Re: triangles of neck
doctor1 - 03-15-08 23:19

sorry but need to look up the step1 stuff for that i guess, but just brushing up my memory thats 3 fascia ,

Re: triangles of neck
rajratna - 03-16-08 14:00

THATS TRUE 3 FASCIAS AND OMOTRACHEAL TRIANGLE COVERS ALL 3 OF THEM

Re: triangles of neck
doctor1 - 03-17-08 09:16

THATS TRUE 3 FASCIAS AND OMOTRACHEAL TRIANGLE COVERS ALL 3 OF THEM ..thanks rajratna for the info r u preparing for step 1 or are u in surgery match

Re: triangles of neck
franciska - 03-17-08 10:40

doctor1 hi ,

i am just preparing for the step 1 .i am not in surgery match but my friend told that there are 5 fascias in the neck for the purpose of better approach
1)superficial fascia
2)fascia proper
3)omoclavicular fascia
4)endocervical fascia ---a)parietal
b)visceral
5)prevertebral fascia
i just wanted to confirm.
now u plZ opine

Re: triangles of neck
rajratna - 03-17-08 11:20

wat about franciska's answer she is also right.
wat do u say about it.
Because as per the practical surgery we have 5 fascias for approach for specifc structures in our body
like franciska said

1)superficial fascia : present all over the body and covers all body but gives special
covering for the platysma

2)fascia proper : gives capsule for sternocleidomastoid & trapezeus & also
forms submandibular gland sac. attaches ant side of sternum &
participates in the formation of interaponeurotic space



3)omoclavicular f. :attached post. to sternum and forms interapo . space with 2nd fascia

4)endocervical f.: a) Parietal------ for covering neck cavities with nerovascular band
b) Visceral------as usual viscera
5)prevertebral f.:in front of the vertebraes and covering the nearby muscles
and as such 3 fascias are also there in this case francisca is also correct but wat should be the perfect answer in case of step 1
plz need expert opinion

Re: triangles of neck
doctor1 - 03-21-08 16:13

I. Fascias of the Head and Neck.

A. Superficial Fascia

1. Extends from the head to the thorax, shoulders and axilla.

2. Envelops the platysma muscle and the muscles of facial expression.

3. Completely encircles the neck.


B. Superficial layer of deep cervical fascia

1. Enveloping layer, completely surrounds the neck.

2. Extends from the zygoma to the pectoral and axillary regions.

3. Envelops the parotid and submandibular glands and the trapezius and
SCM muscles.

4. The space of Burns and the subvaginal space

C. Middle layer of deep cervical fascia

1. Divided into a muscular division and visceral division.

2. The Muscular division surrounds the strap muscles. It extends from
the hyoid bone to the sternum, clavicle and scapula.

3. The visceral division surrounds the thyroid, trachea and esophagus.
Posteriosuperiorly it extends from the skull base, anteriosuperiorly
it extends from the hyoid bone. It then becomes continuous with the
fibrous pericardium and continues as the covering of the esophagus
and trachea in the chest.

D. Deep layer of the deep cervical fascia

1. Divided into a prevertebral and alar layer.

2. Prevertebral layer - from the base of the skull to the coccyx. It
extends from the transverse process around the deep muscles of the
neck and anterior vertebral bodies to re-insert on the spinous
processes.

3. Alar layer - Extends from the base of the skull to T-2 and laterally
from transverse spinous process to transverse spinous process. It
lies between the prevertebral fascia and the posterior visceral fascia
to which it fuses to at T-2.

E. Carotid sheath

The carotid sheath is derived from all three layers of the deep
cervical fascia. Mosher called this the "Lincon Highway" of the neck. It
extends from the base of the skull to the chest.

The fascial spaces of the neck can be arbitrarily divided into
three divisions. These are: 1) spaces involving the entire length of the
neck, 2) spaces above the hyoid bone and 3) spaces below the hyoid bone.
This division is based of the fact that the hyoid bone is the most
important structure limiting the spread of infection.

II. Spaces above the hyoid bone

A. Submandibular space

1. Boundaries- mandible (anterior and lateral), mucosa of the floor of
the mouth (superior), Hyoid bone (posterior), superficial layer of
the deep cervical fascia (inferior).

2. Divided into a sublingual space (above the mylohyoid) and a
submaxillary space (below the mylohyoid).

3. Source of infection - Most are odontogenic. In general periapical
abscess anterior to the second molar cause sublingual space
infections, while those of the second and third molar break through
below the mylohyoid and lead to submaxillary infections. Other
common routes of infection include submandibular gland or lymph node
infection.

4. Symptoms include severe pain, trismus, swallowing difficulties,
respiratory distress, swelling of the neck and floor of the mouth.

5. Ludwig's angina was described in 1836. The infection is usually
secondary to a 2nd or 3rd molar infection. It is a cellulitis of
the submandibular space, drainage yields a putrid serosanguineous
fluid.

6. Treatment- ABC's. Many of these patients will require an awake
tracheotomy prior to drainage. Drainage (for ludwig's) is through
a horizontal submental incisions which divides the platysma, the
mylohyoid is then divided in the midline to relieve tension on the
floor of mouth. The area is then opened with a clamp, drains are
placed, the wound is not totally closed. Small sublingual abscess
may undergo intraoral drainage. One sided submaxillary abscess may
undergo drainage through a horizontal submaxillary incision being
careful to avoid the marginal mandibular nerve.

B. Parapharyngeal space

1. AKA- Pharyngomaxillary space, lateral pharyngeal space and
peripharyngeal space.

2. An inverted pyramid in shape, the space is bounded by the base of
skull (superior), hyoid bone (inferior), pterygomandibular raphe
(anterior), prevertebral fascia (posterior) and fascia of the
superior constrictor (medial).
3. Divided by styloid process into a prestyloid or muscular compartment
and a retrostyloid or neurovascular compartment.

4. This space is frequently involved with infection because of the lymph
nodes contained within it and its integral relationship to most of
the other spaces. This space serves as the conduit to allow infection
to pass from the spaces above the hyoid to those spaces below the
hyoid and then into the chest.

5. Symptoms- Prestyloid space- buldging of peritonsillar region,
trismus and angle of jaw swelling. Poststyloid - Parotid space
swelling and lateral pharyngeal wall swelling but no trismus.
Watch for possible vascular thrombosis or hemorrhage.

6. Drainage - External for vascular control. Use a horizontal incision
or an incision along the anterior boarder of the SCM. Elevate
submandibular gland and finger dissect toward styloid process.
Drain and do not close wound totally.

C. Masticator space.

1. Boundaries- The superficial layer of the deep cervical fascia splits
at the mandible to ensheathe the muscles of mastication, thus the
masticator space is bound on all sides by this layer.

2. Most infections are odontogenic in origin, usual from the 2nd and 3rd
molar.

3. Symptoms- Extreme trismus is the hallmark of these infections. There
may be swelling of the cheeks or in the mouth along the ramus of the
mandible. Frequently the most tender area is along the posterior
border of the ramus of the mandible.

4. Treatment- Usually external through a horizontal incision below the
angle of the mandible. Drain, and do not close wound all the way.

D. Parotid space

1. Boundaries - The gland is bound on all sides by the superficial layer
of the deep cervical fascia which splits to encapsulate the gland
along with its lymph nodes. The fascia is thought to be deficient
superiomedially allowing open communication with the parapharyngeal
space.

2. Symptoms - Swelling of the parotid at the angle of the mandible
without trismus.

3. Treatment- A small abscess can be drained with an incision in the
skin over the swelling parallel to the facial nerve and then bluntly
dissecting into the abscess with a clamp. Larger abscesses should
be drained through a parotidectomy incision. The wound is drained and partially closed.

E. Peritonsillar space

1. Most common deep neck infection.

2. Boundaries - Superior constrictor (medial), anterior and posterior
tonsilar pillars (superiorly and interiorly).

3. Early abscesses generally extend superior and anterior. Later,
posterior extension allows it to decompress into the parapharyngeal
space. Remember, all peritonsillar abscesses are potential
parapharyngeal or retropharyngeal abbesses.

4. Symptoms - Tonsillitis that worsens despite antibiotics. Patients are
usually unable to swallow and have trismus. Exam reveals one tonsil
bulging toward the midline displacing the uvula and causing a
convexity of the faucial arch.

5. Treatment: Antibiotics (clindamycin/unasyn/augmentin) with:

a. Aspiration - 90% effective, 15% require multiple aspirations. Ten
percent need other treatment. May be appropriate in patients over
30 years of age without a history of recurrent tonsillitis.

b. I&D with interval tonsillectomy - incision at superior pole and
dissect with clamp to inferior pole.

c. Quinsy tonsillectomy


III. Spaces involving the entire length of the neck

A. Superficial space

1. Between the superficial fascia and the deep layer of the deep
cervical fascia.

2. Site of superficial cellulitis of the neck usual secondary to
suppuration of a lymph node.

3. Signs of infection are obvious as these abscesses point and are
fluctuant, as opposed to deep space neck infections.

4. Treatment involves local I&D and antibiotics.

B. Retropharyngeal space

1. AKA- Posterior visceral space, retrovisceral spate, retro-esophageal
space and posterior part of Grodinsky and Holyoke space #3.

2. Boundaries - Base of skull (superior), T-2 (interior), middle layer
of deep cervical fascia (anterior) and alar layer (posterior). At
T-2 the alar and middle cervical fascias fuse.

3. Main route of spread of infection from the neck to the chest.
Infections here can easily breakthrough into the danger space which
extends to the diaphragm.

4. Usually caused by suppuration of retropharyngeal lymph nodes receiving
drainage from sinuses, adenoids and nasopharynx.

5. Usually a complication of a URI and more common in children.

6. Signs/symptoms - In children: seen after a URI, may cause swallowing
difficulties, respiratory distress and fever. The neck is usually
held rigid and tilted to the uninvolved side. On oral exam the
lesion is typically seen on one side, although more advanced lesions
cross the midline.

7. Treatment - ABC's. Watch for rupture and aspiration. These patients
may need a tracheotomy prior to drainage. Localized lesions may
undergo peroral I&D, extended lesions will need a external excision.
Typically this incision is along the anterior border of the SCM,
dissection is then carried between the carotid sheath and the
constrictor muscles (Dean approach). Drain the wound and do not
close the wound.

8. Complications - Include hemorrhage, aspiration and extension into
the chest. Mediastinal extension is characterized by chest pain,
dyspnea and persistent fever. Initial CT scans must define the
inferior extent of the spread of infection.

C. Danger space (Grodinsky and Holyoke #4)

1. Boundaries - Between the alar and prevertebral fascia from the base
of the skull to the diaphragm.

2. Usually secondary to spread of infection from the parapharyngeal
space or the prevertebral space. Allows easy spread into the
mediastinum - hence its name: the danger space.

3. Drainage - Similar to that described for the external approach to
the retropharyngeal space.

D. Prevertebral space (Grodinsky and Holyoke #5)

1. Boundaries - Compact space between the prevetebral fascia and the
vertebral bodies, from the base of the skull to the coccyx.

2. Infrequent cause of infection. Generally secondary to TB,
osteomyelitis or surgery.

3. Compactness of space generally limits spread into the chest.

4. Drainage is similar to external approach to retropharyngeal space.

E. Visceral vascular space (carotid space)

1. The space confined by the carotid sheath, from the base of the skull
to the mediastinum. The space is compact and infection does not
usually travel within the sheath.

2. Signs/symptoms - Tenderness and induration deep to the SCM along
with torticollis toward the uninvolved side.

3. Compilations involve thrombosis or rupture of the great vessels of
the neck. A "picket fence" type of fever curve indicates thrombosis
of the IJ vein which may require surgical excision of the vein.


IV. Spaces limited to below the hyoid.

A. Anterior visceral space

1. AKA- Pretracheal space, previsceral space and anterior portion of
Grodinsky and Holyoke space #3.

2. Boundaries - Thyroid cartilage (superior), to superior mediastinum
at the aortic arch (inferior), between the deep surface of the strap
muscles (anterior) and the anterior wall of the esophagus (posterior).
In its upper portion it is continuous with the posterior visceral
space.

3. Usually infections arise from traumatic perforations of the anterior
esophageal wall.

4. Signs/symptoms - Hoarseness, dysphagia, dyspnea, swelling and
erythema of the hypopharynx.

5. If the infection is pointing, a localized drainage can be done.
For more extensive infections drainage via the Dean approach is
useful.


V. Treatment

A. Microbiology

The microbiology of deep neck infections consists of mixed
anaerobic and aerobic bacteria with anaerobes predominating. The usual
organisms found are those that are normal mouth flora. Despite the
anaerobic predominance the most common isolate is aerobic streptococci.
The most common anaerobic bacteria are Peptostreptococcus, Fusobacterium
and Bacteroides. An important exception to this is the parotid abscess
where Staphylocci tend to predominate. Gram-negative rods are not normal
oral fora in health adults. The colonization rate is increased in
diabetics, hospitalized patients and chronic alcoholics. Thus, these
bacteria may participate in the infectious process in these patients.
Eikenella corrodens is an emerging pathogen in deep space neck infections,
especially when secondary to IVDA. This organism has the distinction of
being one of the only anaerobes to be resistant to clindamycin.


B. Antibiotics

The antibiotic choice should obviously reflect the pathogens.
Prior to culture results common pathogens should be covered. This
includes gram-positive cocci and anaerobes. Good initial choices include
high-dose PCN and metronidazole or chloramphenicol. Clindamycin alone may
be a reasonable choice, however the emergence of Eikenella corrodens as a
pathogen must be remembered.


C. Airway Management
The judicious management of the airway is especially important
for retropharyngeal and submandibular space infections. Patients with
Ludwig's angina can experience rapid deterioration of their airway and
expeditious care is crucial to avoid disaster. Techniques of airway
management include awake intubation, fiberoptic intubation and awake
tracheotomy. Of these, it is the authors' opinion that awake tracheotomy
provides the safest airway management.

D. Surgical
Incision and drainage is almost always part of the treatment.
There are two main routes of drainage: intraoral vs. extraoral.
Intraoral drainage is appropriate for peritonsillar abscesses and small
retropharyngeal or sublingual abscesses. Extraoral drainage is most
appropriate for all other abscesses. The incision is either submental
(ludwig), submandibular or along the anterior boarder of the SCM. In
general the wounds should be drained and left open or only partially
closed.

Re: triangles of neck
doctor1 - 03-21-08 16:14

ok so a generalised question on the number of fascias in neck can be a wrong statement as it ha sto be precise regarding the compartment , i am not sure if this has answered the question

Re: triangles of neck
rajratna - 03-21-08 16:48

hey doctor 1 thanks for the awsome info and thanks a lot hope to expect the same kind of answers for my doubts plz dont call them absurd since i am student so expect u all seniors & experienced people's precious guidance with due respect .
thanks again

Re: triangles of neck
doctor1 - 03-21-08 17:04

hey rajratna , thanks for that but all of us have more or less the same knowledge base its just the experience that differs