to gain access to the cavernous sinus Venous Drainage

48. Nerve supply of face Motor supply Facial nerve

49. Sensory supply Ophthalmic division Supratrochlear Supraorbital Lacrimal Infratrochlear External nasal Maxillary nerve Infraorbital Zygomaticofacial and zygomaticotemporal Mandibular nerve Auriculotemporal Buccal nerve Mental Skin over the mandibular angle is supplied by ant. Div. Of greater auricular n.

50. Lymphnodes 3 territories- Upper territories- greater part of forehead, lateral ½ of eye lid, conjunctiva, lateral part of cheek and parotid area– preauricular lymph node (parotid) Middle territories- median part of forehead, external nose, upper lip, lateral part of lower lip, medial ½ of eye lid, medial part of cheek, greater part of lower jaw– submandibular lymph node Lower territories- central part of lower lip, chin– sub mental lymph node

51. Level I Submental (IA) Submandibular (IB) Level II Upper jugular Level III middle jugular Level IV Lower jugular Level V Posterior triangle group (Spinal accessory and transverse cervical chains) Level VI Prelaryngeal Pretracheal Paratracheal Level VII Nodes of upper mediastinum Classification

52. Level I includes : IA Submental nodes, which lie in the submental triangle i.e. between right and left anterior bellies of diagastric muscles and the hyoid bone. IB Submandibular ones, lying between anterior and posterior bellies of diagastric muscle and the body of mandible

53. 55

54. Level II – Upper Jugular Nodes They are located along the upper third of jugular vein I.e. between the skull base above, and the level of hyoid bone (or bifurcation of carotid artery) below

55. Level III – Middle Jugular Nodes They are located along the middle third of jugular vein, from the level of hyoid bone above, to the level of upper border of cricoid cartilage

56. Level IV – Lower Jugular Nodes They are located along the lower third of jugular vein; from upper border of cricoid cartilage to the clavicle

57. Level V – Posterior Cervical Group They are located in the posterior triangle i.e. between posterior border of sternocleidomastoid ( anteriorly ), anterior border of trapezius ( posteriorly ), and the clavicle below. They include lymph nodes of spinal accessary chain,transverse cervical nodes and supraclavicular nodes

58. Level VI – Anterior Compartment Nodes They are located between the medial borders of sternocleidomastoid muscles (or carotid sheaths) on each side, hyoid bone above and superasternal notch below. They include prelaryngeal,pretracheal , paratracheal nodes

59. Numerous fascial spaces in head and neck have been described by: Collier and Yglesias ,1935 Grodinsky and Holyoke,1938 Shapiro ,Sleeper,and Guralnick,1950 Gaughran ,1957 Laskin,1960 Levit ,1970

60. Shapiro defined fascial spaces as potential spaces between the layer of fascia. These spaces are normally filled with loose connective tissue and various anatomical structures like veins, arteries, glands, lymphnodes. Definition

61. It is defined as a broad sheet of dense connective tissue whose function is to separate structure that must pass over each other during movement such as muscles & glands and serve as a pathway for the course of vascular &neural structure Fascia

62. Fascia is described under:- 1) Superficial fascia 2)Deep fascia- a) Superficial or anterior or investing layer b) Middle or pretracheal layer. c) Posterior or prevertebral layer. d) Carotid sheath

63. Superficial fascia : - Similar to subcutaneous tissue Ensheathes platysma and muscles of facial expressions Attachments : zygomatic process to thorax and axilla Contents:platysma,muscles of facial expression

64. Superficial layer of deep cervical fascia Enveloping or investing layer Insertion at nuchal line of the skull Spreads anteriorly to the face and attaches at clavicles Envelopes SCM,trapezius,portion of omohyoid in posterior triangle,parotid and submandibular glands

65. Middle layer of deep cervical fascia Muscular division Attaches superiorly to hyoid and thyroid and inferiorly to sternum ,clavicle and scapula Visceral division surrounds thyroid trachea, oesophagus superiorly attached to base of skull thyroid cartilge and hyoid

66. This division has clinical significance because - below the hyoid bone the visceral layer surrounds the trachea oesophagus and thyroid gland. - above the hyoid bone the visceral fascia wraps around the lateral and posterior side of the pharynx, lying on the superficial side of pharyngeal constrictor muscle – known as buccopharyngeal fascia

67. Posterior layer - the posterior layer of the deep cervical fascia has two divisions 1) the alar 2) the prevertebral The alar fascia passes through the transverse process of the vertebrae on either side, posterior to the retropharyngeal fascia.

68. The alar fascia fuses with retropharyngeal fascia at a variable level between 6 th cervical and 4 th vertebrae Infection of the retro-pharyngeal space may rupture the alar fascia, thus entering the danger space , which is continuous with the posterior mediastinum

69. The prevertebral fascia surround the vertebra and the attached postural muscles of the neck & back Prevertebral fascia is usually not invaded by infection arising in maxillofacial regions.

70. Carotid sheath - Carotid sheath surrounding IJV, CCA & vagus nerve is interposed between the superficial and pretracheal layer on the one hand and prevertebral layer on the other.

71. Grodinsky and Holyoke in1938,described these potential spaces as Space 1 Space 2 Space 3 and 3A Space 4 CLASSIFICATION OF FASCIAL SPACES

72. Space 1- the potential space superficial and deep to the platysma muscle Space 2- the space behind the anterior layer of deep cervical fascia Space 3- Pretracheal space- lies anterior to trachea Space 3A- viscerovascular space-it is the carotid sheath from jugular foramen and carotid canal at the base of the skull to pericardium or middle mediastinum

73. Space 3A is also termed as lincoln’s highway as coined by mosher Space 4 danger space is a potential space between the alar and prevertebral fascia.it extends from the base of the skull to posterior mediastinum .

74. Direct Primary Spaces - Maxillary spaces Mandibular spaces Indirect Secondary spaces Based on the mode of involvement

75. Maxillary Spaces – Canine Buccal Infratemporal Mandibular Spaces – Buccal Submental Submandibular Sublingual

76. Secondary Spaces – Massetric Pterygomandibular Superficial and deep temporal Parotid Lateral pharyngeal Retropharyngeal Prevertebral

77. Face – Buccal Canine Masticatory Parotid Suprahyoid - Sublingual Submandibular Pharyngomaxillary Peritonsillar Based on clinical significance

78. Infrahyoid - Pretracheal Spaces of total neck -Retropharyngeal Space of carotid sheath

79. In relation to uppper jaw - - with in the lip -with in the canine fossa , -Palatal subperisteal interval, -maxillary antrum - infratemporal fossa , - subtemporalis muscle interval Classification according killey and kays’s

80. In relation to lower jaw - buccal, submental , submandibular , sublingual, Submassetric , parotid, pterygomandibular , Lateral pharyngeal, peritonsillar fossa

81. Space with in the lip Infection at the base of upper lip usually occur as a result of an abscess of upper incisors or canine If pus forms oral side of orbicularis oris,it tends to point in vestibule Because of bulk of the muscle taking origin beneath the anterior nasal spine,infection from central incisors point towards the apex of lateral incisors

82. Boundaries Anteriorly – orbicularis oris Posteriorly – buccinator Superorly – levator labi superioris alaque nasi levator labi superioris zygomaticus minor inferiorly - caninus medially - anterolateral surface of maxilla Canine space

83. Contents – angular artery and vein infraorbital nerve Involvement canine premolar mesiobuccal root of 1 st molar(rarely )

84. Superoirly – overlying periosteum and mucosa Inferiorly – cortical plate of hard palate Laterally - alveolar process of maxilla and teeth Palatal space

85. Involvement –palatal root of the posterior teeth are the source of infection Occasionally,lateral incisor is frequent cause ,as infection migrate posteriorly

86. SUPERIORLY : ZYGOMATIC ARCH INFERIORLY : LOWER BORDER OF MANDIBLE ANTERIORLY : MODIOLUS OF MOUTH POSTERIORLY : PTERYGOMANDIBULAR RAPHE MEDIALLY : BUCCINATOR MUSCLE BUCCOPHARYNGEAL FASCIA LATERALLY : SKIN OF CHEEK Buccal Space

87. Contents – - parotid duct - anterior fascial artery & vein - transverse fascial artery & vein - buccal fat pad

88. Source of infection: max bicuspid max. molars mand.molars mand . Bicuspids Spread- pterygomandibular space infratemporal space submasseteric space

89. Boundaries : - Anteriorly – infratemporal surface of maxilla - Posteriorly – mandibular condyle Superiorly – infra temporal crest of sphenoid Inferiorly – lateral pterygoid - Medially – temporal tendon, coronoid process - Laterally – lateral pterygoid plate Infratemporal Space

90. Contents – pterygoid plexus internal maxillary artery & vein mandibular nerve Source of infection – max. molars through infected needle Spread - extended upwards to involve temporal space. inferiorly – pterygomandibular space. upwards into cavernous sinus

91. Submental space - Potential space present just below the chin region on the medial surface of mandible Boundaries – Superiorly: Mylohyoid muscle Inferiorly: Deep fascia, Platysma and Skin Laterally : Lower border of mandible Anterior belly of digastric muscle Spaces associated with lower jaw

92. Contents - Submental lymphnodes Anterior jugular vein Involvement – anterior mandibular teeth secondarily involvement due to infection of submental lymph nodes,following lymphatic spread from lower incisors,lower lip,skin overlying the chin,anterior part of the floor of the mouth,tip of the tounge and sublingual tissues

93. Spread – infection can spread posteriorly,to involve submandibular space or may discharge on the face,in submental region

94. potential space lies between the ant. and post. belly of digastric . Boundaries – Anteriomedially : floor formed by mylohyoid muscle Posteriomedially : floor formed by hyoglossus muscle Superiolaterally : medial surface of mandible below the mylohyoid ridge Submandibular Space

95. Anteriosuperiorly : ant. belly of digastric Posteriosuperiorly : post. belly of the digastric ,stylohyoid and stylopharyngeous muscle Laterally : platysma and skin Contents : Superficial lobe of submandibular salivary gland Submandibular lymphnode ,facial artery,proximal part of wharton’s duct,lingual and hypoglossal nerve

96. Involvement : mandibular molars,apices present below the mylohyoid insertion Spread : Submental, Submandibular space on contralateral side, Sublingual space, Parapharyngeal space

97. it is V-shape trough lying lateral to the muscles of the tounge Boundaries : Superiorly – mucosa of floor of mouth Inferiorly - mylohyoid muscle Medially - genioglossus,hyoglossus,geniohyoid Laterally – medial side of mandible Anteriorly - lingual surface of mandible Posteriorly – submandibular space,hyoid bone Sublingual space

98. Contents – geniohyoid, genioglossus, hyoglossus muscle, deep part of submandibular salivary gland and duct, sublingual salivary gland , lingual nerve ,hypoglossal nerve. Spread- infection may be cross the midline From posterioinferior part to submandibular gland and space Via lymphatics to submental or submandible lymphnodes

99. potential space present around the muscle of mastication Submassetric Pterygoid Temporal Masticatory space

100. Boundaries Anteriorly – anterior border of masseter muscle and buccinator . Posteriorly – parotid gland, posterior part of masseter Inferiorly – lower border of mandible Medially – lateral surface of ramus of mandible Laterally – medial surface of the masseter muscle Submassetric space

101. Contents – masseteric nerve - superficial temporal artery - transverse facial artery - muscles of mastication ramus and posterior part of mandible Involvement – 3 rd molar infection

102. Boundaries- Laterally – medial surface of ramus of mandible Medially – lateral surface medial pterygoid plate Posteriorly – deeper portion of parotid gland Anteriorly – pterygomandibular raphe Superiorly – lateral pterygoid muscle Pterygomandibular space

103. Contents - Lingual nerve Mandibular nerve Inferior alveolar artery Mylohyoid nerve & vessel Spread: Infra temporal fossa Buccal space Lateral & pterygoid space Submandibular space

104. It is secondary to the initial involvement of pterygopalatine & infra temporal space. Temporal pouches are facial spaces in relation to the temporalis muscle. They are two :- ( i ) Superficial temporal space (ii) Deep temporal space Temporal Space

105. Contents:- Superficial-Superficial temporal vessel Auriculo temporal nerve Deep – deep temporal arteries & veins.

106. Boundaries- formed by the splitting of the supreficial layer of deep cervical fascia surrounding the parotid gland and lies to posterior to masticatory space. Inferiorly- stylomandibular ligament,which seprates parotid space from mandibular space Parotid Space

107. Contents - External carotid artery Posterior facial vein Facial nerve Lymph nodes

108. synonyms- pharyngomaxillary space Potential inverted cone shape,with its base at the skull and its apex at the hyoid bone. Lies deep to the pharyngeal constrictor muscle Divided in to anterior and posterior compartments by the styloid process Pharyngeal Space

109. Boundaries – Superiorly – base of the skull Inferiorly – hyoid bone Anteriorly – pterygomandibular raphe Posteroirly – bounded by styloidmuscle,upper part of carotid sheath,prevertebral fascia, Medially – bounded by pharyngeal wall , by buccopharyngeal fascia Laterally – ascending ramus of mandible,medial surface of deep lobe of parotid glands

110. Contents- Anterior compartment – lymphnodes , facial artety loose areolar connective tissue Posterior compartment- carotid sheath (IJV,ICA and Vagus nerve) spinal accessory nerve hypoglossal nerve cervical sympathetic trunk

111. potential midline space between pharyngobasillar fascia ,which attaches the pharyngeal constrictor to base of skull,and prevertebral fascia. Boundaries- laterally carotid sheath - retropharyngeal space is continue with retro-oesophageal space into posterior mediastinum -no midline attachments Retropharyngeal space

112. Medial—capsule of palatine tonsil Lateral—superior pharyngeal constrictor Superior—anterior tonsil pillar Inferior—posterior tonsil pillar Peritonsillar Space

113. Involvment - Infection coming from thedepth of tonsillar crypt or supratonsillar fossa Complication of acute pericoronal abscess

114. POTENTIAL SPREAD OF INFECTION FROM LOWER THIRD MOLAR SUPERIORLY INFRATEMPORAL AND MASTICATOR SPACE POSTERO INFERIORLY PTERYGOMANDIBULAR SPACE INFERIORLY SUBMANDIBULAR SPACE LUDWIG’S ANGINA ANTERIORLY,BUCCALY BUCCAL SPACE BUCCALY MESSETRIC SPACE

115. A through knowledge of anatomy of face and neck is necessary to predict pathways of spread of infection and drain the spaces adequately. Otherwise the infection spread to such an extent causing considerable morbidity and occasional death. Conclusion

116. Oral and maxillofacial infections by Topazian Oral and maxillofacial surgery vol 2 by Daniel M.Laskin Killey and kay’s outline of oral surgery Text book of oral and maxillofacial surgery by Neelima A. Malik Grey’s anatomy Oral anatomy by Sicher and DuBrul’s Human anatomy by B.D.Chaurasia References

117. THANK YOU