Compartments of the head and neck /certified fixed orthodontic courses by Indian dental academy

COMPARTMENTS OF THE HEAD
AND NECK – SURGICAL
ANATOMY & APPLIED ASPECTS

www.indiandentalacademy.com

INDIAN DENTAL ACADEMY
Leader in continuing dental education


“He who sees things grow from
the beginning will have the
finest view of them”

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.

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
(SCF)

DEEP
(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 fascia
+
Platysma muscle

Complex
morphological
unit

Superficial
musculoaponeurotic
system
(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
of deep fascia

Middle layer of
deep fascia


Deep layer of
deep fascia

Superficial layer of deep cervical fascia


Middle layer of deep cervical fascia


Buccopharyngeal fascia


Deep layer of deep cervical fascia


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)
b)
c)
d)

Retropharyngeal space (Space 3).
Danger space (Space 4)
Prevertebral space (Space 5)
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. www.indiandentalacademy.com

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.

Pathways of spread of dental infection

Pericoronitis of third molar area

Spread of infection from erupted and
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
minimal involvement
of nasolabial fold.

Odontogenic cellulitis.
The nasolabial fold is
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
and fasciitis of RT
submandibular
space
B. Contrast enhanced
axial CT
demonstrating
deep and
superficial portion
of right
submandibular
space.

A

B


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.

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.
- 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 spaceNerve sheath tumours
Mandibular & soft tissue
sarcomas
Dental tumours
Cysts & abscesses
Osteomyelitis


Drainage of parotid and Masseter space
infection


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 www.indiandentalacademy.com
• 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 pathognamicwww.indiandentalacademy.com
for parotid gland abscess.
•

Relationship showing lateral pharyngeal,
peritonsillar and pterygomandibular spaces


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
•
1.
2.
3.

4.
5.

Benjamin J. Gans, in his Atlas of oral

surgery, articulated these principles:
Drain all significant deep space infections.
Do not wait for fluctuance. Fluctuance is a late
sign.
Determine incision placement, incisions
designed to avoid important anatomical
structures, provide dependent drainage and leave
cosmetically acceptable scar.
Institute definitive treatment as soon as
possible, Offending tooth to be removed.
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

Two compartments:
Suprahyoid

Sagittal section of retropharyngeal space

Infrahyoid

1. Only fat
1. Lymph nodes and 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
to flex the neck.

•Slight neck rigidity.
•Noisy breathing due to laryngeal
edema.

•Respiratory embarssment may
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 www.indiandentalacademy.com

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
Retropharyngeal tuberculous abscess
anterior border of the
prevertebral muscles.
CT demonstrates hypodense fluid
collection involving the
• Posteriorly displace the
retropharyngeal space (Asterisks)
posterior triangle fat. www.indiandentalacademy.com

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
• 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

– 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 of the trachea.
- Lateral view – In the adult the width of the
prevertebral soft tissue should not exceed 7mm at
the C3 level and 20mmwww.indiandentalacademy.com
at C7 level.

Lateral view

Ultrasound
• 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 submandibular region
demonstrating a branchial cleft cyst

US of Rt parotid showing an
www.indiandentalacademy.com 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
submandibular
space abscess

Percutaneous
needle being
guided into the
abscess

Radiopaque
markers on the
skin

Aspiration to
evacuate the
abscess

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Compartments of the head and neck /certified fixed orthodontic courses by Indian dental academy

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