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Spaces of head and neck and infections /certified fixed orthodontic courses by Indian dental academy
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Spaces of head and neck and infections /certified fixed orthodontic courses by Indian dental academy
HEAD AND NECK
INDIAN DENTAL ACADEMY
Leader in continuing dental education
PATHWAYS OF SPREAD
The infection in orofacial region does not
spread haphazardly through the loose
connective tissue, but tends to accumulate in
these potential spaces around the head and
neck. Many of these spaces communicate
with each other.
Fascia:- It is defined as a broad sheet of
dense connective tissue whose function is to
separate structure that must pass over each
other during movement such as muscles &
glands and serve as a pathway for the course
of vascular &neural structure
Definition:- Shapiro defined facial spaces as
“potential spaces between the layers of the
fascia”. These area are normally filled with
loose connective tissue which readily breaks
down when invaded by infection.
Fascia is described under:1) Superficial fascia
-Similar to subcutaneous
and muscles of facial
Deep fascia:- In the neck the deep fascia upon
dissection forms several more or less distinct layers.
They are:a) Superficial or anterior or investing layer.
b) Middle or pretracheal layer.
c) Posterior or prevertebral layer.
d) Carotid sheath.
Midline layer:- it is the part of the anterior layer of
deep fascia that passes behind the strap muscles.
It is divided into 3 divisions:
1)sternohyoid – omohyoid
2)sternothyroid – thyrohyoid
3)visceral and buccopharyngeal
The 1st two divisions surround the corresponding strap
muscles of the neck between hyoid bone and
The primary surgical significance of these layers is
they must be divided in the midline in a surgical
approach to trachea or thyroid gland.
These are not usually involved in oro-facial
Third division has clinical significance because
- below the hyoid bone the visceral layer
surrounds the trachea oesophagus and thyroid
- above the hyoid bone the visceral fascia wraps
around the lateral and posterior side of the pharynx,
lying on the superficial side of pharyngeal constrictor
muscle – known as buccopharyngeal fascia.
The deep neck spaces –
3)pre tracheal spaces all lie on the
superficial side of visceral division of the
middle layer of the deep cervical fascia.
Posterior layer:- the posterior layer of the deep
cervical fascia has two divisions
1) the alar
2) the prevertebral
The alar fascia passes through the transverse process
of the vertebrae on either side, posterior to the
In the vertical dimension the posterior layer extends
from the base of the skull to diaphragm.
The alar fascia fuses with retropharyngeal fascia at a
variable level between 6th cervical and 4th vertebrae.
This fusion forms the bottom of the retropharyngeal space.
Infection of the retro-pharyngeal space may
rupture the alar fascia, thus entering the
danger space , which is continuous with the
The prevertebral fascia surround the vertebra
and the attached postural muscles of the
neck & back
Prevertebral fascia is usually not invaded by
infection arising in maxillofacial regions.
Carotid sheath:- Carotid sheath surrounding
IJV, CCA & vagus nerve is interposed
between the superficial and pretracheal layer
on the one hand and prevertebral layer on
Its anterolateral wall is infact the superior layer
of fascia deep to sternocleidomastoid muscle
and to a lesser extent, the pretracheal layer
where the infrahyoid muscle overlap the great
The posterior wall is formed by a lamina
given off medially by the superficial layer as
the lather reaches the level of the vessels:
this lamina passes behind the vessels and
nerve to form the posterior wall of the sheath
and the medial wall of the sheath is then
completed by fascia passing from
anterolateral to the posterior wall between the
contents of the sheath and the trachea and
The sheath is attached medially to the
prevertebral layer of fascia. The sympathetic
trunk lies behind it.
Spaces of the head and neck:Grodinsky and Holyoke in 1938, described these
potential spaces as follows:
1)Spaces 1- the potential space superficial and deep
to platysma muscle.
2)Spaces 2- the spaces behind the anterior layer of
deep cervical fascia.
3)Spaces 3- pretracheal spaces lies anterior to
4)Spaces 3a- “lincoln’s highway”
5)Spaces 4- danger spaces is a potential spaces
between the alar &prevertebral fascia.
Classification of fascial spaces:1. based on clinical significance:
a) Face – buccal, canine, maticatiory,
b) Suprahyoid – sublingual, submandibular,
lateral pharyngeal, pretonsillar.
c) Infrahyoid – pretracheal.
d) Spaces of total neck – retropharyngeal,
space of carotid sheath.
2. Based on mode of involvement
a) direct involvement
primary spaces (i) maxillary spaces.
(ii) mandibular spaces.
b) indirect involvement: secondary spaces.
MICROBIOLOGY OF ODONTOGENIC INFECTIONS:Usually the bacteria which causes infections are a
part of the indigenous flora and odontogenic infections
are no exception to this. 60% of all odontogenic
infections are caused by aerobic and anaerobic bacteria.
Only anaerobic make up about 35% and pure
aerobes, 5% only.
The commonly isolated organisms are
Pathways of odontogenic infection:Invasion of dental pulp by bacteria
Inflammation, edema, lack of collateral supply
Reservoir of bacterial growth
Spreading to the surrounding bone
Bacteremia – septicemia
Intra oral soft tissue
Deep facial space
Difference between cellulitis and abscess
The spread can vary based on:
1) number and virulence of organism
2) host resistence
3) Anatomy of the involved area
The microbial factors include VIRULENCE and QUALITY.
Virulence refers to the inherent ability of a microbe to cause
infection. It is the sum total of all microbial quality which are
harmful to the host. To cause an infection the micro-organism
should be able to:
a) enter the host
b) multiply with in the host
c) at least temporarily, resist or not stimulate host
d) cause damage to the host
QUALITY refers to the number of micro organisms that initially
colonize the host.
The host factor defences consists of
a) Local defences
b) Humoral component
c) Cellular component
LOCAL DEFENCES consists of:a) Epithelial lining
b) Secretions and drainage systems
c) Mucosal immune system
d) Microbial flora interference
HUMORAL COMPONENT consists of:a) Immuno globulins
b) complement system
CELLULAR COMPONENT consists of Polymorphs & Lymphocytes.
- LateraL OBLIQUE VIEW
other Diagnostic Aids:
C.T. – Gold Standard in head and neck
1. Showing complete extent of inflammatory process.
2. Difference between myositis – facitis and abscess formation.
3. Demonstrates status of airway and involvement of lymph nodes
4. Abscess drainage and drain placement can be done by C.T.
fine needle aspiration
superiorly – quadratus labii superiories
inferiorly – orbicularies ori
deep – anterior surface of maxilla
medially – levator labii alaeque nasii
laterally – zygomaticus major
- angular artery & vein
- infra orbital nerve
INFRA ORBITAL OR CANINE
Source of infection:
- maxillary canine
- first premolar
c/f:- - swelling of cheek and upper lip
- obliteration of nasolabial fold
- odema of lower eye lid
Treatment of canine space abscess:Incise high in the maxillary labial vestibule.
Hemostat advanced through levator anguli oris
Differential diagnosis of upper face infections
of nasolabial fold.
The nasolabial fold is
Source of infection:-
c/f:- obvious and dome shaped over the cheek
from the zygomatic arch to the lower border
of the mandible.
Spread:- pterygomandibular space
Clinical evaluation: Examination of the patient with the buccal space infection
demonstrate swelling confined to the cheek with abscess forming beneath the
buccal mucosa and bulging into the mouth.
Treatment of buccal space abscess:Intra oral: horizontal incision just above the
depth of vestibule. Hemostat advanced
through the buccinator.
Extra oral: when fluctuance occurs ,it should
be drained percutaneously. Cutaneous
drainage should be performed inferior to point
Infratemporal space or retro zygomatic space
Boundaries:Anteriorly – infratemporal surface of maxilla
posteriorly – mandibular condyle
superiorly – infra temporal crest of sphenoid
inferiorly – lateral pterygoid
medially – temporal tendon, coronoid process
laterally – lateral pterygoid plate
Contents:- pterygoid plexus
internal maxillary artery & vein
Source of infection:max. molars
through infected needle
c/f:- swelling over the TMJ in front of the ear.
intraoral swelling over the tuberosity area.
Spread:- extended upwards to involve temporal space.
inferiorly – pterygomandibular space.
upwards into cavernous sinus.
Treatment of infratemporal space abscess:Intra oral: Vertical incision is made just
lateral to the 3rd molar and medial to upper
extent of ramus.
Extra oral: horizontal incision parallel to the
junction of frontal & temporal processes of
zygoma (JUGAL POINT).
Sub masseteric space:Boundaries:
Anteriorly – anterior border of masseter muscle and
Posteriorly – parotid gland, posterior part of masseter
Inferiorly – lower border of mandible
Medially – lateral surface of ramus of mandible
Laterally – medial surface of the masseter muscle
Contents:- masseteric nerve
superficial temporal artery
transverse facial artery
c/f:- extra oral swelling confined to the
boundaries of masseteric muscle.
limitation of mouth opening
fluctuation is absent
pyrexia & malaise
Treatment of submasseteric space abscess:Intra oral: vertical incision along the external
Extra oral: incision made below and parallel
to angle of mandible.
Midline of the palate is displaced to uneffected side,
uvula is swollen.
Medial displacement of lateral wall of pharynx.
Spread: Infra temporal fossa
Lateral & pterygoid space
Treatment of pterygomandibular space abscess:
Intra oral: Incision along or medial to
Extra oral: Incision is made 1 inch below and
parallel to angle of mandible.
Temporal space:It is secondary to the initial involvement of
pterygopalatine & infra temporal space.
Temporal pouches are facial spaces in relation to
the temporalis muscle.
They are two :(i) Superficial temporal space
(ii) Deep temporal space
Contents:Superficial - Superficial temporal
Auriculo temporal nerve
Deep – deep temporal arteries & veins.
Swelling with in the outline of temporalis
Treatment of temporalis space abscess:Intra oral: Vertical incision is made just lateral to the 3 rd
molar and medial to upper extent of ramus.
Extra oral: horizontal incision parallel to the junction of
frontal & temporal processes of zygoma (JUGAL POINT).
Superficial layer of deep
Dense septa from
capsule into gland
Direct communication to
External carotid artery
Posterior facial vein
Treatment of parotid space abscess:A retromandibular incision through the skin and super
fascia extending from inferior aspect of ear lobule to
angle of mandible.
Curved incision at the angle of the mandible.
Sub mandibular space:Boundaries:
Contents:- Superficial lobe of submandibular salivary
c/f:- moderate trismus
mobility of teeth
sensitivity to percussion
submandibular space on contralateral side
Treatment of submandibular space abscess:Two stab incision at the anterior and
posterior limit of the most dependent,
fluctuant portion of the swelling, placed in the
shadow of the mandible.
lateral: lower border of mandible and anterior belly of digastric
Superiorly: mylohyoid muscle
Inferiorly: deep fascia, platysma and skin
Contents: Submental lymphnodes – anterior jugular vein
c/f:- distinct ,firm swelling in midline, beneath the chin, skin
fluctuation may be present
Treatment of submental space abscess:Two horizontal incisions placed at the most dependant fluctuant
portion of the swelling followed by placement through & through
Sublingual:It is a v- shaped trough lying to muscle of tongue.
Treatment of sublingual space abscess:Incision is placed intraorally at the base of the alveolar
process in the lingual sulcus. It pus is not obtained the
periosteum opp to the offending tooth must be incised
Sublingual abscess when accompanied by submandibular
abscess may be drained through a submandibular incision
with hemostat passing through mylohyoid muscle
superiorly: base of the skull
inferiorly: extends to the level of t7/t8
anteriorly: alar fascia
posteriorly: prevertebral fascia
laterally: carotid sheath
Infections from this space have an unimpeded
progress toward the mediastinum.
Lateral pharyngeal space:Boundaries:
Contents: The styloid process divides this space into two
compartment which are not completely seperated
with several deep
Treatment of lateral pharyngeal space:
Incision into the most prominent part of the soft plate
where fluctuation is maxilla.
Another incision is similar to one used for
pterygomandibular space but after the incision, hemostat
is advanced posteriorly and medial to the medial
Incision is placed 1cm below and behind the angle of
Incision is made another 1cm inferiorly to angle of
preparations for tracheostamy must be at hand because
edema of larynx may arise with suddeness
Spaces of the body of the mandible:
This space is formed by the investing
fascia as it splits at its attachment to the base
of the mandible to become continuous with
the periosteum bordering the buccal lingual
aspects of the body of the mandible. This
space is continuous posteriorly with the
Contents: body of the mandible.
inferior alveolar nerve, artery & vein
dento periodontal apparatus
Management of facial space infections:“THE MORE SEVERE THE INFECTION, THE
MORE AGGRESSIVE SHOULD BE THE
1) Administration of appropriate antibiotics in
appropriate doses through the appropriate route.
2) Surgical removal of source of infection as early
3) Surgical incision and drainage.
4) Constant evaluation and supportive therapy till
PRINCIPLES OF INCISION AND DRAINAGE:1) Incisions are sited according to the location of pus.
2) Incision must be made over the most dependent of a
fluctuant area or over the most direct route to the pus.
3) Resist the temptation to incise over the thinnest point
of an abscess. This area would be ischaemic and
incision can lead to necrosis and unsightly scaring.
4) Incision must be large enough to permit egress of pus
and adequate drainage. The esthetic problem associated
with large incision in cervico facial areas may be
overcome by two stab incisions with a through and
through drainage between them.
5) The location of incision on the skin is also guided by
the direction of the langer’s lines and placement in
esthetically acceptable area such as with the shadow of
Who gets complications?
Most common systemic
Mbio – Klebsiella pneum. (56%)
33% with complications
Higher mortality rate
Prolonged hospital stay
20 days vs. 10 days
Ludwig’s angina may be described as an overwhelming
generalized septic cellulitis of submandibular region with
bilateral involvement of the submental, sublingual and
The three “F”s evident are feared, rarely fluctuant and often
Source of infection:
Dental infection has been reported as the causative
factor in 90% of cases.
Submandibular gland siladinitis, compound fracture of
mandible, puncture wound of oral floor, oral soft tissue
It is usually an extension of infection caused by streptococci,
staphylococci, gram –ve enteric organisms and anaerobic
including bactoroides and streptococci.
Tissues are braway, indurated, flat-board like, non pitting
and non fluctuant.
Pt. has typical open mouthed appearance with protrusion of
tongue and elevation of floor of the mouth.
Tissue may become gangrenous and when cut may a
peculiar lifeless appearance.
Dysphagia, dyspnea may develop.
chills, fever, drooling at saliva may be present.
Sharp limitation between involved and uninvolved tissue.
Immediate danger is edema of glottis with
Incision for surgical drainage of Ludwig’s Angina
most common neurological complication.
Stiffness of neck
Treatment:- combination of chloramphenicol and
Maintainence of hydration and electrolyte balance.
Conclusion:Early recognition of orofacial infections and
prompt appropriate therapy is absolutely
essential. A through knowledge of anatomy of
face and neck is necessary to predict pathways
of spread of infection and drain the spaces
adequately. Otherwise the infection spread to
such an extent causing considerable morbidity
and occasional death.
Leader in continuing dental education