Space Infection

Dr. Amit T. Suryawanshi

Oral and Maxillofacial Surgeon

Pune, India

Contact details :Email ID - amitsuryawanshi999@gmail.com

Mobile No - 9405622455

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

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.

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.

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.

For accomplishment of proper management,

maxillofacial surgeon must understand

physiologic and anatomic factors that influence

the spread and localization of dental infections.

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.

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)

Anatomy of fascia

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

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.

Infection occurs when

host is immunocompromised

or when pathogenesity

and number of microbes

Invading host is more.

Host vs Microbe relationship

Stages of infectionInfections 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

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.

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

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

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.

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)

CLASSIFICATION OF FASCIAL SPACESGRODINSKY 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.

• 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

BASED ON MODE OF INVOLVEMENT1. 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.

Surgical anatomy of deep facial spaces of head and neck

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.

Buccal spaceThe 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 corner of mouth to angle of mandible and superoinferiorly from level of zygomatic arch to inferior border of mandible.

• 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

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.

Boundaries –

Anteriorly – Nasal cartilage

Posteriorly- Buccal space

Superficially – Quadratus labi superioris

Deep- Lavator anguli oris, anterior surface of maxilla

Medially – Levator labi superioris alaquenasi

Laterally – Zygomaticus major,

Superiorly – Quadratus labi superioris

Inferiorly - Oral mucosa ,Orbicularis oris

Canine space / Infraorbital space

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 the nasolabial fold,

• Swelling of the upper lip,

• Oedema occurs in lower eyelid leading to closure of eye.

• 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 hemostat is inserted through levatoranguli oris into abcess cavity.

• Drainage with drain secured.

Submandibular spaceBOUNDARIES:-ANTERIORLY – Anterior bellly of digastric

musclePOSTERIORLY – Posterior bellly of digastric

muscle, stylohyoid, stylopharyngeousmuscle.

LATERALLY -skin, superficial fascia, platysma

SUPERFICIAL- Platysma, Investing fasciaDEEP- Myelohyoid, Hyoglossus, superior

constrictor

INFERIORILY -Anterior & posteriorbellies of the diagastric

SUPERIORILY -Inferior medial aspect of mandible & mylohyoid

muscle

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

Clinical Evaluation:

Swelling begins at lower border of mandible extends to the level of hyoid bone in a shape of inverted cone.

No trismus.

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.

• 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

• BOUNDARIES:-

• ANTERIORLY - Lingual surface of mandible

• POSTERIORLY - Submandibularspace

• INFERRIORLY - Mylohyoid muscle

• SUPERIORIL -oral mucosa

• MEDIALLY- - geniohyoid, genioglossus & styloglossus

• LATERALLY - lingual aspect of mandible

Sublingual space

CAUSE

• Mandibular premolars and molars, trauma

Sublingual spaceClinical 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.

• 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)

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

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

Submental space

ETIOLOGY:-

• From lower anteriors.

• Secondarily due to infection from submentallymph nodes which drain lower lip, skin overlying chin, anterior part of floor of the mouth, tip of the tongue & sublingual tissues.

• Symphysis fracture.

Submental space

Clinical evaluation:

Swelling is limited to the point of the chin & to the region immediately below it

• 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 platysma muscle at most inferior aspect of swelling.

Drain & dressings are placed.

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.

Ludwig’s Angina

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.

- Drooling, dysphagia and neck stiffness are common.

- Anteriorly protruding tongue is present

- Trismus is usually absent.

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

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

There are 5 masticatory spaces .

1. Superficial temporal space

2. Infratemporal space

3. Deep temporal space

4. Submassetric space

5. Pterygomandibular space

Masticatory space

Boundaries –

• Superiorly & Laterally Temporal fascia

• Inferiorly – Zygomatic arch

• Medially Lateral surface Temporalis muscle

Superficial temporal space

cause

• Infection from maxillary and mandibular molars.

Superficial temporal space

Clinical evaluation:

•swelling above & below the zygomatic arch causing a dumbell shapedappearance

• Severe pain & trismus

• 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.

• 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.

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.

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, inferior petrosal sinus

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.

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

Infratemporal space

Cause

• Infection from maxillary molars

Infratemporal space

• Clinical features :

• Marked Trismus• swelling of face in front of ear, over TMJ & zygomatic

arch• Eye is closed and proptosed

• Contents – Pterygoid plexus, Internal maxillary

artery and vein.

• Neighboring Spaces – Buccal, superficial

temporal, inferior petrosal sinus

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.

• 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.

SUBMASSETERIC SPACE

• BOUNDARIES:

AnteriorilyBuccal 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

ETIOLOGY:-

•

– Periocoronal infection, periapical infection with mandibular third molars (linguoversion with root buccally placed)

- Fracture of angle of mandible

CLINICAL FEATURES:-

– Swelling over the angle of mandile from the level of the zygomatic arch to inferior border of mandible , anteriorilyto anterior border of masseter and posteriorly to posterior border of mandible.

– Deep seated severe throbbing pain

– Trismus

– Tenderness over the mandibular ramus,.

CONTENTS -

• Masseteric artery and vein

Neighboring spaces-

• Buccal, pterygomandibular, superficial temporal, parotid space

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.

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 pterygoidmuscle

– Inferiorly – Inferior border of mandible

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 soft palate and the anterior tonsillar pillar with deviation of uvula to the unaffected side.

– If Peritonsillar abscess (Less trismus, no dental involvement)

• 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

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 pterygomandibularraphae.

• Blunt dissection using hemostat.• Drainage.

• Extra oral incision is made below the angle of mandible.

Lateral pharyngeal space infections

• It lies immediately posterior and lateral tothe pharynx

• Anatomically the lateral pharyngeal spacemay be thought of as an inverted pyramidshape-the base of the pyramid being theskull base and the apex the hyoid bone.

• 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

• 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

•

• 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.

Lateral pharyngeal space infection

• Firm swelling with surrounding erythema lateral and anterior to sternocleidomastoid muscle.

• Difficulty in flexing and turning of neck.

• Trismus secondary pterygoidmuscle involvement.

• Dysphagia.

• Dyspnoea.

Clinical evaluation

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.

Complications

• Suppurative jugular venous thrombosis.

• Patient will have shaking chills, high fever.

• Tenderness at the mandibular angle and along sternocleidomastoid muscle.

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)

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

Parotid space infection

• ETIOLOGY:

– From extension of infection from submasseteric, pterygomandibular, lateral pharyngeal spaces,

– Blood-borne infection, retrograde infections through the stensons duct.

Parotid space infection

.

Clinical evaluation:

The symptoms of parotitis include pain andinduration over the involved gland.

Purulent marked swelling of the angle of the jawwithout associated trismus or pharyngealswelling.

Secretions may sometimes be expressed aftermassage from the parotid depth.

Very characteristic pitting edema of the gland ispathognomic for parotid gland abscess.

Drainage of parotid space infection

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)

Retropharyngeal spaceRetropharyngeal space is the potential space sandwichedbetween alar and prevertebral layers of deep layer of thedeep investing fascia.

Extension Base of the skull

Mediastinum

Two compartments:

Suprahyoid

1. Lymph nodes and fat.

Infrahyoid

1. Only fat

Sagittal section of retropharyngeal space

Most dangerous of all types of deep neck infections (Danger space)

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.

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 wideadults – 22mm wide

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.

Management of Retropharyngeal space infection

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.

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 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

MRI

Complications of space infection

• Osteomyelitis

• Mediastenitis

• Brain abcess

• Meningitis

• Cavernous sinus thrombosis

• Scar formation

• Sinus tract formation

Signs & symptoms of toxicity

• Dyspnoea• Dysphagia• Paleness• Tachypnoea• Tachycardia• Fever• Lethargy

• level of consciousness

• Evidence of meningealirritation

(severe headache)

• Eyelid edema & abnormal eye signs

CNS symptoms

Who should be hospitalized ???

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.

• 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.

Controversies

• Surgical vs ultrasound-guided drainage of deep neck space abscesses: a randomized controlled trial: surgical vsultrasound 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.

Controversies

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.

• ConclusionsUltrasound 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.

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.

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)

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)

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.

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,

Head and Neck space infections (Dissertation )

University of sydney.

Websites -http://www.upd8.org.uk

References.

Thank you