deep facial spaces

1. DEEP FASCIAL SPACES &
ITS MANAGEMENT
Presented by-Dr Tejal R Ragji

2. FASCIA
 The term Fascia is used to describe broad
sheets of dense connective tissues whose
function is to separate structures that may
pass over each Other during movement such as
muscles & glands & serves as pathways for the
course of Vascular & Neural structures.

3.  According to Hollinshead
 SUPERFICIAL FASCIA
 DEEP CERVICAL FASCIA
 ANTERIOR LAYER :
1. INVESTING FASCIA ( OVER THE NECK)
2. PAROTIDOMASSETRIC
3. TEMPORAL
 MIDDLE LAYER
1. STERNOHYOID – OMOHYOID DIVISION
2. STERNOTHYROID-THYROHYOID DIVISION
3. VISCERAL DIVISION –
-BUCCOPHARYNGEAL
-PRETRACHEAL
-RETROPHARYNGEAL
 POSTERIOR LAYER
1. ALAR
2. PREVERTEBRAL

4. NUMBERED SPACE ACCORDING TO GRODINSKY AND
HOLYOKE
 In their landmark article of 1938 they described deep fascial spaces of head and neck
 SPACE 1 - LIES SUPERFICIAL TO SUPERFICIAL FASCIA
 SPACE 2 – SPACES SURROUNDING CERVICAL STRAP MUSCLE
 Space 2A- POSTERIOR TRIANGLE BETWEEN SUPERFICIAL LAYER OF DEEP FASCIA AND SHEATH OF
POSTERIOR BELLY OF OMOHYOID
 SPACE 3 – SPACE LYING SUPERFICIAL TO VISCERAL DIVISION ( buccopharyngeal ,pre tracheal,
retropharyngeal and lateral pharyngeal)
 SPACE 3A- CAROTID SHEATH
 DANGER SPACE 4 – SPACE LIES BETWEEN ALAR AND PREVERTEBRAL DIVISION OF POSTERIOR DIVISION
 SPACE 4A –SPACE IN POSTERIOR TRIANGLE OF NECK , POSTERIOR TO CAROTID SHEATH
 SPACE 5 – PREVERTEBRAL SPACE
 SPACE 5 A- ENCLOSED BY PREVERTEBRAL FASCIA , posterior to transverse process of vertebrae as it
surrounds scalene and spinal postural muscle

8. PATHOPHYSIOLOGY
Invasions of dental pulp by bacteria after decay of a
tooth
Inflammation edema and lack of collateral blood supply
Venous congestion or a vascular necrosis (pulpal tissue
death)
Reservoir for bacterial growth (anaerobic)
Periodic spread of bacteria into surrounding of alveolar
bone

9. SPREAD OF INFECTION

10. DEEP SPACES OF NECK
1. LATERAL PHARYNGEAL SPACE
2. RETROPHARYNGEAL SPACE
3. PREVERTEBRAL SPACE
4. DANGER SPACE
5. PERITONSILLAR SPACE

11. PHARYNGEAL SPACES
LATERAL PHARYNGEAL SPACE
 It is also called as PARAPHARYNGEAL SPACE
 Pharyngeal spaces are involved first as they are
contagious
 Infection from pterygomandibular ,submandibular and
sublingual spaces can spread posteriorly in lateral
pharyngeal space.
 It may also extend backward from mandibular 3rd
molar area.

12. Boundaries-
 SUPERIORLY-Base of skull
 INFERIORLY-Hyoid bone
 ANTERIORLY-Pterygomandibular raphe
 POSTERIORLY-carotid sheath, stylohyoid
muscle.
 MEDIALLY-Superior pharyngeal constrictor
muscle.
 LATERALLY-Medial pterygoid muscle and
capsule of parotid gland.
 CONTENT-Carotid artery, ijv, vagus nerve.

13. CLINICAL FEATURES
Anterior compartment : Pain, Dysphagia &
trismus. Fever & chills. Swelling at the
angle of mandible, medial bulging of the
pharyngeal wall & signs of systemic
toxicity
Posterior compartment: Systemic signs of
fever & toxicity. Trismus is uncommon.
Medial bulging of the pharyngeal wall seen
with anterior compartment is not present.
Swelling if present is usually behind the
palatopharyngeal arch & thus is often
missed on examination.

15. SURGICAL MANAGEMENT
 INCISION AND DRAINAGE
EXTRAORAL APPROACH- Extraoral Incision &
Drainage Of Lateral Pharyngeal Space
Abscess.
 A-incision
 Line B-direction For Insertion Of Hemostat
Incision Is Made Along Anterior Border Of
Sternomastoid Extending From Below The
Angle Of Mandible To The Middle Third Of
Submandibular Gland Curved Hemostat Is
Inserted Medially Behind The Mandible As
Well As Superiorly Until Abscess Cavity Is
Reached A Rubber Drain Is Introduced &
Secured In Position With Suture

16.  INTRAORAL APPROACH-A
Vertical Incision Is Placed Over The
Pterygomandibular Raphe. Sinus
Forcep Or Curved Hemostat Is
Passed Through Pterygomandibular
Raphe Along The Medial Surface Of
The Mandible, Medial To Medial
Pterygoid & Lateral To Superior
Constrictor Is Then Divided
Posteriorly
 Combination of both procedures
can be done.

17. RETROPHARYNGEAL SPACE
 Extends vertically from base of the skull to the fusion of the
retropharyngeal fascia a local name for visceral division of middle layer
of deep cervical fascia with alar fascia.

18. BOUNDARIES
 ANTERIORLY-Posterior pharyngeal wall
 POSTERIORLY-Prevertebral fascia
 SUPERIORLY-Base of skull
 INFERIORLY-Mediastinum
 LATERALLY-Lateral pharyngeal wall
 CONTENT-Areolar connective tissue, lymph
nodes that drains into adenoidal tissue of
lateral pharyngeal wall.

19. SPREAD OF INFECTION IN SPACE
d b
a
c

21. CLINICAL FEATURES
 Pain, fever, stiffness of neck, dyspnea,
dysphagia.
 Bulging of posterior pharyngeal wall is
more prominent on one side because of
adherence of median raphe of
prevertebral fascia.
 Hot potato voice
 Refusal to take food
 Cervical lymphadenopathy.
 Noisy breathing due to laryngeal
oedema may occur.

22. SURGICAL MANAGEMENT
 INCISION & DRAINAGE
EXTRAORAL APPROACH
 An incision is made along the anterior
border of sternocleidomastoid muscle,
extending from below the angle of mandible
to the middle third of submandibular gland.
 The fascia behind the gland is incised and a
curved hemostat is inserted and carefully
directed medially behind the mandible, as
well as superiorly and slightly posteriorly
until the abscess cavity is reached and pus
evaluated and drain inserted.

23. INTRAORAL APPROACH-
 A vertical incision is made on pharyngeal
wall lateral to midline .
 Using haemostat abscess cavity is opened
by blunt dissection while patient is in
trendlenberg position to avoid aspiration of
pus
 Tracheostomy is indicated if required.

24. PRETRACHEAL SPACE
 It is the anterior portion of space 3 of
grodinsky and Holyoke
BOUNDARIES-
 ANTERIORLY-STERNOTHYROID-THYROHYOID
FASCIA
 POSERTORLY-Retropharyngeal space
 SUPERIORLY-Thyroid cartilage
 INFERIORLY-Superior mediastinum
 MEDIALLY-Sternothyroid-thyrohyoid fascia
 LATERALLY—Thyroid gland

25. TREATMENT USING CLOSED SURGICAL
DRAIN
• A 3 cm-long skin incision was made along the anterior
margin of the sternocleidomastoid muscle, and the spaces
that were infected, as confirmed by CT, were approached
through dissection while minimizing the damage on the
anatomy and avoiding wide patency if possible .
• Drainage of pus and gas was observed after penetrating
the identified fascia. While the infected spaces were being
observed, finger dissection was performed to prevent
damage of the anatomy, and then inter-space connection
was observed .All the exposed spaces reached were
intensively irrigated.

26. DANGER SPACE
 Potential space between the alar and
prevertebral divisions of the deep layer of
the deep cervical fascia
 Boundaries
• Superiorly:-base of the skull.
• Inferiorly:- upper border of diaphgrm.
• Laterally:- fusion of alar and prevertebral
fascia at transverse process of cervical and
thoracic vertebrae.
• Anteriorly:- alar fascia.
• Posteriorly:- prevertebral fascia.

27. WHY IT IS CALLED DANGEROUS
SPACE?
At the inferior border it continuous with the posterior
mediastinum containing vena cava ,arch of aorta, thoracic
duct, trachea and esophagus
Erosion of major blood vessels, lower airway and upper
digestive tract
Death of patient.

28. CLINICAL FEATURE
 Swollen neck
 Stridor
 Stiffness of neck
 Severe dyspnea
 Pain
 Widened mediastinum
TREATMENT PLAN-
 SURGICAL DRAINAGE OF NECK AND MEDIASTINUM WITH IV
ANTIBOITICS.

29. VISCERAL VASCULAR SPACE
 Space within carotid sheath.
 It is termed as ‘LINCOLN’S HIGHWAY’
 It extends from base of skull into
mediastinum and because it receives
contribution from all three layers of
deep fascia it can be secondarily
involved by infection by direct spread.

30. PREVERTEBRAL SPACE
 Extends from skull base superiorly to
diaphragm inferiorly.
 Fascia is attached to transverse process of
cervical vertebra dividing this space into
anterior and posterior compartments.
 CONTENTS OF ANTERIOR COMPARTMENT
1.Vertebral bodies
2.Spinal cord
3.Vertebral arteries
4.Phrenic nerves
5.Prevertebral and scalene muscles
 CONTENTS OF POSTERIOR COMPARTMENT-
Posterior vertebral elements.

31.  Potential space between two layers of prevertebral fascia
(alar and prevertebral layers)
 Mediastinitis is concern with prevertebral space infections
similarly to retropharyngeal space infections

32. PERITONSILLAR SPACE
 Consists of an area of loose connective tissue between the
fibrous capsule of palatine tonsil medially and superior
constrictor laterally.
Clinical evaluation
 3-7 days history of pharyngitis without resolution
 Severe sore throat, dysphagia, odynophagia and referred
otalgia.
 Speech is muffled and classically described as ‘hot
potato’.

33. BOUNDARIES
 Medially- capsule of palatine
tonsil
 Laterally- superior pharyngeal
constrictor
 Superiorly- anterior tonsillar pillar
 Inferiorly- posterior tonsillar pillar

34.  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 than
spreading laterally the infection
spreads vertically.

35. PAROTID SPACE INFECTION
CONTENTS: –
 Parotid gland
 Parotid lymph nodes
 Facial n.
 Retromandibular vein
 External carotid artery
ETIOLOGY: – From extension of infection from
submasseteric, pterygomandibular, lateral pharyngeal
spaces, – Blood-borne infection, retrograde infections
through the stensons duct.

36. BOUNDARIES :
 LATERALLY- Thick parotid
capsule
 MEDIALLY- Styloid process and
carotid sheath
 SUPERIORLY- Tmj and external
auditory meatus
 POSTERO INFERIORLY- mastoid
process, sternocleidomastoid,
posterior belly of digastric

37. Clinical evaluation:
 The symptoms of parotitis include pain and
induration over the involved gland.
 Purulent marked swelling of the angle of the
jaw without associated trismus or pharyngeal
swelling.
 Secretions may sometimes be expressed
after massage from the parotid depth.
 Very characteristic pitting edema of the
gland is feature for parotid gland abscess.

38. Drainage of parotid space
infection

39. COMPLICATIONS
 Respiratory paralysis – acute edema of pharynx
 Thrombosis of internal jugular vein.
 Erosion of internal carotid artery.
 Mediastinitis
 Cavernous sinus thrombosis
 Meningitis and brain abscess

40. PRINCIPLES OF INCISION AND
DRAINAGE(TOPAZIAN 1987)
 Incise in healthy skin and mucosa where there is maximum fluctuance.
 Place the incision in esthetically acceptable area.
 When possible place incision dependent position to encourage drainage
by gravity.
 Dissect bluntly with closed surgical clamp or finger & explore all portion
of abscess cavity.
 Place drain and stabilize it with sutures.
 Use through-and through drain in bilateral, submandibular space
infections.
 Avoid overly extended period of drain.
 Clean the wound margin daily,remove clots,debris.

41. TREATMENT
MEDICAL THERAPY-
 Hospitalization
 Supportive care-
• Aids in patients own body defenses on combating infection.
• Administration of antibiotics.
• Hydration of patient.
• Analgesic for pain .

42.  SURGICAL THERAPY
SURGICAL TECHNIQUE FOR INCISION AND DRAINAGE OF
AN ABSCESS:
Incision and drainage helps the following:
- To get rid off toxic purulent material
- To decompress the edematous tissues.
-To allow better perfusion of blood, containing antibiotic and
defensive elements.
-To increase oxygenation of the infected area.

43. HILTON’S METHOD OF INCISION AND
DRAINAGE
The method of opening and abscess ensures that no blood
vessel or nerve in the vicinity is damaged and is called
Hiltons method.
STEPS:
- Anesthesia
-Stab incision made over a point of maximum fluctuation in
the most dependent area along the skin creases through skin
and subcutaneous tissue.
-If pus is not encountered further deepening of surgical site
is achieved with sinus forceps (to avoid damage to vital
structures).
-Closed forceps are pushed through the tough deep fascia
and advanced towards pus collection.

44. Abscess cavity is entered and forceps opened in a direction parallel
to vital structures.
-Pus flows along the sides of beaks.
-Explore the entire cavity for additional loculi.
-Placement of drains
Corrugated rubber drain is inserted into the depths of the abscess
cavity and external part is secured to the wound margin with help
of suture
-Drain is left for at least 24 hours.
-Dressing is applied over the site of incision taken extra orally
without pressure.

45. PURPOSE OF KEEPING THE DRAIN:-
The purpose of drain is to allow the discharge fluids and pus
from wound by keeping it patent. The drain allows for
debridement of abscess cavity by irrigation.
Tissue fluids flow along the external surface of a latex drain.
Hence it is not always necessary to make perforations in the drain,
which could weaken and perhaps cause fragmentation within the
tissues.
REMOVAL OF DRAINS:-
Drains should be removed when the drainage has nearly
completely ceased. Drains are left in infected wounds for 2-7 days.

46. REFERENCES
• ORAL AND MAXILLOFACIAL INFECTIONS – TOPAZIAN
• OUTLINES OF ORAL SURGERY – KILLEY AND KAY
• ORAL AND MAXILLOFACIAL SURGERY – DANIEL M LASKIN
• Internet

47. THANK YOU