The Fasciae and Fascial Planes of The Head, Neck and Adiacent Regions

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Buch 2021 Fascial spaces in Head and Neck
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Hasmukh Buch
Faculty of Dental Science, Dharmsinh Desai University, Nadiad- Gujarat-India
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Dr. Hasmukh A. Buch Ahmedabad, February 2, 2021

Department of Human Anatomy,
Faculty of Dental Science,
Dharmsinh Desai University,
Nadiad-Gujarat-India, 387 001
Phone (M) +91 6351593435
E-Mail: drhabuch@gmail.com
Foreword
I am happy to submit the manuscript of my paper “Fascial Spaces in Head and Neck: A Critical
Reappraisal Resolving Descriptive Inconsistencies and Aberrations and Simplifying the Anatomy”
(Narrative Review) for Researchgate community. This is a great platform to share even the
unpublished work.
My experience of teaching and dissecting the spaces for over the last 45 years has taught me that
there is a massacre of anatomy in many descriptive accounts requiring remedy.
The present review is an Anatomist‟s perspective on the topic. We have been requested from time
to time by the students and even fellow Anatomists and Clinicians to simplify the description of
the spaces, and hence this also is a part of the paper.
This is my unpublished work. Because of its length, it is unlikely to be accepted for publication
in any standard journal and I am not willing to submit to any predaters!
This article (fully or partly) was submitted for publication to two Appliied Anatomy journals
and one Oral Maxillofacial Surgery journal, the editor of the latter enjoyed the thoughtful
reflections but advised to submit it to any Applied Anatomy journal-one such journal accepted
the article but the revison was rejected. In all, three reviewers gave positive comments and two
of them recommended its publication. I have benefitted from the comments of the learned
Reviewers. Now you are the peer reviewers.
I have combined two systems of incorporating references in the text and hence mentioned the
year of publication and also the serial No. of the reference. Hope it will be acceptable.
Happy reading!
With regards,
Sincerely Yours,
Hasmukh A. Buch
1
Narrative Review
Fascial Spaces in Head and Neck: A Critical Reappraisal Resolving Descriptive
Inconsistencies and Aberrations, and Simplifying the Anatomy
Abstract
The Advent of transoral robotic and endoscopic surgery and modern medical imaging has paved the
way for the resurgence of interest in the anatomy of the fascial spaces of the head and neck.
Unfortunately, their description and names vary from author to author. Such inconsistencies have made
their anatomy look mystifying. It is not the biological and methodological variability based on original
researches that account for the inconsistent description. Therefore, the main aim of the present
communication is to state and resolve the confusing and complicating description of particularly the
suprahyoid spaces and subsequently to simplify their description hoping that this will improve the
communication between the anatomist, surgeon, and radiologist. An update on the terminology of these
spaces is also overdue. Classic as well as recent standard textbooks and atlases of Anatomy and Surgery
as well as articles from reputed journals from 1934 to 2020 have been chosen for this review enriched
by our revisiting the spaces using a new approach to dissect them on adult embalmed cadavers. To
simplify their description, „rings and columnar‟ arrangement has been worked out. It is suggested that
in describing them, advantage must be taken of the established anatomy which must be respected. The
final word on the spaces in the living human rests with the radiologists using MRI of higher resolution.
The recent redefinition of fascia has made the distinction between the fascial and the tissue spaces
tenuous. The adverse impact of COVID 19 pandemic on the fascial pathology is anticipated.
Keywords: fascial spaces; deep cervical fascia; inconsistencies; odontogenic infections; tumors;
mandible; medical education.
2
Abbreviations used for the spaces:

PMS: Pterygomandibular space
SLS: Sublingual space
SMS: Submandibular space
SMeS: Submental space
SMsS: Submasseteric space
BS: Buccal space
TS: Temporal space
STS: Superficial temporal space
IS: Intermediate temporal space
DTS: Deep temporal space
ITS: Infratemporal space
LPS: Lateral pharyngeal space
PPS: Parapharyngeal space
RPS: Retropharyngeal space
PTS: Paratonsillar space; PeTS: Peritonsillar space
1. Introduction
The fascial spaces in the head and neck appeared to lose their importance with the arrival of
antibiotics but the advent of the Transoral endoscopic and robotic surgery and also modern
methods of medical imaging have revived clinicians‟ interest in them. Bali et al. (2015)[1] and
Ogle (2017)[2] have reviewed the complications of odontogenic infections that spread to the
spaces and include the cavernous sinus thrombosis and necrotizing fasciitis. The vulnerability of
COVID19 patients to odontogenic infections and suspended treatment of odontogenic infections
and cancers leading to the involvement of the fascial spaces, and overall impact of the pandemic
on the fascial pathology is being awaited with concern (Meng et al., 2020[3]; Valentini, 2020[4];
Ather et al., 2020[5]).
The first description of the deep cervical fascia (DCF) dates back to Burns (1811) as mentioned
by Grodinsky and Holyoke (1938)[6]. Chadwick and Gabriel (1953)[7] and Lang (1995)[8] have
provided an account of the history of the fascia and some of the enclosed spaces. Adstrum and
Nicholson (2019)[9] have recently presented the history of the fascia in general. Hall (1934)[10]
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has discussed the fascia and particularly the parapharyngeal space (PPS). The oldest most
comprehensive and most authentic original investigations are by Grodinsky and Holyoke
(1938[6], 1939[11]) (Fig. 1a, Fig. 1b); they have detailed the history of the DCF and enclosed
fascial spaces. Subsequently, some authors have described these spaces individually, e.g.
masticator space (MS) (Gaughran, 1957[12] and Fernandes et al., 2013[13]); pterygomandibular
space (PMS) (Barker and Davies, 1972[14] and also Khoury et al. 2010)[15]. But most have
described them collectively either in adults or fetuses (Hollinshead (1954)[16]; Hollinshead
(1982)[17]; DuBrul (1988)[18]; Seward et al. (1992)[19]; Lang (1995)[8]; Singh et al.
(2000)[20]; Flynn (2004, 2008, 2009)[21, 22, 23]; Standring (2008, 2016)[24, 25]; Thapar et al.
(2008)[26]; Malik (2008)[27]; Berkovitz et al. (2009, 2018)[28, 29]; Gregg (2009)[30]; Laskin
and Laskin (2009)[31]; Miyake et al. (2010, 2011)[32, 33]; Katori et al. (2012)[34]; (Feigl
2020)[35]. However, they are famous for their relative lack of uniformity in their description.
Figures 1a and 1b show some of the outstanding spaces. Table 1 gives a glimpse of such spaces
described by various investigators and Table 2 enlists the principal contents of some outstanding
spaces. Malgaigne‟s (1838) statement as quoted by Grodinsky and Holyoke (1938, 1939)[6, 11]]
that “the cervical fasciae appear in a new form under the pen of each author who attempts to describe
them” equally applies to the fascial spaces as well. Not only this, their names too may change. As
an example, the PPS has at least as many as six other names (Hollinshead, 1982)[16]). Although
Guidera et al. (2012)[36] reviewed some of the inconsistencies in the description of the fascia
and a few of the enclosed spaces, it was thought that another look was warranted at the spaces
and particularly the suprahyoid spaces which are extremely important clinically and surgically in
Dentistry, Oral and Maxillofacial Surgery, Otolaryngology (Warshafsky et al., 2012[37] ) and
Oncology. A detailed description of the boundaries, walls, and contents of these spaces abound
in various textbooks (e.g. Hollinshead, 1982)[17]; DuBrul, 1988[18]; Lang, 1995[8]; Malik,
4
2008[27]; Laskin and Laskin, 2009[31]; Berkovitz et al., 2009, 2018)[28, 29] and hence this
reappraisal is aimed to deal with them mainly to point out the aberrations, inconsistencies, and
discrepancies which are not due to their biological variability; it is hoped that the resolution of
these inconsistencies will improve the communication between the anatomist, surgeon, and the
radiologist. Surgical incisions and surgical accesses of pathologically involved spaces are also
not considered. An attempt has been made to furnish a simplified account of the spaces for
surgical trainees.
5
Fig. 1a Schematic diagram of the suprahyoid fascial spaces-perioral and peripharyngeal.
Courtesy of Grodinsky (1939). Some labels have been modified. For other modifications
and numbers, refer the text. VN, vagus nerve; IJV, internal jugular vein; ICA, internal
carotid artery; ECA, external carotid artery; RMV, retromandibular vein; GHMF,
geniohyoid muscle and fascia. Their SMS includes the SLS and SMeS. PMS and SMaS
are not shown.
6
Fig. 1b Schematic diagram of the infrahyoid fascia and fascial spaces. Courtesy of
Grodinsky (1938). Most of the labels have been modified. DCF, deep cervical fascia;
SCM, sternocleidomastoid; SHM & F, sternohyoid muscle and fascia; OHM & F,
omohyoid muscle and fascia; STM & F, sternothyroid muscle and fascia; Pretracheal S,
pretracheal space; VS, visceral space; CCA, common carotid artery; IJV, internal jugular
vein; VN, vagus nerve; ST, sympathetic trunk. For numbers refer the text. Note that the
pretracheal space (No. 3) is superficial to the pretracheal fascia labeled visceral fascia
here and the VS is deep to the same fascia.
7
2. Materials and Method
Classic as well as recent standard Textbooks of Anatomy, Oral Anatomy, General Surgery, Head
and Neck Anatomy and Surgery, Oral and Maxillofacial Surgery, Otolaryngology, and also
authentic journal articles exclusively on fascia and fascial spaces have been chosen for this
review covering the period from 1934 to 2020. Several editions of some of the textbooks have
been consulted although all of them are not included as References. The oldest, most authentic,
and most comprehensive articles based on original research are Grodinsky and Holyoke (1938,
1939) [6, 10]; most others are not original investigations. A recent review of the fascia by Feigl
et al. (2020) [35] is based on dissections of Thiel embalmed cadavers unlike most other
investigations of formalin embalmed cadavers; however, it excludes most of the spaces. Apart
from the English literature, some of the references have covered-directly and indirectly-German
and Japanese literature also [Feigl (2015)[38] and Feigl et al. (2020)[35], German literature;
Kitamura (2017)[39], Japanese literature]. Inconsistencies in the terminology and description
have been noted and tabulated (Table 1, 3). As it is not the biological variability based on
original researches or methodological variations that account for the inconsistent description by
various authors, there is no scope for systematic review; however, an attempt has been made to
follow the spirit of the guidelines of the Preferred Reporting Items for Systematic Reviews and
Meta-Analyses (PRISMA statement). Humble suggestions to improve the current situation have
been offered and an attempt has been made to simplify the description of the spaces. In addition
to our experience of over 45 years of teaching and dissecting (with instruments including a
dental wax spatula and with digits) the spaces, the present communication is enriched by our
recent revisit of the spaces using a new combined extraoral and transoral approach to dissect
them on 11 authentically donated formalin embalmed adult cadavers of both sexes, keeping the
8
mandible intact except for the midline mandibular osteotomy (Buch, 2013)[40]. It may be added
that there are some merits of preservatives containing formalin as formalin imparts hardness and
rigidity varying from a cadaver to cadaver and also maintains the integrity of the tissues. Our
dissection experience included dissection of sections of the head and neck also.
Apart from modern imaging methods in patients, various materials and methods have been
employed by different investigators to study the spaces including dissection of the whole
cadavers (Fresh, Frozen, Embalmed) and their sections using injections of colored gelatin or
latex; the most recent research was air dissection of some of the spaces (Iwanaga et al.,
2020)[41] combined with intrathoracic endoscopy revealing gross anatomy of the spaces and
their communications with each other and with the mediastinum; pathologically it happens in
cervicofacial and even mediastinal emphysema when a dentist uses high-speed air turbine or
compressed air/water syringe with air entering the breached mucosa (Liebgott, 2018)[42]. The
possibility of differences in materials and methods used by different researchers influencing the
ultimate findings and anatomical description was always kept in mind. Further, we appreciated
differing interpretations. In this article, our focus is the fascial spaces (except those of orbital and
laryngeal) and not the fascia.
3. Discussion
3.1 General remarks
Buch (1999)[43] noted that perhaps given the reputation that the Anatomy enjoys as an accurate
science and, in contrast, ever-changing description of the fascial spaces in the head and neck unlike
the rest of the anatomy, even Gray‟s Anatomy opted to exclude their account; only a passing
9
reference to the suprasternal and retropharyngeal spaces was made in the 38th edition (Williams et
al., 1995)[44]. Notwithstanding this glaring omission from the clinician‟s point of view, it appears
that the fascial spaces have retained their relevance even in the age of antibiotics, particularly for
the third world and for the diabetics (Prabhu and Nirmalkumar, 2019)[45]. Moreover, the
development of antibiotic resistance was also instrumental in reviving them. Further, they are
involved in the spread of tumors-both benign and malignant (primary and metastatic) and are also
important for local anesthesia and various blind and open (surgical) procedures performed on the
contents of the infratemporal fossa. Ever-expanding frontiers of the transoral robotic and
endoscopic surgery (McCool et al., 2010[46]; Wilhelm et al., 2010[47]; Moore et al., 2012[48])
would require adequate grounding in the surgical anatomy of these spaces. No wonder subsequent
editions of the „Gray‟ spared adequate space for the spaces (Standring 2005[49], 2008[24],
2016)[25]. A systematic review of the fascial spaces in the head and neck is not possible as there
are not „many original pieces of research‟, and at present, no Cochrane Systematic Review is
available. The impact of the recent COVID 19 pandemic on the pathology of the fascia and fascial
spaces will be realized in the future but as indicated by Zimmermann and Nkenke (2020)[50],
many head and neck deep infections in positive and negative patients require urgent and
emergency surgical treatments.
The definition of the term „Fascia‟ is still evolving. A recent change in the definition of the term
„fascia‟ (Findley and Shalwala, 2013[51]; Guidera et al., 2014[52]; Adstrum and Nicholson,
2019[9]; Schleip et al., 2019[53]) has played havoc with the existing account of the anatomy of the
fascial spaces; even epidural-subdural and subarachnoid spaces may become now intracranial
fascial spaces! Doubts have been expressed over the existence of the investing layer of the DCF in
the parotid (Coller and Yglesias, 1935[54]), anterior and posterior triangle regions (Zhang and Lee,
10
2002[55]; Nash et al., 2005[56]). Fifty years ago, McGregor (1963)[57] had stated that no surgeon
had ever seen DCF in the living adding that the statement was inaccurate and dangerous, but this is
now partly proving to be accurate.
Arya et al. (2012)[58] have posed a pertinent question regarding the masticator and parapharyngeal
spaces: “Can the radiologist and surgeon speak the same language?” This is true for all the spaces
and the query may be extended to include even the anatomist.
Functional implications of the loose connective tissue filled fascial spaces were discussed by
Weintraub (1941)[59] and Grant (1952)[60], and recently, Snosek et al. (2020)[61] have also
alluded to the role of fascia in swallowing and coughing. Probably functions unique to the head-
neck region like facial expression, mastication, deglutition, speech, and to some extent, the
respiration necessitated the presence of such a large number of shearing tissue containing spaces in
the region.
Firstly, we look at the inconsistencies in their description (Author-wise such inconsistencies are
shown in Table No. 3) and then attempt to simplify their anatomy.
3.2 Inconsistencies in the description of the spaces and their resolution (Table 1, Table 3)
Fascial spaces are variously called compartments [temporal compartments, Balaji (2007)[62];
parotid compartment (Singh et al., 2000)[20]], intervals and fossa (subtemporalis muscle
interval, palatal subperiosteal interval and peritonsillar fossa (Seward, 1992)[19], and pouches
(temporal pouches, Gregg, 2009)[30]. Newell (1999)[63] and Stockwell (1999)[64] have
presented contrasting views on these various designations of „space‟ with the former choosing
the term „compartment‟ and the latter favoring to retain the term „space‟. Exactly a hundred years
back, Mosher (1920)[65] also used the term fascial compartments. Guidera et al. (2014)[52] have
11
recommended the term „Compartment‟ for all these spaces (Given the complexity of fascia, this
is the easy way out!) as they are not unoccupied, but standard anatomy textbooks do describe
triangles, fossae, and regions for the same spaces or compartments. Liebgott (2018)[42] has
called them spaces, areas and regions. The terms „space‟ and „communication‟ include both real
and potential. Because contents- both normal and pathological- are described for all these so-
called spaces, they are certainly not empty. In light of the debate raging over the definition of
the terms „fascia‟ and „space‟, one would be inclined to return to what anatomy textbooks have
been describing for ages, i.e., the designations triangles, regions, compartments, cavities, and
fossae. But, as the designation „space‟ is more clinically oriented, to avoid confusion and for the
sake of uniformity of description till a consensus emerges on anyone designation, it seems
desirable not to discard the term „space‟.
Changing descriptions of the spaces and their names from author to author is extremely
annoying. Seward et al. (1992)[19] have advised not to be overly concerned with the details of
the anatomical boundaries of the spaces adding that none of the muscular and fascial barriers are
impassable by pus. Obviously, the anatomical boundaries are not sacrosanct for pathologies!
Given the unfortunate diversity in describing the walls (boundaries), extent, and consequently the
contents of the spaces, it has been suggested that wherever possible, the established anatomy
must be respected. Submental triangle, submandibular triangle and the region, sublingual region
and infratemporal fossa (ITF) are accurately described as regards their boundaries and contents
in the standard anatomy textbooks and hence the description of the corresponding spaces should
not violate this established anatomy and instead, should take advantage of the fact (Buch,
1999)[43]. Although some investigators (Grodinsky and Holyoke, 1938[6]; Guidera et al.,
2014[52]) advocate clubbing of the sublingual, submandibular and submental spaces to call them
12
„submandibular‟, this should not be done as they are distinctly recognized anatomy regions
which are all affected bilaterally in Ludwig‟s angina which involves, in all, five spaces.
3.2.1 Parotid space
Parotid space anatomy as described by Warshafsky et al. (2012)[37] and parotid space and
compartment described by Guidera et al. (2014)[52] is not much different from the anatomy of
the parotid gland as described in any standard anatomy textbook (Fig. 1a).
3.2.2 Temporal fossa (TF) and its spaces (Fig. 2)
Temporal fossa (TF) as accurately described in anatomy should contain superficial and deep
temporal spaces, and it is well known that the fossa communicates with the ITF medial to the
zygomatic arch and hence the temporal spaces should also communicate with the ITS and they
do but the ITS, of course, is a disputable space. Disregarding the TF and changing the names to
infratemporal fossa space (ITFS) and temporal pouches lead to avoidable confusion. While ITFS
is confusing because there are several fascial spaces in the fossa, the designation canine fossa
space, however, clarifies its location not within the canine tooth but in the vicinity of the
osteological canine fossa as routinely described in anatomy.
According to Berkovitz (2009)[28], the superficial temporal space (STS) lies on the lateral
surface of the temporalis muscle under the skin and the superficial (temporal) fascia; this
description may be confusing terminologically. Guidera et al. (2014)[52] have described the
same space as located between the temporal fascia and the temporoparietal fascia. [According to
O‟Brien et al. (2013)[66], the Temporoparietal fascia has 13 other names.] While Flynn
(2009)[23] has described the STS between the temporalis muscle and the temporal fascia listing
13
temporal branches of the facial nerve and temporal fat pad as the contents, Laskin and Laskin
(2002)[31] have listed the superficial temporal vessels and auriculotemporal nerve as the
contents of the same space. We are facing here a hopeless situation in which from the contents
we have to conjecture on the boundaries of the spaces! We must remember that various
structures change their plane during their course. Moreover, the lower part of the temporal fascia
consists of two layers and the contents of the intervening space are variously described: Flynn
(2009)[23] has mentioned a leaflet of the buccal pad of fat and three small veins as the contents
but Standring (2016)[25] found zygomaticoorbital artery, zygomaticotemporal nerve, and fat in
the same space; this is the plane for Al-Khayat and Bramley (1979)[67]‟s dissection to protect
the temporal (frontal) branch of the facial nerve in temporomandibular joint surgery. This space
must not be called the STS as Kitamura (2017)[39] has done; a better name would be
intermediate temporal space (IS). More superficially, one has to consider also the loose areolar
tissue, the temporoparietal fascia probably representing Superficial Musculo-Aponeurotic
System (SMAS) in the region, the subcutaneous tissue, and skin (Mathes, 2006[68]; Krayenbuhl
et al., 2007[69]; Standring, 2008[24]).
If the STS is described between the temporalis muscle and the temporal fascia as done by Flynn
(2009)[23] and Standring (2016)[25], it cannot be overlooked that the muscle has part of its
origin from the deep surface of the fascia; this is the plane for reduction of the zygomatic
fractures through Gillies approach (Gillies et al., 1927)[70]. Further, this STS contains the
middle temporal vessels. Oliver and Gillespie (2010)[71] have included even the temporalis
muscle as a content of the deep temporal space (DTS). The TF contains superficial and deep
temporal spaces, and also retrozygomatic or zygomaticotemporal space. A better description of
14
the layers in the region as attempted by O‟Brien et al. (2013)[66] would help the understanding
of these spaces although these authors and Krayenbuhl et al., (2007)[69] have refrained from
even mentioning any of the spaces. Li et al. (2018)[72] in their surgical study found the absence
of the deep layer of the temporal fascia which they have labeled deep temporal fascia. [It may be
noted that the Terminologia Anatomica (TA) (2019)[73] (https://fipat.library.dal.ca/TA2/Part2/
Page 74] has recognized the designation-Temporal fascia- consisting of two layers: Superficial
and Deep.]
3.2.3 Infratemporal fossa (ITF) and its spaces (Fig. 2, 3)
ITF of anatomy contains pterygomandibular, infratemporal, parapharyngeal (how much?), a part of
buccal and parts of temporal spaces (the way they are presently described). It may be pertinent to
comment on the „Extended‟ ITF (Standring, 2016)[25] which includes not only the PPS but even
the MS; this may be over-accommodating the pathological and surgical situation. Brennan et al.
(2016)[74] have described four spaces under the floor of the middle cranial fossa which even
include the ITF and the pterygopalatine fossa; further, they have described infrapetrosal space
(IPS) with no less than 13 contents. The IPS is, however, Poststyloid PPS. It may be mentioned
that Guidera et al. (2014)[52] have called the PPS a controversial space describing how there is no
agreement on the actual demarcation between the prestyloid and poststyloid compartments of the
space.
15
Fig. 2 A specimen derived from the New combined (extraoral and transoral) approach of
dissection. The temporomandibular joint also has been dissected. White arrows for
orientation: A, anterior; R, rostral; Ton, tongue; Mu, mucosa; AD, anterior belly of
digastric; SMS, submandibular space; SLS, sublingual space; Ch, cheek; PMS,
temporalis muscle; MaZa, reflected masseter and zygomatic arch. Arrowhead: Entrance
into the LPS/PPS. Contents of some of the spaces are also seen. The ITS requires further
clarifications for which refer the text.
Refer https://www.youtube.com/watch?v=MNrYOijHpPc&t=10s
Whereas Berkovitz et al. (2009, 2018)[28, 29] and Seward et al. (1992)[19]have described the ITS
as the upper extremity of the PMS, Thoma (1963)[75] has stated just the opposite, i. e., that the
lower part of the ITS is the PMS with the mandibular nerve (!) as the content. However, the latter
16
author mentions that the ITS extends from the medial pterygoid to the mandibular ramus which is
a little short of the ITF of descriptive anatomy in contrast to Guidera et al. (2014)[52] including
even parotid and masticatory spaces as subdivisions of the ITF.
Fig. 3 A specimen showing some of the spaces and their contents. The pterygoid muscles
are retracted by threads to display the spaces which are widened. White arrows for
orientation: A, anterior; R, rostral; Temp, temporalis; LPt, lateral pterygoid; MPt, medial
pterygoid; MhM, mylohyoid muscle; SLSG, sublingual salivary gland; BS, buccal space;
ITS, infratemporal space. Star: PMS.
Refer https://www.youtube.com/watch?v=bWXyFT_tJf4
17
Flynn (2008)[22] and Han et al. (2019)[76] have described ITS and DTS together and
considered the ITS as situated between the infratemporal crest and the lateral pterygoid muscle
which means it is in the roof of the ITF where the upper head of the lateral pterygoid originates.
Such a space will be conspicuous by its absence! Scott and Dixon (1978)[77] have used „pterygoid
space‟ as the synonym of the ITS. Indiscriminate use of the designations ITF, ITFS (Seward et al,
1992)[19], and ITS by different authors is utterly confusing. Despite Kostrubala (1945)[78]
providing a satisfactory description of the space akin to the present day ITF and confining it to
the ITF, it is frustrating to note that the ITF and the current ITS are not identical. Temporal
spaces must be described to end at the level of the zygomatic arch and the infratemporal crest
like the TF. Restricting the temporal spaces to TF and the ITS to ITF will match the well-
established anatomy. DTS is deep to the temporalis muscle in the temporal fossa between the
periosteum (not only of just the temporal bone as mentioned by Berkowitz et al. (2018)[29] and
the attached fibers of the temporalis. As the muscle proceeds to its insertion in the ITF, what
happens to the DTS which now contains some fat, pterygoid venous plexus, the second part of
the maxillary artery and some of its branches, and the long buccal nerve? Shall we call it a part
of the DTS extending into the ITF? Shall we call the ITS including or excluding the lateral
pterygoid? Grodinsky and Holyoke (1938)[6] have provided an adequate description of the STS
and DTS, mentioning that they communicate freely with each other and with the MS. It is
recommended that ITF, ITFS, and ITS be made synonyms, and the STS and DTS should be
described to continue and terminate in the ITF or MS where all the anatomical relations of the
temporalis muscle are well known.
3.2.4 Masticator space (MS) (Fig. 4) A designation based on the function of Mastication
18
Fig. 4 Schematic coronal section of head (Black-board diagram) depicting the masticator space
(MS). DCFIL, deep cervical fascia investing layer; MPt, medial pterygoid; MaS, masseter;
SMaS, submasseteric space; RM, mandibular ramus; TF, temporal fascia; Temp,
temporalis muscle; LPt, lateral pterygoid; PMS, pterygomandibular space; LPS, lateral
19
pharyngeal space; SC, superior constrictor; IS, intermediate temporal space (Refer the text
for further details,)
As quoted by Grodynsky and Holyoke (1938)[6], Juvara (1870)[79] was the first one to describe
the space formed by the splitting superficial layer of the DCF to enclose structures between the
medial pterygoid and the masseter muscles; it was later named as the MS by Coller and Yglesis
(1935)[54]. (He was also the first one to describe the lateral pharyngeal space (LPS.) Malik
(2008)[27] has described that the MS contains the pterygomandibular, temporal, and submassetric
fascial spaces omitting the ITS. What was the need to describe such a space (MS) when these three
enclosed spaces were already described? This may be to include particularly the ramus of the
mandible and the masseter as the contents and also to respect any all-encompassing pathology like
MS abscess or sarcoma of such a space as reviewed by Fernandes et al. (2013)[13] and Koch et al.
(2017)[80]. The MS extends laterally beyond the confines of ITF of anatomy and includes most of
its contents. Anyone knowing the anatomy of this fossa would have no difficulty in knowing the
contents of the MS and also their interrelations. The suggestion of Grodinsky and Holyoke
(1938)[6] to extend the MS to include the temporal spaces as they freely communicate with the
MS requires further debate; Koch et al. (2017)[80] have divided the MS into two: suprazygomatic
MS (in the TF) and infrazygomatic MS (in the ITF) components. It is recommended that the
designated individual spaces like the TS, submasseteric space (SMsS), PMS, BS must continue to
coexist with the MS as descriptive anatomy is based on such a reductionist approach providing
precision and ease of teaching and learning, and also for their distinctive applied significance.
3.2.5 Submasseteric space (SMsS)
20
The SMsS (Fig. 5a-c) is within the masseter muscle between its heads or layers (middle and
deep) loosely attached to the periosteum of the ramus of the mandible; presumably, this means it
is supraperiosteal. However, pus spreading under the periosteum here is subperiosteal as well as
Fig. 5a CT scan 3D reconstruction of a patient of an abscess. Courtesy of
Dr. Supreet Prabhu.
21
Fig. 5b Axial CT scan of the patient. Asterisk: submasseteric abscess. Courtesy of Dr.
Supreet Prabhu.
22
Fig. 5c Coronal CT scan of the patient. Asterisk: submasseteric abscess. Courtesy of Dr.
Supreet Prabhu.
submasseteric in location. Flynn (2009)[23] has included even the masseter as one of the
contents of the space as according to him, it is between the ramus of the mandible and the
parotidomasseteric fascia. But this makes it masseteric as well as submasseteric. Indeed, Fonseca
(2000)[81] has mentioned only masseteric space omitting the SMsS altogether. Berkowitz
(2009)[29] has described the space as „a series of spaces‟ whose very existence is dictated by pus
and pathology. One is left wondering as to whether the SMsS is a single entity or several!;
however, this may be an interesting interpretation of the space.
23
3.2.6 Pharyngeal spaces (Fig. 6)
Lang (1995)[8] has described 3 to 6 spaces related to the lateral pterygoid muscle but no details
have been provided. Further, he has described even lateral parapharyngeal space; the anterior
para (peri) pharyngeal space is named the masticator space, and the posterior parapharyngeal, the
lateral parapharyngeal. DuBrul (1988)[18] has designated retropharyngeal and parapharyngeal
spaces: mandibulopharyngeal spaces. Malik (2008)[27] and Singh et al. (2000)[20] have clubbed
lateral and retropharyngeal spaces together giving the name „parapharyngeal' to the combined
space. Inconsistent description of the same spaces by various authors is obvious. Consensus may
be arrived at in retaining the terms lateral pharyngeal and retropharyngeal spaces and discarding
the term parapharyngeal altogether. Although these spaces do communicate, clubbing them is not
advisable. Whereas the retropharyngeal space (RPS) exists (and has always existed) even if the
alar fascia is not resolvable by the current imaging, the danger space (DS) depends entirely upon
the alar fascia. Feigl (2015)[38] has listed, rather intriguingly, the trachea, esophagus, inferior
thyroid artery, and the recurrent laryngeal nerve as the contents of the DS in the lower neck.
24
Fig. 6 Dissection and sectioning to demonstrate particularly the LPS and
the median partitioning of the RPS. The red plastic cone is in the LPS. Arrowhead:
median partition in the RPS. Ton, tongue; D, dentition; B, buccinator; RM, ramus of the
mandible; IAN, inferior alveolar nerve; LN, lingual nerve; MPt, medial pterygoid
muscle; SC, superior constrictor muscle. The instrument at the arrow is in the cavity of
the pharynx. Thin arrow without a label: the space of „quinsy‟.

25
3.2.7 Paratonsillar and Peritonsillar spaces (Fig. 6)
Hollinshead (1982)[17] named the space between the superior constrictor muscle and the lateral
capsule of the tonsil both paratonsillar as well as peritonsillar but Guidera et al. (2014)[52] have
called the same only peritonsillar and a part of the pharyngeal mucosa space. Seward et al.
(1992)[19] have used the term „peritonsillar‟ for the space between the superior constrictor and
the pharyngeal mucosa but the peritonsillar abscess is rather surprisingly described to occur
between the muscle and the connective tissue bed of the palatine tonsil. Gleeson (1997)[82] has
given the name paratonsillar for the space between the wall of the pharynx and the mucosa of the
fauces. Singh et al. (2000)[20] have described that the paratonsillar space (PTS) containing the
tonsil and extending between the superior constrictor muscle and the mucosa of anterior and
posterior pillars of fauces and allowing only the longitudinal spread of infection and
communicating with the DPS. Flynn (2009)[23] has listed even tonsil as one of the contents of
the peritonsillar space (PeTS) which surrounds the organ and is itself considered a part of the
visceral space; Oliver and Gillespie (2010)[71] and Warner et al. (2019)[83] have used the
designation „peritonsillar‟ for the space between the superior constrictor muscle and the capsule
of the tonsil. Hearn et al. (2015)[84] have treated „peritonsillar‟ and „paratonsillar‟ as synonyms
with the space extending between the muscle and the mucosa. Standring (2016)[25] has not
discussed any PTS but paratonsillar vein has been described and has mentioned PeTS around the
tonsil as an intrapharyngeal space. If at all the tonsil is described as a content of any space, it
should be called the tonsillar space. It is desirable to eliminate confusion between the terms
peritonsillar and paratonsillar. Para and Peri are both Greek Prefixes; Para means by the side of,
and Peri means around (Lisowski and Oxnard, 2007)[85]. It may be suggested that the term
„paratonsillar‟ be reserved for the definite space between the superior constrictor muscle and the
26
tonsillar capsule or hemicapsule (on the lateral surface of the tonsil), or else new name could be
lateral tonsillar space (Fig. 6); this space may very well be a part of the PeTS the way it is
usually defined.
If as per the new definition of fascia, even epimysium and perimysium are parts of fascia thus
invading the organs like pharynx, the fascial spaces would also become organ and tissue spaces.
With further advancement of medical imaging and endoscopic surgery, the designation „tissue
space‟ rather than the „facial space‟ will become more and more acceptable and preferable.
Indeed, Weintraub (1941)[59] had classified the spaces as tissue, intraorgan, interorgan, and
intergroup of organs; as an example, he had called PPS, rather convincingly, an „intergroup (of
organs}‟ space. Kostrubala (1945)[78] had stated that the spaces might not be entirely bounded
by the fascia. Citing radiological literature, Guidera et al. (2014)[52] have described a
pharyngeal mucosal space which is also the pure routine anatomy of the wall of the pharynx.
Koch et al. (2017)[80] have discussed in detail the lesions involving the space.
3.2.8 Pretracheal space and fascia (Fig. 7)
It is frustrating to note that there is no agreement on the name, definition, and contents of these
entities. Gray‟s Anatomy (2016)[25] finds the term ‟pretracheal‟ confusing; why so is left to the
reader to search! Plagued by such uncertainties probably, Moore et al. (2018)[86] have avoided
discussing most of the fascial spaces in the head and neck. Provisional TA (2019)[73] has also
opted to omit all the Head Neck fascial spaces except the suprasternal space while discussing at
length similar spaces in other regions of the body.
27
Fig. 7 Schematic sagittal section of the head and neck (Black-board diagram) depicting the
infrahyoid spaces. GIL, general investing layer; PTF, pretracheal fascia; PVF,
prevertebral fascia; N, nasal cavity; O, oral cavity; Ph, pharynx; L, larynx; T, trachea; E,
esophagus. Stippled line: visceral fascia; Line of connected circles: alar fascia. Asterisks:
28
visceral space but not the pretracheal space. Fascial layers enclosing the infrahyoid
muscles are not labeled. The inset is a magnified view at the level shown showing Spaces
Nos. 3 (RPS), 4 (DS) and 5 (PVS) according to Grodinsky and Holyoke (1938)[6].
Hafferl (1969)[87] has clearly labeled and illustrated (His Figure 184) both the pretracheal fascia
and space; the space is shown superficial to the fascia (apparently the visceral division) and its
contents include the isthmus of the thyroid gland, inferior thyroid veins, pretracheal lymph
nodes, etc. According to Feigl (2015)[38], the pretracheal space is behind the middle layer of the
DCF, and the RPS is the dorsal and lateral extension of the pretracheal space. Malik (2016)[88]
has labeled the middle layer of the DCF the pretracheal fascia.
Guidera et al. (2014)[52]have recommended the abolishment of the terms pretracheal space,
anterior visceral space, etc. However, the term „pretracheal‟ is so much entrenched in the
literature that it is unreasonable to discard it. Provisional TA (2019)[73] has retained the term,
and the visceral fascia is named the pretracheal. Bhargav (2014)[89] has mentioned that although
it is flimsy, it forms the first barrier against an extra-thyroidal extension of thyroid malignancy
and is condensed to form the ligament of Berry.
The thyroid gland is famously known to be covered by the pretracheal layer of the DCF forming
the false capsule which is the visceral fascia described by Grodinsky and Holyoke (1938)[6] and
others; the space immediately outside- Space 3 of Grodinsky and Holyoke (1938)[6] - is labeled
as the pretracheal space by Hafferl (1969)[87], DuBrul (1988)[18], Flynn (2004 and 2009)[21,
23], Feigl (2015)[38], and Hearn et al. (2015)[84]. Whereas a plexus of inferior thyroid veins
29
along with the loose fatty areolar tissue as the contents is described by DuBrul (1988)[18] and
inferior thyroid veins as the content by Langdon et al. (2005)[90], Hearn et al. (2015)[84] have
listed the trachea, esophagus, thyroid gland, etc. as the contents of both the pretracheal space as
well as the visceral space!
Age-old description of Grodinsky and Holyoke (1938)[6] of three divisions of the middle layer
of the DCF is still valid; the three parts are: Fascia enclosing the sternohyoid and omohyoid,
fascia of the sternothyroid and thyrohyoid, and finally the visceral fascia. Deep to the visceral
fascia forming the false capsule of the organs like the thyroid gland and the trachea, between the
true and false capsules, the space is called the visceral space by the authors (Fig. 1b); strictly this
should never be called the pretracheal space. The true capsule is generally regarded as a part and
parcel of the organ concerned. If a space contains the trachea, it should be designated the tracheal
space and not pretracheal. Related to the trachea in the anterior neck, from skin inwards, Spaces
No. 1, 2, and 3 of Grodinsky and Holyoke (1938)[6] are present, and the fourth one is the
visceral space which has been explicitly described and illustrated by the authors but
unfortunately not numbered. All these spaces along with their contents are relevant in
tracheostomy and thyroid surgery. If the buccopharyngeal fascia is also included as a part of this
visceral fascia, the visceral space contains the trachea, esophagus, thyroid and parathyroid
glands, larynx, pharynx, recurrent laryngeal nerves, and pre and paratracheal lymph nodes (Level
VI). Just outside circumferentially is „the visceral compartment of the neck‟ so named by Sir
Harold Stiles as quoted by McGregor (1963)[57].
3.2.9 Prevertebral space and fascia (Fig. 1b, 7)
30
Prevertebral fascia (PVF) and the prevertebral space (PVS) are the least controversial. Already,
two layers of the fascia are well established with the DS intervening. The existence of the alar
lamina has been confirmed by Scali et al. (2015)[91], Gavid et al. (2018)[92], Lopez-Fernandez
et al. (2019)[93], Feigl et al. (2020)[38] and Snosek et al. (2020)[61] employing different
materials and methods, i.e., dissection with a surgical microscope, gross sectional cadaveric
study, histological examination and also E 12 plastination; the lamina, however, cannot be
demonstrated by the current techniques of medical imaging (Guidera et al., 2014)[52]. Davis and
Harnsberger (1995)[94] have recommended the designation perivertebral space consisting of
prevertebral and paraspinal portions which should be accepted if the PVF enclosed the entire
vertebra; like peritoneal space or cavity which contains no organs, such a space cannot contain
the vertebra or any part thereof. Contents other than the muscles like longus colli, longus capitis,
scaleni, etc. can be worked out easily by any anatomist. Guidera et al. (2014)[52] have suggested
that they should be called compartments: prevertebral compartment anterior to the bodies and
transverse processes of the cervical vertebrae containing prevertebral muscles and perivertebral
compartment posterior to the bodies and the transverse processes of the vertebrae containing the
paraspinal muscles, etc. If the boundaries are better defined, one can enumerate the contents with
accuracy (the hallmark of Anatomy) thus including the levator scapulae, splenial muscles,
erector spinae, transverso-spinalis, parts of cervical and brachial plexuses and several other
neurovascular elements.
3.2.10 Carotid space (CS) and Sheath (Fig. 1b, 7)
Already, the sheath has been discussed as a content of the Poststyloid PPS. Parsons (1910)[95]
did not find any such sheath in embalmed and fresh cadavers, and vehemently believed it to be
31
manufactured by the scalpel. Weintraub (1941)[59] has reviewed the researches which denied
the existence of the sheath and also found it absent in his gross and histological studies.
However, most researchers thereafter have established it as a fact rather than an artifact.
Traditional teaching is it is made up of all the three layers of the DCF, therefore probably
Mosher (1929) called the CS „Lincoln Highway‟ (Gadre and Gadre, 2006)[96]. According to
Grodinsky and Holyoke (1938)[6], it is mainly the alar fascia with contributions from the
investing layer (sternomastoid sheath) and the sternothyroid-thyrohyoid fascia. Several studies
have found the alar fascia interconnecting the right and left sheaths, and contributing to the
sheath (Feigl, 2020[35]; Snosek et al., 2020[61]). The space within the carotid sheath is
numbered 3A by Grodinsky and Holyoke (1938)[6] who found it extending from the hyoid to the
root of the neck. Each content of the sheath is invested by its individual covering adventitia; this
was confirmed by Feigl et al. (2020)[35] up to the level of the common carotid bifurcation;
Hayashi (2007)[97] too observed separate adventitia for each vessel and common sheath for the
neurovascular contents adding that there are inter-individual and/or inter-site variations.
3.2.11 The spaces tend to make the authors err!
Kaban et al. (1997)[98] have labeled and described PTS as PPS, and have shown related to the
buccinator muscle two spaces: the buccinator space (lateral to the muscle) and buccal space (BS)
(medial to the muscle). Langdon et al. (2005)[90] have mentioned „muscle‟ (which?) as a content of
the prestyloid LPS. Flynn (2009)[23] has described, in a tabulated form, borders of ten (10) fascial
spaces calling superficial border medial and deep border lateral (!) e.g., mylohyoid, hyoglossus and
superior (?) constrictor muscles form the deep or lateral (?) border of the submandibular space (SMS).
It is difficult to understand why the walls of the spaces are called borders. He has also stated that the
32
inferior limit of the DTS is the superior surface of the lateral pterygoid muscle and has considered the
ITS as a part of this DTS mentioning the maxillary artery and the mandibular nerve as its contents.
Gregg (2009)[30] has mentioned the pterygopalatine space which is pterygopalatine fossa and the
anterior part of the ITF but its medial limit is erroneously stated to be the pterygomaxillary fissure.
Warshafsky et al. (2012)[37] have listed the XIth cranial nerve as one of the contents of the sublingual
space (SLS) and have described superior pharyngeal constrictor muscle both as a part of the wall as
well as one of the contents of the peritonsillar space. The spaces have a tendency to make the authors
err!
3.2.12 Summary of recommendations
As the designation „space‟ is more clinically oriented, to avoid confusion and for the sake of
uniformity of description till a consensus emerges on anyone designation, it seems desirable not
to discard the term „space‟.
Wherever possible, the established anatomy must be respected.
Clubbing of the sublingual, submandibular, and submental spaces to call them „submandibular‟
should not be done as this would mean „undoing the Anatomy‟. Anatomy rules by dividing!
Similarly, clubbing the LPS (PPS) and RPS is also not advisable.
The space between the two layers of the temporal fascia should be called the intermediate
temporal space (IS).
It is recommended that ITF, ITFS, and ITS be made synonyms, and the STS and DTS should be
described to continue and terminate in the ITF or MS where all the anatomical relations of the
temporalis muscle are well known. Contents of the ITF can be well described with reference to
the lateral pterygoid muscle.
33
It is recommended that the designated individual spaces like the TS, SMsS, PMS, BS must
continue to coexist with the MS.
It may be suggested that the term „paratonsillar‟ be reserved for the definite space between the
superior constrictor muscle and the tonsillar capsule or hemicapsule (on the lateral surface of the
tonsil), or else new name could be lateral tonsillar space; this space may very well be a part of
the PeTS the way it is usually defined.
Classifying the submental space (SMeS) as peripharyngeal is not justified, it is perioral.
If a space contains the trachea, it should be designated the tracheal space and not pretracheal.
The visceral space strictly should never be called the pretracheal space.
Standardized usage of prefixes like pre, para, and peri concerning the tonsil, pharynx, and the
vertebral column is recommended.
4. Simplifying the anatomy of spaces
Simplification involves putting aside the controversies and arriving at the consensus.
4.1 Muscles and the spaces
Suprahyoid fascial spaces (SHFS) are mostly perioral, peripharyngeal, and perimandibular.
Indeed, most of them could be located about the attachments of various muscles on the mandible
(Fig. 8a). Examples: attachment of the mylohyoid muscle helps locating submental, sublingual
and submandibular spaces; the attachment of the medial pterygoid muscle locates
pterygomandibular and parapharyngeal spaces (The medial pterygoid muscle has related to it on
34
Fig. 8a Mandibular muscle attachments and fascial spaces. MhM, marking of mylohyoid
muscle attachment; SLS, sublingual space; SMS, submandibular space. Other
attachments of muscles-ligaments-meniscus are not labeled.
its deep (medial) surface the PPS and on its superficial (lateral) surface the PMS and these two
spaces communicate with each other around both-anterior and posterior-borders of the muscle;
the buccinator locates the BS, and the attachment of the masseter locates the SMsS. Indeed, the
mandible is the bone in the body with the maximum fascial spaces related to it. It may also be
added that some muscles guide the spread of odontogenic infections depending upon the location
of the root apices of teeth with reference to the attachment of the muscles on the mandible and
maxilla: the mylohyoid muscle decides whether the infection spreads in the sublingual or the
submandibular and submental spaces (Fig. 8b); buccinator governs such a spread either in the
35
oral vestibule or in the BS; spread of maxillary canine infection is affected by the levator anguli
oris (caninus) muscle.
Fig. 8b Orthopentomogram (right half) illustrating the relationship of the roots of the
mandibular teeth with the arbitrarily drawn mylohyoid line (Black). Note particularly
the roots of the mandibular third molar (between arrow heads) projecting below the
line and hence may involve the SMS directly. Courtesy of Dr. Professor Priti P. Shah.
4.2 Classifying the spaces
Guidera et al. (2014)[52] have classified them into two groups: cranial and cervical. Gregg
(2009) has called them surgical fascial spaces and classified them into two complexes with the
36
medial upward extension of the superficial lamina of the DCF as the dividing line: the
masticatory complex and the peripharyngeal complex.
Masticatory complex Peripharyngeal complex
1. Masticatory 1. Submandibular
2. Buccal 2. Paralingual (Is it „sublingual‟?)
3. Submasseteric 3. Lateral pharyngeal
4. Parotid 4. Retropharyngeal
5. Infratemporal
6. Temporal
7. Pterygopalatine extensions
The foregoing classification has omitted several spaces like the SMeS, PVS, DS, and the
Pretracheal space.
Flynn (2004)[21] has classified the spaces severity-wise (severity score 1, 2, 3, 4) based on the
risk to airway and the vital structures as under:
Low risk: Vestibular Space (S), Subperiosteal S, S of the body of the mandible, CS (IOS), BS
Moderate risk: SLS, SMeS, SMS, PtMS, SMsS, STS, DTS (ITS)
High risk: LPS, RPS, Pretracheal Space
Extreme risk: DS, Mediastinum, Intracranial infection
This is a useful classification; confusion between the DTS and ITS must be resolved.
Standring (2008, 2016)[24, 25] has designated the spaces as potential tissue spaces around the
jaws classifying them into Paired and Unpaired groups, and, Pharyngeal tissue spaces have been
classified into Intrapharyngeal and Peripharyngeal, the latter includes SMeS, SMS, RPS, and
37
PPS; PeTS is considered to be a part of the Intrapharyngeal group; this group may be regarded as
organ spaces. Classifying SMeS as peripharyngeal is not justified, it is perioral; further, even
most of the SMS is also perioral rather than peripharyngeal. The designation „tissue spaces‟
rather than „fascial spaces‟ probably reflects their dilemma to use the term fascia in light of the
recent changes in the definition of the term „fascia‟. Conceptually, the distinction between the
fascial and tissue spaces is becoming tenuous with the fascia invading the organs. However,
Weintraub (1941)[59] and Langdon et al. (2005)[90] had opted for the designation long back.
Based on their proximity to tooth-bearing areas of the jaws and the mode of involvement in case
of odontogenic infections, Malik (2008)[27] and Wikipedia (2015)[99] have classified the fascial
spaces into two groups: (1) Primary spaces with infection from tooth or teeth passing directly to
the space and (2) Secondary spaces with the odontogenic infection first involving the primary
space and then passing to the secondary. According to Malik (2008)[27], primary spaces are
maxillary (canine, buccal, and infratemporal) and mandibular (submental, sublingual,
submandibular, and buccal); secondary fascial spaces are masseteric (should be SMaS),
pterygomandibular, superficial and deep temporal, parapharyngeal, retropharyngeal and
prevertebral. The same space may be both primary as well as secondary as exemplified by the
SMS; odontogenic infection from the mandibular third molar may pass primarily into SMS but
from the mandibular premolar teeth it may primarily involve the SLS and secondarily the SMS.
4.3 Disposition of the spaces
The spaces are not only contiguous but also communicating. Rings and columnar (vertical
cylindrical) arrangement of the spaces illustrate how they communicate with each other and also
38
with the mediastinum, and even beyond it. Figure 9 shows the concentric and the stratified
arrangement of the spaces.
The outermost ring (Ring-I) of spaces is formed by the submental, submandibular, buccal,
superficial temporal, and the canine spaces.
Ring-II is the SMsS.
Ring-III is the SLS and the PMS.
Ring-IV is the PPS.
Ring -V is formed solely by the PTS (the space of quinsy) and/or PeTS.
Fig. 9 Schematic diagram to demonstrate the ring and columnar arrangement of the suprahyoid
fascial spaces. On your left, communications between the spaces have been shown with
39
arrows and unlabeled gaps in the outline. Right and left sublingual spaces also
communicate with each other. Para (and Peri) tonsillar spaces belong to pharyngeal
mucosal space.
It may be noted that Thapar et al. (2008[26]) have described a peripharyngeal ring which
includes some of the aforementioned spaces.
At the back, there are three columns with varying vertical extent: the innermost column is the
RPS; the intermediate is the DS no. 4 and the outermost is the PVS. According to Grodinsky
(1938)[6], the RPS extends up to the superior mediastinum (up to 4th thoracic vertebra), the DS
No. 4 extends into the posterior mediastinum may be up to the diaphragm, and the PVS extends
up to the coccyx. Upper parts of the columns are suprahyoid in location.
4.4 Median partition in the RPS
The RPS is divided into two, at least in its upper part, by a median septum which could be
demonstrated in three of our embalmed cadaveric specimens (Fig. 6). Grodinsky and Holyoke
(1938)[6] described midline adhesion between the visceral fascia and the alar fascia. McGregor
(1963)[57] has described and illustrated such a connecting septum between the buccopharyngeal
fascia and the prevertebral fascia helping in the differential diagnosis of the acute (producing
paramedian swelling) and chronic (producing a median swelling) retropharyngeal abscesses.
DuBrul (1988), however, did not find any such partition. Howard and Lund (2004)[100] have
described a tough median partition in the space. Gleeson (1997)[82] and Flynn (2009)[23] have
also mentioned the partition. Skidd et al. (2005)[101] have called the space retropharyngeal
space proper and the partition median raphe which they found in 50% of embalmed cadavers.
40
Malik (2008)[27] has stated categorically that there are no median attachments in the space.
Recently, while Feigl et al. (2020)[35] found such a partition in 48% of Thiel embalmed
cadavers, Snosek et al. (2020)[61] failed to find any midline raphe connecting the visceral and
alar fasciae. Possibly the partition may be present only at a higher level. Is the partition ever seen
in a CT scan or MRI under normal conditions?
4.5 DCF and the spaces (Fig. 1a, 1b, 7)
Within the general investing layer (superficial lamina) of the DCF, two spaces are usually
described: 1. Suprasternal space of Burns 2. Supraclavicular space in the lower part of the
posterior triangle of the neck [confirmed by Feigl et al. (2020)[35] using Thiel embalming]; this
layer also contains the parotid space, space of the submaxillary (mandibular) gland and also the
space of the body of the mandible. Within the prevertebral layer of the DCF related to the body
and the transverse processes of the cervical vertebrae, DS No. 4 is enclosed between the alar
lamina and the prevertebral layer. Two names have been suggested for the DS: 1. Prevertebral
interlaminar space (Honma et al., 2000)[102], and 2. Retroalar space (Lopez-Fernandez et al.,
2019)[93]; if the alar lamina is accepted as an independent layer (and not a derivative of the
prevertebral layer), Retroalar space should be a better option. DuBrul (1988)[18] has mentioned
that true intrafascial spaces are: 1. The Suprasternal space of Burns, and 2. The space between
the two layers of the temporal fascia. Feigl et al. (2020)[35] have reviewed the layers of the
fascia and some of the enclosed spaces using Thiel‟s method of embalming and have mostly
confirmed the findings of the classic work of Grodinsky and Holyoke (1938)[6]. It may be
mentioned that the latter investigators have studied adult cadavers, aborted fetuses, and clinical
cases but they are silent on whether they have used fresh or embalmed cadavers and also about
the preservative used for embalming. Feigl et al. (2020)[35] have confirmed the existence of
41
thick intercarotid fascia which is the alar fascia and have also reintroduced a sagittally oriented
„septum sagittale cervicis‟ (with variable position mediolaterally as per their illustrations)
connecting the carotid sheath with the prevertebral fascia and limiting the DS laterally.
4.6 Numbering of the spaces by Grodinsky and Holyoke (1938)[6], Grodinsky (1939)[11]
(Fig. 1a, 1b)
Space 1 Subcutaneous
Space 2 Between the fascia covering the anterior aspect of the sternothyoid-
thyrohyoid, and the general investing layer of the DCF
Space 2A It is between the inferior belly of the omohyoid and the clavicle.
Space 3 Between the visceral fascia covering the trachea and the thyroid gland,
and the fascia at the back of the sternothyroid and thyrohyoid muscles
Space 3A It is within the carotid sheath.
Space 4 Between the alar lamina and the prevertebral layer proper of the
prevertebral fascia
Space 4A It is between the general investing layer of the deep fascia and the
scalenus fascia (a part of the prevertebral layer) and it communicates
with the axilla.
Space 5 Behind the prevertebral fascia between it and bodies of the cervical
vertebrae
42
Space 5A It is deep to the scalenus fascia (a part of the prevertebral layer).
Note: All the spaces with suffix „A‟ (2A, 3A, 4A, and 5A) are in the posterior triangle
of the neck.
The anterior face is described not to possess the classical deep fascia and hence some
modifications are required here. This numbering system has been extended to the face region
also by Singh et al. (2000)[20] correctly suggesting that they correspond to Space 1 of Grodinsky
and Holyoke (1938)[6]. We suggest that the BS and the infraorbital space (IOS) (also called
canine space) are subcutaneous and hence are akin to Space 1 of Grodinsky and Holyoke
(1938)[6] classification and the BS may be numbered 1A (Facial) and the IOS 1B (Facial); the
original Space 1 will be Space 1 (Cervical). Further, depending upon the interpretation, the STS
may get the number 1 or 2.
Grodinsky and Holyoke (1938)[6] have explicitly described and illustrated the visceral space
(vide supra) but unfortunately, they have not numbered the same; it may be numbered Space 6 in
continuity with their numbering.
To simplify the PPS (a cone shaped space), it is worth considering five „P‟s: It is between the
Pharynx, Pterygoids, and Parotid; it has two subdivisions: Prestyloid and the Poststyloid.
Two spaces-Buccotemporal and Bucco-mandibular-are rarely mentioned, the last one is only
recently described. Lang (1995)[8] has described in rather complicated detail the Buccotemporal
fascia and space in the retromolar region; it is located between the DTS and the BS with the long
buccal nerve coursing through all the three spaces. The bucco-mandibular space (BMS)
43
described by Iwanaga et al. (2017)[103] is very close to the lower vestibule of the oral cavity (It
has to coexist with the vestibular space!) between the attachments of several muscles including
the incisivus labii inferioris and the buccinator muscles with the mandible and buccal mucosa
forming two of the walls; it is below the BS but does not normally communicate with it or any
other space. The BMS was studied in fresh frozen cadavers (dissected under a surgical
microscope), using colored latex and fluoroscopy.
Modern methods of medical imaging like CT scan, MRI (Stambuck and Patel, 2008[104]; Afzl
and Mendal, 2009[105]; Agarwal and Kanekar, 2012[106]; Debnam and Guha-Thakurta,
2012[107]) and more recently ultrasonography (Klem, 2010)[108] have been contributing greatly
in the diagnosis and management of infections and tumors affecting the SHFS. Such methods,
however, are not presently expected to reveal any new spaces and to alter the prevalent
traditional description of the spaces (Warshafsky et al., 2012[37]) but have made it possible to
examine even deep-seated spaces which are inaccessible clinically, both in health and disease,
44
Fig. 10 Alternative approach to the PMS through a window created in the
ramus of the mandible. Star: the PMS with its contents. For orientation
white arrows: A, anterior; R, rostral; TMJ, temporomandibular joint; TF, temporal
fascia; Temp, temporalis; BS, buccal space. Note the long buccal nerve in the BS. The
PMS may be designated as „the space of the IANBA and inferior alveolar
neurectomy‟.
Refer https://www.youtube.com/watch?v=xcym-4K4P00
Based on Space specific symptoms and pathology, the spaces may get additional labels. Symptoms
like dysphagia, dyspnea, and dysphonia may make a space dangerous. To emphasize their principal
clinical importance, the PTS should be called the „space of quinsy‟ (Fig. 6), and sublingual, submental,
submandibular spaces should be collectively called the‟ spaces of Ludwig‟s angina‟ (Fig. 1a). The
45
PMS-the most important space in Dentistry- along with its contents may be demonstrated by several
methods: Figure 10 shows the space by creating a window in the ramus of the mandible. This space
should get the designation of the „space of the inferior alveolar nerve block anesthesia (IANBA) and
inferior alveolar neurectomy‟; it is also responsible for extreme trismus, and is the site in which a
needle accidentally broken during the IANBA will be initially located for retrieval. A tooth or a
fragment of it may be displaced into some of the neighboring fascial spaces. Refer
https://www.youtube.com/watch?v=2Jibj7k_txU
Fascial spaces should be now regarded as dynamic entities as fascia (forming the walls of the
spaces and filling the spaces) itself is not supposed to be passive as suggested by Stecco et al.
(2012)[109] based on its rich innervation and complex vascularity, and also its active role in the
maintenance and repair of tissues and organs as it is increasingly becoming evident that the stem
cells and other multipotent cells may be residing in the fascia.
5. Conclusions:
The fascial spaces in the head and neck are still very much relevant for the spread of odontogenic
infections and tumors, and also for various surgical accesses. They are described as the potential
spaces; indeed, they have the potential not only to fulfill the functional and dissectional
requirements but also to allow expansion to accommodate blood, pus, tumor, etc.
It is a fallacy to believe that different descriptions of the spaces are due to normal anatomical
variations and/or different original materials and methods of investigation; such a fallacy must be
corrected. Original researches are not many but inconsistent descriptions are. The present
46
account has attempted to point out such inconsistencies and suggested how they may be
resolved; this should hopefully improve communication between the anatomist, surgeon, and
radiologist. Further, it has been proposed how to simplify their description by respecting the
established anatomy but at the same time by not being overzealous. „Ring and columnar‟
arrangement has been presented here to facilitate the overall arrangement of the spaces around
the oral cavity and pharynx, and it is suggested that most of the SHFS can be located with
reference to the attachments of various muscles on the mandible.
We wait with hope and eagerness the final word on the fascia and the fascial spaces in the living
from the radiologists as the resolution of modern methods of medical imaging like MRI would
surely improve. An update on the current nomenclature of the spaces is also due.
Acknowledgments:
I am extremely indebted to the donors whose bodies were utilized for the research purpose in this
study.
The author expresses his grateful thanks to Respected Dr. H. M. Desai, the Vice-Chancellor of
the Dharmsinh Desai University, Nadiad-Gujarat-India, and also to Dr. Bimal Jathal, the then.
Dean, the present Dean Dr. Hiren Patel -both of Faculty of Dental Science, Nadiad-Gujarat-
India- for providing all the facilities for the work.
Special thanks are due to Dr. Supreet Prabhu for providing CT scans of his patient. I am also
thankful to Professor and Head Dr. S. S. Saiyad, Dr. Sapana Shah, Dr. Vipul Shah, Dr. Yogesh
Lakhmani, Dr. Falgun Shah, Shri Sanjay Shukla, and Mr. Aakash for their immense help.
47
Conflict of interest
The author declares that he has no conflict of interest.
Ethical approval
The experiments performed in the present study comply with the current laws of India.
ORCID iD
https://orcid.org/0000-0002-5956-5052
48
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64
Buch 2021 Fascial Spaces in Head and Neck
Table 1 Fascial Spaces in Head and Neck described by various authors*
Sr. Space Hollinshead DuBrul Seward et al. Lang Gleeson Fonseca Balaji
No. (1954)[16] (1988)[18] (1992)[19] (1995)[8] (1997)[82] (2000)[81] (2007)[62]
(1982)[17]
1 Submental √ √ √ √ √
submental triangle
2 Sublingual √ √ √ √ √ √
(Part of Space of sublingual SL compartment
submandibular cellulitis
space)
3 Submandibular √ √ √ Submandibular √ √ √
Submaxillary cellulitis mentioned. described to contain anterior
space + belly of digastric and
Sublingual submental lymph nodes.
4 Submasseteric √ √ Labeled √
masseteric
5 Pterygomandibular √ √ √ √ √
6 Infratemporal √? √ √ √ √
7 Parapharyngeal √ √ √ √ √ √ √
Lateral pharyngeal Lateral pharyngeal
8 Peritonsillar √ √ (Paratonsillar) √ √
9 Retropharyngeal √ √ √ √ √
10 Danger space No. 4 √ √
11 Prevertebral √
12 Buccal √? √ √ √ √ √
Superficial facial
compartment
13 Canine/Infraorbital Alluded but not √ √ √
mentioned
14 Pretracheal √ √ √
15 Parotid √ √ √ √ √
Space of also Parotid compartment
the parotid gland
16 Palatal √ √
17 Superficial √ √ √
temporal Temporal space Temporal
Two compartments
18 Miscellaneous 1. Masticator 1. Zygomatico- 1. Maxillary 1. Bucco-Temporal 1. Masticator space is 1. Masticator 1. Carotid
2. Paratonsillar temporal antrum 2. Masticator described as pterygoid. 2. Deep temporal
3. Space of the or 2. Subtem 3. Salpingo 2. Parapharyngeal extends 3. Carotid sheath
body of the Retrozygomatic poralis muscle pharyngeal into the superior
mandible 2. Paravisceral interval 4. Lateral pharyngeal mediastinum.
4. Space of the 3. Perivisceral 3. Within the lip 5. Retromaxillary
Submaxillary 4. Retro-esophageal 6. Retropterygoid
gland, 7. Pterygotemporal
8. Suprapterygoid
9. Carotid sheath
10. Temporal etc.
65
Table 1 (continued): Fascial Spaces in Head and Neck described by various authors*
Sr. Space Malik Singh et al. Flynn Berkovitz Gregg Warshafsky et al.
No. (2008)[27] (2008)[20] (2008)[22] (2009)[28] (2009)[30] (2012)[37]
1 Submental √ √ √ √ √
2 Sublingual √ √ √ √ √ √
3 Submandibular √ √ √ √ √ √
4 Submasseteric √ √ √ √ √
5 Pterygomandibular √ √ √ √ √
labeled Superficial
pterygoid
6 Infratemporal √ √ √ √
Infratemporal fossa space The bottom portion of deep
temporal
7 Parapharyngeal √ √ √ √ √ √
Lateral pharyngeal Labeled deep pterygoid Lateral pharyngeal
8 Peritonsillar √ √ √
9 Retropharyngeal √ √ √ √ √ √
10 Danger space No. 4 √ √ √ √
11 Prevertebral √ √ √ √ √
Perivertebral
12 Buccal √ √ √ √ √
13 Canine/ √ √ √
Infraorbital
14 Pretracheal √ √ √
15 Parotid √ √ √ √ √
Parotid compartment
16 Palatal √ √ √
Alluded as Space for the
palatal abscess
17 Superficial temporal √ √ √ √ √
18 Miscellaneous 1. Masticator spaces 1. Deep temporal 1. Masticator space 1. Also deep temporal 1. Paralingual 1. Masticator space
2. Lincoln’s Highway 2. Masticator 2.Vestibular 2. Masticator 2. Anterior cervical
(Viscerovascular space) 3. Superficial and deep 3. Subcutaneous 3. Lateral pharyngeal 3. Posterior cervical
3. Deep temporal pterygoid 4. Paranasal airsinuses 4. Temporal 4. Carotid* ( Lincoln’s
4. Zygomatico temporal 4. Paratonsillar 5.Cavernous sinus thrombosis (Superficial and Deep) Highway of the neck)
5. Upper lip space alluded 5. Space of the body of the 6.Space of the body of the and Pterygopalatine 5. Pharyngeal mucosal
mandible mandible-(Subperiosteal) extension 6. Visceral
6. The cavity within the 7. Perimandibular spaces
Carotid Sheath 8. Deep temporal
7. 2A, 4A, 5A of Grodinsky 9. Orbital and periorbital
and Holyoke (1939)
*Some inconsistencies in the naming of the spaces are obvious.
66
Table 2: Outstanding Fascial Spaces and Their Principal Contents
Sr. Name of the space Principal contents Remarks

No
.
1. Sublingual Sublingual salivary gland and deep
part of the Submandibular salivary
gland, Submandibular ganglion,
Submandibular duct, Lingual and
Hypoglossal nerves, Sublingual
vessels
2. Submental Submental lymph nodes and
vessels
3. Submandibular Submandibular salivary gland,
Submandibular lymph nodes,
Facial vessels, Submental vessels,
Hypoglossal nerve and its vena
comite, Mylohyoid nerve and
vessels
4. Buccal Buccal pad of fat, Parotid duct,
Buccal nerves and vessels, Facial
vessels
5. Pterygomandibular Lingual nerve and its
accompanying artery, Inferior
alveolar nerve and vessels,
Maxillary artery-first part,
Sphenomandibular ligament
6. Para(Lateral) Contents of the Prestylod It is the deepest
pharyngeal Compartment: mostly fatty areolar part of the ITF
tissue, the deep lobe of the Parotid deep to the
medial pterygoid
gland and minor salivary gland
muscle.
rests, branches of the Maxillary
artery, Ascending pharyngeal
vessels, and divisions and branches
of the Mandibular nerve.
Contents of the Poststyloid It is beyond the

Compartment: Carotid sheath (i.e., traditional ITF. It
67
Internal carotid artery with the may be a part of

accompanying sympathetic plexus, the Extended ITF
Internal jugular vein, Vagus nerve, (Standring,
2016).
and the lymph nodes); 9th, 11th, and
12th cranial nerves; Sympathetic
trunk.
7. Paratonsillar* Loose connective tissue Paratonsillar

vein is usually
mentioned as the
only other
content.
8. Retropharyngeal Retropharyngeal lymph nodes and
the loose connective tissue
9. Pretracheal A plexus of Inferior thyroid veins Refer the text for
along with the loose fatty areolar details.
tissue
10. Visceral Trachea, Esophagus, Thyroid and It should never
Parathyroid glands, Larynx, be called the
Pharynx, Recurrent laryngeal pretracheal
nerves, and Pre and Paratracheal space.
lymph nodes (Level VI).
11. Canine (Infraorbital) Facial vessels, Infraorbital nerve
and vessels, and branches of the
Facial nerve
12. Deep temporal (only Deep temporal nerves and vessels Other contents
above the zygomatic are added if the
arch) definition of the
space is altered.
13. Prevertebral space Longus colli, Longus capitis, Refer the text for
Scaleni, etc. details.
14. Danger space Loose fatty connective tissue
Note: 1. Contents are variably and conservatively mentioned by different authors;
this problem can be resolved by following the available standard anatomy
description which may give a better idea about all the possible contents.
2. Superficial temporal space and infratemporal space are not be included
here as their boundaries are not unequivocally defined. Even for the
68
parapharyngeal space, the boundaries are ‘fluid’. Refer the text for further
details,
*If it is between the superior constrictor and the lateral capsule of the palatine
tonsil. For further clarification on the paratonsillar and peritonsillar spaces,
see the text.
69
Table 3: A Glimpse of Inconsistencies in the Description of the Fascial spaces in Head and Neck
Sr. No. Author Inconsistencies in the description of the fascial spaces

1. Scott and Dixon The ITS is designated as the pterygoid space and the pterygoid
(1978)[77] muscles are described as its contents but the lateral pterygoid is also
mentioned in the medial boundary. The inferior part of the ITS is
called the PMS. MS is also called the masseteric space. Three spaces
are clubbed under one superficial facial space. SMeS omitted.
2. Seward et al. In the case of the PPS (LPS), the walls and contents are not
(1992)[19] satisfactorily delineated, and temporal spaces (TS) are not separately
described.
3. Gleeson (1997)[82] Has described ‘pterygoid space’ which is as good as the masticator
space minus the masseter.
4. Fonseca (2000)[81] Fonseca [12] has mentioned the lateral pterygoid (LPM) and
temporalis (TM) muscles along with the mandibular condyle as the
posterior boundary of the ITS; LPM forms the medial boundary of the
space also, and the TM tendon, the lateral. Superior and inferior
boundaries are not mentioned. The medial and lateral boundaries of
the RPS are stated to be formed by the LPS. Space of the body of the
mandible is described as subperiosteal. Alar fascia is labeled
buccopharyngeal. PeTS’s medial boundary is stated to be the superior
constrictor and the lateral boundary, the tonsil.
5. Flynn (2004)[21]* has called walls borders and the use of their labels medial and lateral
(Peterson’s Principles is utterly confusing. The temporal branch of the facial nerve is listed
of Oral and among the contents of the STS. In the case of SMsS, the masseteric
Maxillofacial Surgery vessels are listed as contents but not the masseteric nerve (This is
by Miloro et al.) based on Flynn, 1994).
6. Lang (2005)[8] Retromaxillary space described by them is as good as the
infratemporal fossa of Anatomy.
7. Balaji (2007)[62] The TS are described as compartments. The lateral pterygoid muscle
is mentioned as the inferior boundary of the ITS. The carotid sheath is
mentioned as both the boundary as well as the contents of the LPS,
and the styloid group of muscles is described as the posterior
boundary of the LPS.
8. Singh et al. (2000)[20] PPS is divided into LPS and RPS. PMS has been called superficial
pterygoid, and PPS includes deep pterygoid space (DPS); DPS is
described as the superior recess of the LPS.
9. Flynn (2008)[22]* has called walls borders; STS is described to be between the temporal
(Contemporary Oral fascia and temporalis muscle but the temporal branch of the facial
and Maxillofacial nerve is listed among the contents. The inferior border (wall) of the
Surgery by Hupp et al.) ITS is described to be formed by the upper surface of the lateral
pterygoid.
10. Malik (2008)[27] has clubbed lateral and retropharyngeal spaces together giving the
name ‘parapharyngeal' to the combined space.
Malik (2016)[88] Contents and boundaries are mixed up in the case of SLS and
Infratemporal fossa space (ITFS), has clubbed lateral and
retropharyngeal spaces together giving the name ‘parapharyngeal' to
the combined space, has used PVS as a synonym for the RPS.
Superficial temporal and transverse facial arteries are listed among the
70
contents of the SMsS. ITFS has been described which is as good as

the infratemporal fossa but here the inferior boundary is mentioned to
be the lateral pterygoid muscle.
11. Standring (2008)[24] Pterygoid space finds mention without any further description. Has
described the ITS as the upper extremity of the PMS.
SMeS is included in the peripharyngeal group along with the SMS.

Standring (2016)[25] (At least, the SMeS must be considered perioral.)
12. Gregg (2009)[30] STS: superficial temporal vessels and the auriculotemporal nerve are
considered as the contents. In the description of the ITS, the walls and
contents are mixed up. Description of the pterygopalatine space is as
good as that of the pterygopalatine fossa of Anatomy but its medial
wall (terminus) is erroneously stated to be the pterygomaxillary
fissure.
13. Berkovitz et al. (2009, have described the SMsS as ‘a series of spaces’ very existence of
2018)[28, 29] which is dictated by pus and pathology. The STS is described to lie
on the lateral surface of the temporalis muscle under the skin and the
superficial (temporal) fascia; this description may be confusing
terminologically. SMS is classified as unpaired. DTS is mentioned to
be between the temporalis muscle and just temporal bone (and not
other bones forming the floor of the temporal fossa).
14. Flynn (2009) [23]* Walls of the spaces are called borders. He has also stated that the
inferior limit of the deep temporal space is the superior surface of the
(Oral and maxillofacial lateral pterygoid muscle but has considered the ITS as a part of this
infections by Topazian deep temporal space mentioning the maxillary artery and the
et al.) mandibular nerve as its contents. He has included even the masseter
as one of the contents of the SMsS.
15. Warshafsky et al. have listed the XIth** cranial nerve as one of the contents of the SLS
(2012)[37] and have described superior pharyngeal constrictor muscle both as a
part of the wall as well as one of the contents of the peritonsillar
space.
16. Hearn et al. (2015)[84] have included the thyroid gland, trachea, and the esophagus as
contents of both the visceral space and the pretracheal space.
(Haggerty and
Laughlin’s Atlas of
Operative Oral and
Maxillofacial Surgery)
71
17. Liebgott (2018)[42] has considered PMS and ITS as synonyms, and used two more
designations for the spaces, i.e., regions and areas.
*Flynn has contributed to several books.

** This may be just a printing or proofreading error.
Abbreviations used for the spaces:

PMS: Pterygomandibular space
SLS: Sublingual space
SMS: Submandibular space
SMeS: Submental space
SMsS: Submasseteric space
BS: Buccal space
TS: Temporal space
STS: Superficial temporal space
DTS: Deep temporal space
ITS: Infratemporal space
LPS: Lateral pharyngeal space
PPS: Parapharyngeal space
RPS: Retropharyngeal space
PTS: Paratonsillar space; PeTS: Peritonsillar space
72
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Buch 2021 Fascial spaces in Head and Neck

Preprint · February 2021

Pain and its Relevance in Dentistry View project

The user has requested enhancement of the downloaded file.

Dr. Hasmukh A. Buch Ahmedabad, February 2, 2021

Fascial Spaces in Head and Neck: A Critical Reappraisal Resolving Descriptive

Inconsistencies and Aberrations, and Simplifying the Anatomy

Abbreviations used for the spaces:

COVID19 patients to odontogenic infections and suspended treatment of odontogenic infections

Ather et al., 2020[5]).

described them collectively either in adults or fetuses (Hollinshead (1954)[16]; Hollinshead

Fig. 1a Schematic diagram of the suprahyoid fascial spaces-perioral and peripharyngeal.

are not shown.

here and the VS is deep to the same fascia.

2. Materials and Method

Kitamura (2017)[39], Japanese literature]. Inconsistencies in the terminology and description

laryngeal) and not the fascia.

3.1 General remarks

emergency surgical treatments.

now partly proving to be accurate.

and the query may be extended to include even the anatomist.

shown in Table No. 3) and then attempt to simplify their anatomy.

sake of uniformity of description till a consensus emerges on anyone designation, it seems

desirable not to discard the term „space‟.

3.2.1 Parotid space

3.2.2 Temporal fossa (TF) and its spaces (Fig. 2)

osteological canine fossa as routinely described in anatomy.

tissue, the temporoparietal fascia probably representing Superficial Musculo-Aponeurotic

et al., 2007[69]; Standring, 2008[24]).

temporal spaces, and also retrozygomatic or zygomaticotemporal space. A better description of

noted that the Terminologia Anatomica (TA) (2019)[73] (https://fipat.library.dal.ca/TA2/Part2/

3.2.3 Infratemporal fossa (ITF) and its spaces (Fig. 2, 3)

ITF of anatomy contains pterygomandibular, infratemporal, parapharyngeal (how much?), a part of

clarifications for which refer the text.

even parotid and masticatory spaces as subdivisions of the ITF.

ITS, infratemporal space. Star: PMS.

temporalis muscle are well known.

for further details,)

3.2.5 Submasseteric space (SMsS)

Fig. 5a CT scan 3D reconstruction of a patient of an abscess. Courtesy of

Dr. Supreet Prabhu.

however, this may be an interesting interpretation of the space.

3.2.6 Pharyngeal spaces (Fig. 6)

lateral parapharyngeal. DuBrul (1988)[18] has designated retropharyngeal and parapharyngeal

Fig. 6 Dissection and sectioning to demonstrate particularly the LPS and

the pharynx. Thin arrow without a label: the space of „quinsy‟.

3.2.7 Paratonsillar and Peritonsillar spaces (Fig. 6)

3.2.8 Pretracheal space and fascia (Fig. 7)

length similar spaces in other regions of the body.

and is condensed to form the ligament of Berry.

well as the visceral space!

Harold Stiles as quoted by McGregor (1963)[57].

3.2.9 Prevertebral space and fascia (Fig. 1b, 7)

Harnsberger (1995)[94] have recommended the designation perivertebral space consisting of

3.2.10 Carotid space (CS) and Sheath (Fig. 1b, 7)

3.2.11 The spaces tend to make the authors err!

3.2.12 Summary of recommendations