Fascial Spaces

Suprasternal Space

Formed superior to the manubrium where the Investing Fascia divided into two layers attached to the anterior and posterior surfaces of the manubrium. Encloses the sternal heads of the SCMs, the inferior ends of the anterior jugular veins, the jugular venous arch, fat and a few lymph nodes Clinical: Trauma to this area can cause a bleeder and subsequently a large bulging above the manubrium and even might distend down posterior to the manubrium into the superior mediastinum.

Pretracheal/Previsceral Space

Surrounding the trachea and lying against the anterior wall of the esophagus Bounded anteriorly by the Investing Cervical Fascia Bounded posteriorly by Visceral Cervical Fascia Limited above by the attachments of the infra-hyoid muscles and their fascia to the thyroids cartilage and to the hyoid bone Below, continues into the anterior portion of the superior mediastinum Bounded inferiorly by the sternum and scalene fascia Extends to approximately the arch of the aorta to about the level of the T4 vertebrae where the posterior surface of the sternum and the fibrous pericardium are united by denser connective tissue Contents: Infrahyoid Strap muscles Clinical: Can be infected directly by anterior perforations or rupture of the esophagus or indirectly by spread from the retrovisceral portion, around the sides of the esophagus and thyroid gland between the levels of the inferior thyroid artery and the oblique line of the thyroid cartilage. Both pretracheal and retrovisceral spaces descend into the superior mediastinum.

Carotid Sheath Space: Potential Cavity within the carotid sheath which extends into the mediastinum

3 Deep Cervical fascial layers: Investing, Pretracheal, and PreVertebral Condenses to form Carotid Sheath (Click here to show another perspective) Tubular space created, extending from the base of the skull to the root of the neck
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Anterior to cervical sympathetic trunk which lies on longus colli and longus capitis muscles in front of cervical vertebrae. Anterolateral wall is composed of the Investing Layer deep to SCM, and Pretracheal Layers Blends posteriorly and medially with the Prevertebral Layer of cervical fascia** (Sympathetic trunk lies posterior and intervenes between the sheath and the prevertebral fascia) Contains the: i. ii. iii. iv. v. vi. Common and internal carotid arteries Internal Jugular vein Vagus nerve (CN X) Deep cervical lymph nodes Carotid sinus nerve Sympathetic fibers

Sheath is extremely strong which prevents easy compression. Therefore a problem in the carotid sheath can crush the internal jugular vein and vagus nerve Clinical: It can be involved in any neck infection because it is made of those three layers: Investing, Pretracheal and Prevertebral Fascia. o Infections tend to be localized within the cervical region (between hyoid and root of the neck) because the sheath is closely adherent to vessels o Infection usually arises from thrombosis of the internal jugular vein or from infection of those deep cervical lymph nodes that lie within the sheath o Thrombosis of the jugular vein from a deep infection of the neck is probably not due to direct infection of the carotid sheath, but rather to the fact that infectious material follows tributaries of the internal jugular vein to reach the sheath.

Drug use (Heroin) usually use carotid route to obtain a fast high. A result can be abscess of the carotid sheath presenting in a patient who is groggy with a weak pulse (bradycardia) and low blood pressure due to the compression of the carotid sinus and irritation of the vagus nerve.

(Retro) Pharyngeal Space

Area of loose connective tissue lying posterior to the pharynx and anterior to the alar layer of the prevertebral fascia Largest interfascial space in the neck which permits movement of the pharynx, esophagus, larynx, and trachea during swallowing Lateral to and bounded anteriorly by the Visceral (Retropharyngeal) Fascia Extends inferiorly behind the lower portion of the pharynx and the esophagus to form the posterior portion of the visceral compartment of the neck, communicate with the pretracheal space, and end at about the level of the bifurcation of the trachea (T1-T2). It is here where the Retropharyngeal Space is closed by the fusion of the Retropharyngeal Fascia with the Alar Fascia. Passes downward and is continuous with the (Retro)Visceral (retroesophageal) space (which begins below the pharynx) and opens inferiorly into the posterior mediastinum Closed superiorly by the base of the skull, superficial layer of fascia of the masticator space, submandibular space and laterally by the carotid sheath Contains retropharyngeal lymph nodes which drain the adenoids, nasal cavities, nasopharynx, and posterior ethmoid sinuses Clinical
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Key to an understanding downward spread of infections of the head and neck: Commonly regarded as a route through which infections of the mouth and throat reach the mediastinum. It can break through the posterior wall of the space through the alar fascia, and can enter Danger Space 4, between the two lamellae of the prevertebral layer of fascia (extends from the base of the skull to the level of the diaphragm).

Fatal hemorrhage could potentially result from an extension of a retropharyngeal abscess to the deep vessels of the neck Majority of cases arising from the internal carotid artery rather than from the jugular vein: the vein is more often occluded by the infectious process than it is eroded to the point of hemorrhage. A sudden enlargement of a retropharyngeal mass may indicate erosion of a large vessel and that in such a case aspiration of the mass before its incision may prevent fatal hemorrhage.

(Retro)Visceral Space

Spaces lying behind the esophagus and the lower part of the pharynx has been variously termed the retrovisceral, retropharyngeal, retroesophageal, or postvisceral space. It is clear that this is confusing... But for simplicity: The space posterior to pharynx is termed the retropharyngeal space. The space below C4 is normally termed retrovisceral. The space located posterior to the esophagus can be called retrovisceral as well, however if you wish to be specific, this space can be termed the retroesophageal space. Inferiorly, like the pretracheal, it extends into the mediastinum and ends at T1-T2, where the space is obliterated through fusion of the connective tissue on the posterior surface of the esophagus to the prevertebral Alar layer of fascia. A prevertebral space exists below this level- Danger Space 4. Clinical
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Important pathway by which infections orginating from various locations in the head and the upper portion of the neck reach the mediastinum. The retrovisceral space may also be infected directly from posterior perforations of the esophagus or by infections of the deep cervical nodes lying adjacent to it.

Prevertebral Spaces

Potential pocket existing between the "prevertebral" fascia and the vertebral bodies. Intervertebral discs exist between vertebrae and are vulnerable to an infection traveling in this space

It extends from skull base to coccyx, allowing for infection from the neck to the psoas muscle. (T.B. commonly presented this way prior to effective T.B. treatment.)

Danger Space 4

An area of delicate loose connective tissue that lies between the alar and prevertebral fascia Extends from the base of the skull to the mediastinum
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Infection can communicate from posterior wall of the oropharynx and oral cavity to the thorax by traveling from the Retropharyngeal Space, and passing downward to the Retrovisceral space (which begins below the pharynx). It can then pierce thru the weak alar fascia into Danger Space #4 "Dangerous" because an infection can easily travel to the thoracic cage and mediastinum, i.e., mediastinitis. Abscess in the mediastinum could go anteriorly to the pericardial area and could affect the manubrium, sternum, etc..

Suprahyoid Spaces
The spaces may be divided into three categories: 1. Blind or Intrafascial spaces: formed by splitting of fascial layers 2. Intercommunicating spaces: surrounding the pharynx and lying between fascial laminae and the pharyngeal walls 3. Blind "spaces": potential only, within the pharyngeal wall deep to the buccopharyngeal fascia. INTRAFASCIAL SPACES Danger Space #4 (already described) i. ii. formed by a splitting of the prevertebral layer of cervical fascia into prevertebral and alar layers extending from the base of the skull into the thorax

The other intrafascial spaces related to the upper part of the neck are all formed by a splitting of the superficial layer of cervical fascia to attach to the skull, as well as to surround glands and muscles

Potential spaces do not communicate with each other: infections within them can spread only through rupture of their walls. The only one of these four spaces containing any appreciable quantity of loose connective tissue is that associated with the muscles of mastication.

Space of the Body of the Mandible

1. Potential cleavage plane between the fascia and the bone. i. ii. iii. iv. v. Limited anteriorly by superfical investing fascia and the attachment of the anterior belly of the digastric Limited posteriorly by investing fascia and the attachment of the medial pterygoid to the jaw Inferiorly closed by the continuity of the fascial layers Superiorly closed by the attachment of fascial layers to the inferior border of the body of the mandible. Formed by the attachment of the superficial layer of fascia to both the outer and inner surfaces of the body of the mandible

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attachment to the outer surface is at the lower border of the mandible attachment to the inner surface can be elevated from the mandible up to the origin of the mylohyoid muscle

2. Clinical: An infection here may remain localized or may spread to the masticator space.
Submandibular Fascial Space

1. Anterior element of the peripharyngeal fascial spaces (Continuous with the lateral pharyngeal space. Infection under the tongue and the floor of the mouth can fill the submandibular space, and pass posterior to the lateral pharyngeal space) 2. Limited above by oral mucous membrane and the tongue (lingual mucosa) 3. Inferior boundary is the superficial layer of cervical fascia (suprahyoid deep investing fascia) as it extends from the hyoid bone to the mandible 4. Posteriorly continuous with the lateral pharyngeal space 5. Subdivided into two compartments:

Mylohyoid muscle, stretching across the floor of the mouth, divides the submandibular space into a portion above this muscle: Sublingual and a portion below:Submaxillary Spaces These two subdivisions can communicate by infection or injection along the free (posterior) edge of the mylohyoid muscle and about the submandibular gland, which lies partly above and partly below the posterior portion of the mylohyoid Sublingual space o Contains the sublingual gland, the duct for the submandibular gland, and the accessory submandibular gland, Lingual Nerve, and the hypoglossal nerve appearing deep o Consist of the loose connective tissue lying between the muscles of the tongue and about the sublingual gland, the lingual and hypoglossal nerves, and a portion of the submandibular gland and its duct.
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Paired but the two sides communicate anteriorly Subdivided based upon their relationships to the genioglossus and geniohyoid muscles

Clinical: Infection will pass down to the submandibular space or can pass directly through the mylohyoid muscle

Submaxillary space is divided into subsidiary submental and submaxillary spaces by attachment of the superficial layer of fascia to the anterior belly of the digastric muscle. A cross section reveals that the submental space represents a median space that separates the two submaxillary spaces. o Submental space containing submental lymph nodes
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Corresponding to the triangle of the same name, lies medial to the anterior belly of the digastric

Submaxillary space lateral and posterior to it

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Contains Submandibular Gland with its fascial covering, Facial Artery and Vein, Hypoglossal Nerve, Vena hypoglossi commitantes

These spaces consist only of an easy line of cleavage between the fascia and the muscles, unless they are abnormally distended. The roots of the third, second, and first molars are all below the level of the mylohyoid. Infection of these teeth pass through the root, directly into the submaxillary space and then to the lateral pharyngeal space. Patient can present with problems in their airway. Never give a nerve block if there is an infection of the submandibular space. Infection can be passed by way of a needle tract infection to a deeper area of the body.

Space of "Submaxillary" Gland proper

The investing layer of fascia splits to form a capsule around the submandibular or submaxillary gland which encloses this space

Submandibular gland and its associated lymph nodes are embedded in and fused with the fascial capsule. o The outer layer of the capsule: the continuation upward of the main portion of the superficial layer of the cervical fascia, is strong o the inner layer is thinner and is perforated by the duct of the gland

Clinical: infections arising in the region of the gland generally break inward

Lateral Pharyngeal Space 1. Lateral portions of the Retropharyngeal space that extend around the pharynx 2. Bounded posteriorly by the carotid sheath which separates it from the retropharyngeal space 3. Deep to medial pterygoid 4. Medial to the masticator space 5. Lateral to where pharynx attaches to mandible 6. Bounded medially by the pharyngeal fascia covering the fascia of the pharynx itself, laterally by the pterygoid muscles and the sheath of the parotid gland. 7. Like the retropharyngeal portion of this visceral ring, the lateral pharyngeal space extends upward to the base of the skull, but it does not extend inferiorly, below the level of the hyoid bone, since it is limited here by the sheath of the submandibular gland and the attachments of this sheath to the sheaths of the stylohyoid muscle and the posterior belly of the digastric. 8. This space is traversed by the styloglossus and stylopharyngeus muscles: both above and below these muscles it opens medially into the retropharyngeal space 9. Anterosuperiorly extends to the Pterygomandibular raphe 10. Anteriorly is continuous with the submandibular (submaxillary portion) space 11. Clinical: Subject to infection from several sources i. Considered to be the route by which infections of diverse origins may be transmitted. Infection generally does not pass directly into the lateral visceral space, but pushes the carotid bundle and passes to the highway-the retropharyngeal spacethat in turn leads to the mediastinum. Through its connection with the spaces about the tongue (Sublingual Space), it may receive and transmit to the retropharyngeal space infections originating here, as from the teeth; similarly, it is adjacent to the submandibular gland, and infections in this gland may spread into the Submaxillary space; Both the masticator space and the parotid gland border the lateral pharyngeal space, and infections within either of these that perforate deeply instead of superficially will necessarily invade the lateral pharyngeal space.

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Tonsillar region of the pharynx is the medial wall of the lateral pharyngeal space, and infections originating about the tonsils may also involve this space. Infections within the petrous portion of the temporal bone may rupture directly into the lateral pharyngeal space, and infection at the tip of the mastoid process may follow the mastoid groove and extend along the styloid and digastric muscles to this space

Masticator Space Formed by the splitting of the Superficial layer of cervical fascia to enclose the ramus of the mandible, the masseter, the medial pterygoid, and the lower portion of the temporal muscle.

Since these structures lie between the fascial layers on the outer surface of the masseter and the inner surface of the medial pterygoid, the loose connective tissue and fat about them forms the potential space

1. Its largest part is medial to the ramus of the mandible, between this and the medial pterygoid, and medial and anterior to the lower portion of the insertion of the temporal muscle. 2. Posteriorly, the fascial walls of this space come together behind the ramus of the mandible. 3. Anteriorly, a part of the masseteric fascia attaches to the mandible in front of the masseter muscle and to the insertion of the temporal muscle along the anterior border of the ramus, 4. Anteriorly, it is limited by another part passes in front of the ramus, across the outer surface of the buccal fat pad, to attach to the maxilla and the buccinator fascia below that 5. Superiorly, it is limited deep to the temporal muscle by the origin of this muscle from the skull. (Inferior temporal ridges and lines) 6. Superficially, it is limited by the muscle's origin from the temporal fascia. 7. Deeply, anterior to the lateral pterygoid plate it extends into the pterygopalatine fossa. (Superior Temporal Line) 8. Lies largely among the muscles of mastication. Those bordering the space are enclosed by thin fascial layers that separate them from the fat pad and subdivide the masticator space into compartments that do not freely communicate with each other. 9. It is traversed particularly by the mandibular nerve (V3) and the maxillary (internal maxillary) vessels

10. Largely filled by the buccal fat pad, pterygoid plexus of veins, and its extends posteriorly, upward, and medially 11. Clinical

Infections of the zygomatic or temporal bones may pass to the masticator space, and so may abscesses from the lower molar teeth Abscesses within this space may apparently point at the anterior aspect of the masseter muscle, either into the cheek or the mouth, or they may point posteriorly below the parotid gland.

Temperomasseteric Recess 1. Temporalis is covered by both superficial layer of deep investing fascia and by the masseteric fascia. 2. Bounded laterally and medially by deep investing fascia 3. Directly inferior it is open and communicates with the masticator space 4. Clinical: Infections can pass outward to the cheek, but can also pass medial to the medial pterygoid muscle or to the parotid gland
Space of Parotid Gland

1. Encloses the parotid gland and its associated lymph nodes and the facial nerve and great vessels traversing it. 2. Attached to its surrounding fascia like the submandibular gland 3. Clinical: Though the deep surface of the parotid gland is strong, infections (usually of the glands or the nodes) may readily pass deeply and therefore into the important lateral pharyngeal space lying deep to the parotid gland. When orally palpating and examining the area, it is important to note that the deep fascia around the parotid gland is weaker medially than laterally . Therefore an infection in this space can evidence itself as a bulge that sticks out medially into the oral cavity.