Fascial spaces of the head and neck

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Fascial spaces (also termed fascial tissue spaces [1] or tissue spaces [2] ) are potential spaces that exist between the fasciae and underlying organs and other tissues. [3] In health, these spaces do not exist; they are only created by pathology, e.g. the spread of pus or cellulitis in an infection. The fascial spaces can also be opened during the dissection of a cadaver. The fascial spaces are different from the fasciae themselves, which are bands of connective tissue that surround structures, e.g. muscles. The opening of fascial spaces may be facilitated by pathogenic bacterial release of enzymes which cause tissue lysis (e.g. hyaluronidase and collagenase). [1] [4] The spaces filled with loose areolar connective tissue may also be termed clefts. Other contents such as salivary glands, blood vessels, nerves and lymph nodes are dependent upon the location of the space. Those containing neurovascular tissue (nerves and blood vessels) may also be termed compartments.

Contents

Generally, the spread of infection is determined by barriers such as muscle, bone and fasciae. Pus moves by the path of least resistance, [5] e.g. the fluid will more readily dissect apart loosely connected tissue planes, such the fascial spaces, than erode through bone or muscles. In the head and neck, potential spaces are primarily defined by the complex attachment of muscles, especially mylohyoid, buccinator, masseter, medial pterygoid, superior constrictor and orbicularis oris. [6]

Infections involving fascial spaces of the head and neck may give varying signs and symptoms depending upon the spaces involved. Trismus (difficulty opening the mouth) is a sign that the muscles of mastication (the muscles that move the jaw) are involved. [2] Dysphagia (difficulty swallowing) and dyspnoea (difficulty breathing) may be a sign that the airway is being compressed by the swelling.

Classification

Different classifications are used. One method distinguishes four anatomic groups: [3]

Since the hyoid bone is the most important anatomic structure in the neck that limits the spread of infection, the spaces can be classified according to their relation to the hyoid bone: [5]

In oral and maxillofacial surgery, the fascial spaces are almost always of relevance due to the spread of odontogenic infections. As such, the spaces can also be classified according to their relation to the upper and lower teeth, and whether infection may directly spread into the space (primary space), or must spread via another space (secondary space):

Perimandibular spaces

The submaxillary space is a historical term for the combination of the submandibular, submental and sublingual spaces, which in modern practice are referred to separately or collectively termed the perimandibular spaces. [7] The term submaxillary may be confusing to modern students and clinicians since these spaces are located below the mandible, but historically the maxilla and mandible together were termed "maxillae", and sometimes the mandible was termed the "inferior maxilla". Sometimes the term submaxillary space is used synonymously with submandibular space. [4] Confusion exists, as some sources [5] describe the sublingual and the submandibular spaces as compartments of the "submandibular space". [4]

Submandibular space

Submental space

Sublingual space

Mental space

Buccal space

Canine space (infra-orbital space)

Masticator space

The four compartents of the right masticator space. A Temporalis muscle, B Masseter muscle, C Lateral pterygoid muscle, D Medial ptaerygoid muscle, E Superficial temporal space, F Deep temporal space, G Submasseteric space, H Pterygomandibular space, I Approximate location of infratemporal space. Masticator space.png
The four compartents of the right masticator space. A Temporalis muscle, B Masseter muscle, C Lateral pterygoid muscle, D Medial ptaerygoid muscle, E Superficial temporal space, F Deep temporal space, G Submasseteric space, H Pterygomandibular space, I Approximate location of infratemporal space.

This term is sometimes used, and is a collective name for the submasseteric (masseteric), pterygomandibular, superficial temporal and deep temporal spaces. The infratemporal space is the inferior portion of the deep temporal space. The superficial temporal and the deep temporal spaces are sometimes together called the temporal spaces. The masticator spaces are paired structures on either side of the head. The muscles of mastication are enclosed in a layer of fascia, formed by cervical fascia ascending from the neck which divides at the inferior border of the mandible to envelope the area. Each masticator space also contains the sections of the mandibular division of the trigeminal nerve and the internal maxillary artery. [4]

The masticator space could therefore be described as a potential space with four separate compartments. Infections usually only occupy one of these compartments, but severe or long standing infections can spread to involve the entire masticator space. [7] The compartments of the masticator space are located on either side of the mandibular ramus and on either side of the temporalis muscle.

Submasseteric space

This is also referred to as the masseter space or the superifical masticator space. The submasseteric space is logically located under (deep to) the masseter muscle, created by the insertions of masseter onto the lateral surface of the mandibular ramus. Submasseteric abscesses are rare and are associated with marked trismus.

Pterygomandibular space

The pterygomandibular space lies between the medial side of the ramus of the mandible and the lateral surface of the medial pterygoid muscle.

Deep temporal space (infra-temporal space)

The infra-temporal space is the inferior portion of the deep temporal space. [7]

Superficial temporal space

History

Modern understanding of the fascial spaces of the head and neck developed from the landmark research of Grodinsky and Holyoke in the 1930s. [4] They injected a dye into cadavers to simulate pus. Their hypothesis was that infection in the head and neck mainly spread by hydrostatic pressure. This is now accepted to be true for most infections in the head and neck, with the exception of actinomycosis which tends to burrow into the skin, and mycotuberculoid infections which tend to spread via the lymphatics. [4]

Related Research Articles

Temporomandibular joint Joints connecting the jawbone to the skull

In anatomy, the temporomandibular joints (TMJ) are the two joints connecting the jawbone to the skull. It is a bilateral synovial articulation between the temporal bone of the skull above and the mandible below; it is from these bones that its name is derived. This joint is unique in that it is a bilateral joint that functions as one unit. Since the TMJ is connected to the mandible, the right and left joints must function together and therefore are not independent of each other.

Parotid gland Major salivary gland in many animals

The parotid gland is a major salivary gland in many animals. In humans, the two parotid glands are present on either side of the mouth and in front of both ears. They are the largest of the salivary glands. Each parotid is wrapped around the mandibular ramus, and secretes serous saliva through the parotid duct into the mouth, to facilitate mastication and swallowing and to begin the digestion of starches. There are also two other types of salivary glands; they are submandibular and sublingual glands. Sometimes accessory parotid glands are found close to the main parotid glands.

Mylohyoid muscle

The mylohyoid muscle or diaphragma oris is a paired muscle of the neck. It runs from the mandible to the hyoid bone, forming the floor of the oral cavity of the mouth. It is named after its two attachments near the molar teeth. It forms the floor of the submental triangle. It elevates the hyoid bone and the tongue, important during swallowing and speaking.

Hyoglossus Muscle

The hyoglossus, thin and quadrilateral, arises from the side of the body and from the whole length of the greater cornu of the hyoid bone, and passes almost vertically upward to enter the side of the tongue, between the styloglossus and the inferior longitudinal muscle of the tongue. It forms a part of the floor of submandibular triangle.

Pericoronitis Inflammation of the soft tissues surrounding the crown of a partially erupted tooth

Pericoronitis is inflammation of the soft tissues surrounding the crown of a partially erupted tooth, including the gingiva (gums) and the dental follicle. The soft tissue covering a partially erupted tooth is known as an operculum, an area which can be difficult to access with normal oral hygiene methods. The hyponym operculitis technically refers to inflammation of the operculum alone.

Deep cervical fascia

The deep cervical fascia lies under cover of the platysma, and invests the muscles of the neck; it also forms sheaths for the carotid vessels, and for the structures situated in front of the vertebral column. Its attachment to the hyoid bone prevents the formation of a dewlap.

Buccal space

The buccal space is a fascial space of the head and neck. It is a potential space in the cheek, and is paired on each side. The buccal space is superficial to the buccinator muscle and deep to the platysma muscle and the skin. The buccal space is part of the subcutaneous space, which is continuous from head to toe.

Investing layer of deep cervical fascia

The Investing layer of deep cervical fascia is the most superficial part of the deep cervical fascia, and it encloses the whole neck.

Submental lymph nodes

The submental glands are situated between the anterior bellies of the digastric muscle and the hyoid bone.

In anatomy, a spatium or anatomic space is a space. Anatomic spaces are often landmarks to find other important structures. When they fill with gases or liquids in pathological ways, they can suffer conditions such as pneumothorax, edema, or pericardial effusion. Many anatomic spaces are potential spaces, which means that they are potential rather than realized. In other words, they are like an empty plastic bag that has not been opened or a balloon that has not been inflated.

Mouth infections, also known as oral infections, are a group of infections that occur around the oral cavity. They include dental infection, dental abscess, and Ludwig's angina. Mouth infections typically originate from dental caries at the root of molars and premolars that spread to adjacent structures. In otherwise healthy patients, removing the offending tooth to allow drainage will usually resolve the infection. In cases that spread to adjacent structures or in immunocompromised patients, surgical drainage and systemic antibiotics may be required in addition to tooth extraction. Since bacteria that normally reside in the oral cavity cause mouth infections, proper dental hygiene can prevent most cases of infection. As such, mouth infections are more common in populations with poor access to dental care or populations with health-related behaviors that damage one's teeth and oral mucosa. This is a common problem, representing nearly 36% of all encounters within the emergency department related to dental conditions.

Parapharyngeal space

The parapharyngeal space, is a potential space in the head and the neck. It has clinical importance in otolaryngology due to parapharyngeal space tumours and parapharyngeal abscess developing in this area. It is also a key anatomic landmark for localizing disease processes in the surrounding spaces of the neck; the direction of its displacement indirectly reflects the site of origin for masses or infection in adjacent areas, and consequently their appropriate differential diagnosis.

Sublingual space

The sublingual space is a fascial space of the head and neck. It is a potential space located below the mouth and above the mylohyoid muscle, and is part of the suprahyoid group of fascial spaces.

Submandibular space

The submandibular space is a fascial space of the head and neck. It is a potential space, and is paired on either side, located on the superficial surface of the mylohyoid muscle between the anterior and posterior bellies of the digastric muscle. The space corresponds to the anatomic region termed the submandibular triangle, part of the anterior triangle of the neck.

Submental space

The submental space is a fascial space of the head and neck. It is a potential space located between the mylohyoid muscle superiorly, the platysma muscle inferiorly, under the chin in the midline. The space coincides with the anatomic region termed the submental triangle, part of the anterior triangle of the neck.

Submasseteric space

The submasseterric space is a fascial space of the head and neck. It is a potential space in the face over the angle of the jaw, and is paired on each side. It is located between the lateral aspect of the mandible and the medial aspect of the masseter muscle and its investing fascia. The term is derived from sub- meaning "under" in Latin and masseteric which refers to the masseter muscle. The submasseteric space is one of the four compartments of the masticator space. Sometimes the submasseteric space is described as a series of spaces, created because the masseter muscle has multiple insertions that cover most of the lateral surface of the ramus of the mandible.

Pterygomandibular space

The pterygomandibular space is a fascial space of the head and neck. It is a potential space in the head and is paired on each side. It is located between the medial pterygoid muscle and the medial surface of the ramus of the mandible. The pterygomandibular space is one of the four compartments of the masticator space.

Canine space

The canine space, is a fascial space of the head and neck. It is a thin potential space on the face, and is paired on either side. It is located between the levator anguli oris muscle inferiorly and the levator labii superioris muscle superiorly. The term is derived from the fact that the space is in the region of the canine fossa, and that infections originating from the maxillary canine tooth may spread to involve the space. Infra-orbital is derived from infra- meaning below and orbit which refers to the eye socket.

Infratemporal space

The Infratemporal space is a fascial space of the head and neck. It is a potential space in the side of the head, and is paired on either side. It is located posterior to the maxilla, between the lateral pterygoid plate of the sphenoid bone medially and by the base of skull superiorly. The term is derived from infra- meaning below and temporal which refers to the temporalis muscle.

Deep temporal space

The deep temporal space is a fascial space of the head and neck. It is a potential space in the side of the head, and is paired on either side. It is located deep to the temporalis muscle

References

  1. 1 2 Newlands C, Kerawala C (2010). Oral and maxillofacial surgery. Oxford: Oxford University Press. pp. 374–375. ISBN   9780199204830.
  2. 1 2 Odell W (2010). Clinical problem solving in dentistry (3rd ed.). Edinburgh: Churchill Livingstone. pp. 151–153, 229–233. ISBN   9780443067846.
  3. 1 2 Kenneth M. Hargreaves; Stephen Cohen; Louis H.Berman, eds. (2010). Cohen's pathways of the pulp (10th ed.). St. Louis, Mo.: Mosby Elsevier. pp. 590–595. ISBN   978-0323064897.
  4. 1 2 3 4 5 6 Topazian RG, Goldberg MH, Hupp JR (2002). Oral and maxillofacial infections (4. ed.). Philadelphia: W.B. Saunders. pp. 188–213. ISBN   978-0721692715.
  5. 1 2 3 Norton NS (2007). Netter's Head and Neck Anatomy for Dentistry. Philadelphia PA: Saunders Elsevier. pp. 460–472. ISBN   9781929007882.
  6. ↑ Standring S (2004). Gray's Anatomy: The Anatomical Basis of Clinical Practice (39th ed.). Elsevier. ISBN   978-0443066764.
  7. 1 2 3 Hupp JR, Ellis E, Tucker MR (2008). Contemporary oral and maxillofacial surgery (5th ed.). St. Louis, Mo.: Mosby Elsevier. pp. 317–333. ISBN   9780323049030.
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