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MANDIBULAR SPACE INFECTIONS &
COMPLICATIONS
Submitted by
Geetha R
Final Year BDS part II
KANNUR DENTAL COLLEGE
Department ...
CONTENTS

INTRODUCTION
 Odontogenic infections are among the most frequently
encountered infections affecting humans. In majority o...
CLASSIFICATION
BASED ON MODE OF INVOLVEMENT
 Primary Maxillary Space
Canine space
Buccal space
Infratemporal space
 Prim...
MANDIBULAR SPACES
 Infection may erode from mandibular teeth into a variety
of spaces, in addition to the usual vestibula...
SUBMENTAL SPACE
 Etiology
1. Infection from anterior mandibular teeth.
2. Spread of infections from lower lip, skin aroun...
SURGICAL ANATOMY
 Boundaries
Deep or Lateral : Anterior belly of digastric
Superficial or medial : Investing layer of dee...
CLINICAL FEATURES
 Extraoral findings
Distinct, firm swelling in midline, beneath the chin. Skin
overlying the swelling i...
INCISION & DRAINAGE
 Transverse incision placed in skin below symphysis
of mandible.Blunt dissection done with kelly’s
fo...
SPREAD
 Infection can extend
a) Posteriorly, to submandibular space
b) Dicharge of contents in submental region in face
SUBLINGUAL AND SUBMANDIBULAR SPACES
 The sublingual and submandibular spaces exit on
the medial aspect of the mandible.Th...
SUBMANDIBULAR SPACE
 If the apex of the tooth is inferior to the muscle (third
molar) , the submandibular space is involv...
SURGICAL ANATOMY
 Anteromedially :mylohyoid muscle
 Posteromedially: hyoglossus muscle
 Superolaterally : medial surfac...
CLINICAL FEATURES
Extraoral
(i) Firm swelling in submandibular region, below the
inferior border of mandible.
(ii) General...
INCISION & DRAINAGE
 Incision of about 1.5 to 2 cm in length is made 2 cm
below lower border of mandible. Skin & subcutan...
SPREAD
 Involve contralateral submandibular space
 Involve submental space
 Involve sublingual space
 Involve paraphar...
SUBLINGUAL SPACE
 Submandibular and sublingual spaces surgically distinct, but
should be considered as surgical unit due ...
SURGICAL ANATOMY
 Boundaries
1. Inferiorly : Mylohyoid muscle
2. Laterally : Medial surface of mandible
3. Medially : Hyo...
CLINICAL FEATURES
 Extraoral : There is little or no swelling. The lymph
nodes may be enlarged and tender. Pain and disco...
INCISION AND DRAINAGE
 Intraorally : an incision is made close to the ligual
cortical plate lateral to the sublingual pli...
SPREAD
 Infection can spread to contralateral side
 Infection can spread to submandibular,
pterygomandibular & paraphary...
SECONDARY SPACES
 The three secondary spaces of the mandible are
posterior to the tooth-bearing portion of the
mandible i...
MASSETERIC
 The masseteric space exists between the lateral
aspect of the mandible and the masseter muscle.
 This space ...
ETIOLOGY
 Infection of third molar
 Infection from fracture of angle of mandible
SURGICAL ANATOMY
 Boundaries
Anterior : Anterior border of masseter & buccinator
Posterior : Parotid gland
Superior : Zyg...
CLINICAL FEATURES
INCISION & DRAINAGE
PTERYGOMANDIBULAR SPACE
 The pterygomandibular space lies between the
medial aspect of the mandible and the medial
pteryg...
SURGICAL ANATOMY
Boundaries
Lateral : Ramus of mandible.
Medial : Medial pterygoid muscle.
Posterior : Parotid gland
Anter...
CLINICAL FEATURES
 Severe degree of limitation of mouth opening.
 Tenderness over the area of swollen soft tissues media...
INCISION & DRAINAGE
 Intraoral : A vertical incision, approximately 1.5 cm in
length, is made on the anterior and medial ...
MASTICATOR SPACES
 Masseteric, pterygomandibular, and temporal spaces
spaces are collectively known as the masticator spa...
 .If all three of the primary mandibular spaces become involved
with the infection, the infection is known as Ludwig's an...
CERVICAL (DEEP NECK) SPACES
CERVICAL (DEEP NECK) SPACES
 Extension of odontogenic infection beyond the mandibular
spaces is an unusual event.
 When ...
LATERAL PHARYNGEAL SPACE
 The lateral pharyngeal space is classically described as
having the shape of an inverted pyrami...
LATERAL PHARYNGEAL SPACE
 Around the boundary is pterygomandibular raphe, it
communicates with the spaces of the mandible...
CLINICAL FEATURES
 Severe trismus
 Lateral swelling of the neck
 Bulging of the lateral pharyngeal wall
 Rapid progres...
INCISION & DRAINAGE
Extraoral approach
 An incision is made along the anterior border of
sternocleidomastoid muscle, exte...
INCISION & DRAINAGE
Intraoral appraoch
 A vertical incision is placed over the
pterygomandibular raphe.
 A sinus forcep ...
SPREAD
 Infection can spread upwards through foramina
such as f. ovale, f.lacerum & juglar foramen
resulting in brain abs...
RETROPHARYNGEAL SPACE
 The retropharyngeal space lies posteromedial to
the lateral pharyngeal space.
SURGICAL ANATOMY
 Anterior : Superior pharyngeal muscle and its
investing fascia
 Posterior : Alar layer of prevertebral...
CLINICAL FEATURES
 When the retropharyngeal space becomes involved
condition is always fatal.
 Clinical signs and sympto...
INCISION & DRAINAGE
 Suprahyoid portion : The space is approached through the
lateral pharyngeal space, hence the dissect...
PREVERTEBRAL SPACE
 A potential space between the two layers of prevertebral
fascia, the alar and prevertebral layers.
 ...
COMPLICATIONS
 First, the upper airway is in danger of obstruction as a
result of anterior displacement of the posterior ...
LUDWIG’S ANGINA
DEFINITION
 Ludwig's angina is a bacterial infection of the floor of the
mouth.
ALTERNATE NAMES
PATHOLOGY
MICROBIOLOGY
ETIOLOGY
 Ludwig's angina is a type of cellulitis that involves
inflammation of the tissues of the floor of the mouth,
un...
ETIOLOGY
CLINICAL FEATURES
 Swelling of the tissues occurs rapidly and may block the
airway or prevent swallowing of saliva.
Sympt...
SWELLING IN SUBMANDIBULAR AREA
EXAMINATION & INVESTIGATION
 An examination of the neck and head shows redness and
swelling of the upper neck, under the ...
MANAGEMENT
 If the swelling blocks the airway, emergency medical help is
needed to maintain an open airway. This may invo...
PROGNOSIS
 Ludwig's angina can be life threatening. However, it can
be cured with proper protection of the airways and
ap...
CAVERNOUS SINUS THROMBOSIS
 Is the formation of a blood clot within the cavernous
sinus, a cavity at the base of the brai...
 Cavernous sinus thrombosis causes decrease or loss of
vision, drooping or bulging eyes, headaches, and
paralysis of the ...
ETIOLOGY
 CST most commonly results from contiguous spread of
infection from the sinuses (sphenoid, ethmoid, or frontal)
...
 Staphylococcus aureus is the most common infectious
microbe, found in 50% to 60% of the cases.
 Streptococcus is the se...
CLINICAL FEATURES
 The clinical presentation of CST can be varied.
 Both acute, fulminant disease and indolent, subacute...
 Other common signs and symptoms include:
 Ptosis, Chemosis, Cranial nerve palsies (III, IV, V, VI).
Sixth nerve palsy i...
 Fever, tachycardia, sepsis may be present.
Headache with nuchal rigidity may occur.
 Pupil may be dilated and sluggishl...
DIAGNOSIS
 The diagnosis of cavernous sinus thrombosis is made
clinically, with imaging studies to confirm the clinical
i...
DIFFERENTIAL DIAGNOSIS
 Orbital cellulitis
 Internal carotid artery aneurysm
 CVA
 Migraine headache
 Allergic blepha...
CONCLUSION
 Most odontogenic infections are caused by anaerobes
 Identify possible complications of odontogenic
infectio...
 Textbook of oral surgery by Neelima Malik.
 Textbook of oral surgery by Peterson ,2 nd edition.
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  1. 1. MANDIBULAR SPACE INFECTIONS & COMPLICATIONS Submitted by Geetha R Final Year BDS part II KANNUR DENTAL COLLEGE Department of Oral & Maxillofacial Surgery
  2. 2. CONTENTS 
  3. 3. INTRODUCTION  Odontogenic infections are among the most frequently encountered infections affecting humans. In majority of cases, these infections are minor and resolve either by spontaneous drainage through the gingival tissues of the tooth or by extraction of the offending tooth.  Chronic sinus tracts from the apex of the tooth to the surface mucosa or skin are not uncommon in populations who receive little or no dental care.  A great deal of pain and suffering accompany establishment of these draining sinus tracts. Removal of the offending tooth almost always results in rapid resolution of the infection, even with antibiotic therapy. Unfortunately, these minor tooth- related infections occasionally become serious and life- threatening. Aggressive surgical and medical care is necessary to prevent disastrous results.
  4. 4. CLASSIFICATION BASED ON MODE OF INVOLVEMENT  Primary Maxillary Space Canine space Buccal space Infratemporal space  Primary Mandibular Space Buccal space Submental space Submandibular space Sublingual space  Secondary Facial Space Massetric space Pterygomandibular space Superficial & deep temporal space Lateral pharyngeal space Retropharyngeal space Prevertbral space Parotid space Direct involvement Indirect involvement
  5. 5. MANDIBULAR SPACES  Infection may erode from mandibular teeth into a variety of spaces, in addition to the usual vestibular abscess.  The three primary spaces are the submental, sublingual,and submandibular spaces; the three secondary spaces are the pterygomandibular, masseteric, and temporal spaces.  The primary spaces are those into which infection spreads directly from the teeth and bone.
  6. 6. SUBMENTAL SPACE  Etiology 1. Infection from anterior mandibular teeth. 2. Spread of infections from lower lip, skin around cheek, floor of mouth , tip of tongue & sublingual tissues
  7. 7. SURGICAL ANATOMY  Boundaries Deep or Lateral : Anterior belly of digastric Superficial or medial : Investing layer of deep cervical fascia Superior : Mylohyoid muscle Inferior : Investing layer of deep cervical fascia Anterior : Inferior border of mandible Posterior : Hyoid bone  Contents Submental lymph nodes & anterior juglar vein
  8. 8. CLINICAL FEATURES  Extraoral findings Distinct, firm swelling in midline, beneath the chin. Skin overlying the swelling is board like and taut. Fluctuation may be present.  Intraoral findings The anterior teeth, are either non-vital, fractured or carious. The offending tooth may exhibit tenderness to percussion and may show mobility. The patient may experience considerable discomfort on swallowing.
  9. 9. INCISION & DRAINAGE  Transverse incision placed in skin below symphysis of mandible.Blunt dissection done with kelly’s forceps or sinus forceps
  10. 10. SPREAD  Infection can extend a) Posteriorly, to submandibular space b) Dicharge of contents in submental region in face
  11. 11. SUBLINGUAL AND SUBMANDIBULAR SPACES  The sublingual and submandibular spaces exit on the medial aspect of the mandible.They are usually involved by lingual perforation of infection from the mandibular molars. The factor determining whether the infection is in the sublingual or submandibular space is the relationship between the area of the infection's perforation and the location of the mylohyoid muscle's attachment .
  12. 12. SUBMANDIBULAR SPACE  If the apex of the tooth is inferior to the muscle (third molar) , the submandibular space is involved.  Etiology 1.Infection of mandibular molars 2.Infection from submandibular salivary gland 3.Infection from submental space 4.Infection from sublingual space 5.Infection from tongue , floor of mouth & cheek.
  13. 13. SURGICAL ANATOMY  Anteromedially :mylohyoid muscle  Posteromedially: hyoglossus muscle  Superolaterally : medial surface of mandible  Anteroinferiorly : anterior belly of digastric  Posteroinferiorly : posterior belly of digastric, stylohyoid & stylopharyngeus muscle  Superficial: platysma & skin  Deep : Mylohyoid ,hyoglossus & superior constrictor  Contents : superficial lobe of submandibular salivary gland & lymph nodes , facial artery & vein
  14. 14. CLINICAL FEATURES Extraoral (i) Firm swelling in submandibular region, below the inferior border of mandible. (ii) Generalized constitutional symptoms (iii) Some degree of tenderness (iv) Redness of overlying skin. Intraoral (i) Teeth are sensitive to percussion (ii) Mobile (iii) Dysphagia (vi) Trismus.
  15. 15. INCISION & DRAINAGE  Incision of about 1.5 to 2 cm in length is made 2 cm below lower border of mandible. Skin & subcutaneous tissue are incised .A sinus forceps is inserted through incision superiorly & posteriorly on lingual side to mandible to drain pus. Rubber drain is placed & secured with sutures.
  16. 16. SPREAD  Involve contralateral submandibular space  Involve submental space  Involve sublingual space  Involve parapharyngeal space
  17. 17. SUBLINGUAL SPACE  Submandibular and sublingual spaces surgically distinct, but should be considered as surgical unit due to proximity and frequent dual involvement in odontogenic infections.  Etiology 1. Infected premolar and 1st molar teeth frequently drain into this space due to their root apices existing superior to the mylohyoid muscle
  18. 18. SURGICAL ANATOMY  Boundaries 1. Inferiorly : Mylohyoid muscle 2. Laterally : Medial surface of mandible 3. Medially : Hyolglossus, genioglossus & geniohyoid 4. Posteriorly : Submandibular space 5. Laterally & inferiorly : Mylohyoid muscle & lingual side of mandible  Contents Geniohyoid & genioglossus muscle , hyoglossus muscle ,submandibular & sublingual salivary gland, lingual & hypoglossal nerve.
  19. 19. CLINICAL FEATURES  Extraoral : There is little or no swelling. The lymph nodes may be enlarged and tender. Pain and discomfort on deglutition. Speech may be affected.  Intraoral : Firm, painful swelling seen in the floor of the mouth on the affected side. The floor of the mouth is raised. The tongue may be pushed superiorly.
  20. 20. INCISION AND DRAINAGE  Intraorally : an incision is made close to the ligual cortical plate lateral to the sublingual plica, as the important structure at this site is the sublingual nerve.  Extraorally : When both the submental and sublingual spaces contain pus, they can be drained via a skin incision placed in the submental region, pushing a closed sinus forceps through the mylohyoid muscle.
  21. 21. SPREAD  Infection can spread to contralateral side  Infection can spread to submandibular, pterygomandibular & parapharyngeal space  Infection can spread to submental or submandibular lymph nodes  Infection spread through aperatures of perforating arteries into submental space
  22. 22. SECONDARY SPACES  The three secondary spaces of the mandible are posterior to the tooth-bearing portion of the mandible in the angle-ramus area. They are called secondary spaces because they become infected by secondary spread of infection from other anterior spaces. The primary spaces feeding them are the buccal, sublingual, and submandibular spaces.
  23. 23. MASSETERIC  The masseteric space exists between the lateral aspect of the mandible and the masseter muscle.  This space is involved most often by spread from the buccal space or from soft tissue infection around the third molar. When it is involved, the posteroinferior portion of the face swells.  In addition to the swelling, the patient has mild to moderate trismus caused by inflammation of the masseter muscle.
  24. 24. ETIOLOGY  Infection of third molar  Infection from fracture of angle of mandible
  25. 25. SURGICAL ANATOMY  Boundaries Anterior : Anterior border of masseter & buccinator Posterior : Parotid gland Superior : Zygomatic arch Inferior : Inferior border of mandible Medial : Lateral surface of ramus Lateral : Medial surface of masseter  Contents Massetric nerve , superficial temporal artery & transverse facial artery
  26. 26. CLINICAL FEATURES
  27. 27. INCISION & DRAINAGE
  28. 28. PTERYGOMANDIBULAR SPACE  The pterygomandibular space lies between the medial aspect of the mandible and the medial pterygoid muscle. Etiology 1.This space becomes involved from spread from the sublingual and submandibular spaces and from soft tissue infection around the third molar(pericoronitis) 2.Use of contaminated needle for inferior alveolar nerve block 3.Infection can arise from maxillary third molar from posterior superior alveolar nerve block injection
  29. 29. SURGICAL ANATOMY Boundaries Lateral : Ramus of mandible. Medial : Medial pterygoid muscle. Posterior : Parotid gland Anterior : Pterygomandibular raphae. Contents : Lingual nerve, Mandibular nerve, Inferior alveolar, Mandibular artery. Mylohyoid nerve and vessels. Loose areolar connective tissue.
  30. 30. CLINICAL FEATURES  Severe degree of limitation of mouth opening.  Tenderness over the area of swollen soft tissues medial to anterior border of ramus.  Dysphagia is present.  Medial displacemnet of lateral wall of the pharynx.  Redness and edema of the area around the third molar.  Midline of the palate is displaced to the unaffected side.  Uvula is swollen.  Difficulty in breathing.
  31. 31. INCISION & DRAINAGE  Intraoral : A vertical incision, approximately 1.5 cm in length, is made on the anterior and medial aspect of the ramus of mandible. A sinus forceps in inserted in the abscess cavity, opened and closed & withdrawn. The pus is evacuated, a rubber drain is introduced and is secured in position with a suture.  Extraoral : An incision is taken in the skin below the angle of the mandible. A sinus forceps is inserted towards the medial side of the ramus in an upward and backward direction. Pus is evacuated and the drain inserted from an intraoral approach and sutured in position.
  32. 32. MASTICATOR SPACES  Masseteric, pterygomandibular, and temporal spaces spaces are collectively known as the masticator space, since they are bounded by the muscles of mastication: masseter, medial pterygoid, and temporalis.  The three individual spaces communicate freely with one another and are simultaneously involved
  33. 33.  .If all three of the primary mandibular spaces become involved with the infection, the infection is known as Ludwig's angina. Ludwig's angina, described in 1936, was a relatively common occurrence until the antibiotic era. It is a rapid, bilaterally spreading, gangrenous cellulitis of the submandibular, sublingual, and submental spaces. It usually spreads posteriorly to the secondary spaces as well. It produces gross swelling, elevation and displacement of the tongue, and tense, brawny induration of the submandibular region superior to the hyoid bone. There is usually little or no fluctuance (Finch et al, 1980; Patterson et al, 1982). The patient experiences severe trismus, drooling of saliva, tachypnea, and dyspnea. Impending compromise of the airway produces marked anxiety. The cellulitis can progress with alarming speed, producing an upper airway obstruction that may lead to death. The usual cause of Ludwig's angina is an odontogenic infection, usually from the mandibular second or third molar. The microbes involved are usually Streptococcus, oral anaerobes, or both.
  34. 34. CERVICAL (DEEP NECK) SPACES
  35. 35. CERVICAL (DEEP NECK) SPACES  Extension of odontogenic infection beyond the mandibular spaces is an unusual event.  When it does occur, spread to the cervical or deep neck spaces from the submandibular, sublingual, or pterygomandibular spaces may have serious, life-threatening sequelae. These sequelae may result of complications, such as upper airway obstruction or mediastinitis.  Odontogenic infections cause as much as 30% of all deep neck infections (Virolainen et al, 1979).  The deep neck spaces have a variety of names and descriptions.Three are relatively consistent through the literature: the lateral pharyngeal space, the retropharyngeal space, and the prevertebral space, or danger space No, 4.  The layers of deep cervical fascia form and bind these three spaces.
  36. 36. LATERAL PHARYNGEAL SPACE  The lateral pharyngeal space is classically described as having the shape of an inverted pyramid or funnel. Etiology  Infection from third molars  Tonsillar infection in neighbouring spaces Surgical Anatomy  Superior : Skull base at the sphenoid bone  Inferior : Hyoid bone.  Lateral : Medial pterygoid muscle  Medial : Superior & middle pharyngeal constrictor muscle  Anterior : Pterygomandibular raphe  Posterior : Carotid sheath & scalena fascia  Contents : Carotid artery , Internal juglar vein, Vagus nerve, Cervical sympathetic chain
  37. 37. LATERAL PHARYNGEAL SPACE  Around the boundary is pterygomandibular raphe, it communicates with the spaces of the mandible.  Posteromedially it extends to and is bounded by the prevertebral fascia and communicates freely with the retropharyngeal space.  The styloid process and associated muscles and fascia divide the lateral pharyngeal space into an anterior compartment, which contains muscles, and a posterior compartment, which contains the carotid sheath and cranial nerves
  38. 38. CLINICAL FEATURES  Severe trismus  Lateral swelling of the neck  Bulging of the lateral pharyngeal wall  Rapid progression of infection in this space is common  Posterior compartment involvement can result in thrombosis of the internal jugular vein, erosion of the carotid artery or its branches, and interference with cranial nerves IX to XII
  39. 39. INCISION & DRAINAGE Extraoral approach  An incision is made along the anterior border of sternocleidomastoid muscle, extending from below the angle of the mandible, to the middle third of submandibular gland.  The fascia behind the gland is incised and a curved hemostat is inserted and carefully directed medially behind the mandible, as well as superiorly and slightly posteriorly until the abscess cavity is reached.  A rubber drain is inserted and secured to skin with suture
  40. 40. INCISION & DRAINAGE Intraoral appraoch  A vertical incision is placed over the pterygomandibular raphe.  A sinus forcep or curved hemostat is passed through the pterygomandibular raphae along the medial surface of the mandible, medial to the medial pterygoid and just lateral to the superior constrictor is then divided posteriorly
  41. 41. SPREAD  Infection can spread upwards through foramina such as f. ovale, f.lacerum & juglar foramen resulting in brain abscess, meningitis or sinus thrombosis  Infection can spread downward into carotid sheath towards mediastinum ; a pathway Mosher called the “Lincoln’s highway” of neck
  42. 42. RETROPHARYNGEAL SPACE  The retropharyngeal space lies posteromedial to the lateral pharyngeal space.
  43. 43. SURGICAL ANATOMY  Anterior : Superior pharyngeal muscle and its investing fascia  Posterior : Alar layer of prevertebral fascia  Superior : Skull base at pharyngeal tubercle  Inferior : Fusion of alar & prevertebral fascia at C6 to T1.This level is at the posterosuperior mediastinum.  Lateral : Carotid sheath & Lateral pharyngeal space
  44. 44. CLINICAL FEATURES  When the retropharyngeal space becomes involved condition is always fatal.  Clinical signs and symptoms are those of a severe infection.  Trismus is severe in essentially all patients at this stage.  Evaluation of the retropharyngeal space is performed with the greatest sucess by a lateral radiograph of the neck  Involvement of the retropharyngeal space may also include the prevertebral space
  45. 45. INCISION & DRAINAGE  Suprahyoid portion : The space is approached through the lateral pharyngeal space, hence the dissection is the same, until the lateral pharyngeal space is further explored by blunt finger dissection. the dissection is continued until the surgeon is able to palpate the contralateral transverse processes of the vertebrae, the endotracheal tube from its posterior aspect, and if necessary the opposite carotid artery.  Infrahyoid portion : If the space is involved below the hyoid bone, then the posterior end of the low submandibular incision described above is extended inferiorly along the anterior border of sternocleidomastoid muscle. As the dissection passes deep to anterior layer of deep cervical fascia, the sternocleidomastoid muscle is retracted posterolaterally to expose the carotid sheath.
  46. 46. PREVERTEBRAL SPACE  A potential space between the two layers of prevertebral fascia, the alar and prevertebral layers.  It extends from the skull base inferiorly to the diaphragm.  The space is also known as the danger space No. 4 (Grodinsky and Holyoke, 1938).  Mediastinitis is concern with prevertebral space infections similarly to retropharyngeal space infections
  47. 47. COMPLICATIONS  First, the upper airway is in danger of obstruction as a result of anterior displacement of the posterior pharyngeal wall into the oropharynx. Narrowing of the upper airway as the retropharyngeal space swells.  Second, when the retropharyngeal spaces are filled with pus, a danger exists of spontaneous rupture of the abscess, resulting in aspiration, pneumonia, and asphyxiation. Rupture may also be caused by attempts at insertion of an endotracheal tube to secure the airway.  Third, once the infection has gained access to the retropharyngeal spaces, the posterosuperior mediastinum or the entire posterior mediastinum may become infected also.
  48. 48. LUDWIG’S ANGINA
  49. 49. DEFINITION  Ludwig's angina is a bacterial infection of the floor of the mouth.
  50. 50. ALTERNATE NAMES
  51. 51. PATHOLOGY
  52. 52. MICROBIOLOGY
  53. 53. ETIOLOGY  Ludwig's angina is a type of cellulitis that involves inflammation of the tissues of the floor of the mouth, under the tongue. It often occurs after an infection of the roots of the teeth (such as tooth abscess) or a mouth injury.  This condition is uncommon in children.
  54. 54. ETIOLOGY
  55. 55. CLINICAL FEATURES  Swelling of the tissues occurs rapidly and may block the airway or prevent swallowing of saliva. Symptoms include:  Breathing difficulty  Confusion or other mental changes  Fever  Neck pain  Neck swelling  Redness of the neck  Weakness, fatigue, excessive tiredness  Additional symptoms that may be associated with this disease:  Drooling  Earache
  56. 56. SWELLING IN SUBMANDIBULAR AREA
  57. 57. EXAMINATION & INVESTIGATION  An examination of the neck and head shows redness and swelling of the upper neck, under the chin. The swelling may reach to the floor of the mouth. The tongue may be swollen or out of place.  A CT scan of the neck may be recommended.  Culture of fluid from the tissues may show bacteria
  58. 58. MANAGEMENT  If the swelling blocks the airway, emergency medical help is needed to maintain an open airway. This may involve placing a breathing tube through the mouth or nose and into the lungs, or surgery called a tracheostomy that creates an opening through the neck into the windpipe.  Antibiotics, usually penicillin or a penicillin-like medication, are given to fight the infection. They are usually given through a vein until symptoms go away. Antibiotics taken by mouth may be continued until tests show that the bacteria have gone away.  Dental treatment may be needed for tooth infections that cause Ludwig's angina.  Surgery may be needed to drain fluids that are causing the swelling.
  59. 59. PROGNOSIS  Ludwig's angina can be life threatening. However, it can be cured with proper protection of the airways and appropriate antibiotics
  60. 60. CAVERNOUS SINUS THROMBOSIS  Is the formation of a blood clot within the cavernous sinus, a cavity at the base of the brain which drains deoxygenated blood from the brain back to the heart.  The cause is usually from a spreading infection in the sinuses, ears, or teeth.  Staphylococcus aureus and Streptococcus are often the associated bacteria.
  61. 61.  Cavernous sinus thrombosis causes decrease or loss of vision, drooping or bulging eyes, headaches, and paralysis of the cranial nerves which course through the cavernous sinus.  This infection is life-threatening and requires immediate treatment, which usually includes antibiotics and sometimes surgical drainage
  62. 62. ETIOLOGY  CST most commonly results from contiguous spread of infection from the sinuses (sphenoid, ethmoid, or frontal) or middle third of the face.  Less common primary sites of infection include dental abscess, nares, tonsils, soft palate, middle ear, or orbit (orbital cellulitis).  The highly anastomotic and valveless venous system of the paranasal sinuses allows retrograde spread of infection to the cavernous sinus via the superior and inferior ophthalmic veins.
  63. 63.  Staphylococcus aureus is the most common infectious microbe, found in 50% to 60% of the cases.  Streptococcus is the second leading cause.  Gram-negative rods and anaerobes may also lead to cavernous sinus thrombosis.  Rarely, Aspergillus fumigatus and mucormycosis cause CST.
  64. 64. CLINICAL FEATURES  The clinical presentation of CST can be varied.  Both acute, fulminant disease and indolent, subacute presentations have been reported in the literature.  The most common signs of CST are related to anatomical structures affected within the cavernous sinus, notably cranial nerves III-VI, as well as symptoms resulting from impaired venous drainage from the orbit and eye.  Classic presentations are abrupt onset of unilateral periorbital edema, headache, photophobia, and bulging of the eye (proptosis).
  65. 65.  Other common signs and symptoms include:  Ptosis, Chemosis, Cranial nerve palsies (III, IV, V, VI). Sixth nerve palsy is the most common. Sensory deficits of the ophthalmic and maxillary branch of the fifth nerve are common.  Periorbital sensory loss and impaired corneal reflex may be noted. Papilledema, retinal hemorrhages, and decreased visual acuity and blindness may occur from venous congestion within the retina.
  66. 66.  Fever, tachycardia, sepsis may be present. Headache with nuchal rigidity may occur.  Pupil may be dilated and sluggishly reactive.  Infection can spread to contralateral cavernous sinus within 24–48 hr of initial presentation
  67. 67. DIAGNOSIS  The diagnosis of cavernous sinus thrombosis is made clinically, with imaging studies to confirm the clinical impression. Proptosis, ptosis, chemosis, and cranial nerve palsy beginning in one eye and progressing to the other eye establish the diagnosis.
  68. 68. DIFFERENTIAL DIAGNOSIS  Orbital cellulitis  Internal carotid artery aneurysm  CVA  Migraine headache  Allergic blepharitis  Thyroid exophthalmos  Brain tumor  Meningits  Mucormycosis  Trauma
  69. 69. CONCLUSION  Most odontogenic infections are caused by anaerobes  Identify possible complications of odontogenic infections  Antibiotics may not sufficient and incision and drainage of these abscesses may be necessary for resolution  Extracting the causative tooth facilitates the resolution of the infection
  70. 70.  Textbook of oral surgery by Neelima Malik.  Textbook of oral surgery by Peterson ,2 nd edition.

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