FASCIAL SPACES

- DOVELIN WITTY .V
CONTENTS

• Introduction
• Definition
• Classification
• Canine space
• Buccal space
• Submandibular space
• Submental space
• Sublingual space
• Ludwig’s angina
• Pterygomandibular space
• Submasseteric space
• Lateral pharyngeal space
• Retropharyngeal space
• Carotid space infection
• Parotid space infection
• Infratemporal space
• Temporal space
• Peritonsillar abscess
• Conclusion
• Reference
INTRODUCTION

The head and neck region has structures separated from each other
through specific natural connective tissue barriers called Fascia.

These fascial layers can be anatomically divided into superficial &

deep and forms the fascial spaces
DEFINITION

SHAPIRO (1950)

Fascial spaces are potential spaces between the layers of fascia normally filled
with loose connective tissues and various anatomical structures like veins , arteries , glands and
lymph nodes etc.

 The word space is a misnomer

(no voids in the tissues )
CLASSIFICATION

• TOPAZIAN CLASSIFICATION
1)FACE
-Buccal, Canine, Masticatory (masseteric ,pterygoid, zygomaticotemporal), Parotid
2)SUPRAHYOID
- Sublingual, Submandibular, Submaxillary, Submental, Lateral pharyngeal, Peritonsillar
3)INFRAHYOID
- Aterovisceral (pretracheal), Retrovisceral
4)SPACES OF TOTAL NECK
- Retropharyngeal, Danger space , Spaces of carotid sheath
• CLASSIFICATION ACCORDING TO INVOLVEMENT OF SPACES
1) Primary maxillary spaces
canine (infraorbital) , buccal , infratemporal
2) Primary mandibular spaces
submental , submandibular, sublingual , buccal
3) Secondary fascial spaces
masseteric , pterygomandibular, superficial and deep temporal, lateral pharyngeal,
retropharyngeal, prevertebral
CANINE SPACE ( INFRAORBITAL SPACE )

Boundaries
• Superficial and superior – Quadratus labii superioris
• Inferior – orbicularis oris
• Deep – levator anguli oris, anterior surface of maxilla
• Medial – levator labii superioris alaeque nasii
• Lateral – zygomaticus major
INVOLVEMENT
maxillary canines , premolars, mesiobuccal root of first molars
CONTENTS
• angular artery and vein
• Infraorbital nerve
CLINICAL FEATURES
• swelling of cheek & upper lip
obliteration of nasolabial fold
drooping of angle of mouth
• Oedema of lower eyelid
• SURGICAL MANAGEMENT
- Intraoral incison made high in the maxillary labial vestibule
- a small hemostat is inserted through the levator anguli oris muscle into the
abscess cavity
- rubber drain is placed into canine space & sutured to the lower margin of the
vestibular incison
BUCCAL SPACE

potential space between buccinator and masseter

Boundaries
• Superior – zygomatic arch
• Inferior – inferior border of mandible
• Anterior – posterior border of zygomatic bone above & depressor oris below
• Posterior – anterior border of masseter muscle
• Medial – buccinator muscle and its fascia
• Lateral – skin & subcutaneous tissue
Involvement
• maxillary & mandibular premolars & molars
Contents
• Space filled with buccal pad of fat
• Parotid duct
• Anterior and transverse fascial artery & vein
Clinical features
• Dome shaped swelling on the anterior aspect of the cheek
extending from the lower border of mandible to the
level of zygomatic arch
• Pus accumulation on the

oral side of muscle – gum boil on vestibule

lateral side – prominent extraoral swelling is seen
Extending from lower border of mandible to infraorbital margin & from anterior margin of masseter muscle to the
corner of mouth.
• Oedema of lower eyelid
• Surgical management

- horizontal incision through the oral mucosa of cheek in the molar & premolar region
- if pus accumulation is lateral to the muscle ,then curved mosquito forceps is used to penetrate the
buccal space
- drain is placed and secured with suture
• Differential diagnosis

- cellulitis
- erysipelas
- crohn’s disease ( recurrent buccal space abscess)
SUBMANDIBULAR SPACE

Space lies between the anterior and posterior bellies of

diagastric muscles

Boundaries
• Lateral – skin , superficial fascia, investing fascia, platysma
• Medial – mylohyoid , hyoglossus , superior constrictor styloglossus muscle
• Superior – inferior and medial surface of the mandible and attachment of mylohyoid muscle
• Inferior - anterior and posterior belly of diagastric muscle
Contents
• Submandibular salivary gland and lymph nodes
• Facial artery
• Lingual nerve
Involvement
• Mandibular molars ( mostly 2nd & 3rd )
Clinical features
• Swelling ( inverted cone) in the lower border of mandible and extends to hyoid bone
• Restricted mouth opening
• Generalized constitutional symptoms
• Tenderness
• Redness of overlying skin
• Intraorally, teeth are sensitive to percussion
• Mobility
• dysphagia,
• moderate trismus
Surgical management
- incision made 2 cm below the lower border of mandible
- sinus forceps is inserted superiorly and posteriorly on the lingual side of mandible below the mylohyoid to
release pus
- corrugated rubber drain is inserted
- secured with a suture and dressing is applied

Differential diagnosis
• Secondary deposits of malignant neoplasm
• Lymphoma
• TB Lymphadenitis
SUBMENTAL SPACE

Boundaries
• Superior – mylohyoid muscle
• Inferior – skin and subcutaneous tissue, platysma and deep cervical fascia
• Medial – single midline space with no medial wall
• Lateral – anterior belly of diagastric ( bilateral )
• Anterior – mandible
• Posterior – hyoid bone
Contents
• Space has no vital structures
• Lymph nodes and anterior jugular vein

Involvement
• Lower incisors ,lower lip , chin , tip of tongue
• Anterior part of floor of mouth
Clinical features
• Extraorally
- distinct , firm swelling in the midline, beneath the chin
- skin overlying the swelling is board like and taut
- fluctuation may present
• Intraorally
- anterior teeth are either non vital , fractured or carious
- offending tooth may exhibit TOP and mobility
- discomfort on swallowing
Surgical management

- Transverse incision in the skin below the symphysis of the mandible

- Blunt dissection is carried out by inserting Kelly’s or Sinus forceps through this
incision , upward and backward
- Rubber drain is inserted and secure the wound with suture
SUBLINGUAL SPACE

V shaped trough space lying lateral to muscles of tongue

Boundaries
• Superior –mucosa of floor of mouth
• Inferior – superior surface of mylohyoid muscle
• Medial – hyoglossus , genioglossus , geniohyoid muscles
• Lateral – medial surface of mandible
• Anterior – mandible
• Posterior – hyoid bone
Contents
• Deep part of submandibular & sublingual glands and their draining ducts
• Lingual nerve

Involvement
• Mandibular premolars or molars
• Direct trauma to the region
Clinical features
• Extraorally

- little or no swelling
- lymph nodes enlarged and tender
- pain & discomfort on deglutition
- affects speech
• Intraorally
- firm , painful swelling seen in floor of mouth
- floor of mouth is raised
- tongue may be pushed superiorly; airway obstruction
- ability to protrude the tongue beyond vermilion border of upper lip is affected
• Surgical management
- An incision made closer to the lingual cortical plate ,
lateral to the sublingual plica
- sinus forceps then inserted and opened to evacuate the pus
LUDWIG’S ANGINA

• First described by Wilhelm friedreich von Ludwig (1836)

• It is a form of firm , acute , toxic and severe diffuse cellulitis

that spreads rapidly , bilaterally affecting the
submandibular, sublingual and submental spaces
• Grodinsky ( 1939 ) proposed 4 criteria to distinguish
Ludwig’s angina from other forms of deep neck abscesses

• occur bilaterally in more than one compartment of the submandibular space

• produce a gangrenous serosanguinous infiltrate with or without pus
• involve connective tissue fascia and muscle but not glandular structures
• spread by continuity rather than by the lymphatics
Aetiology
• Odontogenic ( 90% ) - mandibular 2nd and 3rd commonly involved
• Iatrogenic – use of contaminated needles for LA administration
• Traumatic injuries to orofacial region
• Osteomyelitis
• Submandibular & sublingual sialadenitis
• Secondary infections of oral malignancies
• Cervical lymphoid tissues
• Miscellaneous –
- purulent tonsilitis
- foreign bodies ( fish bone)
- oral soft tissue lacerations
Microbiology
• Staphylococci & Streptococci
• Gram negative enteric micro organisms
• Anaerobes - Bacteriodes , anaerobic streptococci, peptostreptococcus & fusospirochaetes

Involvement
• Mandibular 2nd & 3rd molars
• Submandibular & sublingual spaces
Clinical features
• Systemic features
- pyrexia , anorexia , chills & malaise
- dysphagia
- impaired speech & hoarseness of voice
• Extraorally
- firm / hard brawny ( board or wood like) in the bilateral submandibular & submental regions
- non pitting, non fluctuant swelling with severe tenderness
- trismus
- airway obstruction
- increased respiratory rate
- cyanosis may occur
• Fatal death may occur in untreated cases of Ludwig’s angina within
10 – 24 hours due to asphyxia
Intraorally
• Swelling in sublingual tissues
• Woody oedema on floor of mouth & tongue
• Raised tongue
• Increased salivation
• Stiffness of tongue movements
• Difficulty in swallowing
• Backward spread of infection leads to oedema of glottis
resulting in respiratory obstruction

Spread
• Sublingual spaces – region of epiglottis – swelling around laryngeal inlet
• Submandibular space – submasseteric , pterygomandibular , paratonsillar , parapharyngeal spaces
– worsening airway
• Submandibular region – spreads downwards – clavicle & mediastinum
• Carotid sheath , pterygopalatine fossa – cavernous sinus thrombosis & meningitis
Treatment
• Maintanence of patent airway - tracheostomy or laryngotomy
• Surgical decompression
• Antibiotic therapy

- penicillinG , 500 mg or 2-4 million units IV ; 4-6 hourly

- erythromycin , 600 mg ; 6-8 hourly( allergic to penicillin)
- gentamicin 80 mg IM
- clindamycin 300 – 600 mg IV ; 8 hourly
• Hydration
• Removal of cause & surgical drainage
COMPLICATIONS OF LUDWIGS ANGINA

• MEDIASTINITIS

- Rare and life threatening complication

- suspected in patients who exhibits fever associated with substernal pain
- 40 % mortality rate
- progressive septicaemia , mediastinal abscess, pleural effusion , empyema, compression
of mediastinal veins with decreased venous return to heart and pericarditis may occur
Clinical features
• Abscess in the parapharyngeal / retropharyngeal spaces include dysphagia , dyspnoea, stiff neck &
oesophageal regurgitation
• Swelling occurs underneath sternocleidomastoid muscle
• Painful on palpation
• Retrosternal pain & non- productive cough
• Crepitation & oedema in upper thorax
• Fever and chills
Diagnosis
• Anteroposterior chest X-ray reveals broadening of mediastinal space
• Lateral X-ray of neck reveals displacement of posterior wall of pharynx
Management
• Medically
- IV administration of antibiotics
- penicillin G , metronidazole , chloramphenicol , gentamicin
• Surgically
- incision & drainage
- Transcervical approach is recommended
• CAVERNOUS SINUS THROMBOSIS
unilateral involvement but can develop through the inter cavernous sinuses
Involvement
- cranial nerve 3rd , 4th , 6th
- carotid sympathetic plexus
Clinical features
• Eye pain
• Sensitivity of eyeball to pressure
• High fever , chills
• Tachycardia
• Sweating
Subsequently venous obstruction produces
• Palpebral oedema
• Ptosis
• Tearing of eye
• Chemosis
• Retinal bleeding
• Affected cranial nerves produces Opthalmoplegia, Mydriasis

Causal agents
• Streptococcus , staphylococcus , gram negative bacteria

Treatment
• Antibiotics and steroids
• CEREBRAL ABSCESS
- Organisms on reaching brain produces inflammation , localized oedema & septic
thrombosis
- associated with oral manipulations i.e) dental extractions, dental or periodontal
surgery , infection of LA )
- increased incidence in immunocompromised patients
- 0-24% mortality rate
- direct spread or via blood stream
Clinical features
• Elevated intracranial pressure with intense headache , nausea & projectile vomiting
• Cerebral irritation may present as
convulsions , aphasia
involvement of frontal lobe – changes in character & behavior
• Temporal – spatial disorientation
• Hemiplegia , papilledema , abducent nerve palsy
• Hemisensory deficit
• Diagnosis

- CT scan
- opthalmoscope

• Management

- antibiotics
- anti-inflammatory drugs
- steroids
- mannitol to reduce cerebral oedema
- surgical drainage
• MENINGITIS

- most common neurological complication

- develop from metastatic spread or thrombophlebitis
Clinical features
• Intense headache
• Mental confusion
• Irritability or stupor
• High fever with chills & vomiting
• Stiff neck ( Brudzinski’s sign )
• convulsions
• Diagnosis
- cerebrospinal fluid analysis ( cloudy or purulent opalescent fluid obtained)
- increased plymorphonuclear leucocytes & protein levels
- decreased glucose levels

• Management

- chloramphenicol ;4 g /day IV
- penicillin G; 24 million units/day IV
- maintanence of hydroelectrolytic balance
• NECROTISING FASCITIS OF HEAD & NECK
- Multimicrobial , uncommon soft tissue infection
- characterized by formation of large necrotic lesion & gas formation located in subcutaneous
tissue & superficial fascia
- predominantly in limbs & abdominal wall

Causative agents
• A hemolytic streptococcus
• staphylococcus
Clinical features
• Soft tissue involvement leads to gangrene of subcutaneous cell tissue & muscular
aponeurosis
• Intense pain at onset
• Affected skin (turns purple or dark with poorly defined edges)
• Vesicles with foul smelling & purulent exudate
• Cutaneous necrosis on 4th or 5th day
Systemic complications ;
• Neck organ involvement
• Pneumonia
• Pulmonary abscess
• Vascular erosion
• Venous thrombosis
• Cranial neuropathies

Associated manifestations
• Fever , crepitation , features of sepsis
• Diagnosis
- MRI & Computerized axial tomography

• Management
- antibiotic therapy
- incision and drainage
PTERYGOMANDIBULAR SPACE

Boundaries
• Anterior – buccal space
• Posterior – parotid gland with lateral pharyngeal space
• Superior – lateral pterygoid muscle
• Inferior – inferior border of mandible
• Superficial or medial – lateral surface of medial pterygoid muscle
• Deep or lateral – medial surface of ascending ramus of mandible
Involvement
- mandibular 3rd molar
- contaminated needle used for IANB & posterior superior alveolar nerve block

Contents
- mandibular division of trigeminal nerve
- inferior alveolar artery and vein
Clinical features
• Extra orally ,swelling is not obvious
• Intraorally , swelling of the soft palate & anterior tonsillar pillar
• Deviation of uvula to opposite side
• Severe trismus
• dysphagia
• Surgical management
- because of severe trismus GA or mandibular nerve block is given
- incision and drainage
( blunt dissection using a hemostat )
SUBMASSETERIC SPACE

Boundaries
• Anterior – buccal space , parotidomasseteric fascia
• Posterior – parotid gland and its fascia
• Superior - zygomatic arch
• Inferior – inferior border of mandible
• Superficial or medial – ascending ramus
• Deep or lateral – masseter muscle
Involvement
- lower 3rd molars
Contents
- masseteric artery and vein
Clinical features
• Swelling over angle of mandible
• Posterior mandibular sulcus is obliterated
• Severe trismus & throbbing pain
• Osteomyelitis with sequestrum formation
• Chronic submasseteric space infection can be punctuated by exacerbation
Surgical management
- vertical incision made intraorally along the external oblique line of mandible
- hemostat is inserted
- rubber drain is inserted and sutured
• Differential diagnosis
- peritonsillar abscess
LATERAL PHARYNGEAL SPACE

Boundaries
• Anterior – superior & middle pharyngeal constrictor
• Posterior – carotid sheath , stylohyoid, styloglossus , stylopharyngeus
• Superior – skull base
• Inferior – hyoid bone
• Superficial or medial – superior pharyngeal constrictor &retropharyngeal space
• Deep or lateral – medial pterygoid muscle & capsule of parotid gland
Involvement
- extends backwards from mand.3rd molar area

Contents
• Carotid artery
• Internal jugular vein
• Vagus nerve
• Cervical sympathetic chain
Clinical features
• Severe pain
• Dysphagia
• Deviation of tonsil , tonsillar pillar, uvula
Cardinal signs
• Trismus , induration , swelling of angle of jaw
• Fever & pharyngeal bulging
Complications
• Septic jugular thrombophlebitis
• Carotid artery erosion
• Inequality of pupils
• Bleeding from nose , mouth ,ear
• Potential to cause cavernous sinus thrombosis, meningitis & brain abscess

Management
• Incision & drainage
RETROPHARYNGEAL SPACE

Boundary
• Anterior – superior & middle constrictor
• Posterior – alar fascia
• Superior – skull base
• Inferior – fusion of alar & prevertebral fascia at T4
• Superficial or medial – common space ;no wall
• Deep or lateral – carotid sheath & lateral pharyngeal space
Involvement
lateral pharyngeal space

Clinical features
• Pain , fever , stiffness of neck
• Dyspnoea
• Drooling , dysphagia and bulging of posterior pharyngeal wall
Complications
• Supraglottic oedema
• Airway obstruction
• Aspiration pneumonia
• Acute mediastinitis

Management
intraoral approach – vertical incision
extraoral incision – incision made along anterior border of sternocleidomastoid inferior to hyoid bone &
muscle
CAROTID SPACE INFECTION

• Tender swelling in the lateral aspect of neck under sternocleidomastoid muscle

• Pain on palpation , while rotating head laterally

• Torticollis on affected side

• incision & drainage

incision made along the middle third of anterior border of sternocleidomastoid muscle
PAROTID SPACE INFECTION

Enclosed by superficial layer of deep cervical fascia surrounding the parotid gland.

Clinical features
• Swelling everts the lobule of ear
• Severe pain while eating
• Trismus is absent
• Differential diagnosis
- submasseteric space infection
( trismus present)
Management
- large incision made in the retromandibular area
- blunt dissection with hemostat
- multiple drains are used
INFRATEMPORAL SPACE

Boundary
• Superior – skull base; sphenoid crest
• Inferior – lateral pterygoid muscle
• Medial – lateral pterygoid plate
• Lateral – temporals muscle or tendon
• Anterior – maxillary tuberosity
• Posterior – mandibular condyle
Contents
• Internal maxillary artery
• Pterygoid venous plexus
• Mandibular division of trigeminal nerve

clinical features
• swelling with severe trismus & pain
• If untreated , infection spreads to whole side of face & optic neuritis may occur
• Infection can spread to cavernous sinus & present with
headache , irritability , photophobia , vomiting , drowsiness.

Surgical management –
intraorally , incision made on the buccolabial fold lateral to maxillary 3 rd molar
extraorally , horizontal incision made just above zygomatic arch
TEMPORAL SPACE

Boundary
• Superficial compartment
laterally – temporal fascia
medially – lateral surface of temporalis muscle
• Deep compartment
laterally – medial surface of temporalis muscle
medially – temporal bone
Contents
• Superficial temporal vessels
• Auriculotemporal nerve
• Temporal fat pad

Clinical features
• Severe pain & trismus
• Swelling is more obvious in superficial infection
• Deep temporal space infection produces less swelling
with pain and trismus

Management
incision and drainage
PERITONSILLAR ABSCESS ( QUINSY )

• Deep neck infection

• Complication of acute tonsilitis
• Rarely life threatening
• Potential space of loose areolar tissue that surrounds the tonsil & is bounded laterally by
superior constrictor
Clinical features
• Swelling of tonsils
• Uvular displacement
• Trismus
• Muffled voice
• Usually unilateral; rarely bilateral occurs
• Younger patients with fever , sore throat & dysphagia
Complications
- spontaneous rupture & aspiration
- contiguous spread to pterygomaxillary space

Surgical management
- antibiotic therapy
- incision & drainage

In case of recurrence; tonsillectomy performed 6 to 8 weeks after formation of abscess

CONCLUSION

• Odontogenic infections are the most common of all infections of head and neck
• Although most of these infections can be managed successfully with minimal
complications ; some can produce serious morbidity and even death
• The key to successful management is prompt therapy
REFERENCE

• SM.Balaji.Textbook of oral and maxillofacial surgery 2nd edition

• Neelima malik. Textbook of oral and maxillofacial surgery 2nd edition
• Laskin . Textbook of oral and maxillofacial surgery vol.2
• Jun-Kai Kao. Ludwig’s angina in children. A case report. Journal of Acute Medicine 1
2011; 23-26.
• Leonard B.Kaban. Textbook of Pediatric oral and maxillofacial surgery.