2. Index
Introduction
Classification of infection
Stages of infection
Microbiology of odontogenic infections
Management of odontegic infections
Classification of fascial planes
Progression of infection
Space infections of maxilla
Space infections of mandible
Space infections of neck
Principles of treatment
Management
Refrences
3. Introduction
Potential or actual space between fascia and muscles containing
nerves, blood vessels and connective tissue but this becomes
pathway of infection in presence of infection
Infection may be defined as invasion and multiplication of
microorganisms in body tissues, especially that causing local
cellular injury due to competitive metabolism, toxins,
intracellular replication, or antigen-antibody response
Fascial space infections are a relatively common presentation to
both general medical and dental practitioners.
Infections originating in deeper structures can be severe, rapidly
progressive and may cause prolonged morbidity, long term
complications as well as potentially endanger life.
4. Classification of infections
According to the clinical appearance:
a) Acute infections
b) Chronic infections
c) Acute exacerbation of a chronic infection
Depending on the etiological agent:
a) Bacterial
b) Viral
c) Fungal
According to source of infection:
a) Odontogenic
b) Secondary infections of lesions such as cyst or tumors
c) Infections arises from contaminated wound/trauma
d) Iatrogenic infections
5. Stages of infections
Stage I: Initiation of infection
• Mostly odontogenic in origin,
• Periapical/periodontal/pericoronal infection
• Mildly symptomatic or asymtomatic.
Stage II: Entry of infection in medullary bone
• Symptomatic, patient seeks treatment
• Tender on percussion
• No space for pus to drain starts effecting the medullary bone
Stage III: Path of drainage
• Pus follow path of least resistance
• Perforates cortex that is thinner
• Appears in soft tissues, extra oral swelling
• May lead to cellulitis or abscess formation
Stage IV: Spread of infection
• Spreads to another space along anatomical barriers
• May perforate the skin to form sinus
6. Microbiology of odontogenic infections
Bacterial composition
1. 5%-aerobic bacteria
2. 60%-anaerobic bacteria
3. 35% mixed aerobic and anaerobic bacteria
Commonly cultured organisms: alpha-
hemolytic Streptococcus, Peptostreptococcus,
Peptococcus, Eubacterium, Bacteroides
(Prevotella) melaninogenicus, and
Fusobacterium.
Quantitative estimations of the number of
microorganisms in saliva and plaque range as
high as 1011/ml.
9. Management of odontogenic infections
Determine the severity of the infection
Complete history
Physical examination
State of the patients host defense
Treat the infection surgically
Support the patient medically
Choose the appropriate AB
Re-evaluate the patient frequently
10. Severity of infection
How the patient feels
Previous treatment
Self treatment
Past Medical History
Complete History
Chief Complaint
Onset
Duration
Symptoms
11. Clinical presentation
History-previous toothaches (onset,
duration), presence of fever, and previous
treatments (antibiotics ) important
Patients may complain of trismus, dysphagia
and have shortness of breath should be
investigated.
Findings vary from mild swelling and pain
to life-threatening airway compromise and
CNS impairment
12. Inspection, palpation, and percussion are
integral parts of the exam
Begin extraorally and then move intraorally
Skin of the face, head, and neck for
swelling, erythema, sinus or fistula
formation.
Assess for cervical lymphadenopathy and
fascial space involvement
Assess for the presence and magnitude of
trismus
13. Examine quality and consistency:
Soft to fluctuant (fluid filled) to hard (indurated)
Normal vs abnormal tissue architecture:
Distortion of mucobuccal fold
Soft palate symmetric with uvula in midline
(deviation → involvement of lateral pharyngeal
space)
nasolabial fold, circumorbital areas
14. Identify causative factors:
Tooth, root tip, foreign body, etc.
Vital signs should be taken:
Temperatures > 101 to 102°F
accompanied by an elevated heart rate
indicate systemic involvement of the
infection and increased urgency of
treatment.
15. Imaging studies can further substantiate
diagnosis – Panorex, Plain Films , CT , MRI
Computerized tomograms should be
obtained when infection has spread into
fascial spaces in the orbit or neck
Infections, well-localized to oral cavity do
not require special imaging studies with a
panorex being sufficient for diagnosis and
treatment
18. One of the most common & difficult
problems
Range from low-grade to severe, life-
threatening
Most are easily managed with minor
surgery and antibiotics
19. Common types of infection:
Periapical, periodontal, postsurgical,
pericoronal
May begin as well-delineated, self-limiting
condition with potential to spread and result in
a major fascial space infection.
Life-threatening sequelae can ensue:
Septicemia, cavernous sinus thrombosis,
airway obstruction, mediastinitis
20. Progression of Odontogenic Infections
Periapical
Periodontal
Soft tissue involvement
Determined by perforation of the cortical
bone in relation to the muscle attachments
Cellulitis- acute, painful, diffuse borders
Abscess- chronic, localized pain, fluctuant,
well circumscribed.
21. Cellulitis: initial stage of infection
Diffuse, reddened, soft or
hard swelling that is tender
to palpation.
Inflammatory response not
yet forming a true abscess.
Microorganisms have just
begun to overcome host
defenses and spread beyond
tissue planes.
22. True abscess formation
As inflammatory
response matures,
may develop a focal
accumulation of pus.
May have
spontaneous drainage
intraorally or
extraorally.
23. Differences between cellulitis & abscess
Cellulitis Abscess
Duration Acute Chronic
Pain Severe generalized Localised
Size Large Small
Localization Diffuse borders Well circumscribed
Palpation Doughy indurated Fluctuant
Presence of pus No Yes
Degree of seriousness Greater Less
Bacteria Aerobic anaerobic
24.
25. Classification of fascial spaces
Based on mode of involvement
I. Direct involvement (Primary spaces) – maxillary
spaces , mandibular spaces
II. Indirect involvement (Secondary spaces ) – Lateral
pharyngeal space
Based on clinical significance by Topazian
I. Face – buccal, canine, masticatory, parotid
II. Suprahyoid – sublingual, submandibular
(submaxillary, submental) pharyngomaxillary
(lateral pharyngeal) peritonsillar
III. Infrahyoid – anterovisceral (pretracheal)
IV. Spaces of total neck – retropharyngeal, space of
carotid sheath
26. BASED ON FASCIA
I. Superficial fascia
II. Deep cervical fascia
1. Anterior layer
• Investing fascia ( over the neck)
• Parotidomasseteric
• Temporal
2. Middle layer
• Sternohyoid - omohyoid division
• Sternothyroid - thyrohyoid division
• Visceral division –
• Buccopharyngeal
• Pretracheal
• Retropharyngeal
3. Posterior layer
• Alar division
• Prevertebral division
27. According to Grodinsky & Holyoke in 1938
I. Space 1 – potential space superficial and deep to the
platsyma muscle
II. Space 2 – space behind the anterior layer of deep
cervical fascia
III. Space 3 – pretracheal space, ant to layer of deep
cervical fascia
IV. Space 3A – viscerovascular space; is the carotid
sheath from the jugular foramen and carotid canal at
the base of skull to the pericardium (lincoln’s
highway)
V. Space 4 – ‘Danger space’ potential space b/w alar
and prevertebral fascia. Extends from base of skull to
the prevertebral fascia
VI. Space 5 – it is the space enclosed by the prevertebral
fascia posterior to transverse processes of vertebrae
28. According to killey and kay
1. In relation to lower jaw:
1. Submental
2. Submandibular
3. Sublingual
4. Buccal
5. Submassetric
6. Parotid
7. Pterygomandibular
8. Lateral pharygeal
9. Peritonsillar
2. In relation to the upper jaw:
a) Canine space
b) Palatal space
c) Maxillary antrum
d) Infratemporal space
e) Subtemporal space
29. SPACE OF BURNS : The Suprasternal
Space
The superficial fascia splits below the level of
the hyoid bone to form 2 spaces
- Forms lower part of the roof of the post
triangle, the fascia splits into two layers,
attached to clavicle
- Forms lower part of the roof of the ant
triangle and fascia splits to form the
suprasternal space
32. Canine space infection/ Infraorbital space
infection
This is a potential space present on the
anterior surface of the maxilla in the region
of canine fossa
Appear commonly as labial sulcus swelling
Levator anguli oris and levator labii
superioris muscle overlies apex of canine
root
Origin: canine fossa.
Insertion: angle of mouth
33. Boundries:
• superiorly:
a) Levator angulii oris
b) Levator labii superioris
• Posteriorly:
a) Buccal space
• Inferiorly:
a) Orbicularis muscle
Contents: infrorbital nerve and its branches
34. Canine space infection
Signs:
• Obliteration of the nasolabial
fold
• Drooping of angle of mouth
• Superior extension can
involve lower eyelid
• Open in relation to medial
canthus of eye
35. Incision for canine space infection
Intra-oral approach, high in labial vestibule
by sharp and blunt dissection
Percutaneous drainage – lateral to the nose
37. Palate is covered by tightly
adherent mucoperiosteum
Periosteum is tightly bound to
the mucosa, periodontal
membrane of the adjacent teeth
and to the suture in the midline
Pus tends to accumulate
between periosteum and bone
Infections begin in lateral
incisor or upper post tooth
It is in the subperiosteal space
of palate
Exquisitely painful due to rich
innervations of the periosteum
Palatal space infection
38. Signs and symptoms
circumscribed fluctant swelling confined to one
side
May discharge from the gingival sulcus
Infection does not cross midline
Infection from:
• Upper lateral incisor
• Palatal pocket in premolars or molars
• Infection of palatal root
39. Management:
Incision should be in AP direction to avoid
injury to anterior palatine nerve
Treatment of offending tooth
Differential diagnosis:
Extravasation cyst
Gumma
Pleomorphic adenoma
Carcinoma of maxillary antrum
40. Infratemporal space infection
Odontogenic infections of maxillary posterior teeth
Odontogenic infections involving the
pterygomandibular space or infection from buccal
space coursing along the masticatory fat pad.
Anatomical boundries:
a. laterally: ramus of mandible, temporalis muscle and
temporalis tendon
b. Medially: lateral pterygoid plate
c. Superiorly: infratemporal surface of the greater wing of
sphenoid
d. Inferiorly: lower head of lateral pterygoid muscle
41. Contents:
a. Origin of pterygoid muscles
b. Pterygoid venous plexus
c. Internal maxillary artery
d. Mandibular nerve and its branches
Signs and symptoms:
a. Infected upper molar teeth
b. Severe trismus is universal finding
c. extraoral swelling over the sigmoid notch, intra
oral swelling in the tuberosity area
42. Management:
a. Intravenous antibiotics
b. Incision in upper buccal sulcus in third molar
region
c. Use of sinus forceps along medial surface of
coronoid and temporalis upwards and
backwards
43. Mandibular Space Infections
Sublingual space
Submental space
Submandibular space
Ludwigs angina
Masticator space
Lateral pharyngeal space
Temporal space
44. Submental space
Potential space present just below the chin
region on the medial surface of the mandible
It is a midline structure bordered laterally by
the anterior bellies of digastric muscle
Infections begin in the anterior mandibular
teeth
Secondarily Infected skin wounds or
anterior mandibular fractures may also cause
infections
45. BORDERS:
• Anterior – inf border of mandible
• Posterior – hyoid bone
• Superior – mylohyoid muscle
• Inferior – investing layer of deep cerical fascia
• Deep/Lateral - ant. bellies of digastric muscle
Contents:
• Submental lymphnodes
• Anterior juglar veins
• Adipose tissue
46. Signs and symptoms:
• Firm circumscribed swelling beneath the
chin
• Patient complains of discomfort and
difficulty in swallowing
Management:
• Incision is made bilaterally through the skin,
subcutaneous tissue and platsyma muscle at the
most inferior aspect of swelling
• A hemostat is inserted through one incision and
then exited through the second incision
48. Sublingual space
It is a potential space present in the anterior part of
the floor of the mouth
It almost always involved with submandibular
space
Only loose connective tissue separates right and left
sublingual spaces and infection spreads easily from
side to the other
Boundries:
• Anteriorly and laterally– medial surface of mandible
• Posteriorly – submandibular space
• Superiorly – sublingual mucosa
• Inferiorly – mylohyoid muscle
• medially - genioglossus, geniohyoid, styloglossus muscles
• Superficial – muscles of tongue
• Deep – ant.bellies of digastric muscle
49. The styloglossus muscle passes b/w superior
& middle pharyngeal constrictor muscles in
this region to enter the tongue
The seperation b/w these pharyngeal
constrictors formed by the styloglossus
muscle is termed BUCCOPHARYNGEAL GAP
51. Incision is placed at the
base of the alveolar
process in the lingual
sulcus so that the
sublingual gland, lingual
nerve & submandibular
duct are not injured
A hemostat is inserted
through the incision in
an ant & post direction
& beneath the sublingual
gland to evacuate the
pus
Incision for Sublingual space
infection
52. Submandibular space
It is a potential space present on the medial surface of the
posterior aspect of the mandible
Anatomical boundries:
• Anteriorly – ant. belly of digastric muscle
• Posteriorly - post. belly of digastric muscle, stylohyoid muscle,
stylopharyngeus muscle
• Superior – inf & medial surfaces of mandible
• Inferior – digastric tendon
• Superficial – platsyma muscle, investing fascia
• Deep – mylohyoid, hypoglossus, sup constricting muscles
• Laterally – bounded by skin, superficial fascia, platysma
Contents:
• Submandibular salivary gland
• Lymph nodes
• Facial artery
• Lingual and hypoglossal nerves
53. Submandibular space
Triangular swelling
Begins at the lower
border of mandible,
extends to level of
hyoid bone
Brawny induration
Usually associated
with lowermolar
infection
54. Two stab incisions are placed at the inf
aspect of swelling in the shadow of the
mandible
Extended through the skin &
superficial fascia
Dissection is bluntly done through one
incision with a curved hemostat, which
is inserted through the platsyma
muscle & deep fascia in abscess for
drainage
Submandibular incision
55. A hemostat is passed thru the
cavity and out the other incision
A thin rubber drain is inserted through the
wound beaks of the hemostat & withdrawing
the Instrument Dressing is placed
56. Ludwig’s angina
First described by wilhelm fredreich
von ludwig in 1836.
Its rapidly spreading in nature
Ludwig’s angina is a form of firm,
acute, toxic and severe diffuse
cellulitis that spreads rapidly,
bilaterally, affecting the
submandibular, sublingual and
submental spaces and resulting in a
woody swelling
57. Clinical features
Bilateral suprahyoid swelling with hard cardboard like
consistency, non fluctuating & painful on palpation
Swelling is characterized by rapid onset
Difficulty in breathing (dyspnea),
Difficulty in swallowing (odynophagia)
Restricted tongue movements, elevated tongue ,inability to
open the mouth, salivation
Patients may exhibit muffled voice due to edema of vocal
apparatus (hot potato voice)
58. Eitiology
Odontogenic infections
Traumatic injuries
Infective conditions like osteomyelitis
Pathology:
Infection from the source reaches the submandibular
space
The submental spaces gets involved via the lymphatics
It’s a cellulitis it rapidly spreads reaches the epiglottis
producing edema and inflammation of laryngeal inlet.
Spreads to pterygomandibular, massetric and lateral
pharyngeal spaces
Patient may die with in 24 hours due asphyxia if not
treated
May die from septic shock, aspiration of pus or
mediastinitis
59. Signs and symptoms:
a. Pyrexic
b. Dehydration
c. Dysphagia
d. Rapid shallow breathing
e. Hoarseness of voice
Extra oral features:
a. Hard to firm brawny, board like swellin
b. Skin is shiny stretched and erythmatous
c. Tender swelling with local rise in temperature
d. Unable to close the mouth and drooling of saliva
e. Evident respiratory distress, use of accessory muscle of respiration
f. Trismus
Intra oral features:
a. Floor of mouth is raised
b. Tongue appears swollen and raised upwards towards the palate
c. Increased salivation
60. The cardinal signs of Ludwig’s angina are:
1. Bilateral involvement of more than a single deep tissue space
2. Gangrene with serosanguinous, putrid infiltration but little
or no frank pus
3. Involvement of connective tissue, fascia, and muscle but not
glandular structures
4. Spread via fascial space continuity rather than by lymphatic
system
Danger signs:
1. Dysapnoea
2. Dysphagia
3. Hoarseness of voice
4. Stridor
5. Swelling below the clavicles
61. Diagnosis & investigations
UltraSonography: Used to identify fluid
collection in the soft tissues.
C.T. Scan
M.R.I
62. UltraSonography:
Effective diagnostic tool in treatment of acute
odontogenic fascial space infections and cellulitis
Micro convex probe of 6.5Mhz is used
Probe is applied over skin, covering the swelling
in transverse and axial sections
Echoing of sound from the fluids is absent
thereby detecting the fluid collection
64. Complications
Septicemia
Carotid blow out
Obstruction of upper respiratory airways
Aspiration pneumonia
Spread of infection into Para pharyngeal
spaces-mediastinum-produce thoracic
empyema
Death due to airway compromise
65. TREATMENT :
Early diagnosis of incipient cases
Maintenance of patent airway
Intense & prolonged antibiotic therapy
Extraction of affected teeth
Hydration
Early surgical drainage
66. “ A chance to cut is a chance to cure ”
Classic approach / Cut- throat approach:
Horizontal incision midway b/w chin & hyoid
bone.
Bilateral incision into the submandibular
spaces with blunt dissection to the midline
Through and through drain or bilateral drains
meeting at the midpoint
67. Buccal space infection
Buccal space occupies portion of
subcutaneous space b/w facial skin
& buccinator muscle
Maxillary & mandibular premolar
and molar teeth tend to drain in
lateral & buccal direction
Relation of root apices to
buccinator muscle determines path
of infection : intraorally in buccal
vestibule or deeply in buccal space
68. BORDERS:
Anterior – corner of mouth
Posterior – masseter muscle, pterygomandibular
space
Superior – maxilla, infraorbital space
Inferior – mandible
Medial – subcutaneous skin
Lateral – buccinator muscle
69. BUCCAL SPACE INFECTION
Signs and symptoms:
•Dome shaped swelling
beginning at lower border of
mandible
• extending upwards to level of
zygomatic arch
•Diagnosed because of marked
cheek swelling associated with
diseased molar/premolar tooth
•Not associated with trismus
70. Management
Intra – oral drainage:
Is done with the incision made through the buccinator muscle
It is difficult in maintaining a patent opening for drainage
because contraction of muscle fibres tend to close it off
Hence a horizontal rather than a vertical incision is made just
above the depth of the vestibule
Extra oral drainage:
Inferior to point of fluctuance with blunt dissection
Incisions are placed below the lower border of mandible
2 stab incisions are made with a no.11 blade through the skin &
subcutaneous tissue
A curved hemostat is inserted thru the anterior incision into the
buccal space and then turned & exited through the posterior
incision
Beaks of hemostat are opened, strip of rubber drain is grasped.
Hemostat is withdrawn carrying drain through the tissues
Ends are fastened, dressing placed
71. Submasseteric space
Earliear this space was considered to
between masseter and the lateral aspect
of the ramus of the mandible.
Now it is found to be between three
layers of the masseter muscle itself
Submasseteric swellings can be
differentiated from parotid swellings as
these produce marked Trismus
overlying masseter muscle
Obscure earlobe or elevation of ear lobe
in frontal view
72. BORDERS:
Anterior– buccal space
Posterior – Parotid gland
Superior – zygomatic arch
Inferior – pterygomassetric sling
Medial – ascending ramus of mandible
Lateral – masseter muscle
Infection can spread from lower third molars
Signs and symptoms:
• External facial swelling confined to masseter
muscle
• Swelling usually does not extend beyond the
posterior border of the masseter into the
postauricular area
• Swelling acutely tender
• Almost complete trismus
• Overlying skin reddened and stretched
• Pus may drain at the angle of the mandible
73. Management:
Intraorally:
Drainage is done through a vertical incision along the ext
oblique line of the mandible
Starting at the level of the occlusal plane and extending
downward & forward in the buccal sulcus to a point opp
the second molar
A hemostat is inserted and passed posteriorly along the
lateral aspect of the ramus to point beneath masseter
muscle
Beaks are opened
Rubber drain is inserted & sutured
Extraorally:
• Incision is made behind the angle of the mandible
(retromandibular incision)
• Hemostat is inserted and passed along the lateral aspect of
the ramus
• Rubber drain is inserted
74. Pterygomandibular space
Most frequently affected anatomical compartment
Correlated highly with pericoronitis & mandibular
third molar
secondary infection results from spread from the
sublingual and submandibular spaces
Symptoms:
• Trismus – due to edema & inflamm of med pterygoid
• Swollen ant tonsillar pillar
• Deviation of uvula to opposite side
75.
76. Communications:
• Deep temporal space: By passing around the
lateral pterygoid muscle superiorly, running from
the mandibular condyle neck and the articular
disc to the medial pterygoid plate.
• Lateral pharyngeal space:by along the anterior
border of medial border of medial pterygoid
muscle following postereolateral surface of the
buccinator and the superior pharyngeal
constrictor muscles
78. BORDERS:
• Anteriorly – pterygo mandibular raphae,buccal space
• Inferior – inf border of mandible upto attachment of
medial pterygoid muscle, pterygomassetric sling
• Superior – Lateral pterygoid muscle
• Posterior – deep lobe of parotid gland
• Superficial – lateral pterygoid muscle
• Deep – ascending ramus of mandible
• Medially – medial pterygoid muscle
• Laterally – ascending ramus of the mandible
Contents:
• Inferior alveolar nerve
• Lingual nerve
• Nerve to mylohyoid
• Inferior alveolar artery and vein
79. NOTE : DANGER SPACE 4 IS THE SPACE BETWEEN
PREVERTIBRAL AND ALAR FASCIA
PTERYGOMANDIBULAR SPACE
PTERYGOID SPLEXUS
EMISSERY VEINS
CAVERNOUS SINUS
THROMBOSIS
LATERAL PHARYNGEAL SPACE
RETROPHARYNGEAL SPACE
MEDIASTINUM
CAROTID SHEATH
DANGER SPACE 4
80. Management
Extra oral mandibular block
is given
Incision is placed through
the mucosa in the area b/w
medial aspect of the ramus &
pterygomandibular raphe.
Abscess is opened by blunt
dissection and Drain is
placed
81. Temporal space
Two divisions:
a. Superficial – It is between superficial temporal
fascia and lateral aspect of temporalis muscle
b. Deep – It is between the medial surface of the
temporalis muscle and periosteum of temporal bone.
Inferiorly the temporal space is limited to the
attachments of the temporalis muscle and fascia.
Inferiorly, it communicates with the pterygomandibular
space
Its contains loose connective tissue and vessels
supplying the temporalis muscle
82.
83. Signs and symptoms:
• Swelling confined to the shape of the muscle extending from the
lateral orbital rim, above the zygomatic arch, covering the lateral
aspect of tempral bone.
• swelling more prominent in a superficial temporal space infection.
• severe trismus
Deep temporal abscess
Produce less swelling
Lies deep to temporalis muscle
Less fluctuant
Management:
Intra oral sicher’s incision along the anterior border of the ramus of
the mandible
Extra oral cutaneous incision slightly above the zygomatic arch made
parallel to zygomatic arch followed by blunt dissection and placement
of drain
84. Lateral pharyngeal space
Also known as Pharyngomaxillary/
parapharyngeal space
Lateral neck space shaped like an inverted
cone
Base is uppermost at the base of the skull
Apex is at the greater horn of the hyoid
bone
Infections may result from – pharyngitis,
tonsilitis, parotitis, otitis, mastoiditis and
dental infection
85.
86. Pharyngomaxillary space
Suprahyoid
• superior—skull base
• Inferior—hyoid
• Anterior—ptyergomandibular raphe
• Posterior—prevertebral fascia
• Medial—buccopharyngeal fascia
• Lateral—superficial layer of deep fascia
• Prestyloid
Muscular compartment
Medial—tonsillar fossa
Lateral—medial pterygoid
Contains fat, connective tissue, nodes
Poststyloid
Neurovascular compartment
Carotid sheath
Cranial nerves IX, X, XI, XII
Sympathetic chain
Stylopharyngeal aponeurosis of Zuckerkandel
and Testut
Alar, buccopharyngeal and stylomuscular
fascia.
Prevents infectious spread from anterior to
posterior.
87. Borders:
Anterior – sup & middle pharyngeal constrictor muscles
Medially – superior constrictor, styloglossus muscle,
stylopharyngeus and middle constrictor muscle
Posterior – carotid sheath & scalene fascia
Superior – skull base
Inferior – hyoid bone
Superficial – pharyngeal constrictors, retropharyngeal space
Deep – medial pterygoid muscle
Signs and symptoms:
For surgical & anatomical purposes, it is divided into anterior &
posterior compartments
Ant comp infection pt exhibits pain, fever, chills, medial
bulging of lat pharyngeal wall with deviation of palatal uvula
from midline, dysphagia, swelling below the angle of the
mandible
Post comp has absence of trismus & visible swelling, BUT resp
obstruction, septic thrombosis of int jugular vein and carotid
artery hemorrhage
88. Severe trismus
Lateral swelling of the
neck
Bulging of the lateral
pharyngeal wall
pushed to midline
Usually no extra oral
swelling
Rapid progression of
infection in this space
is common
Lateral pharyngeal space infection
89. Management
Aggressive antibiotic therapy
If the mouth can be opened, intra oral incision
medial to the anterior border of the ramus
Extra orally
The incision is placed 1cm below and behind the
angle of the mandible. Sinus forceps are inserted into
the space between submandibular and parotid gland
and passed medial to mandible and upwards along
the inner aspect of medial pterygoid muscle.drain is
inserted
90. Peritonsillar Space
The peritonsillar space consists of
loose connective tissue between the
capsule of the palatine tonsil and the
superior constrictor muscle. The
anterior and posterior tonsillar
pillars contribute to its anterior and
posterior borders, respectively. The
posterior tongue forms the inferior
boundary. Peritonsillar infections
may readily spread to the
parapharyngeal space.
92. Peri-tonsillar space
Clinical evaluation:
3-7 days H/o pharyngitis .
Severe sore throat, dysphagia, Odyonophagia and referred
otalgia.
The speech is muffled and classically described as hot potato
voice.
Trismus is not present
In recent literature,needle aspiration instead of open incision
and drainage (JOMS,Vol 51,1993)
93.
94. Parotid Space
Formed by the superficial layer of deep
cervical fascia surrounding the gland
Boundaries :
Swelling extends from level of zygomatic
above to lower border of mandible
Anteriorly it ends at the anterior border of
mandible
Posteriorly it extends into the
retromandibular region
95.
96.
97.
98. Parotid space
Superficial layer of deep fascia
Dense septa from capsule into gland
Direct communication to parapharyngeal space
Contains
External carotid artery
Posterior facial vein
Facial nerve
Lymph nodes
99. C/F
Everted ear lobule
Severe pain referred to the ear, accentuated
by eating
Trismus
100. Spaces of the neck
1. Retropharyngeal space
2. Prevertebral space
3. Mediastinitis
101. Retropharyngeal ,danger space and
prevertebral spaces lie between deep
cervical fascia the surrounds the pharynx
and oesophagus anteriorly and vertebral
spine with its muscle attachments
posteriorsly
102.
103. Retropharyngeal space
Anatomical boundries:
1. anteriorly: constrictor muscles of the neck and their
fascia
2. Posteriorly: alar layer of deep cervical fascia which
extends from the base of the skull to the superior
mediastinum
A midline septum exists between the right and left
retropharyngeal spaces that is crossed easily.
Contents
1. Adenoidal tissues draining posterior pharyngeal wall
2. Lymphnodes draining waldeyers ring
104.
105. Prevertebral space:
extends from base of the skull to the coccyx
anteriorly bounded by prevertebral fascia
For spaces of the neck the infections may
arise from nasal, pharyngeal, dental
infections
106.
107. Clinical features of space of neck
Drooling
Fever
Irritatibility
Nuchal rigidity –
neck siffness
Irritability light
Head ache
Dyapnoea
Dysphagia
Bulging in the posterior pharyngeal wall may be
there
108. Dangers involves
severe laryngeal edema
Rupture of abscess leading to aspiration
pnemonia or asphyxia
Mediastinitis
109. Management
Tracheostomy
Extreme trendelburg position
Surgical intervention
Intra oral: through posterior pharyngeal wall
Extra oral:
inferior to hyoid parallel to sternocleidomastoid,
retraction of muscle and carotid sheath, blunt
dissection till hypopharynx.
Deep dissection to carotid sheath between it and
inferior constrictor muscles rupture retropharyngeal
abscess
Deep drains inserted
110. Principles in Treatment of Oral and
Paraoral Infections
a) Remove the cause.
b) Establish drainage.
c) Institute antibiotic therapy.
d) Supportive care, including proper rest and
nutrition.
111. Management of Odontogenic Infections
General principles
Goals of management of odontogenic
infection:
1. Airway protection
2. Surgical drainage
3. Medical support of the patient
4. Identification of etiologic bacteria
5. Selection of appropriate antibiotic therapy
112. Airway protection
1.Floor of mouth and tongue elevation or
narrowing can cause respiratory
distress
2.Expedient assessment and diagnosis of
airway compromise is the most
important initial step in managing
odontogenic infections
3.Airway loss is primary cause of death
in these patients
113. • Initially intact airway must be
continuously reevaluated during
treatment
• Signs and findings of airway
compromise: inability to assume a
supine position, stridor, and
restlessness etc.
• Surgeon must decide the need, timing
and method to establish an emergency
airway
114. Surgical drainage
1. Administration of intravenous antibiotics
without drainage of pus may not allow for
resolution of an abscess
2. Starting antibiotic therapy without Gram's
stain and cultures may result in failure to
identify pathogens
3. Important to drain all primary spaces as well
as explore and drain potentially involved
secondary spaces
115. • CT scans may help identifying spaces
involved
• Panorex can help identify putative
teeth involved
116. • Canine, sublingual and vestibular
abscesses are drained intraorally
• Masseteric, pterygomandibular, and
lateral pharyngeal space abscesses can
be drained with combination intraoral
and extraoral drainage
• Temporal, submandibular, submental,
retropharyngeal, and buccal space
abscesses may mandate extraoral
incision and drainage
117. Technique:
1. Small incision are made in a dependent
area
2. Placement of a hemostat in the abscess
cavity with entry into all loculations of
the abscess
3. drains inserted into cavity to allow for
postoperative drainage of the abscess
118. PURPOSES OF SURGICAL DRAINAGE & INCISION
Rid the body of toxic purulent material
Decompress the tissues
Allowing better perfusion of blood containing
antibiotics and defensive elements
Increased oxygenation of the infected area
119. Dependent drainage of
the space is
performed by
placing a horizontal
incision in the most
dependent area of
the swelling
extraorally /
intraorally with a
cosmetic scar being
the result
120. Medical support of the patient
1. Rehydrate patient as dehydration may
be present
2. Treat conditions that predispose
patient to infection (DM)
3. Oral pain, trismus , and swelling can
be addressed by appropriate analgesia
and treatment of underlying infection
121. Identification of etiologic bacteria
1. Expected causes are alpha hemolytic
streptococci and oral anaerobes
2. Cultures should be performed on all
patients undergoing incision and drainage
and sensitivities ordered if patient is not
progressing well (possible antibiotic
resistance)
3. An aspirate of the abscess can be performed
and sent for culture and sensitivities if
incision and drainage delayed
122. Antibiotic Therapy
Removal of the cause, drainage, and supportive
care more important than antibiotic therapy.
Infections are cured by the patient’s defenses,
not antibiotics.
Risks of allergy, toxicity, side effects,
resistance and superinfection causing serious
or potentially fatal consequences must be
considered.
123. Principles of antibiotic use
– Necessity
– Empirical therapy
– Narrow spectrum
– Low toxicity
– Bacteriocidal
– Administer properly
– Cost
124. Antibiotic therapy, con’t.
Oral infections are typically polymicrobial.
Antibiotic effectiveness dependent upon
adequate tissue (not serum) concentration for an
appropriate amount of time.
Antibiotics should be prescribed for at least one
week – adequate tissue concentration achieved
in 24-48 hours, with bacteriocidal activity
occurring over the next 3-5 days.
125.
126. EMPIRIC ANTIBIOTIC TREATMENT
Modified from Flynn TR. The swollen face.
Severe odontogenic infections.Emerg Med
Clin N Am 2000;18:
Early infection (first 3 days of symptoms or
mildly immunocompromised)
Penicillin
Clindamycin
Cephalexin (or other first-generation
cephalosporin)
127. Late infection (after 3 days of symptoms or
moderately to severely
immunocompromised)
Clindamycin (maximum dose)
Penicillin and metronidazole
Ampicillin and sulbactam
Cephalosporin (first or second generation)
Mild, moderate, and severe compromise is
based on CD4/viral loads, glycemic control,
and the degree of alcoholic related disease.
128. Antibiotic therapy, con’t.
Penicillin (bacteriocidal) drug of choice for
treatment of odontogenic infections (5%
incident of allergy).
Clindamycin (bactericiodal) 1st line after
penicillin; effective against anaerobes;
Cephalosporin (slightly broader spectrum and
bacteriocidal); cautious use in penicillin-
allergic patients → cross-sensitivity; if history
of anaphylaxis to penicillin, do not use.
129. Antibiotic therapy, con’t.
Erythromycin (bacteriostatic) good 2nd line
drug after penicillin; use enteric-coated to
reduce GI upset.
Metronidazole (bacteriocidal) excellent
against anaerobes only.
Augmentin (amoxicillin + clavulanic acid)
kills penicillinase-producing bacteria that
interferes with amoxicillin; expensive.
130. Selection of antibiotic therapy
1.Penicillin
2.Metronidazole in combination with
penicillin can be used in severe infections
3.Clindamycin for penicillin-allergic
patients
Causes for clinical failure include
inadequate drainage or antibiotic
resistance
132. Drug Therapy – antibiotics & steroids
Mannitol to reduce to edema
Chloramphenicol ; antibiotic of choice
Surgery to provide drainage
133. MENINGITIS
Most common neurological complication
C/F : headache, fever, stiffness of neck &
vomiting
Kernig’s sign – passive resistance to extend the
knee from flexed thigh position
Brudzinski’s sign – abrupt neck flexion in
supine resulting in involuntary flexion of
knees
Diagnosis : lumbar puncture
134. Rx : chloramphinicol + penicillin G
Hydration
Electrolyte balance
Control of cerebral edema
Avoidance of vascular collapse and shock
135. MEDIASTINITIS
Late complication due to delayed diagnosis &
inadequate surgical drainage
It is a descending cervical cellulitis that arises
from submandibular space infection,
parapharyngeal space, pterygomandibular
space or buccal space
136. S/S : unremitting high fever, tachycardia,
tachypnoea & hypotension
Brawny edema, induration of neck n chest and
crepitus may be palpable
Rx :early recognition , airway control, agg
surgical intervention (transthoracic or
cervicomediastinal approach), app antibiotic
therapy, supportive systemic care &
hyperbaric oxygen therapy
137. CAVERNOUS SINUS
THROMBOPHLEBITIS :
External route – danger area of face
Internal route – odontogenic infection from
post maxillary region through pterygoid
plexus
C/F : Initial – swelling of face with
involvement of eyelids
Pulsating exopthalmos
139. Rx : antibiotic therapy
Heparinization – heparin 20,000 units in
1500ml off 5% dextrose or Dicumarol
200mg
Neurosurgical consultation
Mannitol
Anticoagulants
Surgical drainage
140. Early recognition of orofacial infection and
prompt , appropriate therapy is absolutely
necessary
A thorough knowledge of anatomy of the face
and neck is necessary to predict pathways
of spread and to drain these spaces
adequately
142. REFERENCES:
Topazian , Oral & maxillofacial infections ,
Vol 4
Daniel M Laskin , text book of oral &
maxillofacial surgery vol II
Peterson ,text book of oral & maxillofacial
surgery
Neelima malik, text book of oral &
maxillofacial surgery