ODONTOGENIC INFECTIONS OF HEAD

AND NECK

PRESENTED BY: DR MOHAMMED HANEEF

Index Introduction Classification of infection Stages of infection Microbiology of odontogenic infections Management of odontegic infections Classification of fascial planes Progression of infection Space infections of maxilla Space infections of mandible Space infections of neck Principles of treatment Management Refrences

Introduction Potential or actual space between fascia and muscles containing nerves, blood

vessels and connective tissue but this becomes pathway of infection in presence of infection

Infection may be defined as invasion and multiplication of microorganisms in body tissues, especially that causing local cellular injury due to competitive metabolism, toxins, intracellular replication, or antigen-antibody response

Fascial space infections are a relatively common presentation to both general medical and dental practitioners.

Infections originating in deeper structures can be severe, rapidly progressive and may cause prolonged morbidity, long term complications as well as potentially endanger life.

Classification of infections

According to the clinical appearance:a) Acute infections

b) Chronic infections

c) Acute exacerbation of a chronic infection Depending on the etiological agent:

a) Bacterial

b) Viral

c) Fungal According to source of infection:

a) Odontogenic

b) Secondary infections of lesions such as cyst or tumors

c) Infections arises from contaminated wound/trauma

d) Iatrogenic infections

Stages of infections Stage I: Initiation of infection

• Mostly odontogenic in origin, • Periapical/periodontal/pericoronal infection• Mildly symptomatic or asymtomatic.

Stage II: Entry of infection in medullary bone•Symptomatic, patient seeks treatment•Tender on percussion•No space for pus to drain starts effecting the medullary bone

Stage III: Path of drainage•Pus follow path of least resistance•Perforates cortex that is thinner•Appears in soft tissues, extra oral swelling•May lead to cellulitis or abscess formation

Stage IV: Spread of infection•Spreads to another space along anatomical barriers•May perforate the skin to form sinus

Microbiology of odontogenic infections Bacterial composition

1. 5%-aerobic bacteria 2. 60%-anaerobic bacteria3. 35% mixed aerobic and anaerobic bacteria

Commonly cultured organisms: alpha-hemolytic Streptococcus, Peptostreptococcus, Peptococcus, Eubacterium, Bacteroides (Prevotella) melaninogenicus, and Fusobacterium.

Quantitative estimations of the number of microorganisms in saliva and plaque range as high as 1011/ml.

Microbiology – aerobic Gram-positive cocci 85%

Streptococcus spp. Streptococcus (group D) spp. Staphylococcus spp. Eikenella spp.

Gram-negative cocci (Neisseria spp.) 2%

Gram-positive rods (Corynebacterium spp.) 3%

Gram-negative rods (Haemophilus spp.) 6%

Miscellaneous and

undifferentiated 4%

Microbiology- Anaerobic Gram-positive cocci 30%

Streptococcus spp. Peptostreptococcus spp. Staphylococcus spp.

Gram-negative cocci (Veillonella spp.) 4%

Gram-positive rods 14% Eubacterium spp. Lactobacillus spp. Actinomyces spp. Clostridia spp.

Gram-negative rods 50% Bacteroides spp. Fusobacterium sp.

Management of odontogenic infections Determine the severity of the infection Complete history Physical examination State of the patients host defense Treat the infection surgically Support the patient medically Choose the appropriate AB Re-evaluate the patient frequently

Severity of infection

How the patient feels Previous treatment Self treatment Past Medical History Complete History

Chief ComplaintOnsetDuration Symptoms

Clinical presentation History-previous toothaches (onset,

duration), presence of fever, and previous treatments (antibiotics ) important

Patients may complain of trismus, dysphagia and have shortness of breath should be investigated.

Findings vary from mild swelling and pain to life-threatening airway compromise and CNS impairment

Inspection, palpation, and percussion are integral parts of the exam

Begin extraorally and then move intraorally Skin of the face, head, and neck for

swelling, erythema, sinus or fistula formation.

Assess for cervical lymphadenopathy and fascial space involvement

Assess for the presence and magnitude of trismus

Examine quality and consistency:Soft to fluctuant (fluid filled) to hard (indurated)

Normal vs abnormal tissue architecture:Distortion of mucobuccal foldSoft palate symmetric with uvula in midline

(deviation → involvement of lateral pharyngeal space)

nasolabial fold, circumorbital areas

Identify causative factors:Tooth, root tip, foreign body, etc.

Vital signs should be taken:Temperatures > 101 to 102°F

accompanied by an elevated heart rate indicate systemic involvement of the infection and increased urgency of treatment.

Imaging studies can further substantiate diagnosis – Panorex, Plain Films , CT , MRI

Computerized tomograms should be obtained when infection has spread into fascial spaces in the orbit or neck

Infections, well-localized to oral cavity do not require special imaging studies with a panorex being sufficient for diagnosis and treatment

Host – Defense mechanisms Local defenses

Intact anatomic barrierIndigenous bacteria

Humoral defensesImmunoglobulinsComplement

Cellular defensesPhagocytesLymphocytes

Medically compromised patients

Uncontrolled metabolic diseasesDiabetesAlcoholismMalnutrition

Suppressing diseasesLeukemiaLymphomaMalignant Tumors

Suppressing drugsChemotherapeutic agentsImmunosuppressives

One of the most common & difficult problems

Range from low-grade to severe, life-threatening

Most are easily managed with minor surgery and antibiotics

Common types of infection: Periapical, periodontal, postsurgical,

pericoronal

May begin as well-delineated, self-limiting condition with potential to spread and result in a major fascial space infection.

Life-threatening sequelae can ensue: Septicemia, cavernous sinus thrombosis,

airway obstruction, mediastinitis

Progression of Odontogenic InfectionsProgression of Odontogenic Infections

Periapical Periodontal Soft tissue involvement

Determined by perforation of the cortical bone in relation to the muscle attachments

Cellulitis- acute, painful, diffuse borders Abscess- chronic, localized pain, fluctuant,

well circumscribed.

Cellulitis: initial stage of infection

Diffuse, reddened, soft or hard swelling that is tender to palpation.

Inflammatory response not yet forming a true abscess.

Microorganisms have just begun to overcome host defenses and spread beyond tissue planes.

True abscess formation

As inflammatory response matures, may develop a focal accumulation of pus.

May have spontaneous drainage intraorally or extraorally.

Differences between cellulitis & abscess

Cellulitis Abscess

Duration Acute Chronic

Pain Severe generalized Localised

Size Large Small

Localization Diffuse borders Well circumscribed

Palpation Doughy indurated Fluctuant

Presence of pus No Yes

Degree of seriousness

Greater Less

Bacteria Aerobic anaerobic

Classification of fascial spaces

Based on mode of involvement I. Direct involvement (Primary spaces) – maxillary

spaces , mandibular spaces II. Indirect involvement (Secondary spaces ) – Lateral

pharyngeal space Based on clinical significance by Topazian

I. Face – buccal, canine, masticatory, parotid II. Suprahyoid – sublingual, submandibular (submaxillary,

submental) pharyngomaxillary (lateral pharyngeal) peritonsillar

III. Infrahyoid – anterovisceral (pretracheal)IV. Spaces of total neck – retropharyngeal, space of carotid

sheath

BASED ON FASCIA I. Superficial fascia

II. Deep cervical fascia

1. Anterior layer • Investing fascia ( over the neck)• Parotidomasseteric• Temporal

2. Middle layer • Sternohyoid - omohyoid division • Sternothyroid - thyrohyoid division • Visceral division – • Buccopharyngeal • Pretracheal • Retropharyngeal

3. Posterior layer• Alar division• Prevertebral division

According to Grodinsky & Holyoke in 1938

I. Space 1 – potential space superficial and deep to the platsyma muscle

II. Space 2 – space behind the anterior layer of deep cervical fascia

III. Space 3 – pretracheal space, ant to layer of deep cervical fascia

IV. Space 3A – viscerovascular space; is the carotid sheath from the jugular foramen and carotid canal at the base of skull to the pericardium (lincoln’s highway)

V. Space 4 – ‘Danger space’ potential space b/w alar and prevertebral fascia. Extends from base of skull to the prevertebral fascia

VI. Space 5 – it is the space enclosed by the prevertebral fascia posterior to transverse processes of vertebrae

According to killey and kay

1. In relation to lower jaw:1. Submental

2. Submandibular

3. Sublingual

4. Buccal

5. Submassetric

6. Parotid

7. Pterygomandibular

8. Lateral pharygeal

9. Peritonsillar

2. In relation to the upper jaw:a) Canine space

b) Palatal space

c) Maxillary antrum

d) Infratemporal space

e) Subtemporal space

SPACE OF BURNS : The Suprasternal Space

The superficial fascia splits below the level of the hyoid bone to form 2 spaces

- Forms lower part of the roof of the post triangle, the fascia splits into two layers, attached to clavicle

- Forms lower part of the roof of the ant triangle and fascia splits to form the suprasternal space

Spaces involved in odontogenic infections Primary maxillary spaces – canine, palatal, and

infratemporal spaces Primary mandibular spaces – submental, buccal,

submandibular and sublingual spaces Secondary fascial spaces – masseteric,

pterygomandibular, superficial & deep temporal, lateral pharyngeal, retropharyngeal, prevertebral , parotid

Maxillary Odontogenic Infections

Canine space Palatal space Infratemporal

space Subtemporal space

Canine space infection/ Infraorbital space infection

This is a potential space present on the anterior surface of the maxilla in the region of canine fossa

Appear commonly as labial sulcus swelling Levator anguli oris and levator labii

superioris muscle overlies apex of canine root

Origin: canine fossa. Insertion: angle of mouth

Boundries:• superiorly:

a) Levator angulii oris

b) Levator labii superioris

• Posteriorly:a) Buccal space

• Inferiorly:a) Orbicularis muscleContents: infrorbital nerve and its branches

Canine space infection

Signs: • Obliteration of the nasolabial

fold • Drooping of angle of mouth• Superior extension can

involve lower eyelid• Open in relation to medial

canthus of eye

Incision for canine space infection Intra-oral approach, high in labial vestibule

by sharp and blunt dissection Percutaneous drainage – lateral to the nose

Differential diagnosis:

a) Maxillary sinusitis

b) Dacryocystitis

Palate is covered by tightly adherent mucoperiosteum

Periosteum is tightly bound to the mucosa, periodontal membrane of the adjacent teeth and to the suture in the midline

Pus tends to accumulate between periosteum and bone

Infections begin in lateral incisor or upper post tooth

It is in the subperiosteal space of palate

Exquisitely painful due to rich innervations of the periosteum

Palatal space infection

Signs and symptoms circumscribed fluctant swelling confined to

one sideMay discharge from the gingival sulcusInfection does not cross midlineInfection from:•Upper lateral incisor•Palatal pocket in premolars or molars•Infection of palatal root

Management: Incision should be in AP direction to

avoid injury to anterior palatine nerve Treatment of offending toothDifferential diagnosis:Extravasation cystGummaPleomorphic adenomaCarcinoma of maxillary antrum

Infratemporal space infection

Odontogenic infections of maxillary posterior teeth Odontogenic infections involving the

pterygomandibular space or infection from buccal space coursing along the masticatory fat pad.

Anatomical boundries:a. laterally: ramus of mandible, temporalis muscle and

temporalis tendon

b. Medially: lateral pterygoid plate

c. Superiorly: infratemporal surface of the greater wing of sphenoid

d. Inferiorly: lower head of lateral pterygoid muscle

Contents:a. Origin of pterygoid muscles

b. Pterygoid venous plexus

c. Internal maxillary artery

d. Mandibular nerve and its branches Signs and symptoms:

a. Infected upper molar teeth

b. Severe trismus is universal finding

c. extraoral swelling over the sigmoid notch, intra oral swelling in the tuberosity area

Management:a. Intravenous antibiotics

b. Incision in upper buccal sulcus in third molar region

c. Use of sinus forceps along medial surface of coronoid and temporalis upwards and backwards

Mandibular Space Infections

Sublingual space Submental space Submandibular space Ludwigs angina Masticator space Lateral pharyngeal

space Temporal space

Submental space

Potential space present just below the chin region on the medial surface of the mandible

It is a midline structure bordered laterally by the anterior bellies of digastric muscle

Infections begin in the anterior mandibular teeth

Secondarily Infected skin wounds or anterior mandibular fractures may also cause infections

BORDERS: • Anterior – inf border of mandible • Posterior – hyoid bone • Superior – mylohyoid muscle • Inferior – investing layer of deep cerical fascia• Deep/Lateral - ant. bellies of digastric muscle

Contents:•Submental lymphnodes•Anterior juglar veins•Adipose tissue

Signs and symptoms:• Firm circumscribed swelling beneath the

chin• Patient complains of discomfort and

difficulty in swallowingManagement:•Incision is made bilaterally through the skin,

subcutaneous tissue and platsyma muscle at the most inferior aspect of swelling• A hemostat is inserted through one incision and

then exited through the second incision

Incision for submental abscess

Sublingual space It is a potential space present in the anterior part of

the floor of the mouth It almost always involved with submandibular space Only loose connective tissue separates right and left

sublingual spaces and infection spreads easily from side to the other

Boundries: • Anteriorly and laterally– medial surface of mandible • Posteriorly – submandibular space • Superiorly – sublingual mucosa• Inferiorly – mylohyoid muscle • medially - genioglossus, geniohyoid, styloglossus muscles• Superficial – muscles of tongue • Deep – ant.bellies of digastric muscle

The styloglossus muscle passes b/w superior & middle pharyngeal constrictor muscles in this region to enter the tongue

The seperation b/w these pharyngeal constrictors formed by the styloglossus muscle is termed BUCCOPHARYNGEAL GAP

Sublingual space

Elevation of floor of mouthTongue raised Respiratory difficulty

Incision is placed at the base of the alveolar process in the lingual sulcus so that the sublingual gland, lingual nerve & submandibular duct are not injured

A hemostat is inserted through the incision in an ant & post direction & beneath the sublingual gland to evacuate the pus

Incision for Sublingual space infection

Submandibular space It is a potential space present on the medial surface of the

posterior aspect of the mandible Anatomical boundries:

• Anteriorly – ant. belly of digastric muscle• Posteriorly - post. belly of digastric muscle, stylohyoid muscle,

stylopharyngeus muscle • Superior – inf & medial surfaces of mandible • Inferior – digastric tendon • Superficial – platsyma muscle, investing fascia • Deep – mylohyoid, hypoglossus, sup constricting muscles• Laterally – bounded by skin, superficial fascia, platysmaContents:

•Submandibular salivary gland•Lymph nodes•Facial artery•Lingual and hypoglossal nerves

Submandibular space

Triangular swelling Begins at the lower

border of mandible, extends to level of hyoid bone

Brawny induration Usually associated

with lowermolar infection

Two stab incisions are placed at the inf aspect of swelling in the shadow of the mandible

Extended through the skin & superficial fascia

Dissection is bluntly done through one incision with a curved hemostat, which is inserted through the platsyma muscle & deep fascia in abscess for drainage

Submandibular incision

A hemostat is passed thru the

cavity and out the other incision A thin rubber drain is inserted through the

wound beaks of the hemostat & withdrawing the Instrument Dressing is placed

Ludwig’s angina First described by wilhelm fredreich

von ludwig in 1836. Its rapidly spreading in nature Ludwig’s angina is a form of firm,

acute, toxic and severe diffuse cellulitis that spreads rapidly, bilaterally, affecting the submandibular, sublingual and submental spaces and resulting in a woody swelling

Clinical features

Bilateral suprahyoid swelling with hard cardboard like

consistency, non fluctuating & painful on palpation

Swelling is characterized by rapid onset

Difficulty in breathing (dyspnea),

Difficulty in swallowing (odynophagia)

Restricted tongue movements, elevated tongue ,inability to

open the mouth, salivation

Patients may exhibit muffled voice due to edema of vocal

apparatus (hot potato voice)

EitiologyOdontogenic infectionsTraumatic injuriesInfective conditions like osteomyelitis

Pathology:Infection from the source reaches the submandibular spaceThe submental spaces gets involved via the lymphaticsIt’s a cellulitis it rapidly spreads reaches the epiglottis

producing edema and inflammation of laryngeal inlet.Spreads to pterygomandibular, massetric and lateral

pharyngeal spacesPatient may die with in 24 hours due asphyxia if not treatedMay die from septic shock, aspiration of pus or mediastinitis

Signs and symptoms:

a. Pyrexic

b. Dehydration

c. Dysphagia

d. Rapid shallow breathing

e. Hoarseness of voice Extra oral features:

a. Hard to firm brawny, board like swellin

b. Skin is shiny stretched and erythmatous

c. Tender swelling with local rise in temperature

d. Unable to close the mouth and drooling of saliva

e. Evident respiratory distress, use of accessory muscle of respiration

f. Trismus Intra oral features:

a. Floor of mouth is raised

b. Tongue appears swollen and raised upwards towards the palate

c. Increased salivation

The cardinal signs of Ludwig’s angina are:1. Bilateral involvement of more than a single deep

tissue space2. Gangrene with serosanguinous, putrid infiltration

but little or no frank pus3. Involvement of connective tissue, fascia, and

muscle but not glandular structures4. Spread via fascial space continuity rather than by

lymphatic system

Danger signs:5. Dysapnoea6. Dysphagia7. Hoarseness of voice8. Stridor9. Swelling below the clavicles

Diagnosis & investigations UltraSonography: Used to identify fluid

collection in the soft tissues. C.T. Scan M.R.I

UltraSonography: Effective diagnostic tool in treatment of acute

odontogenic fascial space infections and cellulitis Micro convex probe of 6.5Mhz is used Probe is applied over skin, covering the swelling

in transverse and axial sections Echoing of sound from the fluids is absent

thereby detecting the fluid collection

Differential diagnosis

Angioneurotic edema Lingual carcinoma Sub lingual hematoma Salivary Gland abscess Peri-tonsillar abscess

Complications

Septicemia Carotid blow out Obstruction of upper respiratory airways Aspiration pneumonia Spread of infection into Para pharyngeal

spaces-mediastinum-produce thoracic empyema

Death due to airway compromise

TREATMENT : Early diagnosis of incipient cases Maintenance of patent airway Intense & prolonged antibiotic therapy Extraction of affected teeth Hydration Early surgical drainage

“ A chance to cut is a chance to cure ”

Classic approach / Cut- throat approach:

Horizontal incision midway b/w chin & hyoid bone.

Bilateral incision into the submandibular spaces with blunt dissection to the midline

Through and through drain or bilateral drains meeting at the midpoint

Buccal space infection Buccal space occupies portion of

subcutaneous space b/w facial skin & buccinator muscle

Maxillary & mandibular premolar and molar teeth tend to drain in lateral & buccal direction

Relation of root apices to buccinator muscle determines path of infection : intraorally in buccal vestibule or deeply in buccal space

BORDERS: Anterior – corner of mouth Posterior – masseter muscle, pterygomandibular

space Superior – maxilla, infraorbital space Inferior – mandible Medial – subcutaneous skin Lateral – buccinator muscle

BUCCAL SPACE INFECTION

Signs and symptoms:•Dome shaped swelling beginning

at lower border of mandible• extending upwards to level of

zygomatic arch•Diagnosed because of marked

cheek swelling associated with diseased molar/premolar tooth •Not associated with trismus

Management Intra – oral drainage:

Is done with the incision made through the buccinator muscle It is difficult in maintaining a patent opening for drainage because

contraction of muscle fibres tend to close it off Hence a horizontal rather than a vertical incision is made just

above the depth of the vestibule Extra oral drainage:

Inferior to point of fluctuance with blunt dissection Incisions are placed below the lower border of mandible 2 stab incisions are made with a no.11 blade through the skin &

subcutaneous tissue A curved hemostat is inserted thru the anterior incision into the

buccal space and then turned & exited through the posterior incision

Beaks of hemostat are opened, strip of rubber drain is grasped. Hemostat is withdrawn carrying drain through the tissues

Ends are fastened, dressing placed

Submasseteric space Earliear this space was considered to

between masseter and the lateral aspect of the ramus of the mandible.

Now it is found to be between three layers of the masseter muscle itself

Submasseteric swellings can be differentiated from parotid swellings as these produce marked Trismus overlying masseter muscle

Obscure earlobe or elevation of ear lobe in frontal view

BORDERS: Anterior– buccal space Posterior – Parotid gland Superior – zygomatic arch Inferior – pterygomassetric sling Medial – ascending ramus of mandible Lateral – masseter muscle

Infection can spread from lower third molarsSigns and symptoms:

•External facial swelling confined to masseter muscle

•Swelling usually does not extend beyond the posterior border of the masseter into the postauricular area

•Swelling acutely tender

•Almost complete trismus

•Overlying skin reddened and stretched

•Pus may drain at the angle of the mandible

Management: Intraorally:

Drainage is done through a vertical incision along the ext oblique line of the mandible

Starting at the level of the occlusal plane and extending downward & forward in the buccal sulcus to a point opp the second molar

A hemostat is inserted and passed posteriorly along the lateral aspect of the ramus to point beneath masseter muscle

Beaks are openedRubber drain is inserted & sutured Extraorally:

•Incision is made behind the angle of the mandible (retromandibular incision)

•Hemostat is inserted and passed along the lateral aspect of the ramus

•Rubber drain is inserted

Pterygomandibular space

Most frequently affected anatomical compartmentCorrelated highly with pericoronitis & mandibular third molar

secondary infection results from spread from the sublingual and submandibular spaces

Symptoms: • Trismus – due to edema & inflamm of med pterygoid• Swollen ant tonsillar pillar • Deviation of uvula to opposite side

Communications:• Deep temporal space: By passing around the

lateral pterygoid muscle superiorly, running from the mandibular condyle neck and the articular disc to the medial pterygoid plate.

• Lateral pharyngeal space:by along the anterior border of medial border of medial pterygoid muscle following postereolateral surface of the buccinator and the superior pharyngeal constrictor muscles

Rt.Pterygomandibular Space Infection

BORDERS: • Anteriorly – pterygo mandibular raphae,buccal space • Inferior – inf border of mandible upto attachment of

medial pterygoid muscle, pterygomassetric sling• Superior – Lateral pterygoid muscle • Posterior – deep lobe of parotid gland • Superficial – lateral pterygoid muscle • Deep – ascending ramus of mandible • Medially – medial pterygoid muscle• Laterally – ascending ramus of the mandible

Contents:• Inferior alveolar nerve• Lingual nerve• Nerve to mylohyoid• Inferior alveolar artery and vein

NOTE : DANGER SPACE 4 IS THE SPACE BETWEEN PREVERTIBRAL AND ALAR FASCIA

PTERYGOMANDIBULAR SPACE

PTERYGOID SPLEXUSEMISSERY VEINS

CAVERNOUS SINUS THROMBOSIS

LATERAL PHARYNGEAL SPACE

RETROPHARYNGEAL SPACE

MEDIASTINUMCAROTID SHEATHDANGER SPACE 4

Management Extra oral mandibular block

is given Incision is placed through

the mucosa in the area b/w medial aspect of the ramus & pterygomandibular raphe.

Abscess is opened by blunt dissection and Drain is placed

Temporal space Two divisions:

a. Superficial – It is between superficial temporal fascia and lateral aspect of temporalis muscle

b. Deep – It is between the medial surface of the temporalis muscle and periosteum of temporal bone.

Inferiorly the temporal space is limited to the attachments of the temporalis muscle and fascia. Inferiorly, it communicates with the pterygomandibular space

Its contains loose connective tissue and vessels supplying the temporalis muscle

Signs and symptoms:• Swelling confined to the shape of the muscle extending from the

lateral orbital rim, above the zygomatic arch, covering the lateral aspect of tempral bone.

• swelling more prominent in a superficial temporal space infection.

• severe trismus Deep temporal abscess

Produce less swellingLies deep to temporalis muscleLess fluctuant

Management: Intra oral sicher’s incision along the anterior border of the ramus of the

mandible Extra oral cutaneous incision slightly above the zygomatic arch made

parallel to zygomatic arch followed by blunt dissection and placement of drain

Lateral pharyngeal space Also known as Pharyngomaxillary/

parapharyngeal space Lateral neck space shaped like an inverted

cone Base is uppermost at the base of the skull Apex is at the greater horn of the hyoid

bone Infections may result from – pharyngitis,

tonsilitis, parotitis, otitis, mastoiditis and dental infection

Pharyngomaxillary space Suprahyoid• superior—skull base• Inferior—hyoid• Anterior—ptyergomandibular raphe• Posterior—prevertebral fascia• Medial—buccopharyngeal fascia• Lateral—superficial layer of deep fascia• Prestyloid

Muscular compartment Medial—tonsillar fossa Lateral—medial pterygoid Contains fat, connective tissue, nodes

Poststyloid Neurovascular compartment Carotid sheath Cranial nerves IX, X, XI, XII Sympathetic chain

Stylopharyngeal aponeurosis of Zuckerkandel and Testut

Alar, buccopharyngeal and stylomuscular fascia.

Prevents infectious spread from anterior to posterior.

Borders: Anterior – sup & middle pharyngeal constrictor muscles Medially – superior constrictor, styloglossus muscle,

stylopharyngeus and middle constrictor muscle Posterior – carotid sheath & scalene fascia Superior – skull base Inferior – hyoid bone Superficial – pharyngeal constrictors, retropharyngeal space Deep – medial pterygoid muscle Signs and symptoms: For surgical & anatomical purposes, it is divided into anterior &

posterior compartments Ant comp infection pt exhibits pain, fever, chills, medial bulging

of lat pharyngeal wall with deviation of palatal uvula from midline, dysphagia, swelling below the angle of the mandible

Post comp has absence of trismus & visible swelling, BUT resp obstruction, septic thrombosis of int jugular vein and carotid artery hemorrhage

Severe trismusLateral swelling of

the neckBulging of the lateral

pharyngeal wall pushed to midline

Usually no extra oral swelling

Rapid progression of infection in this space is common

Lateral pharyngeal space infection

Management

Aggressive antibiotic therapy If the mouth can be opened, intra oral incision

medial to the anterior border of the ramus Extra orally

The incision is placed 1cm below and behind the angle of the mandible. Sinus forceps are inserted into the space between submandibular and parotid gland and passed medial to mandible and upwards along the inner aspect of medial pterygoid muscle.drain is inserted

Peritonsillar Space The peritonsillar space consists of

loose connective tissue between the capsule of the palatine tonsil and the superior constrictor muscle. The anterior and posterior tonsillar pillars contribute to its anterior and posterior borders, respectively. The posterior tongue forms the inferior boundary. Peritonsillar infections may readily spread to the parapharyngeal space.

Quincy

Peri-tonsillar spaceClinical evaluation: 3-7 days H/o pharyngitis . Severe sore throat, dysphagia, Odyonophagia and referred

otalgia. The speech is muffled and classically described as hot potato

voice. Trismus is not present In recent literature,needle aspiration instead of open incision

and drainage (JOMS,Vol 51,1993)

Parotid Space

Formed by the superficial layer of deep cervical fascia surrounding the gland

Boundaries :

Swelling extends from level of zygomatic above to lower border of mandible

Anteriorly it ends at the anterior border of mandible

Posteriorly it extends into the

retromandibular region

Parotid space Superficial layer of deep fascia

Dense septa from capsule into gland Direct communication to parapharyngeal space

Contains External carotid artery Posterior facial vein Facial nerve Lymph nodes

C/F Everted ear lobule Severe pain referred to the ear, accentuated

by eating Trismus

Spaces of the neck

1. Retropharyngeal space2. Prevertebral space3. Mediastinitis

Retropharyngeal ,danger space and prevertebral spaces lie between deep cervical fascia the surrounds the pharynx and oesophagus anteriorly and vertebral spine with its muscle attachments posteriorsly

Retropharyngeal spaceAnatomical boundries:

1. anteriorly: constrictor muscles of the neck and their fascia

2. Posteriorly: alar layer of deep cervical fascia which extends from the base of the skull to the superior mediastinum

A midline septum exists between the right and left retropharyngeal spaces that is crossed easily.Contents

1. Adenoidal tissues draining posterior pharyngeal wall

2. Lymphnodes draining waldeyers ring

Prevertebral space: extends from base of the skull to the coccyxanteriorly bounded by prevertebral fascia

For spaces of the neck the infections may arise from nasal, pharyngeal, dental infections

Clinical features of space of neck Drooling Fever Irritatibility Nuchal rigidity –

neck siffnessIrritability lightHead ache

Dyapnoea Dysphagia Bulging in the posterior pharyngeal wall may be there

Dangers involves severe laryngeal edemaRupture of abscess leading to aspiration

pnemonia or asphyxiaMediastinitis

Management Tracheostomy Extreme trendelburg position Surgical intervention Intra oral: through posterior pharyngeal wall Extra oral:

inferior to hyoid parallel to sternocleidomastoid, retraction of muscle and carotid sheath, blunt dissection till hypopharynx.

Deep dissection to carotid sheath between it and inferior constrictor muscles rupture retropharyngeal abscess

Deep drains inserted

Principles in Treatment of Oral and Paraoral Infections

a) Remove the cause.

b) Establish drainage.

c) Institute antibiotic therapy.

d) Supportive care, including proper rest and nutrition.

Management of Odontogenic InfectionsGeneral principles

Goals of management of odontogenic infection:

1. Airway protection2. Surgical drainage3. Medical support of the patient 4. Identification of etiologic bacteria5. Selection of appropriate antibiotic therapy

Airway protection1.Floor of mouth and tongue elevation or

narrowing can cause respiratory distress

2.Expedient assessment and diagnosis of airway compromise is the most important initial step in managing odontogenic infections

3.Airway loss is primary cause of death in these patients

• Initially intact airway must be continuously reevaluated during treatment

• Signs and findings of airway compromise: inability to assume a supine position, stridor, and restlessness etc.

• Surgeon must decide the need, timing and method to establish an emergency airway

Surgical drainage

1. Administration of intravenous antibiotics without drainage of pus may not allow for resolution of an abscess

2. Starting antibiotic therapy without Gram's stain and cultures may result in failure to identify pathogens

3. Important to drain all primary spaces as well as explore and drain potentially involved secondary spaces

• CT scans may help identifying spaces involved

• OPG can help identify putative teeth involved

• Canine, sublingual and vestibular abscesses are drained intraorally

• Masseteric, pterygomandibular, and lateral pharyngeal space abscesses can be drained with combination intraoral and extraoral drainage

• Temporal, submandibular, submental, retropharyngeal, and buccal space abscesses may mandate extraoral incision and drainage

Technique:1. Small incision are made in a dependent

area 2. Placement of a hemostat in the abscess

cavity with entry into all loculations of the abscess

3. drains inserted into cavity to allow for postoperative drainage of the abscess

PURPOSES OF SURGICAL DRAINAGE & INCISIONPURPOSES OF SURGICAL DRAINAGE & INCISION

Rid the body of toxic purulent material

Decompress the tissues

Allowing better perfusion of blood containing

antibiotics and defensive elements

Increased oxygenation of the infected area

Dependent drainage of the space is performed by placing a horizontal incision in the most dependent area of the swelling extraorally / intraorally with a cosmetic scar being the result

Medical support of the patient

1. Rehydrate patient as dehydration may be present

2. Treat conditions that predispose patient to infection (DM)

3. Oral pain, trismus , and swelling can be addressed by appropriate analgesia and treatment of underlying infection

Identification of etiologic bacteria1. Expected causes are alpha hemolytic

streptococci and oral anaerobes2. Cultures should be performed on all

patients undergoing incision and drainage and sensitivities ordered if patient is not progressing well (possible antibiotic resistance)

3. An aspirate of the abscess can be performed and sent for culture and sensitivities if incision and drainage delayed

Antibiotic Therapy Removal of the cause, drainage, and supportive

care more important than antibiotic therapy. Infections are cured by the patient’s defenses,

not antibiotics. Risks of allergy, toxicity, side effects,

resistance and superinfection causing serious or potentially fatal consequences must be considered.

Principles of antibiotic use

– Necessity – Empirical therapy – Narrow spectrum – Low toxicity – Bacteriocidal – Administer properly – Cost

Antibiotic therapy, con’t.

Oral infections are typically polymicrobial. Antibiotic effectiveness dependent upon

adequate tissue (not serum) concentration for an appropriate amount of time.

Antibiotics should be prescribed for at least one week – adequate tissue concentration achieved in 24-48 hours, with bacteriocidal activity occurring over the next 3-5 days.

EMPIRIC ANTIBIOTIC TREATMENT

Early infection (first 3 days of symptoms or mildly immunocompromised)

Penicillin

Clindamycin

Cephalexin (or other first-generation cephalosporin)

Flynn TR. The swollen face. Severe odontogenic infections.Emerg Med Clin N Am 2000;18:

Late infection (after 3 days of symptoms or moderately to severely immunocompromised)

Clindamycin (maximum dose)

Penicillin and metronidazole

Ampicillin and sulbactam

Cephalosporin (first or second generation)

Mild, moderate, and severe compromise is based on CD4/viral loads, glycemic control, and the degree of alcoholic related disease.

Antibiotic therapy, con’t.

Penicillin (bacteriocidal) drug of choice for treatment of odontogenic infections (5% incident of allergy).

Clindamycin (bactericiodal) 1st line after penicillin; effective against anaerobes;

Cephalosporin (slightly broader spectrum and bacteriocidal); cautious use in penicillin-allergic patients → cross-sensitivity; if history of anaphylaxis to penicillin, do not use.

Antibiotic therapy, con’t.

Erythromycin (bacteriostatic) good 2nd line drug after penicillin; use enteric-coated to reduce GI upset.

Metronidazole (bacteriocidal) excellent against anaerobes only.

Augmentin (amoxicillin + clavulanic acid) kills penicillinase-producing bacteria that interferes with amoxicillin; expensive.

Selection of antibiotic therapy

1. Penicillin 2. Metronidazole in combination with

penicillin can be used in severe infections 3. Clindamycin for penicillin-allergic patients

Causes for clinical failure include inadequate drainage or antibiotic resistance

COMPLICATIONS OF SPACE INFECTIONS

Brain Abscess :

Etiology – bacteremia accompanying any odontogenic infection

C/F – headache, nausea, vomiting,

Other symptoms : hemiplegia, pappiloedema, aphasia, convulsions, hemisensory deficit

Drug Therapy – antibiotics & steroids

Mannitol to reduce to edema

Chloramphenicol ; antibiotic of choice

Surgery to provide drainage

MENINGITIS

Most common neurological complication

C/F : headache, fever, stiffness of neck & vomiting

Kernig’s sign – passive resistance to extend the knee from flexed thigh position

Brudzinski’s sign – abrupt neck flexion in supine resulting in involuntary flexion of knees

Diagnosis : lumbar puncture

Rx : chloramphinicol + penicillin G Hydration Electrolyte balance Control of cerebral edema Avoidance of vascular collapse and shock

MEDIASTINITIS

Late complication due to delayed diagnosis & inadequate surgical drainage

It is a descending cervical cellulitis that arises from submandibular space infection, parapharyngeal space, pterygomandibular space or buccal space

S/S : unremitting high fever, tachycardia, tachypnoea & hypotension

Brawny edema, induration of neck n chest and crepitus may be palpable

Rx :early recognition , airway control, agg surgical intervention (transthoracic or cervicomediastinal approach), app antibiotic therapy, supportive systemic care & hyperbaric oxygen therapy

CAVERNOUS SINUS THROMBOPHLEBITIS :

External route – danger area of face

Internal route – odontogenic infection from post maxillary region through pterygoid plexus

C/F : Initial – swelling of face with involvement of eyelids

Pulsating exopthalmos

Cranial nerve involvement (oculomotor, trochlear, abducens, opthalmic & carotid sympathetic plexus)

Late – thrombophlebitis

Advanced – toxaemia , meningitis, + Kernig’s sign and brudzinski’s sign

Septicimia

Rx : antibiotic therapy Heparinization – heparin 20,000 units in

1500ml off 5% dextrose or Dicumarol 200mg

Neurosurgical consultation Mannitol Anticoagulants Surgical drainage

Early recognition of orofacial infection and prompt , appropriate therapy is absolutely

necessary

A thorough knowledge of anatomy of the face and neck is necessary to predict pathways

of spread and to drain these spaces adequately

THANK YOU

REFERENCES: Topazian , Oral & maxillofacial infections ,

Vol 4 Daniel M Laskin , text book of oral &

maxillofacial surgery vol II Peterson ,text book of oral & maxillofacial

surgery Neelima malik, text book of oral &

maxillofacial surgery

Fasciae of head and neck