OS1- 6.2

FASCIA

• a broad sheet of dense connective tissue that separates structures (adjacent muscle, vessels, and glands) during movement and serves as a pathway for the course of vascular and neural structures

CLASSIFICATION OF FASCIA IN THE HEAD AND NECK

→ superficial fascia

→ deep cervical fascia or fascia colli

• anterior/investing layer

• middle/ pretracheal layer

• posterior layer

• carotid sheath or lincoln highway

SUPERFICIAL FASCIA

• directly beneath the skin

• consists of subcutaneous tissues, muscle of the fascial expression and platysma

DEEP CERVICAL FASCIA

• has 4 layers:

  • anterior/ investing layer

  • middle/ pretracheal layer

  • posterior layer

  • carotid sheath or lincoln highway

ANTERIOR/ INVESTING LAYER

• follows the “rule of twos” as it encloses 2 muscles (sternocleidomastoid and trapezius), 2 salivary gland (submandibular and parotid), 2 fascial spaces (parotid and masticator), and forms 2 neck muscles (suprasternal space of burns and supraclavicular space)

MIDDLE/ PRETRACHEAL LAYER

• consists of 2 layes:

  • muscular layer

  • visceral layer

MUSCULAR LAYER

• surrounds the infrahyoid muscles

  • sterno-omohyoid

  • sternothyroid- thyroihyoid

VISCERAL LAYER

• envelopes the pharynx, larynx, trachea, esophagus, and thyroid gland

  • buccopharyngeal

  • pretracheal

  • retropharygeal

POSTERIOR LAYER

• consists of:

  • alar fascia

  • prevertebral fascia

ALAR FASCIA

• forms the carotid fascia

PREVERTEBRAL FASCIA

• covers the prevertebral muscles and the deep muscles of the posterior neck region

CAROTID SHEATH/ LINCOLN HIGHWAY

• is formed by the contributions of all 3 layers of the deep cervical muscles but anatomically separates all layers: carotid artery, vagus nerve, and internal jugular vein

FASCIAL SPACES

• refers to a fasca line tissue compartment/area that is filled with loose, areolar connective tissue that is located between the layers of the fascia that do not exist in a healthy individual, and is only created in the presence of pathology

CLASSIFICATION OF DEEP FASCIAL SPACES ACC TO MODE OF INVOLVEMENT

→ maxillary association

• primary spaces

  • infraorbital/ canine space

  • infratemporal/postzygomatic space

  • palatal space

• secondary spaces

  • sinuses

    • paranasal sinuses

    • cavernous sinus

  • peritonsillar space

  • temporal space

    • superficial temporal space

    • deep temporal space

→ mandibular association

PRIMARY SPACES OF MAXILLARY ASSOCIATION (3)

• infraorbiral/ canine space

• infratemporal/ postzygomatic space

• palatal space

INFRAORBITAL/ CANINE SPACE (4,3)

• s/s:

  • swelling of the cheeks on the canine fossa, shallow nasolabial fold, drooping of the angle of the mouth, swelling of the lower eyelid, upper lip, and labial vestibule

• route:

  • buccal space, superficial temporal space, cavernous sinus

• possible originating site:

  • maxillary canine and maxillary first premolar

INFRATEMPORAL/ POSTZYGOMATIC SPACE (4,3)

• s/s:

  • severe trismus, swelling over the TMJ in front of the ear, tense or tender temporalis muscle, intraoral swelling of the maxillary tuberosity area

• route:

  • deep temporal space, pterygomandibular space, and cavernous sinus

• possible originating site:

  • maxillary molars

PALATAL SPACE (1,3)

• s/s:

  • swollen palatal area

• route:

  • buccal space, vestibular space, sinuses

• possible originating site:

  • palatal root of max molars and max incisors

SECONDARY SPACE OF MAXILLARY ASSOCIATION

→ sinuses

• paranasal sinuses

• cavernous sinus

→ peritonsillar space

→ temporal space

• superficial temporal space

• deep temporal space

SINUSES

• includes the

  • paranasal sinuses

  • cavernous sinus

PARANASAL SINUS (4,3)

• refers to four sets of paired air filled bony spaces within the skull (frontal, ethmoid, sphenoid, and maxillary sinus)

• s/s:

  • sinusitis, headache, dyspnea, foul smelling nasal or pharyngeal discharge

• route:

  • adjacent paranasal sinus, nasal cavity, cranial cavity and the brain

• possible originating site:

  • maxillary and mandibular molars

CEVERNOUS SINUS (6,4)

• refers to paired, dual, venous sinus that consists of numerous cranial nerves including: oculomotor (3), trochlear (4), opthalmic (V1), maxillary (V2), and abducens (VI)

• also referred as the dangerous triangle of the face

• s/s:

  • loss of function of involved cranial nerve, nerve paralysis, double vision, exopthalmos, edema of the eyelids, chemosis

• route:

  • nasal region, paransal region, orbital region, cranial region, brain

• origin:

  • any teeth

TESTS FOR MENINGEAL IRRITATION OR MENINGITIS

→ kernig’s sign

→ brudzinki’s sign

POSITIVE KERNEL’S SIGN

• pain along the spinal cord when the knee is flexed and passively straightened

POSITIVE BRUDZINKI’S SIGN

• involuntary flexion of the knee and hip with the flexion of the neck

PERITONSILLAR SPACE (5,6)

• s/s:

  • trismus, odynophagia, dysphagia, uvula deviation, hot potato voice

• route:

  • retropharyngeal space, lateral pharyngeal spaace, submasseteric space, infraorbital space, temporal space, and pterygomandibular space

• origin:

  • tonsil

HOT POTATO VOICE

• open mouth breathing resulting in a muffled, thicker, deeper voice

TEMPORAL SPACE

→ superficial temporal space

→ deep temporal space

SUPERFICIAL TEMPORAL SPACE (3,4)

• s/s:

  • pain at the temporal region above the zygomatic arch, swelling limited to the temporalis fascia, trismus

• route:

  • lateral pharyngeal space, submasseteric space, pterygomandibular space, and buccal space

• origin:

  • max and mand molars

DEEP TEMPORAL SPACE

• s/s:

  • trismus and less swelling than infection of the superficial temporal space

• region:

  • lateral pharyngeal space, submasseteric space, pterygomandibular space, buccal space

• origin:

  • max molars

MANDIBULAR ASSOCIATION

• primary spaces

  • submental space

  • sublingual space

  • submandibular space

  • spaces of the body of the mandible

• secondary spaces

  • parotid space

  • lateral pharyngeal space

  • retropharyngeal space

  • pretracheal space

  • maseeteric space

    • superificial and deep temporal space

    • pteryogmandibular space

    • submasseteric space

PRIMARY SPACES OF THE MANDIBULAR ASSOCIATION

→ submental space

→ sublingual space

→ submandibular space

→ spaces of the body of the mandible

SUBMENTAL SPACE (2,3)

• s/s:

  • distinct, firm swelling at the lower border of the anterior mandible just beneath the chin that presents a glossy appearance, and dysphagia without tongue elevation

• route:

  • sublingual, submandibular, and lateral pharyngeal space

• origin:

  • mandibular anterior teeth

SUBLINGUAL SPACE (2,2)

• s/s:

  • swelling of the floor of the mouth and dysphagia with tongue elevation

• route:

  • submandibular and lateral pharyngeal space

• origin:

  • mandibular posterior region and mandibular traumatic injury

SUBMANDIBULAR SPACE (5,6)

• s/s:

  • swelling inferior to the lower border of the mandible, trismus, dysphagia, tooth mobility, sensitivity to percussion

• route:

  • sublingual, submental, lateral pharyngeal, deep neck spaces, deep temporal space, and buccal space

• origin:

  • mandibular posterior teeth

SPACE OF THE BODY OF THE MANDIBLE (3,5)

• s/s:

  • pain, tenderness, and swelling that presents as an indurated mass on the buccal or labial sulcus

• route:

  • temporal, pterygomandibular, lateral pharyngeal, submasseteric, and submandibular spaces

• origin:

  • mandibular teeth and mandibular fractures

SECONDARY SPACES OF THE MANDIBULAR ASSOCIATION

• parotid space

• lateral pharyngeal space

• retropharyngeal space

• pretracheal space

• masticator space

  • superficial and deep temporal space

  • pterygomandibular space

  • submasseteric space

PAROTID SPACE (1,4)

• s/s:

  • trismus

• route:

  • lateral pharyngeal space, infraorbital, temporal, pterygomandibular, and submasseteric space

• origin:

  • parotid gland

LATERAL PHARYNGEAL SPACE (5,4)

• s/s:

  • severe odynophagia, trismus, swelling of the angle of the mandible, medial bulge on the lateral pharyngeal wall, deviation of the pharynx, uvula, and pharyngeal wall to the opporite side

• route:

  • submandibular, sublingual, retropharyngeal, pterygomandibular space

• origin:

  • mandibular 3rd molar, larynx, pharynx, and adjacent fascial spaces

RETROPHARYNGEAL SPACE (5,4)

• s/s:

  • severe odynophagia, dyspnea, trismus, bulging of the posterior pharyngeal wall, neck stiffness resulting to difficulty in turning the head

• route:

  • submandibular, sublingual, lateral pharyngeal, and pterygomandibular spaces

• origin:

  • andjacent fascial spaces including pharynx and nasal cavity

PRETRACHEAL SPACE (3,2)

• s/s:

  • dysphagia, odynophagia, and hoarseness

• route:

  • retropharyngeal and lateral pharyngeal space

• origin:

  • adjacent fascial spaces

MASTICATOR SPACES

• superficial and deep temporal space

• pterygomandibular space

• submasseteric space

PTERYGOMANDIBULAR SPACE (6,5)

• s/s:

  • absence of extraoral swelling, swelling of the uvula, moderate to severe trismus, odynophagia, swelling of the pterygomandibular raphe or ligament, and deviation of the lateral wall of the pharynx

• route:

  • deep temoral, submandibular, lateral pharyngeal, submandibular, submasseteric, and buccal spaces

• origin:

  • mand 3rd molars and mand fracture

SUBMASSETERIC SPACE

• s/s:

  • severe trismus, throbbing pain, mild swelling confined to the masseter muscle

• route:

  • superficial temporal, infratemporal, lateral pharyngeal, pterygomandibular, submandibular, buccal space

• origin:

  • mand 3 molars

MAXILLARY AND MANDIBULAR ASSOCIATION

→ vestibular space

→ buccal space

VESTIBULAR SPACE

• s/s:

  • swelling or shallowness of the buccal and labial vestibular, and swelling of the cheeks and lip commissure

• route:

  • buccal space, infraorbital space, and cavernous sinus

• origin:

  • any tooth

BUCCAL SPACE

• a portion of the subcutaneous space that extends from head to toe

• s/s:

  • dome shaped swelling of the cheeks located posterior to the lip commissure, including anterior to the masseter muscle or ascending ramus, and inferior to the lower border of the mandible, absence of trismus, and dumbbell shaped appearance when associated with deep temporal space

• route:

  • lateral pharyngeal space, pterygomandibular space, deep temporal space, infratemporal space, infraorbital space, submasseteric space

• origin:

  • any tooth

CLASSIFICATION OF DEEP FASCIAL SPACES ACC. TO ANATOMIC LOCATION

→ fascial spaces of the face

→ suprahyoid fascial space

→ infrahyoid fascial space

→ fascial spaces of the neck

FASCIAL SPACES OF THE FACE

→ buccal space

→ infraorbital space

→ infratemporal space

→ masticator space

→ parotid space

SUPRAHYOID FASCIAL SPACE

→ sublingual space

→ submental space

→ submandibular space

→ lateral pharyngeal space

→ peritonsillar space

→ space of the body of the mandible

INFRAHYOID FASCIAL SPACE

→ pretracheal space

FASCIAL SPACES OF THE NECK

→ retropharyngeal space

→ carotid space

→ danger space

DANGER SPACE

• located between the alar fascia and prevertebral fascia

• offers little resistance to spread of infection and can extend from the pharynx to the mediastinum requiring cardiothoracic surgical support

CLASSIFICATION OF INFECTION OF THE DEEP FASCIAL SPACES

• is based on their potential to obstruct the airway and damage other vital structures

→ low intensity infection

→ moderate intensity infection

→ high intensity infection

LOW INTENSITY INFECTION

• little threat to airway and other vital structures

  • ex: buccal space, infraorbital space, vestibular space

MODERATE INTENSITY INFECTION

• hiders airway access by causing trismus and elevation of the tongue

  • ex: infratemporal space, submandibular space, submental space, sublingual space, and masticator space

HIGH INTENSITY INFECTION

• directly compresses/ deviates airway and damage vital structures

  • ex: lateral pharyngeal space, retropharyngeal space, pretracheal space, cavernous sinus, danger space

DEEP NECK SPACES

• interconnected, potential areas of the neck located within the deep cervical fascia

CLASSFICATION OF DEEP NECK SPACES

→ spaces involving the entire length of the neck

→ spaces limited/ located above the hyoid bone

→ spaces limited/ located below the hyoid bone

SPACES INVOLVING THE ENTIRE LENGTH OF THE NECK

→ prevertabral space

→ retropharyngeal space

→ carotid space

→ danger space

SPACES LOCATED/ LIMITED ABOVE THE HYOID BONE

→ lateral pharyngeal space

→ submandibular space

→ parotid space

→ peritonsillar space

→ masticator space

→ temporal space

SPACES LOCATED/ LIMITED BELOW THE HYOID BONE

→ anterior visceral space

→ substernal space of burns

DEEP NECK SPACE INFECTIONS

• refers to severe infections that can spread rapidly along the deep neck spaces, which can progress to life threatening complications by compromising airway, cervical vessels, and spinal canal

• s/s:

  • swelling below the inferior border of the mandible, dysphagia, dyspnea, odynophagia, neck pain and stiffness, severe sore throat, laryngeal voice change and trismus

• route:

  • adjacent fascial space

• origin:

  • mandibular teeth, tonsil, parotid gland, sinuses, middle ear, and deep cervical lymph nodes

IMPENDING AIRWAY DISASTER TRIAD

• rapid onset of aphagia or severe dysphagia that is usually associated with severe sore throat

• rapid onset laryngeal voice change

• systemically unwell

MANAGEMENT OF FASCIAL SPACE INFECTION (5)

• for mild to moderate cases only:

  • medical support of the patient with special attention to the protection of airway and correcting host defense mechanism where it exist

  • surgical removal of the cause of infection as early as possible

  • surgical drainage of the infection with proper placement of drains

  • administration of correct antibiotics with appropriate doses

  • frequent re evaluation of the patients progress towards the resolution of infection

DANGEROUS AREAS OF THE HEAD AND NECK WHERE INFECTION CAN SPREAD

1. from the maxilla, upper lip, nose, to the cavernous sinus

2. from the lateral laryngeal space up towards the base of the skull, down to the glottis, or into the mediastinum

3. from the mandible, via the sublingual and submandibular space, to the deep neck tissues

CAVERNOUS SINUS

• an important structure because of its location and can lead to cavernous sinus thrombosis

• the dangerous triad of the face

MEDIASTINUM

• a space in the thorax or chest cavity between two pleural sacs

LATERAL LARYNGEAL SPACE

• infection in this space is considered as the most dangerous condition in dentistry

COMPLICATIONS OF ODONTOGENIC INFECTIONS

• candidiasis

• cavernous sinus thrombosis

• actinomycosis

• necrotizing fasciitis

• ledwig’s angina

• osteomyelitis

CANDIDIASIS

• refers to a superficial fungal infection that can affect most areas such as the skin and mucous membrane

• etiology: xerostomia, chronic use of antibiotic, inhaled corticosteroid medication, weak immune system, and underlying medical condition

• s/s:

  • can appear as pseudomembranous candidiasis, erythematous candidiasis, or angular cheilitis

PSEUDOMEMBRANOUS CANDIDIASES

• a distinct, white patches that can be rubbed off exposing an underlying red raw surface

ERYTHEMATOUS CANDIDIASIS

• a red raw area with loss of filiform papillae on the tongue

ANGULAR CHEILITIS

• white, ulcerated patches on the cornes of the mouth

CAVERNOUS SINUS THROMBOSIS

• the result of a formation of thrombus or blood clot within the cavernous sinus that can be potentially fatal

• etiology: fascial infections particularly on the maxillary teeth, ears, eyes, nose, and sinuses

• s/s:

  • sharp severe headache particularly around the eyes, double vision, elevated temperature, loss of function of involved cranial nerve or nerve paralysis, exopthalmos, chemosis, severe malaise

NECROTIZING FASCIITIS

• refers to a potentially fatal and rapidly progressing soft tissue infection of polymicrobial origin with secondary necrosis of the dermal, fascial, and subcutaneous layers of the skin

• also known as the flesh eating disease

• etiology: bacterial invasion from a cut, scrape, needle puncture, surgical wound, or traumatic injury

• early s/s:

  • pain, oreness, swelling of the affected area, hot and erythematous area, elev body temperature, fatigue

• late s/s:

  • dark and necrotic discoloration, gas formation in the tissues, fluid or pus draining from the affected site and septicemia

MAIN ASPECTS OF SURGICAL REMOVAL OF NECROTIZING FASCIITIS

→ necrosectomy

→ fasciotomy

NECROSECTOMY

• blunt removal/ dissection of the necrotic tissue using fingers and sponges

FASCIOTOMY

• incision of the fascial compartment to prevent compression syndrome

ACTINOMYCOSIS OR CERVICOFACIAL ACTINOMYCOSIS

• slow progressive bacterial infection of the hard and soft tissues of the head and neck

• etiology: infection from teeth, sinuses, tongue, middle ear, larynx, thyroid gland, and lacrimal pathways

• s/s:

  • indurated mass that develops into multiple abscesses with draining sinus tracts on the skin or oral mucosa, thick yellow exudate with characteristic sulfur granules, pain and trismus

LEDWIG’S ANGINA

• firm, acute, toxic, severe diffuse cellulitis that spreads rapidly, bilaterally affecting the submandibular, sublingual, and submental spaces that may extend to the neck and clavicle area

• etiology: odontogenic infection in the mandible that results in fever and severe toxicity, septic fractire, salivary gland infection, and hematogenous infection

• s/s:

  • bilateral swelling of the mandibular area, texture of the skin is described as wood like, pitting and blanching of the skin, double chin appearance, tongue protrusion

OSTEOMYELITIS

• infection of the bone that usually begins in the medullary cavity, extending to the cancellous bone which spreads to the cortical bone, and eventually involves the periosteum

• etiology: odontogenic infection and jaw fractures in a patient with suppressed host defenses such as antibiotics, alcoholism, ilicit drig use, malnutrition

ACUTE OSTEOMYELITIS

• onset: develops in less than 2 weeks

• radiograph shows little or no radiographic change because at least 10-12 days are required for bone loss to be detected

CHRONIC OSTEOMYELITIS

• occurs in more than 6 weeks

• radiograph demonstrates bony destruction in the area of infection which is seen as a moth eaten appearance due to areas of radiopacity within radiolucent field