Applied Anatomy of Fascial Spaces In Head and Neck

Author(s): Singh T.P., Bala Sanju, 1Kalsey G., 1Singla Rajan 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 with some of their clinical aspects. Does it mean that these are not clinically important or their importance has decreased with the advent of antiboitics and so these should not be taught to medical and dental students. Actually it is not so. Neither the patients or abscesses in these spaces have vanished nor have these lost importance. So basic knowledge of these is a must for both medical and dental students For importing this information Faculty of Anatomy including P.G. Students and budding specialists in oral and 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 are multiplication in the observations making the description of a fixed pattern difficult. An attempt is made to classify and discuss important anatomical and clinical aspects about these spaces. Keywords: Fascial spaces, Supra-hyoid spaces, Infrahyoid spaces

Introduction
A sizeable segment of patients reporting to the oral and maxillofacial surgery department of Pb. Govt. Dental College and Hospital, Amritsar needing surgical intervention for infections of the fascial spaces of head and neck and the difficulty in locating exactly the spaces involved in these cases has given an impetus to revise and review the fasciae and fascial spaces in the different outlooks. Here it is pertinent to keep in mind that many other patients might have reported to the other institutes and/or private practitioners and many more might have undergone non-surgical interventions as well. The inherent difficulty in dissecting these structures and varied approaches in describing these by different authors led to more of controversies and less of a clear and fixed pattern as is evident by reviewing different books of reference on this subject. It has been a subject of great controversy since its first description by Burns (1811). Hollinshead (1958) devoted a chapter to these mainly because of their clinical significance and recognition as an anatomical entity. Almost all the textbooks of oral and maxillofacial surgery (Moore; Killey et al, 1975; Topazian and Goldberg, 1991 and Srinivasan, 1996) and ENT (Paparella et al, 1991) have laid a great stress on these. The pioneer work of Burns (1811) kindled a spark of light for further research by various workers 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 a few to name who worked hard to solve this controversy during the 19th century. However the mystery remained unsolved as is well indicated by Malgaigne's statement that, "the cervical fasciae (and hence spaces as well) appear in a new form under the pen of each author who attempts to describe them." During the earlier years of 20thcentury there appeared the works of Testut (1902); Charply (1912); Dean (1919); Mosher (1920 and 1929): Furstenberg (1929): Coller and

Yglesia (1935 and 1937) and Grodinsky and Holyoke (1938) who have added a lot to our knowledge of the subject. During the recent years Archer (1966); Barker and Davies (1972); Killey et al (1975): Moore; Paperella et al (1991); Topazian and Goldberg (1991) and Srinivasan (1996) have discussed their anatomical and clinical facts in good stead. The purpose of the article is to review the earlier works to find out the controversies and their solutions and to make out an easily understandable, reproducible and clinically significant explanation of these fascial spaces which 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 layers of fascia normally filled with loose connective tissue (Shapiro, 1950) and bounded by anatomical barriers, usually of bone, muscle or fascial layers (Moore). However, their effectiveness varies as in some sites the fascial membranes particularly are so weak and indefinite that they do not contain the infection (Moore). Last (1972) names the buccopharyngeal fascia as a very delicate fascial layer which is unable to contain the identified on anatomical specimens. In life, these infected cavities are formed partly by the destruction of tissue by inflammatory enzymes and so during the course of an infection they take some time to become patent (Moore).

Classification
Unfortunately, there are many classifications of these spaces. Almost all of these classify these spaces into suprahyoid and infrahyoid spaces. Scott (1952) classified fascial spaces 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) based upon the data of dissected materials, results of spread of injected masses and infections observed clinically, designated and described these spaces by numerals (spaces of anterior triangle) and numerals followed by letter A (spaces of posterior triangle) as follows: (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 of parotid 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 and superficial layer of deep fascia extending in whole of head and neck and upper part of thorax. In neck and upper thorax, it can be subdivided into superficial and deep divisions by 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 by epicranius muscle. In face, the subcutaneous fat is minimal in eyelids and so greatest amount of swelling is apt to occur there in subcutaneous region and deep to muscles of facial expression in rest of the face. In scalp, swelling can occur in loose areolar tissue deep to the epicranius muscle. In axilla, fat of space 1, becomes continuous with fat within the axillary space through the opening in the deep fascia of the axilla, placing the 2 spaces in communication. (d) Subdivisions: (Topazian and Goldberg, 1991 and Laskin 1996). (i) Canine space: It overlies the canine fossa of maxilla and underneath levator labii superioris and levator labii superioris alaquae nasi. Gap between two preceeding muscles affords an opening near the inner corner of the eye through which the skin surface may be 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 maxillary canine) and is even less frequently implicated in nasal infections (Topazian and Goldberg, 1991). From here pus can track superiorly into the superficial fascial compartment upto medial angle of the eye or even lower eyelid (Moore). Infection from maxillary premolars can pass upwards and posteriorly through infraorbital foramen to the orbit and superomedially to nasolacrimal duct and nose. Infection from maxillary molars can spread to 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 with each 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 and styloglossus 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 myelohyoid muscle. (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, Submental lymph 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 of chin. (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 mandible below 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 being attached to lower border of mandible and deep layer to myelohyoid line. (b) Contents :Superficial part of submandibular salivary gland, Submandibular lymph nodes, 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 of digastric but Grodinsky and Holyoke (1938) observed that injections spread readily beneath 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 infections of head and neck. Infection may arise from injuries to the oral mucosa, submandibular or sublingual 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 cervical fascia at the anterior, posterior and inferior borders of mandibular ramus to include ramus of mandible, massetor, medial et lateral pterygoid and that part of temporalis muscle which is attached to the coronoid process. This space has following recesses or subdivisions(a) Temporal or zygomatico temporal space - it is a superior extension of the masticator space both superficial and deep to temporalis muscle and named accordingly. It is limited superficially by thick sheet of temporalis fascia arising from zygomatic arch and extending upto superior temporal line. (b) Submasseteric space (Fig. 4) it is an inferior extension between lateral surface of ramus 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 extension between medial surface of ramus of mandible laterally, lateral surface of medial pterygoid muscle 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 masticator space. Clinical Significance : (a) Masticator space may be infected from infection of zygoma, temporal bone or lower molar 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 dental nerve block anaesthesia. (iii) Trauma to mandible involving molar teeth. (b) Abscess in this space may point at anterior border of masseter muscle either into the cheeck or mouth or posteriorly beneath the parotid gland.

Fig.5. Spread of Infection From 3rd Molar to Various Fascial Spaces 4. Parapharyngeal space: (Fig. 5)
It is also known as lateral pharyngeal space, peripharyngeal space, pharyngomasticator space, pharyngomaxillary space, or pterygopharyngeal space. These lie immediately posterior and lateral to the pharynx, and extend forwards into the sublingual region, so that together they actually form a ring about the pharynx. They lie entirely deep to the superficial or anterior layer of the deep fascia, and communicate more or 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 by extension from them; moreover, it is these spaces which are most intimately related to the lymph nodes receiving the drainage from the nose, throat and jaw, so that abscesses within them may develope as a result of breakdown of nodes secondarily infected from their regions of drainage. It is one or more of these spaces that is more commonly infected 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 towards the lesser cornu of hyoid bone and base directed superiorly towards skull base (Paparella et 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 muscle anteriorly and styloid process with its attached structures posteriorly and deep surface of parotid 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 that inferiorly the space communicates with superior mediastinum along the carotid sheath and 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 et al, 1991) contains lymph nodes, ascending pharyngeal and facial arteries, maxillary artery, inferior alveolar nerve, lingual nerve, auriculotemporal nerve and loose areolar tissue. (ii) Posterior compartment (called post styloid compartment by Hall, 1934 and Paparella et al, 1991) contains carotid sheath with its contents, 9, 11, 12th cranial nerves and cervical sympathetic chain. (c) Communications: (i) Superiorly to deep pterygoid space bounded by medial pterygoid laterally, pharyngeal wall 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 in relationship with floor of the mouth (Grodinsky and Holyoke, 1938). (d) Clinical Significance: According to Hollinshead (1958), parapharyngeal space is more subject to infection than any of other spaces. It may recieve infection from teeth, submandibular gland, masticator space, parotid space and

paratonsillar space. From this space infection can pass to retrophargyngeal space and then to superior mediastinum. Grodinsky (1939), Faier (1933) and Beck (1942) all agree that causative agent for this infection lies in nose, throat, middle ear, pharynx and tonsils and that lymphatic spread is the mode of infection. However about 20% of infections in Beck's (1942) series and about 1/3rd of adult cases in Boemer's (1937) series arose from infections of dental origin passing to these spaces via lymphatics as well as via root canals. Rarely fatal haemorrhage can occur from extension of an abscess to deep vessels of neck mainly internal carotid artery (Lifschutz, 1931). Capes et al (1999) reported a case of bilateral cervicofacial, axillary and anterior mediastinal emphysema as a rare complication of 3rd molar extraction with spread of air occuring through masticatory and then parapharyngeal and retropharyngeal spaces. Since the masticatory, parapharyngeal, retropharyngeal, vascular and pretracheal spaces are 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 the face down to the neck and mediastinum (Rhymes, 1964). Further quoting the works of Chen and Chen (1986), Capes et al (1999) emphasize that if inflowing air contains bacteria 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 of prevertebral fascia. (a) Boundaries: Anteriorly - Posterior wall of pharynx Posteriorly - Pre vertebral fascia Superiorly - Base of skull Inferiorly - Communicates with superior mediastinum (b) Clinical Significance : It acts as a route through which infection from the mouth and throat can reach the superior mediastinum. Pearse (1938) pointed out that 71% of cases of mediastinitis are due to spread through this space. However, New and Erich (1939) could not find a single case of mediastinitis secondary to cervical infection in 267 cases they studied. Belcerek et al (1988) reported three cases of fatal cervicofacial necrotizing fasciitis spreading to mediastinum possibly through this pathway.

5. Parotid compartment: (Fig. 2)

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

(a) Contents: - Parotid gland with structures within its substance - Superficial parotid lymph nodes on lateral aspect of the gland. - Deep parotid lymph nodes within the gland (b) Surgical Significance: Infection in this space may be because of infection of gland or lymph nodes and not a cellulitis 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 spread longitudinally but not transversally. These may extend as high as hard palate or pharyngeal 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 be formed by attachment of superficial layer of deep cervical fascia to both outer and inner surfaces of the body of mandible. Outer lamina is attached to lower border while deeper lamina 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. It may 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 externally along inferior border of mandible. 3. Infection in this space may spread by rupture of its wall into the masticator space posteriorly 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 and oesophagus as a whole was long known as visceral compartment. Around the upper parts of trachea oesophagus and thyroid gland, this compartment surrounds these structures completely while below the level where inferior thyroid artery enters the thyroid gland, it is divided into 2 portions by a dense connective tissue layer attaching oesophagus laterally to carotid sheath and prevertebral fascia. The anterior part of the compartment, surrounds the trachea and lies against the anterior wall of esophagus and is known as previsceral or pretracheal space. The posterior part of the compartment lying behind the pharynx and oesophagus is known as retrovisceral, retropharyngeal, retroesophageal or post visceral space (Hollinshead, 1958). (These 2 previsceral and retrovisceral spaces together correspond 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 and hyoid bone. Inferiorly:continuous with superior mediastinum and extends upto upper border of arch of aorta (Body of T4 vertebra), where it is limited by dense adhesions between fibrous pericardium and posterior surface of sternum. Laterally: It is blind at root of the neck because of dense adhesions between alar and visceral fasciae.

Clinical importance:
1. This space can get infected from retrovisceral space, around the sides of esophagus and thyroid gland between the levels of upper border of thyroid cartilage and inferior thyroid artery; or directly by anterior perforation of oesophagus. 2. The space can be opened by an incision anterior to sternocleidomastoid carried medially 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 fusion between prevertebral fascia and fascia on posterior surface of oesophagus (Grodinsky and Holyoke, 1938). Coller and Yglesias (1937) gave the lower level of this space at about bifurcation of treachea, but their lower part is probably same as danger space or space 4 of Grodinsky and Holyoke (1938).

Clinical importance:
1. This is the important route for spread of infections originating in head and upper portion of 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 deep cervical lymph nodes. 3. According to lglauer (1935) it can be approached by an incision posterior to sternocleidomastoid carried medially behind the carotid sheath and its great vessels.

II. Visceral space:

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

III. Other spaces:

(a) Cavity within carotid sheath: This alongwith visceral space is grouped under visceral vascular space by Coller and Yglesias (1935) who point out that infection from visceral space readily spreads to the potential cavity within carotid sheath, later also being a pathway for the spread of infections from upper to the lower part of the neck and into 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 transverse processes of one side to the other. Its presence has apparently been ignored in many studies 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, it divides into an anterior alar fascia forming posterior boundary of retrovisceral space and a posterior prevertebral fascia proper lying anterior to prevertebral muscles and vertebrae. Between these two layers lies this space which has been designated asspace 4 or danger space by Grodinsky and Holyoke (1938). This space is also designated as prevertebral space, but this is not clear and Grodinsky and Holyoke (1938) reserve the term prevertebral space for the potential cleavage plane between posterior layer of prevertebral fascia and vertebral bodies (space 5). Anyhow, this space lies behind the retrovisceral space and between alar and posterior layers of prevertebral fascia. Accoding to Grodinsky and Holyoke (1938), this is almost an actual rather than a potential 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 walls commonest being from anterior wall. They furtheited to superior mediastinum but may extend throughout the length of posterior mediastinum.

Apart from the spaces described above Grodinsky and Holyoke (1938) described following 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 and sternothyroid 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 to clavicle 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 deep fascia 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 of vertebrae. Superolaterally It extends between sheaths of trapezius and splenius capitis to vertebral spines 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) is attached 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 bodies limited laterally upto transverse processes of vertebrae. (a) Boundarie: Superiorly - Base of skull Inferiorly - Coccyx Laterally - Transverse process of verte- brae Anteriorly - Prevertebral fascia Posteriorly - Vertebral bodies (b) Communications : At various levels along the spinal column where muscles have attachment to the bodies of the vertebrae; their sheaths are continuous with prevertebral fascia and the spaces within their sheaths with space 5. (c) clinical importance : Because of its communications, it is possible for collection of pus in this space to travel great distances before pointing superficially e.g. caries of cervical or thoracic vertebrae, extending down space 5, transferring to space within the psoas major sheath and presenting 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 infection which opened on chest and another on the upper one third of thigh. Later could be because 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 from axilla. 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 cross posterior triangle of neck into axilla, receive an axillary sheath from anterior wall of this space (Scalenus fascia) (c) Clinical implications: The potential space within axillary sheath is in continuation with space 5A and infection can track from here to upper limb. However, Grodinsky and Holyoke (1938) by injection method 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 and the discrepancies in observations and description noted. Their anatomy, communications and surgical significance is discussed. It is found that understanding their anatomy is a must to appreciate the likely spread of an infection. The first permanent tooth to erupt in human beings is first molar (maxillary and mandibular) and these are commonest source of infection for these spaces because of their being commonly involved in caries. 2nd important source of infection is impacted third molar which may be involved in pericoronitis though not carious. From these, the commonest spaces involved are sub lingual (first molar) and submandibular (commonly from 2ndor 3rdMolar and sometimes from Ist molar). However these 2 spaces communicate with each other at posterior border of myelohyoid. Also submandibular space communicates with superficial facial compartment where the pus can track. It also communicates with parotid space and through that to pterygomandibular space and then to deep pterygoid space, later being considered superior recess of lateral pharyngeal space. Thus infection can reach lateral pharyngeal space and from there to retropharyngeal space which communicates with superior mediastinum of thorax. Once that is involved, it becomes a potentially life threatening situation. Another such clinical situation is ludwig angina in which there is bilateral involvement of sublingual, submandibular and submental spaces. Involvement of sublingual space leads to lifting of tongue causing airway obstruction. This condition has to be treated surgically by incision and drainage to relieve patient of respiratory distress.

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

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