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Space Infection 
Dr. Amit T. Suryawanshi 
Oral and Maxillofacial Surgeon 
Pune, India 
Contact details : 
Email ID - amits...
Contents 
• Introduction 
• History 
• Anatomy of fascia 
• Host defense and infection 
• Microbiology and antibiotic ther...
Introduction 
Space infections of head and neck are very common 
in Oral and maxillofacial practice. Although most of 
the...
They flow following the path of least resistance , 
into loose areolar connective tissue of fascia 
surrounding the muscle...
Early extraction of offending tooth and incision 
and drainage tend to shorten the usual course of 
infection and minimize...
For accomplishment of proper management, 
maxillofacial surgeon must understand 
physiologic and anatomic factors that inf...
History 
Burns (1811) first described fascial space as an 
anatomical entity and gave their clinical significance. 
In 183...
The term “ Quinsy “ was given by Muckleston in 
1928. 
In 1929 Mosher called Viscerovascular space as 
“Lincoln highway” 
...
Anatomy of fascia
Functions of the fascia 
• Acts as a musculovenous pump- 
• Limits outward expansion of muscles as they 
contract. 
• Cont...
Infections and Host defense 
• In establishing presence of an infection, interaction 
occurs among three factors. 
1. Host...
Host vs Microbe relationship 
Infection occurs when 
host is immunocompromised 
or when pathogenesity 
and number of micro...
Stages of infection 
Infections generally pass through these 4 stages before they 
undergo complete resolution. 
• Stage I...
Stage III –After day 5 underlying abcess undermines 
skin or mucosa making it compressible. 
Stage IV - Finally there is r...
Differences between cellulitis and abscess 
Characteristics Cellulitis Abscess 
Duration. Acute phase Chronic phase 
Pain ...
Microbiology –Space infection 
Aerobic bacteria (25%) 
Gram positive cocci (85%)– 
Streptococcus species( 90% ) - 
• S.Mil...
Staphylococcus causes –osteomyelitis and abscess 
Streptococcus causes- cellulitis 
• In an abscess, common causative orga...
Fascial spaces 
Definition - 
The fascial spaces in head and neck are the 
potential spaces between the various layers of ...
CLASSIFICATION OF FASCIAL SPACES 
GRODINSKY AND HOLYOKE (1938) 
Space 1 – Superficial to superficial fascia 
Space 2 – Gro...
• Hollinshead’s classification(1958) 
Infrahyoid spaces - 
1.Visceral compartment 
A) Pretracheal / previsceral 
B) Retrov...
BASED ON MODE OF INVOLVEMENT 
1. Direct Involvement. (Primary Spaces) 
»Maxillary Spaces – Canine, buccal infratemporal 
»...
Surgical anatomy of deep facial 
spaces of head and neck
Buccal space 
The buccal space occupies the portion of subcutaneous space 
between the fascial skin and buccinator muscle....
Cause 
Infection from maxillary premolars, molars and 
mandibular premolars 
Relation of root with buccinator muscle
Buccal space 
Clinical features: 
Dome shaped swelling on the 
anterior aspect of cheek extending 
anteroposteriorly from ...
• CONTENTS OF BUCCAL SPACE:- 
• Buccal pad of fat 
• Stensons (Parotid duct) 
• Anterior and transverse facial artery and ...
TREATMENT:- (I & D) 
• Antibiotic prophylaxis. 
• Intra oral horizontal vestibular 
incision. 
• Extra oral (2 stab) incis...
Canine space / Infraorbital space 
Boundaries – 
Anteriorly – Nasal cartilage 
Posteriorly- Buccal space 
Superficially – ...
ETIOLOGY - 
• Maxillary canine, rarely from maxillary first 
premolar. 
• Rarely from nasal & upper lip infections.
Canine space / Infraorbital space 
• Clinical features: 
• Swelling lateral to the nose 
over cheek. 
• Obliteration of th...
• Contents – Angular artery and vein, 
Infraorbital nerve 
• Neighboring spaces – Buccal space
TREATMENT:- 
• Antibiotic prophylaxis 
• Incision is made intraorally high in the 
maxillary labial vestibule. 
• Small he...
Submandibular space 
BOUNDARIES:- 
ANTERIORLY – Anterior bellly of digastric 
muscle 
POSTERIORLY – Posterior bellly of di...
Cause - 
• Infection from Mandibular molars. 
• From sublingual space 
• Infections from middle third of the tongue, 
post...
Clinical Evaluation: 
Swelling begins at lower 
border of mandible extends 
to the level of hyoid bone in 
a shape of inve...
Contents - 
• Superficial lobe of submandibular salivary gland 
& submandibular lymph nodes, facial artery & 
vein 
Neighb...
• I & D through Extra-oral 
incision. 
• Incision – 2 stab incisions 
are given over the 
dependent part below the 
lower ...
• BOUNDARIES:- 
• ANTERIORLY - Lingual surface of 
mandible 
• POSTERIORLY - Submandibular 
space 
• INFERRIORLY - Mylohyo...
CAUSE 
• Mandibular premolars and molars, trauma
Sublingual space 
Clinical evaluation: 
•Swelling in anterior part of 
floor of the mouth on the 
affected side displacing...
• CONTENTS:- 
• Sublingual artery and vein 
• Lingual nerve. 
• Deep part of submandibular salivary gland and its duct 
an...
TREATMENT:- 
• Antibiotic prophylaxis 
• Incision is made Intraorally over lingual sulcus at the base 
of the alveolar pro...
Submental space 
BOUNDARIES:- 
ANTERIORLY – Inferior border of 
mandible 
POSTERIORLY – Hyoid bone 
• LATERALLY – Anterior...
ETIOLOGY:- 
• From lower anteriors. 
• Secondarily due to infection from submental 
lymph nodes which drain lower lip, ski...
Submental space 
Clinical evaluation: 
Swelling is limited to the 
point of the chin & to the 
region immediately below 
i...
• MUSCLE RELATED – mentalis muscle 
• CONTENTS – submental lymph nodes and anterior 
jugular vein.
• TREATMENT:- 
Extraoral Incisions are made bilaterally (two 
stab incisions) through skin, subcutaneous 
tissue and platy...
Ludwig’s Angina
Ludwig’s Angina 
• The original description of the disease was given by Wilhelm 
Friedrich von Ludwig. 
1. Rapidly spreadi...
Ludwig’s Angina 
Ludwig’s angina is acute, aggressive 
and rapidly spreading cellulitis of 
the submandibular and sublingu...
- Drooling, dysphagia and neck stiffness are 
common. 
- Anteriorly protruding tongue is present 
- Trismus is usually abs...
Principles of Management of Ludwig’s 
Angina 
• Hospitalization. 
• Securing the airway. 
• Antibiotics & hydration. 
• Ex...
Incision for surgical drainage of Ludwig’s Angina 
Classic method – Not used nowadays Bilateral through and though drainag...
Masticatory space 
There are 5 masticatory spaces . 
1. Superficial temporal space 
2. Infratemporal space 
3. Deep tempor...
Superficial temporal space 
Boundaries – 
• Superiorly & Laterally  Temporal fascia 
• Inferiorly – Zygomatic arch 
• Med...
cause 
• Infection from maxillary and mandibular 
molars.
Superficial temporal space 
Clinical evaluation: 
•swelling above & below 
the zygomatic arch 
causing a dumbell shaped 
a...
• Contents- Temporal fat pad, temporal branch 
of the facial nerve. 
• Neighboring spaces – Buccal , Deep temporal.
TREATMENT:- 
Intraorally vertical incision made medial to the upper 
extent of the anterior border of the mandibular ramus...
Deep Temporal space 
Boundaries - 
• Laterally  medial surface of temporalis m. 
• Medially  Temporal bone 
• Below the ...
Cause 
• Infection from maxillary molars
Clinical features 
Mild swelling over temporal 
Region. 
Difficult to diagnose.
• Contents – Pterygoid plexus, Internal maxillary 
artery and vein. 
• Neighboring Spaces – Buccal, superficial 
temporal,...
TREATMENT:- 
• Intraorally vertical incision made medial to the 
upper extent of the anterior border of the 
mandibular ra...
Infratemporal space 
Boundaries – 
• Anteriorly, -Infratemporal surface of the maxilla 
• Posteriorly,- the articular tube...
Cause 
• Infection from maxillary molars
Infratemporal space 
• Clinical features : 
• Marked Trismus 
• swelling of face in front of ear, over TMJ & zygomatic 
ar...
• Contents – Pterygoid plexus, Internal maxillary 
artery and vein. 
• Neighboring Spaces – Buccal, superficial 
temporal,...
TREATMENT:- 
• Intraoral and extraoral approach 
• Intraorally, incision is made into buccolabial fold 
lateral to maxilla...
• Extraoral approach in presence of severe 
trismus. 
It consists of horizontal incision above the 
zygomatic arch and the...
SUBMASSETERIC SPACE 
• BOUNDARIES: 
Anteriorily Buccal space 
Posteriorily  parotid fascia and retromandibular portion o...
ETIOLOGY:- 
• 
– Periocoronal infection, periapical infection with 
mandibular third molars (linguoversion with root 
bucc...
CLINICAL FEATURES:- 
– Swelling over the angle of mandile from 
the level of the zygomatic arch to 
inferior border of man...
CONTENTS - 
• Masseteric artery and vein 
Neighboring spaces- 
• Buccal, pterygomandibular, superficial 
temporal, parotid...
TREATMENT:- 
• Incision  Intra oral approach - vertical incision along the 
external oblique line of the mandible startin...
Pterygomandibular space 
• BOUNDARIES: 
– Anterior  Buccal space 
– Posterior  deep portion of 
parotid gland 
– Lateral...
ETIOLOGY-Infection 
from impacted mandibular molars 
, from contaminated needle during I.A.N.B
CLINICAL FEATURES: 
– Trismus, Dysphagia, Dyspnoea 
– No external evidence of swelling 
– Anterior bulging of half the sof...
• CONTENTS: 
– Mandibular division of trigeminal nerve 
– Inferior alveolar artery and vein 
• Neighboring spaces - 
– Dee...
TREATMENT: I & D 
• If trismus is severe. 
-Extraoral mandibular nerve block or G.A. is given 
• Incision  intra oral inc...
Lateral pharyngeal space infections 
• It lies immediately posterior and lateral to 
the pharynx 
• Anatomically the later...
• BOUNDARIES:- 
– Superiorly  Base of skull 
– Inferiorly  Hyoid bone 
– Medially  superior pharyngeal 
constrictor 
– ...
• ETIOLOGY:- 
Spread from 
– Sublingual spaces 
– Submandibular spaces 
– Pterygomandibular spaces 
– Lateral spread from ...
• CONTENTS: 
– Anterior compartment: 
• Ascending pharyngeal A. 
• Loose areolar connective tissue. 
– Posterior compartme...
Lateral pharyngeal space infection 
Clinical evaluation 
• Firm swelling with 
surrounding erythema lateral 
and anterior ...
Management 
• Hospitalization with I.v. antibiotics. 
• Airway protection. 
• Rapid surgical drainage. 
• Surgical approac...
Complications 
• Suppurative jugular venous thrombosis. 
• Patient will have shaking chills, high fever. 
• Tenderness at ...
Peritonsillar space infection 
Clinical evaluation: 
• pharyngitis . 
• Severe sore throat, dysphagia, 
and referred otalg...
Parotid space infection 
BOUNDARIES:- 
• superiorly zygomatic arch 
• Inferiorly lower border of mandible 
• Anteriorly ...
• ETIOLOGY: 
– From extension of infection from submasseteric, 
pterygomandibular, lateral pharyngeal spaces, 
– Blood-bor...
Parotid space infection
. 
Clinical evaluation: 
The symptoms of parotitis include pain and 
induration over the involved gland. 
Purulent marked ...
Drainage of parotid space infection
Deep neck infections 
• All involve only posterior side of neck. 
a)Retropharyngeal space 
b)Danger space 
c) Prevertebral...
Retropharyngeal space 
Retropharyngeal space is the potential space sandwiched 
between alar and prevertebral layers of de...
Clinical Evaluation 
• Children less than 4 yrs commonly affected. 
• Sore throat, dysphagia, 
• Hot potato voice. 
Clinic...
Diagnosis of the soft tissue radiograph for 
retropharyngeal space infection 
Step I: 
• Look at the prevertebral or 
retr...
Step III. 
- Finally, the lateral radiograph will show the curve of the cervical spine 
- Loss of the curve is a strong in...
Management of Retropharyngeal 
space infection
Prevertebral space 
• Is formed by the deep cervical fascia. 
• It extends from skull base to coccyx 
• Facia attaches to ...
Diagnostic Imaging for Space infections 
Plain film. MRI
Plain Film 
• Diagnostic imaging starts with a plain film study 
of pharyngeal or cervical airways. 
• Views taken 
– AP v...
MRI
Complications of space infection 
• Osteomyelitis 
• Mediastenitis 
• Brain abcess 
• Meningitis 
• Cavernous sinus thromb...
Who should be hospitalized ??? 
Signs & symptoms of 
toxicity 
• Dyspnoea 
• Dysphagia 
• Paleness 
• Tachypnoea 
• Tachyc...
Controversies 
• Does the Investing Layer of the Deep Cervical Fascia 
Exist? 
- Nash, Lance M.Sc November 2005 
Journal o...
Controversies 
• Conclusion of study: 
This study provides anatomical evidence to 
indicate that the so-called investing c...
Controversies 
• Surgical vs ultrasound-guided drainage of deep neck space 
abscesses: a randomized controlled trial: surg...
Results 
• Seventeen patients were recruited .They found a 
significant difference in mean Length of hospital 
stay betwee...
Recent advances 
Effective antibiotics for severe infections caused 
by resistant bacteria are needed urgently. The 
speed...
FDA approved newer antibiotics 
Compound name 
(Brand name ) 
Targeted Microorganisms 
Quinupristin/ dalfopristin (1999) 
...
Compound name 
(Brand name ) 
Targeted Microorganisms 
Faropenem (2005) 
(medoxomil ) 
G+ and G-Telavancin 
(2007) G+ (inc...
Conclusion 
We being Oral & maxillofacial surgeons must 
understand anatomy of fascial spaces, spread of 
infection and pr...
References. 
Books - 
• Oral &maxillofacial Infections-Topazian 
• Oral & Maxillofacial Surgery-Laskin Vol. II 
Articles –...
References. 
Head and Neck space infections (Dissertation ) 
University of sydney. 
Websites - 
http://www.upd8.org.uk
Thank you
Space infection.  by  Dr. Amit Suryawanshi .Oral & Maxillofacial Surgeon, Pune , India
Space infection.  by  Dr. Amit Suryawanshi .Oral & Maxillofacial Surgeon, Pune , India
Space infection.  by  Dr. Amit Suryawanshi .Oral & Maxillofacial Surgeon, Pune , India
Space infection.  by  Dr. Amit Suryawanshi .Oral & Maxillofacial Surgeon, Pune , India
Space infection.  by  Dr. Amit Suryawanshi .Oral & Maxillofacial Surgeon, Pune , India
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Space infection. by Dr. Amit Suryawanshi .Oral & Maxillofacial Surgeon, Pune , India

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Space infection. by Dr. Amit Suryawanshi .Oral & Maxillofacial Surgeon, Pune , India

  1. 1. Space Infection Dr. Amit T. Suryawanshi Oral and Maxillofacial Surgeon Pune, India Contact details : Email ID - amitsuryawanshi999@gmail.com Mobile No - 9405622455
  2. 2. Contents • Introduction • History • Anatomy of fascia • Host defense and infection • Microbiology and antibiotic therapy • Stages of infection • Definition of fascial spaces • Classification of fascial spaces • Anatomy of fascial spaces • Diagnosis of Space infection • Complications • Controversies • Recent advances • Conclusion • Reference
  3. 3. Introduction Space infections of head and neck are very common in Oral and maxillofacial practice. Although most of the infections can be managed successfully with minimal or no complication, some can produce serious morbidity or even death. Depending on the virulence of microorganisms and host resistance, bacterial infections have the potential to spread beyond the bony confines of jaw bones into surrounding soft tissues.
  4. 4. They flow following the path of least resistance , into loose areolar connective tissue of fascia surrounding the muscles. This tissue is destroyed by hyaluronidases and collagenases produced by bacteria, thus opening the potential SPACES surrounding the muscles. Thus such innocuous periapical infections have a potential to develop into life-threatening deep fascial infections.
  5. 5. Early extraction of offending tooth and incision and drainage tend to shorten the usual course of infection and minimize the chances of further complications. In new era of antibiotics, incidence of death due to infection is reduced but due to developing drug resistance, there is outbreak of new range of infections requiring invention of newer antibiotics.
  6. 6. For accomplishment of proper management, maxillofacial surgeon must understand physiologic and anatomic factors that influence the spread and localization of dental infections.
  7. 7. History Burns (1811) first described fascial space as an anatomical entity and gave their clinical significance. In 1836 Wilhelm Frederick von Ludwig described his observations concerning repeated occurrences of inflammation of throat. Hence most severe orofacial Infection at that time was named as Ludwigs angina. Greek author Parker(1879) gave vivid descriptions of infections which produced inflammation oral cavity, tonsil and larynx.
  8. 8. The term “ Quinsy “ was given by Muckleston in 1928. In 1929 Mosher called Viscerovascular space as “Lincoln highway” Space of the body of mandible is described by Coller & Iglesias. (1935)
  9. 9. Anatomy of fascia
  10. 10. Functions of the fascia • Acts as a musculovenous pump- • Limits outward expansion of muscles as they contract. • Contraction of muscles compresses the intramuscular veins (push the blood towards the heart). • Determine the direction of spread of infection
  11. 11. Infections and Host defense • In establishing presence of an infection, interaction occurs among three factors. 1. Host 2. Environment 3. Microorganism In state of Homeostasis , balance exists among these three and disease occurs when imbalance exists.
  12. 12. Host vs Microbe relationship Infection occurs when host is immunocompromised or when pathogenesity and number of microbes Invading host is more.
  13. 13. Stages of infection Infections generally pass through these 4 stages before they undergo complete resolution. • Stage I – Inoculation Time between exposure of microorganism and the first set of symptoms . During 1-3 days, Swelling is soft, mildly tender, doughy in consistency • Stage II – cellulitis Chronic stage-fistulous/sinus tract or osteomyelitis During 3-7 days, centre of lesion begins to soften
  14. 14. Stage III –After day 5 underlying abcess undermines skin or mucosa making it compressible. Stage IV - Finally there is resolution of abcess that may be spontaneous or after surgical drainage. During resolution phase, the involved region is firm on palpation due to process of removing tissue and bacterial debris.
  15. 15. Differences between cellulitis and abscess Characteristics Cellulitis Abscess Duration. Acute phase Chronic phase Pain Severe and generalised Localised Size Large. Small Localization Diffuse borders Well-demarcated Palpation Doughy / indurated Fluctuant Presence of pus No Yes Degree of seriousness Greater Less Bacteria. Aerobic Anaerobic/mixed
  16. 16. Microbiology –Space infection Aerobic bacteria (25%) Gram positive cocci (85%)– Streptococcus species( 90% ) - • S.Milleri • S.sanguis • S.Salivarius • S.Mutans Staphylococcus species (6 %) Anaerobic bacteria (75%) Gram positive cocci (30%)– Peptococcus species 33% Pepto Streptococcus species 33% Gram pasitive bacilli (50%) – Prevotella species, Porphyromonas species (75%) Fusobacterium -20% Ref – Micro-organisms and Odontogenic infections 2009 ADJ
  17. 17. Staphylococcus causes –osteomyelitis and abscess Streptococcus causes- cellulitis • In an abscess, common causative organisms are anaerobic (Higher percentage) & Aerobic. • Fusobacterium + strep. Milleri – cause aggressive infections. Eg.,.mediastinum.infections.
  18. 18. Fascial spaces Definition - The fascial spaces in head and neck are the potential spaces between the various layers of fascia normally filled with loose connective Tissue and bounded by anatomical barriers, usually of bone, muscle or fascial layers. (Ref – Moore-1975)
  19. 19. CLASSIFICATION OF FASCIAL SPACES GRODINSKY AND HOLYOKE (1938) Space 1 – Superficial to superficial fascia Space 2 – Group of spaces surrounding cervical strap muscles lying superficial to sternothyroid-thyrohyoid division of middle layer of deep cervical fascia. Space 3 – Space lying superficial to visceral division of middle layer of deep cervical fascia Space 3A – Carotid sheath space or viscerovascular space (Lincoln’s High way) Space 4 – Space lies between alar & prevertebral division of posterior layer of deep cervical fascia (Danger space) Space 4A – Posterior triangle space posterior to carotid sheath Space 5 - Prevertebral space Space 5A- Space enclosed by Prevertibral fascia.
  20. 20. • Hollinshead’s classification(1958) Infrahyoid spaces - 1.Visceral compartment A) Pretracheal / previsceral B) Retrovisceral 2. Visceral space 3. Other space I. Cavity within carotid sheath II. Space between 2 layers of prevertebral fascia
  21. 21. BASED ON MODE OF INVOLVEMENT 1. Direct Involvement. (Primary Spaces) »Maxillary Spaces – Canine, buccal infratemporal »Mandibular Spaces – Submental, Submandibular, Sublingual, Buccal 2. Indirect involvement (Secondary Spaces) »Masseteric »Pterygomandibular »Superficial and deep temporal »Lateral and retro pharyngeal »Prevertebral, parotid, carotid sheath,peritonsillar and danger spaces.
  22. 22. Surgical anatomy of deep facial spaces of head and neck
  23. 23. Buccal space The buccal space occupies the portion of subcutaneous space between the fascial skin and buccinator muscle. BOUNDARIES:- • ANTERIORLY - Corner of mouth • POSTERIORLY-Masseter muscle, Pterygomandibular space • SUPERFICIAL- skin and Subcutaneous tissue • DEEP- Buccinator muscle • SUPERIORILY - Maxilla, Infraorbital space • INFERIORLY - Lower border of mandible.
  24. 24. Cause Infection from maxillary premolars, molars and mandibular premolars Relation of root with buccinator muscle
  25. 25. Buccal space Clinical features: Dome shaped swelling on the anterior aspect of cheek extending anteroposteriorly from corner of mouth to angle of mandible and superoinferiorly from level of zygomatic arch to inferior border of mandible.
  26. 26. • CONTENTS OF BUCCAL SPACE:- • Buccal pad of fat • Stensons (Parotid duct) • Anterior and transverse facial artery and vein. MUSCLE RELATED – Buccinator muscle Neighboring spaces- Infraorbital, pterygomandibular, infratemporal space
  27. 27. TREATMENT:- (I & D) • Antibiotic prophylaxis. • Intra oral horizontal vestibular incision. • Extra oral (2 stab) incisions below the lower border of the mandible with No. 11 blade. • Drainage – Hemostat is passed from anterior incision and taken out from the posterior incision then the rubber drain is inserted and secured with pins and dressing is done.
  28. 28. Canine space / Infraorbital space Boundaries – Anteriorly – Nasal cartilage Posteriorly- Buccal space Superficially – Quadratus labi superioris Deep- Lavator anguli oris, anterior surface of maxilla Medially – Levator labi superioris alaque nasi Laterally – Zygomaticus major, Superiorly – Quadratus labi superioris Inferiorly - Oral mucosa ,Orbicularis oris
  29. 29. ETIOLOGY - • Maxillary canine, rarely from maxillary first premolar. • Rarely from nasal & upper lip infections.
  30. 30. Canine space / Infraorbital space • Clinical features: • Swelling lateral to the nose over cheek. • Obliteration of the nasolabial fold, • Swelling of the upper lip, • Oedema occurs in lower eyelid leading to closure of eye.
  31. 31. • Contents – Angular artery and vein, Infraorbital nerve • Neighboring spaces – Buccal space
  32. 32. TREATMENT:- • Antibiotic prophylaxis • Incision is made intraorally high in the maxillary labial vestibule. • Small hemostat is inserted through levator anguli oris into abcess cavity. • Drainage with drain secured.
  33. 33. Submandibular space BOUNDARIES:- ANTERIORLY – Anterior bellly of digastric muscle POSTERIORLY – Posterior bellly of digastric muscle, stylohyoid, stylopharyngeous muscle. LATERALLY -skin, superficial fascia, platysma SUPERFICIAL- Platysma, Investing fascia DEEP- Myelohyoid, Hyoglossus, superior constrictor INFERIORILY -Anterior & posterior bellies of the diagastric SUPERIORILY -Inferior medial aspect of mandible & mylohyoid muscle
  34. 34. Cause - • Infection from Mandibular molars. • From sublingual space • Infections from middle third of the tongue, posterior part of floor of the mouth. • From submental space / submental lymph nodes • Infection from the submandibular gland
  35. 35. Clinical Evaluation: Swelling begins at lower border of mandible extends to the level of hyoid bone in a shape of inverted cone. No trismus.
  36. 36. Contents - • Superficial lobe of submandibular salivary gland & submandibular lymph nodes, facial artery & vein Neighboring spaces – Submental, sublingual, lateral pharyngeal, buccal and submandibular space of other side.
  37. 37. • I & D through Extra-oral incision. • Incision – 2 stab incisions are given over the dependent part below the lower border of mandible in the neck (shadow) of the mandible • Curved hemostat is inserted & Blunt dissection through subcutaneous fat not to damage facial A, anterior facial vein and the facial nerve • Drainage – Drain is placed & dressing is given TREATMENT
  38. 38. • BOUNDARIES:- • ANTERIORLY - Lingual surface of mandible • POSTERIORLY - Submandibular space • INFERRIORLY - Mylohyoid muscle • SUPERIORIL -oral mucosa • MEDIALLY- - geniohyoid, genioglossus & styloglossus • LATERALLY - lingual aspect of mandible Sublingual space
  39. 39. CAUSE • Mandibular premolars and molars, trauma
  40. 40. Sublingual space Clinical evaluation: •Swelling in anterior part of floor of the mouth on the affected side displacing tongue medially and superiorly. •Interferes with swallowing and is extremely painful. •Elevation of tongue to palate causes airway compromise.
  41. 41. • CONTENTS:- • Sublingual artery and vein • Lingual nerve. • Deep part of submandibular salivary gland and its duct anteriorily. • Sublingual salivary gland Neighboring spaces – Submandibular, Lateral pharyngeal, visceral(trachea, esophagus)
  42. 42. TREATMENT:- • Antibiotic prophylaxis • Incision is made Intraorally over lingual sulcus at the base of the alveolar process. • Haemostat is passed beneath sublingual gland in an antero posterior dissection and drain is placed. • When infection crosses midline, same incision is made bilaterally, hemostat is passed through floor of mouth from one side to other & drain is placed
  43. 43. Submental space BOUNDARIES:- ANTERIORLY – Inferior border of mandible POSTERIORLY – Hyoid bone • LATERALLY – Anterior bellies of the digastric m. • SUPERIORILY – Mylohyoid muscle • INFERIORILY – skin, investing fascia • SUPERFICIAL – Investing fascia • DEEP – Anterior bellies of digastric
  44. 44. ETIOLOGY:- • From lower anteriors. • Secondarily due to infection from submental lymph nodes which drain lower lip, skin overlying chin, anterior part of floor of the mouth, tip of the tongue & sublingual tissues. • Symphysis fracture.
  45. 45. Submental space Clinical evaluation: Swelling is limited to the point of the chin & to the region immediately below it
  46. 46. • MUSCLE RELATED – mentalis muscle • CONTENTS – submental lymph nodes and anterior jugular vein.
  47. 47. • TREATMENT:- Extraoral Incisions are made bilaterally (two stab incisions) through skin, subcutaneous tissue and platysma muscle at most inferior aspect of swelling. Drain & dressings are placed.
  48. 48. Ludwig’s Angina
  49. 49. Ludwig’s Angina • The original description of the disease was given by Wilhelm Friedrich von Ludwig. 1. Rapidly spreading gangrenous cellulitis. 2. Originates in the region of submandibular gland but never involves one single space and 3. Arises from extension by continuity and not by lymphatics. 4. Produces gangrene with serosanguinous, putrid infiltration but very little or no frank pus.
  50. 50. Ludwig’s Angina Ludwig’s angina is acute, aggressive and rapidly spreading cellulitis of the submandibular and sublingual spaces bilaterally and of the submental space. Clinical evaluation: Bilateral swelling below chin extending inferiorly at the level of hyoid bone. Fever, chills. - Airway compromise occur quickly and with little fore warning.
  51. 51. - Drooling, dysphagia and neck stiffness are common. - Anteriorly protruding tongue is present - Trismus is usually absent.
  52. 52. Principles of Management of Ludwig’s Angina • Hospitalization. • Securing the airway. • Antibiotics & hydration. • External surgical exploration with bilateral through and through drainage of the submandibular spaces with simultaneous exploration of the submental and sublingual spaces. • Medical supportive therapy • Review and re-evaluation in the post op period
  53. 53. Incision for surgical drainage of Ludwig’s Angina Classic method – Not used nowadays Bilateral through and though drainage of spaces - Ref – Laskin Vol. 2 pg no. 249
  54. 54. Masticatory space There are 5 masticatory spaces . 1. Superficial temporal space 2. Infratemporal space 3. Deep temporal space 4. Submassetric space 5. Pterygomandibular space
  55. 55. Superficial temporal space Boundaries – • Superiorly & Laterally  Temporal fascia • Inferiorly – Zygomatic arch • Medially Lateral surface Temporalis muscle
  56. 56. cause • Infection from maxillary and mandibular molars.
  57. 57. Superficial temporal space Clinical evaluation: •swelling above & below the zygomatic arch causing a dumbell shaped appearance • Severe pain & trismus
  58. 58. • Contents- Temporal fat pad, temporal branch of the facial nerve. • Neighboring spaces – Buccal , Deep temporal.
  59. 59. TREATMENT:- Intraorally vertical incision made medial to the upper extent of the anterior border of the mandibular ramus. • Haemostat  passed superiorily along the lateral aspect of the coronoid process to enter superficial temp. space • Intra oral approach  good • Extra-oral incision  horizontal incision • Haemostat is passed medially to enter superficial temporal space. • Drainage  drain is placed, dressing is given.
  60. 60. Deep Temporal space Boundaries - • Laterally  medial surface of temporalis m. • Medially  Temporal bone • Below the level of zygomatic arch both the spaces communicate with each other and with the infratemporal space.
  61. 61. Cause • Infection from maxillary molars
  62. 62. Clinical features Mild swelling over temporal Region. Difficult to diagnose.
  63. 63. • Contents – Pterygoid plexus, Internal maxillary artery and vein. • Neighboring Spaces – Buccal, superficial temporal, inferior petrosal sinus
  64. 64. TREATMENT:- • Intraorally vertical incision made medial to the upper extent of the anterior border of the mandibular ramus. • Haemostat  passed supero-medially to enter deep temporal space. • Through blunt dissection deep temporal space is approached through temporalis muscle • Drainage  drain is placed, dressing is given.
  65. 65. Infratemporal space Boundaries – • Anteriorly, -Infratemporal surface of the maxilla • Posteriorly,- the articular tubercle of the temporal bone, mandibular condyle • Superiorly, - Greater wing of the sphenoid below the infratemporal crest • Inferiorly, - Medial pterygoid muscle • Medially - lateral pterygoid plate • Laterally, - Ramus of mandible
  66. 66. Cause • Infection from maxillary molars
  67. 67. Infratemporal space • Clinical features : • Marked Trismus • swelling of face in front of ear, over TMJ & zygomatic arch • Eye is closed and proptosed
  68. 68. • Contents – Pterygoid plexus, Internal maxillary artery and vein. • Neighboring Spaces – Buccal, superficial temporal, inferior petrosal sinus
  69. 69. TREATMENT:- • Intraoral and extraoral approach • Intraorally, incision is made into buccolabial fold lateral to maxillary third molar. (Kruger) • Curved hemostat is inserted behind max. tuberosity superomedially within the cavity and drain is inserted. • Intraorally vertical incision made medial to the upper extent of the anterior border of the mandibular ramus.(Laskin) • Curved hemostat is passed superiorly into infratemporal region and drain is inserted.
  70. 70. • Extraoral approach in presence of severe trismus. It consists of horizontal incision above the zygomatic arch and then curved hemostat is directed in inferior and medial direction to enter infratemporal space followed by insertion of drain.
  71. 71. SUBMASSETERIC SPACE • BOUNDARIES: Anteriorily Buccal space Posteriorily  parotid fascia and retromandibular portion of the parotid gland Laterally  masseter muscle Medially  lateral surface of the mandibular ramus Superiorily  zygomatic arch Inferiorly – Inferior border of mandible
  72. 72. ETIOLOGY:- • – Periocoronal infection, periapical infection with mandibular third molars (linguoversion with root buccally placed) - Fracture of angle of mandible
  73. 73. CLINICAL FEATURES:- – Swelling over the angle of mandile from the level of the zygomatic arch to inferior border of mandible , anteriorily to anterior border of masseter and posteriorly to posterior border of mandible. – Deep seated severe throbbing pain – Trismus – Tenderness over the mandibular ramus,.
  74. 74. CONTENTS - • Masseteric artery and vein Neighboring spaces- • Buccal, pterygomandibular, superficial temporal, parotid space
  75. 75. TREATMENT:- • Incision  Intra oral approach - vertical incision along the external oblique line of the mandible starting at the level of the occlusal plane and extending downward and forward in buccal sulcus opposite 2nd molar. Haemostat is passed along lateral aspect of ramus beneath masseter muscle to enter submasseteric space. drainage is done. • Incision  Extra oral incision - beneath angle of mandible. • Blunt dissection through masseter muscle fibres. – Drainage with plastic or rubber catheter to withstand muscle contraction.
  76. 76. Pterygomandibular space • BOUNDARIES: – Anterior  Buccal space – Posterior  deep portion of parotid gland – Laterally  medial surface of ramus of mandible – Medially  Lateral aspect of the medial pterygoid m. – Superiorly  lateral pterygoid muscle – Inferiorly – Inferior border of mandible
  77. 77. ETIOLOGY-Infection from impacted mandibular molars , from contaminated needle during I.A.N.B
  78. 78. CLINICAL FEATURES: – Trismus, Dysphagia, Dyspnoea – No external evidence of swelling – Anterior bulging of half the soft palate and the anterior tonsillar pillar with deviation of uvula to the unaffected side. – If Peritonsillar abscess (Less trismus, no dental involvement)
  79. 79. • CONTENTS: – Mandibular division of trigeminal nerve – Inferior alveolar artery and vein • Neighboring spaces - – Deep temporal spaces – Lateral pharyngeal space – Buccal space – Submasseteric space – Parotid space
  80. 80. TREATMENT: I & D • If trismus is severe. -Extraoral mandibular nerve block or G.A. is given • Incision  intra oral incision in the mucosal area between medial aspect of ramus and the pterygomandibular raphae. • Blunt dissection using hemostat. • Drainage. • Extra oral incision is made below the angle of mandible.
  81. 81. Lateral pharyngeal space infections • It lies immediately posterior and lateral to the pharynx • Anatomically the lateral pharyngeal space may be thought of as an inverted pyramid shape-the base of the pyramid being the skull base and the apex the hyoid bone.
  82. 82. • BOUNDARIES:- – Superiorly  Base of skull – Inferiorly  Hyoid bone – Medially  superior pharyngeal constrictor – Laterally  medial pterygoid m., capsule of parotid gland – Posteriorly  carotid sheath ,styohyoid, styloglossus, & stylopharyngeus. This is a cone – shaped space
  83. 83. • ETIOLOGY:- Spread from – Sublingual spaces – Submandibular spaces – Pterygomandibular spaces – Lateral spread from tonsillar abscess, pharyngitis, parotitis, otitis, mastoiditis – Abcess from the region of 38,48 – Surgical displacement of roots of 38,48 into this space •
  84. 84. • CONTENTS: – Anterior compartment: • Ascending pharyngeal A. • Loose areolar connective tissue. – Posterior compartments:- • Cervical sympathetic trunk • Carotid sheath with its contents Neighboring spaces - Pterygomandibular, submandibular, sublingual, peritonsillar, retropharyngeal space.
  85. 85. Lateral pharyngeal space infection Clinical evaluation • Firm swelling with surrounding erythema lateral and anterior to sternocleidomastoid muscle. • Difficulty in flexing and turning of neck. • Trismus secondary pterygoid muscle involvement. • Dysphagia. • Dyspnoea.
  86. 86. Management • Hospitalization with I.v. antibiotics. • Airway protection. • Rapid surgical drainage. • Surgical approach always through neck not through oral cavity. • Incision is made at the level of hyoid bone across the sternocleidomastoid muscle.
  87. 87. Complications • Suppurative jugular venous thrombosis. • Patient will have shaking chills, high fever. • Tenderness at the mandibular angle and along sternocleidomastoid muscle.
  88. 88. Peritonsillar space infection Clinical evaluation: • pharyngitis . • Severe sore throat, dysphagia, and referred otalgia. • The speech is muffled and classically described as hot potato voice. • Trismus is not present • According to recent literature,needle aspiration is done instead of incision and drainage . • (JOMS,Vol 51,2009)
  89. 89. Parotid space infection BOUNDARIES:- • superiorly zygomatic arch • Inferiorly lower border of mandible • Anteriorly  posterior border of the mandible • Posteriorly  Retromandibular region – Space formed by splitting of the superficial layer surrounding the parotid gland and lies posterior to the masticator space. • CONTENTS: – Parotid gland – Parotid lymph nodes – Facial n. – Retromandibular vein – External carotid artery
  90. 90. • ETIOLOGY: – From extension of infection from submasseteric, pterygomandibular, lateral pharyngeal spaces, – Blood-borne infection, retrograde infections through the stensons duct.
  91. 91. Parotid space infection
  92. 92. . Clinical evaluation: The symptoms of parotitis include pain and induration over the involved gland. Purulent marked swelling of the angle of the jaw without associated trismus or pharyngeal swelling. Secretions may sometimes be expressed after massage from the parotid depth. Very characteristic pitting edema of the gland is pathognomic for parotid gland abscess.
  93. 93. Drainage of parotid space infection
  94. 94. Deep neck infections • All involve only posterior side of neck. a)Retropharyngeal space b)Danger space c) Prevertebral space d)Visceral vascular space (within the carotid sheath)
  95. 95. Retropharyngeal space Retropharyngeal space is the potential space sandwiched between alar and prevertebral layers of deep layer of the deep investing fascia. Extension Base of the skull Mediastinum Most dangerous of all types of deep neck infections (Danger space) Two compartments: Suprahyoid 1. Lymph nodes and fat. Sagittal section of retropharyngeal space Infrahyoid 1. Only fat
  96. 96. Clinical Evaluation • Children less than 4 yrs commonly affected. • Sore throat, dysphagia, • Hot potato voice. Clinical features •Refusal to take food. •Cervical lymphadenopathy. •Slight neck rigidity. •Noisy breathing due to laryngeal edema. Late Clinical features - •Neck tilts towards involved side. •Hyperextended complete inability to flex the neck. •Respiratory embarrassment may occur if abscess is not ruptured or drained.
  97. 97. Diagnosis of the soft tissue radiograph for retropharyngeal space infection Step I: • Look at the prevertebral or retropharyngeal soft tissue shadow. • In the area of 2nd and 3rd CV, shadow should be less than 7mm in width. • In the area of 6 cervical vertebra soft tissue shadow is behind the trachea and includes the thickness of esophagus making it approx. Children – 14mm wide adults – 22mm wide
  98. 98. Step III. - Finally, the lateral radiograph will show the curve of the cervical spine - Loss of the curve is a strong indication of retropharyngeal space infection. - Tipping of the head forward in sniffing position to maintain an open airway.
  99. 99. Management of Retropharyngeal space infection
  100. 100. Prevertebral space • Is formed by the deep cervical fascia. • It extends from skull base to coccyx • Facia attaches to the transverse process of the cervical vertebra dividing this space into anterior and posterior compartments. Anterior compartment contains: -Vertebral bodies. -Spinal cord. -Vertebral arteries. -Phrenic nerve. -Prevertebral and scalene muscles Posterior compartment contains: -Posterior vertebral elements. -Paraspinous muscles.
  101. 101. Diagnostic Imaging for Space infections Plain film. MRI
  102. 102. Plain Film • Diagnostic imaging starts with a plain film study of pharyngeal or cervical airways. • Views taken – AP view – Lateral view • Plain film findings: - In the AP view the normal cervical airway should appear symmetrical over the middle third of the cervical spine. - Lateral view – In the adult the width of the prevertebral soft tissue should not exceed 7mm at the C3 level and 20mm at C7 level. AP view Lateral view
  103. 103. MRI
  104. 104. Complications of space infection • Osteomyelitis • Mediastenitis • Brain abcess • Meningitis • Cavernous sinus thrombosis • Scar formation • Sinus tract formation
  105. 105. Who should be hospitalized ??? Signs & symptoms of toxicity • Dyspnoea • Dysphagia • Paleness • Tachypnoea • Tachycardia • Fever • Lethargy CNS symptoms • level of consciousness • Evidence of meningeal irritation (severe headache) • Eyelid edema & abnormal eye signs
  106. 106. Controversies • Does the Investing Layer of the Deep Cervical Fascia Exist? - Nash, Lance M.Sc November 2005 Journal of American society of anesthesiologists The placement of the superficial cervical plexus block has been the subject of controversy. Although the investing cervical fascia has been considered as an impenetrable barrier, clinically, authors went on a trial and found that the placement of the block deep or superficial to the fascia provides the same effective anaesthesia.
  107. 107. Controversies • Conclusion of study: This study provides anatomical evidence to indicate that the so-called investing cervical fascia does not exist in the anterior triangle of the neck. Here the author’s findings strongly suggest that deep potential spaces in the neck are directly continuous with the subcutaneous tissue.
  108. 108. Controversies • Surgical vs ultrasound-guided drainage of deep neck space abscesses: a randomized controlled trial: surgical vs ultrasound drainage -Vincent L Biron, George Kurien Journal of Otolaryngology - Head and Neck Surgery 2013, • Introduction - Deep neck space abscesses are relatively common head and neck surgery emergencies and can result in significant morbidity . Traditionally, surgical incision and drainage (I&D) with antibiotics has been the mainstay of treatment. Some reports have suggested that ultrasound-guided drainage is a less invasive and effective alternative in selected cases.
  109. 109. Results • Seventeen patients were recruited .They found a significant difference in mean Length of hospital stay between patients who underwent USD (3 days) vs I&D (5 days).They identified significant cost savings (41%) in comparison to I&D. • Conclusions Ultrasound drainage of deep neck space abscesses in a certain cases is effective, cost saving & safe as it is less invasive. Still this remains a controversial topic whether to follow Incision and drainage or ultrasound drainage.
  110. 110. Recent advances Effective antibiotics for severe infections caused by resistant bacteria are needed urgently. The speed with which bacteria develop resistance to antibiotics, in contrast with the slow development of new drugs, has led some experts to develop newer antibiotics.
  111. 111. FDA approved newer antibiotics Compound name (Brand name ) Targeted Microorganisms Quinupristin/ dalfopristin (1999) (Synercid) methicillin-susceptible S. aureus and Streptococcus pyogenes Moxifloxacin (1999 ) (Avelox) G+ and G-, including multi-drug resistant Streptococcus pneumoniae Linezolid (2000) (Zyvox) G+; including MRSA Cefditoren pivoxil (2001) (Spectracef) methicillin-susceptible S. aureus and Streptococcus pyogenes Daptomycin (2003 ) (Cubicin) G+, including MRSA Tigecycline (2005 ) ( Tigacil) G+ and G-Dalbavancin (2004 ) G+ (including VRE and MRSA)
  112. 112. Compound name (Brand name ) Targeted Microorganisms Faropenem (2005) (medoxomil ) G+ and G-Telavancin (2007) G+ (including MRSA) Ceftobiprole (2007) G+ and G-Oritavancin (2011) G+ (including MRSA) Iclaprim (2012) G+ (including MRSA)
  113. 113. Conclusion We being Oral & maxillofacial surgeons must understand anatomy of fascial spaces, spread of infection and proper management for the prevention of further complications and betterment of health of the patient.
  114. 114. References. Books - • Oral &maxillofacial Infections-Topazian • Oral & Maxillofacial Surgery-Laskin Vol. II Articles – 1. Does the Investing Layer of the Deep Cervical Fascia Exist? - Nash, Lance M.Sc November 2005 Journal of American society of anesthetist 2. Surgical vs ultrasound-guided drainage of deep neck space abscesses: a randomized controlled trial: surgical vs ultrasound drainage -Vincent L Biron, George Kurien Journal of Otolaryngology - Head and Neck Surgery 2013,
  115. 115. References. Head and Neck space infections (Dissertation ) University of sydney. Websites - http://www.upd8.org.uk
  116. 116. Thank you

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