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Applied Anatomy of Fascial SpacesIn Head and NeckAuthor(s): Singh T.P., Bala Sanju, 1Kalsey G., 1SinglaRajan K.

Vol. 49, No. 1 (2000-01 - 2000-06)

Department of oral and Maxillofacial Surgery, Pb. Govt. Dental College, Amritsar.1Department of Anatomy, Government Medical College, Amritsar. Punjab INDIA.

Abstract:

Fascial spaces in head and neck find no mention in standard text books of anatomy(Williams et al, 1999 or Huber, 1930) though Hollinshead (1958) has described these withsome of their clinical aspects. Does it mean that these are not clinically important or theirimportance has decreased with the advent of antiboitics and so these should not betaught to medical and dental students. Actually it is not so. Neither the patients orabscesses in these spaces have vanished nor have these lost importance. So basicknowledge of these is a must for both medical and dental students For importing thisinformation Faculty of Anatomy including P.G. Students and budding specialists in oraland Maxillofacial Surgery should have a clear cut picture of these in their mind, However,there are numerous discrepancies. This is particularly due to the fact that there aremultiplication in the observations making the description of a fixed pattern difficult. Anattempt is made to classify and discuss important anatomical and clinical aspects aboutthese spaces.

Keywords: Fascial spaces, Supra-hyoid spaces, Infrahyoid spaces

Introduction

A sizeable segment of patients reporting to the oral and maxillofacial surgery departmentof Pb. Govt. Dental College and Hospital, Amritsar needing surgical intervention forinfections of the fascial spaces of head and neck and the difficulty in locating exactly thespaces involved in these cases has given an impetus to revise and review the fasciaeand fascial spaces in the different outlooks. Here it is pertinent to keep in mind that manyother patients might have reported to the other institutes and/or private practitioners andmany more might have undergone non-surgical interventions as well. The inherentdifficulty in dissecting these structures and varied approaches in describing these bydifferent authors led to more of controversies and less of a clear and fixed pattern as isevident by reviewing different books of reference on this subject. It has been a subject ofgreat controversy since its first description by Burns (1811). Hollinshead (1958) devoted achapter to these mainly because of their clinical significance and recognition as ananatomical entity. Almost all the textbooks of oral and maxillofacial surgery (Moore; Killeyet al, 1975; Topazian and Goldberg, 1991 and Srinivasan, 1996) and ENT (Paparella etal, 1991) have laid a great stress on these.

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The pioneer work of Burns (1811) kindled a spark of light for further research by variousworkers on fasciae and fascial spaces in head and neck. Velpaeu (1826-37); Froriep(1834); Malgaigne (1838); Richet (1857); Dittel (1857); Gruber (1868); Juvara (1870);Henke (1872); Tillaux (1882); Poulson (1886); Taguchi (1890) and Merkel (1892) are afew to name who worked hard to solve this controversy during the 19th century. Howeverthe mystery remained unsolved as is well indicated by Malgaigne's statement that, "thecervical fasciae (and hence spaces as well) appear in a new form under the pen of eachauthor who attempts to describe them." During the earlier years of 20thcentury thereappeared the works of Testut (1902); Charply (1912); Dean (1919); Mosher (1920 and1929): Furstenberg (1929): Coller and Yglesia (1935 and 1937) and Grodinsky andHolyoke (1938) who have added a lot to our knowledge of the subject. During the recentyears Archer (1966); Barker and Davies (1972); Killey et al (1975): Moore; Paperella et al(1991); Topazian and Goldberg (1991) and Srinivasan (1996) have discussed theiranatomical and clinical facts in good stead. The purpose of the article is to review theearlier works to find out the controversies and their solutions and to make out an easilyunderstandable, reproducible and clinically significant explanation of these fascial spaceswhich have long lured the anatomists and oral and maxillofacial surgeons.

Definition

The fascial spaces in head and neck are the potential spaces between the various layersof fascia normally filled with loose connective tissue (Shapiro, 1950) and bounded byanatomical barriers, usually of bone, muscle or fascial layers (Moore). However, theireffectiveness varies as in some sites the fascial membranes particularly are so weak andindefinite that they do not contain the infection (Moore). Last (1972) names thebuccopharyngeal fascia as a very delicate fascial layer which is unable to contain theidentified on anatomical specimens. In life, these infected cavities are formed partly bythe destruction of tissue by inflammatory enzymes and so during the course of aninfection they take some time to become patent (Moore).

Classification

Unfortunately, there are many classifications of these spaces. Almost all of these classifythese spaces into suprahyoid and infrahyoid spaces. Scott (1952) classified fascialspaces of head and neck as follows:

(A)Suprahyoid spaces:

1. Superficial facial compartment

2. Floor of the mouth(a) Sublingual space(b) Submandibular space(c) Submental space

3. Masticator space

(a) Temporal space :

- Superficial

- Deep

(b) Submasseteric space(c) Superficial Pterygoid space

4. Parapharyngeal space including deep pterygoid space

5. Parotid compartment

6. Paratonsillar space



7. Space of the body of mandible. (Described by Coller and Yglesias, 1935)

(B)Infrahyoid spaces - these are classified by Hollinshead (1958) as follows.

1. Visceral compartment

(a) Pretracheal space / Previsceral space

(b) Retrovisceral space

2. Visceral space

3. Other spaces

(a) Cavity within carotid sheath

(b) Space between 2 layers of prevertebral fascia. Grodinsky and Holyoke (1938) basedupon the data of dissected materials, results of spread of injected masses and infectionsobserved clinically, designated and described these spaces by numerals (spaces ofanterior triangle) and numerals followed by letter A (spaces of posterior triangle) asfollows:

(i) Space 1 - Superficial facial compartment

(ii) Space 2 and 2A - Described separately

(iii) Space 3 and 3A - Visceral compartment and space within carotid sheath respectively.

(iv) (a) Space 4 - Space between 2 laminae of prevertebral fascia

(b) Space 4A - Described separately

(v) Space 5 and 5A - Described separately

(A) Suprahyoid spaces

1. Superficial facial compartment

(a) Boundaries

Superiorly - Inferior border of zygomatic arch

- Infraorbital margin

- Zygoma

Inferiorly - Lower border of mandible

Anteriorly - Anterior bony aperture of nasal cavity superiorly

- Anterior nasal spine to symphysis menti inferiorly

Posteriorly - Posterior border of ramus of mandible where it meets fascial covering ofparotid gland

Superficially - Skin and superficial fascia containing platysma if present

Deep - Buccinator

- Masseter

- External aspects of mandible and maxilla

(b) Communi- - With pterygoid cations space deep to ramus of mandible

(c) Contents - Muscles of facial expression



- Buccal pad of fat

- Branches of facial vessels and nerves

- Lymph nodes(Moore)

Fig. 1. The Superficial facial compartment

The superficial facial compartment corresponds to space 1 of Grodinsky and Holyoke(1938) in face. Space 1 as described by them is a potential space between skin andsuperficial layer of deep fascia extending in whole of head and neck and upper part ofthorax. In neck and upper thorax, it can be subdivided into superficial and deep divisionsby platysma both divisions being fairly loose and allowing moderate accumulation of fluid.In face, it is likewise subdivided by muscles of facial expression and in scalp byepicranius muscle. In face, the subcutaneous fat is minimal in eyelids and so greatestamount of swelling is apt to occur there in subcutaneous region and deep to muscles offacial expression in rest of the face. In scalp, swelling can occur in loose areolar tissuedeep to the epicranius muscle. In axilla, fat of space 1, becomes continuous with fatwithin the axillary space through the opening in the deep fascia of the axilla, placing the 2spaces in communication.

(d) Subdivisions: (Topazian and Goldberg, 1991 and Laskin 1996).

(i) Canine space: It overlies the canine fossa of maxilla and underneath levator labiisuperioris and levator labii superioris alaquae nasi. Gap between two preceeding musclesaffords an opening near the inner corner of the eye through which the skin surface maybe reached (Laskin, 1996).

(ii) Buccal space:It has following boundaries:

Laterally - skin and subcutaneous tissue

Medially - Buccinator and buccopharyngeal fascia

Anteriorly - Labial musculature

- Posterior border of z. major above

- Depressor anguli oris below

Posteriorly - Pterygomandibular raphe and anterior edge of masseter muscle

Superiorly - Zygomatic arch

Inferiorly - Lower border of mandible

Contents - Buccal pad of fat

- Parotid duct

- Facial artery

(e) Clinical implications:

Canine space may be infrequently involved in odontogenic infections (roots of maxillarycanine) and is even less frequently implicated in nasal infections (Topazian and Goldberg,1991). From here pus can track superiorly into the superficial fascial compartment uptomedial angle of the eye or even lower eyelid (Moore). Infection from maxillary premolarscan pass upwards and posteriorly through infraorbital foramen to the orbit andsuperomedially to nasolacrimal duct and nose. Infection from maxillary molars can spreadto buccal space (Moore).



Fig.2. The Deep facial speaces

2. Floor of the Mouth: (See Fig. 2)

(i) Sublingual spaces: (Fig 2 and 3)

These are present above the myelohyoid muscle, largely paired but communicate witheach other anteriorly (Williams, 1940).

(a) Boundaries:

Laterally - Alveolar process of mandible above myelohyoid line.

Medially - Genioglossus and geniohyoid

Roof - Mucosa of oral cavity

Posteriorly - Body of hyoid bone at midline along with geniohyoid, genioglossus andstyloglossus muscles.

(b) Contents : - Deep part of submandibular salivary gland and submandibular duct -Sublingual salivary gland - Lingual vessels and nerve - Hypoglossal nerve

(c) Communications :

It communicates with submandibular space posterior to the posterior border of myelohyoidmuscle. (Srinivasan, 1996)

Coller and Yglesias (1935) subdivided sublingual space into as many as 3 compartments.

ii) Submental space : It is a conical, small anterior, midline, single space (Fig. 2).

(a) Boundaries :

- Anterosuperiorly- Symphysis menti

(Apex of Cone)

- Posteroinferiorly- Hyoid bone

(Base of Cone)

- Superolaterally - Anterior bellies of digastric

- Superficially - Skin

- Superficial fascia containing platysma

- Deep fascia

- Deep - Myelohyoid muscle

(b) Contents: Anterior Jugular vein, Submentallymph nodes

(c) Communications:

- It communicates with submandibular space posteriorly.

(d) Clinical significance :

- It may be involved in infections of mandibular incisors causing a swelling at the point ofchin. (Tiecke et al 1959; Sicher 1960)

(iii) Submandibular spaces : (See Fig. 3)

These bilateral spaces, are located lateral to submental space.



(a) Boundaries:

Superiorly - Myelohyoid and genioglosus

Inferiorly - Skin

- Superficial fascia containing platysma

- Deep fascia

Laterally - Lingual aspect of mandiblebelow myelohyoid line.

Anteroinferiorly - Anterior belly of digastric

Posteroinferiorly - Posterior belly of diagastric

This space is enclosed in investing layer of deep cervical fascia, its superficial layer beingattached to lower border of mandible and deep layer to myelohyoid line.

(b) Contents :Superficial part of submandibular salivary gland, Submandibular lymphnodes, Myelohyoid vessels and nerves

(c) Communications:

- Superficial fascial compartment

- Parotid compartment

- Sublingual space from posterior border of myelohyoid

- Deep pterygoid space (Srinivasan, 1996)

The boundary line between submental and submandibular space is anterior belly ofdigastric but Grodinsky and Holyoke (1938) observed that injections spread readilybeneath the anterior belly of digastric from one space to the other.

(d) Clinical Implications:

Submandibular space is perhaps the most commonly involved space in primary infectionsof head and neck. Infection may arise from injuries to the oral mucosa, submandibular orsublingual gland sialadenitis or infection from roots of mandibular teeth.

Fig. 3 Routes of Spread of Infection From Periapical Abscess

Fig. 4. Coronal Section Showing Surperficial Pterygoid and Temporal Spaces

3. Masticator space :

So called by Coller and Yglesias (1935) is a space formed by splitting of deep cervicalfascia at the anterior, posterior and inferior borders of mandibular ramus to include ramusof mandible, massetor, medial et lateral pterygoid and that part of temporalis musclewhich is attached to the coronoid process. This space has following recesses orsubdivisions-

(a) Temporal or zygomatico temporal space - it is a superior extension of the masticatorspace both superficial and deep to temporalis muscle and named accordingly. It is limitedsuperficially by thick sheet of temporalis fascia arising from zygomatic arch and extendingupto superior temporal line.

(b) Submasseteric space (Fig. 4) it is an inferior extension between lateral surface oframus of mandible and deep surface of masseteric muscle and in between the three



layers of the masseteric muscle. (Srinivasan, 1996).

(c) Superficial pterygoid or pterygmandibular space (Fig. 4) it is also an inferior extensionbetween medial surface of ramus of mandible laterally, lateral surface of medial pterygoidmuscle inferomedially and lateral pterygoid muscle superomedially (Barker and Davies,1972).

Contents:-Inferior alveolar nerve and vessels- Lingual nerve - Mandibular nerve- Maxillary artery - Loose connective tissue and fat

Kostrubala (1945)has described spaces which are more or less subdivisions of masticatorspace.

Clinical Significance :

(a) Masticator space may be infected from infection of zygoma, temporal bone or lowermolar teeth (Coller and Yglesias, 1935). Hall and Morris (1941) Srinivasan (1996)categorized the causes of infection of this space as follows :-

(i) Infection of mandibular molars

(ii) Infection of pterygomandibular space due to septic needles during the inferior dentalnerve block anaesthesia.

(iii) Trauma to mandible involving molar teeth.

(b) Abscess in this space may point at anterior border of masseter muscle either into thecheeck or mouth or posteriorly beneath the parotid gland.

Fig.5. Spread of Infection From 3rd Molar to VariousFascial Spaces

4. Parapharyngeal space: (Fig. 5)

It is also known as lateral pharyngeal space, peripharyngeal space, pharyngomasticatorspace, pharyngomaxillary space, or pterygopharyngeal space.

These lie immediately posterior and lateral to the pharynx, and extend forwards into thesublingual region, so that together they actually form a ring about the pharynx. They lieentirely deep to the superficial or anterior layer of the deep fascia, and communicate moreor less freely with each other around the muscles and vessels which traverse them.

Since they intervene between the interfascial spaces and the mandible, on the one hand,and the pharynx on the other, they are liable to infection from either of these sources byextension from them; moreover, it is these spaces which are most intimately related to thelymph nodes receiving the drainage from the nose, throat and jaw, so that abscesseswithin them may develope as a result of breakdown of nodes secondarily infected fromtheir regions of drainage. It is one or more of these spaces that is more commonlyinfected in the neck.

For convenience of description, parapharyn-geal space can be divided into :

(i) Lateral pharyngeal space:

This space has been described as being pyramidal with apex directed inferiorly towardsthe lesser cornu of hyoid bone and base directed superiorly towards skull base (Paparellaet al, 1991).

(a) Boundaries :



Anteriorly - Posterior pharyngeal wall

Posteriorly - Vertebrae and their attached ligaments and muscles

Laterally - Deep cervical fascia covering medial surface of medial pterygoid muscleanteriorly and styloid process with its attached structures posteriorly and deep surface ofparotid gland in between.

Medially - Tough midline fibrous septum separating two parapharyngeal spaces.

Fascia covering pharyngeal constrictors and tensor et levator palati (Paparella et al,1991).

Superiorly - Deep pterygoid space and if that is considered a part of it, then base of skull.

Inferiorly - It extends upto hyoid bone where it is limited by fusion of fascia over,submandibular gland with fascia over stylohyoid and posterior belly of digastric(Hollinshead, 1958; Paparella et al, 1991; Srinivasan, 1996). It is to be noted here thatinferiorly the space communicates with superior mediastinum along the carotid sheathand its communication with retropharyngeal space.

(b) Divisions and Contents :

The lateral pharyngeal space is subdivided by styloid process into two compartments -anterior and posterior, not separated from each other, in anatomical sense.

(i) Anterior compartment (called pre styloid compartment by Hall, 1934 and Paparella etal, 1991) contains lymph nodes, ascending pharyngeal and facial arteries, maxillaryartery, inferior alveolar nerve, lingual nerve, auriculotemporal nerve and loose areolartissue.

(ii) Posterior compartment (called post styloid compartment by Hall, 1934 and Paparellaet al, 1991) contains carotid sheath with its contents, 9, 11, 12th cranial nerves andcervical sympathetic chain.

(c) Communications:

(i) Superiorly to deep pterygoid space bounded by medial pterygoid laterally, pharyngealwall medially and base of skull superiorly.

(ii) Inferiorly with superior mediastinum of thorax along the carotid sheath.

(iii) Coller and Yglesias (1935) pointed out that it communicates with carotid sheath.

(iv) Submandibular space, (deep to the floor of submaxillary capsule) thus coming inrelationship with floor of the mouth (Grodinsky and Holyoke, 1938).

(d) Clinical Significance:

According to Hollinshead (1958), parapharyngeal space is more subject to infection thanany of other spaces. It may recieve infection from teeth, submandibular gland, masticatorspace, parotid space and paratonsillar space. From this space infection can pass toretrophargyngeal space and then to superior mediastinum.

Grodinsky (1939), Faier (1933) and Beck (1942) all agree that causative agent for thisinfection lies in nose, throat, middle ear, pharynx and tonsils and that lymphatic spread isthe mode of infection. However about 20% of infections in Beck's (1942) series and about1/3rd of adult cases in Boemer's (1937) series arose from infections of dental originpassing to these spaces via lymphatics as well as via root canals. Rarely fatalhaemorrhage can occur from extension of an abscess to deep vessels of neck mainlyinternal carotid artery (Lifschutz, 1931).

Capes et al (1999) reported a case of bilateral cervicofacial, axillary and anteriormediastinal emphysema as a rare complication of 3rd molar extraction with spread of airoccuring through masticatory and then parapharyngeal and retropharyngeal spaces.



Since the masticatory, parapharyngeal, retropharyngeal, vascular and pretracheal spacesare in direct communications with mediastinal spaces of thorax (Hollinshead, 1958,Sicher, 1975), the air under either positive or negative pressure may find its way from theface down to the neck and mediastinum (Rhymes, 1964). Further quoting the works ofChen and Chen (1986), Capes et al (1999) emphasize that if inflowing air containsbacteria serious infections ensue.

(ii) Retropharyngeal space:

This is discussed under the broad heading of parapharyngeal spaces by Hollinshead(1958). It is the area of loose connective tissue lying behind the pharynx and in front ofprevertebral fascia.

(a) Boundaries:

Anteriorly - Posterior wall of pharynx

Posteriorly - Pre vertebral fascia

Superiorly - Base of skull

Inferiorly - Communicates with superiormediastinum

(b) Clinical Significance :

It acts as a route through which infection from the mouth and throat can reach thesuperior mediastinum. Pearse (1938) pointed out that 71% of cases of mediastinitis aredue to spread through this space. However, New and Erich (1939) could not find a singlecase of mediastinitis secondary to cervical infection in 267 cases they studied.

Belcerek et al (1988) reported three cases of fatal cervicofacial necrotizing fasciitisspreading to mediastinum possibly through this pathway.

5. Parotid compartment: (Fig. 2)

The parotid gland is completely enclosed in a well defined compartment of deep fasciaderived from superficial layer of deep cervical fascia. It becomes very thin on its deepaspect antero-superior to the thickened stylomandibular ligament where it can readilyrupture. Since the parotid gland is strongly attached to its surrounding fascia, the parotidspace is therefore not so much an anatomical as a clinical one (Hollinshead, 1958).

(a) Contents: - Parotid gland with structureswithin its substance - Superficial parotid lymphnodes on lateral aspect of the gland. - Deepparotid lymph nodes within the gland

(b) Surgical Significance:

Infection in this space may be because of infection of gland or lymph nodes and not acellulitis in loose connective tissue. This infection according to Grodinsky and Holyoke(1938) and Coller and Yglesias (1935) may readily pass deep to parapharyngeal space.

6. Paratonsillar space: (Fig. 5)

This space contains palatine tonsils

(a) Boundaries:

Laterally - Superior pharyngeal constrictor

Medially - Mucous membrane of anterior and posterior pillar of fauces

Superiorly - Extends into soft palate which is considered its part



(b) Communications:

It communicates with deep pterygoid space along tensor veli palatini.

According to Wood (1934), injections into the para-tonsillar spaces tend to spreadlongitudinally but not transversally. These may extend as high as hard palate orpharyngeal orifice of eustachian tube and as low as piriform sinus.

(7) Space of the body of the mandible

Referring to Coller and Yglesias (1935), Hollishead (1958) describes this space to beformed by attachment of superficial layer of deep cervical fascia to both outer and innersurfaces of the body of mandible. Outer lamina is attached to lower border while deeperlamina is said to be easily elevated from the mandible upto mylohyoid line.

(a) Boundaries :

Anteriorly - Attachment of anterior belly of digastric.

Posteriorly - Attachment of medial pterygoid to jaw.

Inferiorly - Closed by continuity of fascial layers

Superiorly - Closed by attachment of layers of mandible at myelohyoid line.

(b) Surgical significance:

1. Infection in this space can occur from osteomyelitis secondary to dental infections. Itmay remain localized, may discharge into mouth or may spread to masticator space.

2. This space can be drained by an incision through buccal gingival mucosa or externallyalong inferior border of mandible.

3. Infection in this space may spread by rupture of its wall into the masticator spaceposteriorly or submandibular space inferiorly.

(B) Inframoid Fascial Spaces:

Following pattern of Hollinshead (1958), the classification is as below :

1. Visceral compartment :

The area of loss connective tissue surrounding the thyroid gland, trachea andoesophagus as a whole was long known as visceral compartment. Around the upper partsof trachea oesophagus and thyroid gland, this compartment surrounds these structurescompletely while below the level where inferior thyroid artery enters the thyroid gland, it isdivided into 2 portions by a dense connective tissue layer attaching oesophagus laterallyto carotid sheath and prevertebral fascia. The anterior part of the compartment, surroundsthe trachea and lies against the anterior wall of esophagus and is known as previsceral orpretracheal space. The posterior part of the compartment lying behind the pharynx andoesophagus is known as retrovisceral, retropharyngeal, retroesophageal or post visceralspace (Hollinshead, 1958). (These 2 previsceral and retrovisceral spaces togethercorrespond to space 3 of Grodinsky and Holyoke,1938).

(a) Pre-tracheal space

Boundaries:

Superiorly: limited by attachment of strap muscles and their fascia to thyroid cartilage andhyoid bone.



Inferiorly:continuous with superior mediastinum and extends upto upper border of arch ofaorta (Body of T4 vertebra), where it is limited by dense adhesions between fibrouspericardium and posterior surface of sternum.

Laterally: It is blind at root of the neck because of dense adhesions between alar andvisceralfasciae.

Clinical importance:

1. This space can get infected from retrovisceral space, around the sides of esophagusand thyroid gland between the levels of upper border of thyroid cartilage and inferiorthyroid artery; or directly by anterior perforation of oesophagus.

2. The space can be opened by an incision anterior to sternocleidomastoid carriedmedially behind the carotid sheath.

(b) Retrovisceral space

Boundaries:

Superiorly: base of skull (behind the pharynx)

Inferiorly: superior mediastinum. However this level varies from C6-T4 vertebra by fusionbetween prevertebral fascia and fascia on posterior surface of oesophagus (Grodinskyand Holyoke, 1938). Coller and Yglesias (1937) gave the lower level of this space atabout bifurcation of treachea, but their lower part is probably same as danger space orspace 4 of Grodinsky and Holyoke (1938).

Clinical importance:

1. This is the important route for spread of infections originating in head and upper portionof neck to superior mediastinum (as much as 71% as reported by Pearse, 1938).

2. This space may be infected by posterior perforation of oesophagus or infection of deepcervical lymph nodes.

3. According to lglauer (1935) it can be approached by an incision posterior tosternocleidomastoid carried medially behind the carotid sheath and its great vessels.

II. Visceral space:

The oesophagus is enclosed in a connective tissue sheath continuous above withbuccopharyngeal fascia, posterior surface of pharynx and adjacent to surface of thyroidgland and trachea. Grodinsky and Holyoke (1938) call this the visceral fascia. Thevisceral space is a potential space which may be imagined to exist between visceralfascia and the organs themselves (may these be trachea or oesophagus). Actually, thisvisceral fascia is firmly united to structures which it covers and the visceral space in thelatter sense does not really exist. Also infections lying deep to the fascia on oesophagusdo not tend to spread within this fascia up and down the oeasophagus but ratherperforate it to reach the visceral compartment.

III. Other spaces:

(a) Cavity within carotid sheath: This alongwith visceral space is grouped undervisceral vascular space by Coller and Yglesias (1935) who point out that infection fromvisceral space readily spreads to the potential cavity within carotid sheath, later alsobeing a pathway for the spread of infections from upper to the lower part of the neck andinto the mediastinum. According to Pearse (1938), 21% of mediastinal suppurations



originating in neck spread along this pathway.

(b) Space between 2 laminae of prevertebral fascia as it passes from transverseprocesses of one side to the other. Its presence has apparently been ignored in manystudies of fascial spaces of the neck, yet it is easily demonstrated in most dissections.After the prevertebral layer of deep cervical fascia attaches to transverse processes, itdivides into an anterior alar fascia forming posterior boundary of retrovisceral space anda posterior prevertebral fascia proper lying anterior to prevertebral muscles andvertebrae. Between these two layers lies this space which has been designated asspace 4 or danger space by Grodinsky and Holyoke (1938). This space is alsodesignated as prevertebral space, but this is not clear and Grodinsky and Holyoke (1938)reserve the term prevertebral space for the potential cleavage plane between posteriorlayer of prevertebral fascia and vertebral bodies (space 5). Anyhow, this space liesbehind the retrovisceral space and between alar and posterior layers of prevertebralfascia.

Accoding to Grodinsky and Holyoke (1938), this is almost an actual rather than apotential space and extends upwards till base of skull and downwards upto diaphragm.Since it is closed above, below and laterally, it can be infected only through wallscommonest being from anterior wall. They furtheited to superior mediastinum but mayextend throughout the length of posterior mediastinum.

Apart from the spaces described above Grodinsky and Holyoke (1938) describedfollowing more spaces:

(i) Space 2 : This space is present in paramedian position anteriorly

(a) Boundaries:

Superficially - Skin

Superficial fascia with platysma

Superficial layer of deap fascia

Deep - Deep surface of sternothyroid fascia

Deep surface of thyrohyoid fascia

Medially - Continuous with fellow of opposite side

Leterally - Blind where sternothyroid and sternohyoid fuse with sternomastoid sheath

Superiorly - Blind at hyoid bone and along superior belly of omohyoid

Inferiorly -Blind at clavicle because of attachment of superficial layer of deep fascia andsternothyroid and sternohyoid layers to sternum and clavicle.

(b) Contents: Sternohyoid muscle superficially

Sternothyroid and thyrohyoid with their anterior sheaths

Superior belly of omohyoid

(c) Communications: Along pully of omohyoid muscle to space 2A

May be to space 1 and 3 also.

(ii) Space 2A: This lies in posterior triangle

(a) Boundaries:

Superficially - Skin



Superficial fascia with platysma

Deep - Sheath of inferior belly of omohyoid

Anteriorly - Blind at posterior border of Sternomastiod

Posteroin - Blind at attachment of feriorly omohyoid fascia and deep cervical fascia toclavicle and scapula.

(b) Communication: Along pully of omohyoid to space 2.

(iii) Space 4A: It is the space lying in posterior triangle between superficial layer of deepfascia and scalenus fascia.

(a) Boundaries:

Superficially - Skin, superficial fascia, superficial layer of deep fascia.

Deep - Scalenus fascia and space 5 A

Anteromedially Sternomastoid sheath, carotid sheath and Transverse process ofvertebrae.

Superolaterally It extends between sheaths of trapezius and splenius capitis to vertebralspines

Superiorly - Junction of sternomastoid and trapezius.

Anteriorly - In subclavian triangle-inferior belly of omohyoid.

Inferolaterally - It is open to axilla because its superficial boundary (deep fascia) isattached to 1st and 2nd ribs and deep boundary (scalenus fascia) to clavicle.

(iv) Space 5: This is a potential space between prevertebral fascia and vertebral bodieslimited laterally upto transverse processes of vertebrae.

(a) Boundarie:

Superiorly - Base of skull

Inferiorly - Coccyx

Laterally - Transverse process of vertebrae

Anteriorly - Prevertebral fascia

Posteriorly - Vertebral bodies

(b) Communications :

At various levels along the spinal column where muscles have attachment to the bodiesof the vertebrae; their sheaths are continuous with prevertebral fascia and the spaceswithin their sheaths with space 5.

(c) clinical importance :

Because of its communications, it is possible for collection of pus in this space to travelgreat distances before pointing superficially e.g. caries of cervical or thoracic vertebrae,extending down space 5, transferring to space within the psoas major sheath andpresenting below the inguinal ligament at insertion of that muscle into lesser trochanter.

Endelman (1927)quoted by Mahler et al (1971) reported a sinus from dental infectionwhich opened on chest and another on the upper one third of thigh. Later could bebecause of tracking of pus along this space.

V. Space 5A : This lies in the posterior triangle



deep to scalenus fascia

(a) Boundaries:

Superiorly - An apex at junction of sternomastoid and trapezius.

Inferiorly - Blind at attachment of scalenus fascia to 1st and 2nd rib which limits it fromaxilla.

Superficially - Skin, superficial fascia and space 4A.

Deep - Floor of posterior triangle

Medially - Transverse processes and spines of vertebrae.

(b) Contents: Cords of brachial plexus take origin in this space and as they crossposterior triangle of neck into axilla, receive an axillary sheath from anterior wall of thisspace (Scalenus fascia)

(c) Clinical implications:

The potential space within axillary sheath is in continuation with space 5A and infectioncan track from here to upper limb. However, Grodinsky and Holyoke (1938) by injectionmethod found this communication not very free.

Pus can also go to lowest limit of space i.e. 2nd rib or to thorax but extra pleurally.

Summary and Conclusions

The literature on the subject of fascial spaces in head and neck has been reviewed andthe discrepancies in observations and description noted. Their anatomy, communicationsand surgical significance is discussed. It is found that understanding their anatomy is amust to appreciate the likely spread of an infection. The first permanent tooth to erupt inhuman beings is first molar (maxillary and mandibular) and these are commonest sourceofinfection for these spaces because of their being commonly involved in caries. 2ndimportant source of infection is impacted third molar which may be involved inpericoronitis though not carious. From these, the commonest spaces involved are sublingual (first molar) and submandibular (commonly from 2ndor 3rdMolar and sometimesfrom Ist molar). However these 2 spaces communicate with each other at posterior borderof myelohyoid. Also submandibular space communicates withsuperficial facial compartment where the pus can track. It also communicates with parotidspace and through that to pterygomandibular space and then to deep pterygoid space,later being considered superior recess of lateral pharyngeal space. Thus infection canreach lateral pharyngeal space and from there to retropharyngeal space whichcommunicates with superior mediastinum of thorax. Once that is involved, it becomes apotentially life threatening situation.

Another such clinical situation is ludwig angina in which there is bilateral involvement ofsublingual, submandibular and submental spaces. Involvement of sublingual space leadsto lifting of tongue causing airway obstruction. This condition has to be treated surgicallyby incision and drainage to relieve patient of respiratory distress.

Thus merely a carious tooth can lead to superior mediastinitis or ludwig angina, the lifethreatening conditions by means of spread of infection through intercommunicae betweenthese spaces. No doubt, early management of carious tooth in the form of endodonticrestoration or extraction can prevent these complications but once these occur it canthreaten the life of petient. Proper and thorough knowledge of anatomy of the spacesright in the first year of MBSS/BDS can help the medical and dental students to correlatethe clinical findings and plan surgery when they go to clinics. The paper is an attempt inthe direction of better understanding of anatomy of facial spaces and possible pathwaysof infection in these.



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