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- Welcome to Thieme E-Books & E-Journals
- Deep Neck Space Infections: A Case Series and Review of the Literature
- Fascial spaces of the head and neck
Welcome to Thieme E-Books & E-Journals
The goal of this chapter is to present the basis for correct diagnosis and management of severe odontogenic infections. The knowledge of the anatomy of fascial spaces is essential for the correct diagnosis and treatment of head and neck infections, because both facial and cervical fasciae work as an effective barrier against the spread of infections in this region[ 1 , 2 ].
Once these infections occur, they are often difficult to assess accurately by clinical examinations and conventional radiographic techniques, and the outcome may be serious and potentially life-threatening[ 3 ]. The fasciae of the neck are glossy and divided into two separated layers: the superficial fascia and the deep fascia.
The superficial fascia is actually a component of the fatty subcutaneous tissue while the deep cervical fascia is divided into three layers: the superficial layer, the visceral or middle layer, and the pre vertebral or deep layer.
The deep cervical fascia plays an important role in determining the location and course of spread of infections within the soft tissues of the neck. The infections that commonly affect head and cervical areas are frequently from odontogenic origin and to a lesser frequency, proceeding from foreign bodies or trauma to this region[ 4 ]. An impacted mandibular third molar is one of the most frequent causes of odontogenic infection[ 5 - 7 ].
Moreover, an semi-impacted third molar results in odontogenic infection more commonly than fully erupted or completely impacted molars [ 7 ]. Odontogenic infections occasionally spread beyond the barriers of the fascial spaces, which are formed, as seen, by the deep cervical fascia of the suprahyoid regions of the neck[ 2 ].
Among various spaces, the submandibular space is one of the first to be involved in odontogenic infections, similar to the masticatory space[ 2 ]. As infection may spread along deep cervical facial planes and neck cavities, widespread cellulitis, necrosis, abscess formation, and sepsis may occur in these cases[ 4 ]. Therefore, it is important to understand the anatomy, rate of progression and potential for airway compromise of an infection[ 7 ]. Spontaneous dissemination of an odontogenic infection is however, very rare in immunocompetent patients[ 8 , 9 ].
In patients with anatomical abnormalities, systemic diseases or immunosuppression, bacteremia caused by dental procedures may lead to generalized or metastatic systemic infection complications leading to hospital care[ 10 , 11 ]. In particular, patients with poorly controlled diabetes mellitus are more susceptible to bacterial infections[ 12 - 14 ]. However, death from odontogenic infection is quite rare [ 9 , 15 , 16 ]. Despite being rare, facial and neck fasciae spaces involved by infections from odontogenic origin may lead to a very morbid condition.
The diagnosis delay and late or wrong therapeutic approachs to deep infections in these areas are the main causes of high mortality rate in this life-threatening situation.
The introduction of antibiotics reduced significantly the mortality and morbidity of these infections, however, even in this contemporary postantibiotic era, serious infections such as a descending necrotizing mediastinitis still have a high mortality rate with a fulminating course, leading frequently to death. The knowledge of the relevant facial and cervical anatomy of the face is essential for todays clinical practice, allowing precise and successful diagnosis.
Figure 1 describes the principal anatomic structures and spaces of the face. Anatomy of the fascial spaces in axial A and coronal B images. The superficial fascia a component of the fatty subcutaneous tissue and the deep cervical fascia is an important anatomic structure, determining the location and course of spread within the soft tissues of the neck. The deep cervical fascia is divided into three layers: the superficial layer, the visceral or middle layer, and the pre-vertebral or deep layer.
The superficial layer of the deep cervical fascia encircles the neck, enveloping the sternocleidomastoid and trapezius muscles and the muscles of mastication, along with the submandibular and parotid salivary glands. It extends from the nuchal line of the skull, mastoid processes, and mandible inferiorly to the scapula, clavicle, and lower cervical vertebrae. The middle layer of the deep cervical fascia encloses the anterior viscera of the neck thyroid gland, larynx, trachea, and pharynx and the strap muscles.
It attaches to the skull base and extends into the mediastinum. The deep layer of the deep cervical fascia is divided into the pre-vertebral and alar divisions. The pre-vertebral division tightly encloses the spine and paraspinous muscles. Ventrally, it lies immediately anterior to the vertebral bodies, forming the anterior wall of the pre-vertebral space.
It extends from the base of the skull to the coccyx. The alar division of the deep layer of the deep cervical fascia lies between the pre-vertebral division and the middle layer of the deep cervical fascia.
It extends from the skull base to the mediastinum. The carotid sheath is made of contributions from all three layers of the deep cervical fascia and envelops the carotid artery, jugular vein, and vagus nerve. The parapharyngeal space fascia is in an area of fatty areolar tissue with complex fascial margins that lies in a central location in the deep face.
It extends from the skull base to the hyoid bone, containing only fat tissue, branches of the trigeminal nerve, and the pterygoid venous plexus. Posterior to the parapharyngeal space is the carotid space. All three layers of deep cervical fascia contribute to the carotid sheath that circumscribe this space.
The carotid space extends from the skull base to the aortic arch. Its suprahyoid contents include the internal carotid artery, jugular vein, cranial nerves IX—XII, and deep cervical lymph node chain. The retropharyngeal space is a posterior midline space that has the middle layer of deep cervical fascia as its anterior margin and the deep layer of deep cervical fascia as its posterior and lateral margins.
It extends from the skull base to the level of the T3 vertebral body. The danger space lies posterior to the retropharyngeal space and is separated from the retropharyngeal space by the alar fascia. The posterior margin of the danger space is the pre-vertebral division of the deep layer of the deep cervical fascia. The importance of the danger space, and the reason for its name, is that it extends from the skull base to the level of the diaphragm, providing a pathway into the posterior mediastinum and pleural spaces.
Infections of danger space most commonly occurs when an abscess in the retropharyngeal space ruptures through the alar fascia. Invasive dental manipulation is known to cause bacteremia and generally considered high-risk procedures for the spread of infection in susceptible patients. Lower third molars are more frequently involved in odontogenic infections when compared with other teeth. Flynn et al. The severe infections of odontogenic origin frequently involve a complex polymicrobial mix of aerobes, facultative aerobes and strict anaerobes working together.
Infections originating in the facial planes of the head and neck spread downward along the cervical fascia, facilitated by gravity, breathing, and negative intrathoracic pressure. Knowledge of the facial spaces and fascial planes is essential for understanding the propagation, pathways, symptoms, and complications of cervical infections.
Some studies clearly demonstrated that the masticatory space is the most prevalent site for odontogenic infection spread. Taken together with the finding that the masticatory space encompasses the posterior mandibular body, ramus, and a part of the alveolar bones of the maxilla, this suggests that the masticatory space may be the initial site of spread of odontogenic infection.
This contention was further supported by the finding that mandibular infection more frequently involved the masseter and medial pterygoid muscles located in the lower compartment of the masticatory space where the mandible is included than the temporalis and lateral pterygoid muscles located in the upper compartment of the space where part of the maxilla is included. The spaces adjacent to the masticatory space are the parotid space posteriorly, the parapharyngeal space medially, and the submandibular and sublingual spaces inferiorly Figure 1.
Therefore, infections in the parapharyngeal space may originate from any adjacent space. A fascia extends from the posterior superior margin of the medial pterygoid muscle to the base of the skull to separate the masticatory space from the parapharyngeal space. Yonetsu et al. However, in none of their cases spread from the submandibular into the pharyngeal spaces.
The parotid space abuts the posterior masticatory space and is enveloped by a layer of the deep cervical fascia. Thus, the retropharyngeal space is considered to be important due to its proximity to the airway and because infections in this space may cause mediastinitis, bronchial erosion, and septicemia.
The infection spread occurs when accumulated pus perforates bone at the weakest and thinnest part. In the mandible, the lingual aspect of the molar region represents the easiest way. As these spaces are partially separated by a thin sheet of mylohyoid muscle, infection in either space easily spreads into the other.
It is generally believed that the midline enables free communication from either the sublingual or submandibular space. Delineating the maxillary spread pattern is quite difficult, because limited data is available regarding its infections. For instance, maxillary infection was associated with temporalis muscle involvement more often than mandibular infection. Maxillary infection also spreads first to the masticatory space, but the temporalis and lateral pterygoid muscles are predominant targets for the infection.
Involvement of the sublingual and submandibular spaces is rare. Otherwise, odontogenic infection arising in the mandible spreads first to the masticatory space.
The masseter and medial pterygoid muscles in the masticatory space are most frequently involved. Thereafter, the infection spreads medially into the parapharyngeal space and posteriorly into the parotid space.
Involvement of the sublingual and submandibular spaces seems to occur directly from the primary site of mandibular infection. There are complex pathways which allow infection to spread along the facial and neck structures. Thus, it is important for dental practitioners to know more about the possibility of a dental intervention to be a cause of severe infections. The sequence of odontogenic infection spread that most commonly occurs is:. The parotid and pharyngeal spaces are the secondary sites of spread from the masticatory space.
Maxillary infection spreads to the deep facial and neck spaces in a different way from that of mandibular infection Figure 2. The pattern of maxillary infection spread differs from that of the mandible. Generally, the main maxillary spaces involved were found to be the buccal maxillary The downward spread into the sublingual and submandibular spaces from maxillary infections did not occur. Other spaces were also involved, but less frequently. Different locations of odontogenic infections.
A Submandibular and sublingual region. B Submandibular region. C Cervical region. D Palate. E Orbital region. F Submandibular and buccal region. Pericoronitis is an infection of the gingiva of a partially erupted tooth. The most frequent form of pericoronitis is caused by the partially erupted lower third molar, mainly due to the favorable niche that is created once the mucous cap covering the molar becomes retentive and deep enough to trap food particles and reduce the oxygen potential.
These factors create the perfect microenvironment for the onset and subsequent development of a recurrent infectious, inflammatory condition caused by polymicrobial microorganisms, especially strict anaerobes. The most significant clinical condition of all bacterial infections of periapical origin is the so-called acute apical periodontitis.
In acute apical periodontitis there is an accumulation of pus inside the apical space of the tooth involved. This condition is commonly underestimated by dental practitioners in terms of its morbidity and mortality. Cervical cellulitis is most commonly from odontogenic origin and despite modern antibiotic therapy, cases with an initial delay in diagnosis and treatment may still result in this life-threatening situation.
Deep Neck Space Infections: A Case Series and Review of the Literature
Department of oral and Maxillofacial Surgery, Pb. Dental College, Amritsar. Fascial spaces in head and neck find no mention in standard text books of anatomy Williams et al, or Huber, though Hollinshead 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.
The initial use of penicillin in the therapy of odontogenic infections in the s led to a dramatic decline in the mortality rates for these infections. In the intervening decades, further refinements in diagnosis, airway management, and surgical therapy have rendered serious morbidity and mortality from odontogenic infections so uncommon that death from odontogenic infection is virtually inconceivable to the lay public. The reduced frequency of these infections makes their diagnosis more difficult for the average practitioner, and therefore careful study of severe odontogenic infections is necessary, or preventable deaths can occur. The most common cause of abscesses involving the deep fascial planes of the head and neck is odontogenic infection. The otherwise closed cavities of the head and neck all have natural drainage pathways, such as the ostia of the sinuses and the Eustachian tube.
The goal of this chapter is to present the basis for correct diagnosis and management of severe odontogenic infections. The knowledge of the anatomy of fascial spaces is essential for the correct diagnosis and treatment of head and neck infections, because both facial and cervical fasciae work as an effective barrier against the spread of infections in this region[ 1 , 2 ]. Once these infections occur, they are often difficult to assess accurately by clinical examinations and conventional radiographic techniques, and the outcome may be serious and potentially life-threatening[ 3 ]. The fasciae of the neck are glossy and divided into two separated layers: the superficial fascia and the deep fascia. The superficial fascia is actually a component of the fatty subcutaneous tissue while the deep cervical fascia is divided into three layers: the superficial layer, the visceral or middle layer, and the pre vertebral or deep layer.
Fascial spaces of the head and neck
Introduction: The cervical spaces infections compose severe pictures and result in a high degree of mortality when they evolve with complications. Objective: To set up a graduation protocol of the cervical abscesses and organize a sequence to treat these patients. Method: We carried out a retrospective study of patients with cervical abscess in which we evaluated the clinical impression, general state, respiratory state, locoregional state, antibiotics used and comorbidity. Then we organized a classification with severity levels.
Fascial spaces also termed fascial tissue spaces  or tissue spaces  are potential spaces that exist between the fasciae and underlying organs and other tissues.
Deep neck spaces are regions of loose connective tissue filling areas between the 3 layers of deep cervical fascia, namely, superficial, middle, and deep layers. The superficial layer is the investing layer, The pretracheal layer is the intermediate layer and the prevertebral layer is the deepest layer. Deep neck space infection DNI is defined as an infection in the potential spaces and actual fascial planes of the neck. Once the natural resistance of fascial planes is overcome, spread of infection occurs along communicating fascial boundaries. More recent trends include the increasing prevalence of resistant bacterial strains, a decline in DNIs caused by pharyngitis or tonsillitis, and a relative increase in DNIs of odontogenic origin.
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