Spaces and its infections

1. FASCIAL SPACES
1

2. PRESENTED BY GUIDED BY
Dr.Neha Bhasin Dr. R.N.Mody
1st year P.G. Student Dr. Ganapathi
Dr. Sreedevi
Dr. Poonam
2

3. CONTENTS-
Definitions
History
Fascia of the Head and Neck
Classifications
Fascial Spaces and their Infections
Complications and their Management
Bibliography
3

4. FASCIAE-
 1. Broad sheath of dense connective tissue whose function
is to separate structures that must pass over each other
during movement like muscles & glands (TOPAZIAN)
 2. A series of connective tissue sheaths in the head and
neck that contains and protect nerves vessels and glands;
permit free movement of individual muscle and bone
groups; and define the boundaries of natural tissue
compartments for the surgeon( SICHER & DUBRUL1975,
WOODBURNE 1975)
4

5. Fascia is an uninterrupted 3-d web of tissues that extends
from head to toe, from front to back, from interior to
exterior.
 Maintains structural integrity, provides support &
protection , acts as a shock absorber.
 Essential role in hemodynamic & biochemical processes
, provides a matrix that allows for intercellular
communication
 Body’s first line of defense against the pathogens
5

6.  The fascial spaces in head and neck are the potential
spaces between the various layers of fascia normally filled
with loose connective tissue (SHAPIRO, 1950)
 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
(MOORE).
6

7. HISTORY OF RESEARCHERS:
 19th Century
 Burns 1811 – pioneer
 Velpaeu 1826 – 37
 Froriop 1834
 Malgaigne 1838
 Dittel 1857
 Juwara 1870
 Henke 1872
 Tillaux 1882
 Poulson 1886
 Shapiro 1950
 Hollinshead 1958
 Furstenberg 1929
 Coller & Yglesia 1935 & 1937
 Grodinsky & Holyoko 1938
7

8.  20th Century (Recent are)
 Archer 1966
 Barker & Davies 1972
 Killey et al 1975
 Moore
 Paperella et al 1991
 Topazian & Gold berg 1991
 Srinivasan 1996
8

9. 9

10. 10

11. Superficial Layer-
 Superior attachment – zygomatic process
 Inferior attachment – thorax, axilla.
 Similar to subcutaneous tissue
Clinical considerations:
 Most important component of rhytidectomy / face-lift
surgery / plastic surgery of the face.
 Necrotizing fascitis
11

12. Superficial Layer
12

13. Deep Fascia of the Jaws
 Temporal fascia
 Aponeurosis
 Parotideomasseteric fascia
 Masseteric fascia
 Parotid fascia
 Pterygoid fascia
13

14. Deep Layer of neck
 Superficial
 Enveloping layer
 Investing layer
 Middle
 Visceral fascia
 Prethyroid fascia
 Pretracheal fascia
 Deep
14

15. Superficial Layer of the Deep Cervical Fascia
 Superior border – nuchal line, skull base, zygoma,
mandible.
 Inferior border – Manubrium, Clavicles, Acromion
 Envelopes
 SCM,Trapezius,Submandibular and parotid.
 Spaces-Posterior Triangle, Suprasternal space of Burns
15

16. Superficial Layer of the Deep Cervical
Fascia
16

17. Middle Layer of the Deep Cervical Fascia
Visceral Division
 Superior border
 Anterior – hyoid and thyroid cartilage
 Posterior – skull base
 Inferior border – continuous with fibrous pericardium in
the upper mediastinum.
Envelopes
 Thyroid
 Trachea
 Esophagus
 Pharynx
 Larynx
17

18. Muscular Division
 Superior border – hyoid and thyroid cartilage
 Inferior border – sternum, clavicle and scapula
 Envelopes infrahyoid strap muscles
18

19. Middle Layer of the Deep Cervical Fascia
19

20. Deep Layer of Deep Cervical Fascia
 Splits into two layers at the transverse processes:
 Alar layer
 Superior border – skull base
 Inferior border – upper mediastinum at T1-T2
 Prevertebral layer
 Superior border – skull base
 Inferior border – coccyx
 Envelopes vertebral bodies and deep muscles of the neck.
 Extends laterally as the axillary sheath.
20

21. Suprahyoid Cross-Section
Showing Layers of Deep
Cervical Fascia 21

22. Carotid Sheath:
 Formed by all three layers of deep fascia
 Anatomically separate from all layers.
 Contains carotid artery, internal jugular vein, and vagus nerve
 “Lincoln’s Highway”
 Extends from skull base to thorax.
22

23. 23

24. Relations
 The ansa cervicalis lies embedded in the anterior wall of
carotid sheath.
 The cervical sympathetic chain lies behind the sheath .
 The sheath is overlapped by the anterior border of the
sternocleidomastoid muscle.
24

25. CLASSIFICATION OF FASCIAL SPACES
BASED ON MODE OF INVOLVEMENT, PETERSON
Direct Involvement. (Primary Spaces)
 Maxillary Spaces – Canine, buccal infratemporal
 Mandibular Spaces – Submental, Submandibular,
Sublingual, Buccal
Indirect inv. (Secondary Spaces)
 Masseteric
 Pterygomandibular
 Superficial and deep temporal
 Lateral and retro pharyngeal
 Prevertebral, parotid, carotid sheath,peritonsillar and
danger spaces.
25

26. Scott’s Classification (1952)
I. Suprahyoid spaces
Hollinshead’s classification(1958)
I. Infrahyoid spaces
1. Superficial facial compartment
a) Canine
b) Buccal
1.Visceral compartment
a) Pretracheal / previsceral
b) Retrovisceral
2. Floor of the mouth
a) Sublingual
b) Submandibular
c) Submental
2. Visceral space
b. Scott’s Classification & Hollinshead’s Classification
26

27. 3.Masticator space
a) Temporal
i. Superficial
ii. Deep
b) Submasseteric
c) Superficial Pterygoid space
3. Other space
a.Cavity within carotid
sheath
b.Space between 2 layers of
prevertebral fascia
27

28. 4.Parapharyngeal space
Including deep pterygoid
space
5.Parotid compartment
6.Paratonsillar space
7.Space of body of mandible
28

29.  GRODINSKY AND HOLYOKE (1938)
Space 1
 It lies superficial to the superficial fascia and therefore is
synonymous with the subcutaneous space.
Space 2
 Spaces surrounding the cervical strap muscles, lying
superficial to the sternothyroid-throhyoid division of the
middle layer of the deep cervical fascia
Or
 Between the sternothyroid-thyrohyoid division and the
sternohyoid-omohyoid division
29

30. Space 3
 It is the potential anatomical space lying superficial
(toward the skin) to the visceral division of the middle
layer of the deep cervical fascia.
 Space 3 contains the pretracheal, retropharyngeal, and
lateral pharyngeal spaces.
 Space 3A is the carotid sheath
30

31. Space 4
 It is the potential space that lies between the alar and the
prevertebral divisions of the posterior layer of the deep
cervical fascia.
 This space is also known as the danger space.
 Space 4A is in the posterior triangle of the neck, posterior
to the carotid sheath.
31

32. Space 5
 It is the prevertebral space.
 Space 5A is enclosed by the prevertebral fascia, posterior
to transverse processes of the vertebrae, as it surrounds
the scalene and the spinal postural muscles.
32

33. 33

34. WILLIAM.W.SHOCKLEY, HAROLD.C.PILLSBURY
I Spaces of the Face
 Maxillary spaces
 Buccal space.
 Canine space.
 Mental space.
II Spaces of neck
 Spaces involving the entire length of the neck.
 Superficial space
 Deep neck spaces (all involve only the posterior side of the
neck)
 Retropharyngeal space (Space 3).
 Danger space (Space 4)
 Prevertebral space (Space 5)
 Visceral vascular space (within carotid sheath).
34

35.  Suprahyoid spaces:
1) Mandibular space
 Submandibular space.
 Submental space.
 Sublingual space.
 Space of the body of the mandible.
2) Masticatory space.
3) Lateral pharyngeal space (Pharyngomaxillary, peripharyngeal )
4) Peritonsillar space.
5) Parotid space.
 Infrahyoid space (involves anterior side of the neck
only).
1) Pretracheal space.
35

36. Concepts about space infections
 The spaces of head and neck are not perfectly enclosed
they are pathways around the muscles through which infection
can spread. Infections within each space have its own
diagnostic signs and tend to spread in an orderly, anatomic
fashion from one space to another by continuous extension.
36

37. ETIOLOGY
General Classification (Based on Origin)
a.Odontogenic
 Pulp disease
 Periodontal disease
 Secondary infected cysts
 Residual infection
 Pericoronal infection
37

38. b. Traumatic
c. Secondary to oral malignancies
d. Implant surgery
e. Reconstructive surgery AND others includes
f. Infected antrum, salivary gland
afflictions,tonsillar,nasal infections,skin
infections – furuncles
38

39. Stages of infections-
 Stage I – Inoculation
 Stage II –Acute stage- cellulitis, abscess
 Stage III – Chronic stage-fistulous/sinus tract or
osteomyelitis
 Stage IV – Resolution
39

40. INTERRELATIONSHIP OF PERIAPICAL INFECTIONS
PULPITIS
ACUTE CHRONIC
APICAL PERIODONTITIS
ACUTE CHRONIC
40

41. PERIAPICAL ABSCESS PERIAPICAL GRANULOMA
ACUTE CHRONIC PERIODONTAL CYST
OSTEOMYELITIS
ACUTE CHRONIC
FOCAL DIFFUSE
PERIOSTITIS
41

42. CELLULITIS ABSCESS
Cellulitis-
 Diffuse inflammation of connective tissue
 Inflammatory response not yet forming a true abscess.
 Microorganisms have just begun to overcome host defenses
and spread beyond tissue planes
42

43. DIFFERENCES BETWEEN CELLULITIS AND ABSCESS
CELLULITIS ABSCESS
DURATION Acute Chronic
PAIN Severe & generalized Localized
SIZE Large Small
LOCATION Diffuse borders Well-circumscribed
43

44. PALPATION Doughy to indurated Fluctuant
PRESENCE OF PUS No Yes
DEGREE OF
SERIOUSNESS
Greater Less
BACTERIA Aerobic Anaerobic / mixed
44

45. SPREAD OF ORAL INFECTIONS
ROUTES OF SPREAD
 Direct continuity through tissues
 By Lymphatic's
 By blood stream
FACTORS INFLUENCING SPREAD
 General factors
 Local factors
45

46. SPACES PERTAINING TO THE UPPER JAW
VESTIBULAR SPACE
46

47. Etiology: - Upper anteriors (infections arising from them,
periapical, periodontal)
Presentation - Based on the muscle attachment
Complications - orbital cellulitis or cavernous sinus
thrombophlebitis.
Upper anterior
Superior Labial venous plexus
Facial Vein then from retrograde direction via
ophthalmic veins
Cavernous sinus
47

48. D.D of swelling of upper lip: -
 Trauma to upper lip/upper Incisions
 Cyst: Nasolabial / Nasopalatine cyst
 Neoplasms: Pleomorphic
Adenoma/mucoepidermoid carcinoma
 Hypersensitivity reactions: Allergic swellings,
odematous swellings  Melkerson Rosenthal
Syndrome
Treatment
 Antibiotics
 Incision  at most dependent part of the swelling Extraction
of offending tooth/RCT
48

49. PALATAL SPACE:
Etiology
 Periapical abscess from posterior teeth, (palatal roots)
 Lateral IncisorsCommon cause, Periodontal abscess
49

50. Boundaries:
 Laterally  Alveolar process of maxilla & teeth
 Supero-Inferiorily  Between cortical plate of hard palate &
overlying periosteum & mucosa
Clinical Features
 Well-defined circumscribed fluctuant swelling confined
to one side of the palate adjacent to the offending tooth & the
tooth is tender on percussion
50

51. Treatment
 I&D, [Intra Orally] for both vestibular & palatal abscess
 For palatal abscess, at the margins incision is done & not at the
dependent part [Antero Posterior Incision]
51

52. CANINE SPACE-
Boundaries-
 Superiorly- levator labii superioris alaeque nasi, levator labii
superioris,zygomatic minor muscles.
 Inferiorly- levator anguli oris muscle
 Anteriorly-orbicularis oris
 Posteriorly-buccinator
 Medially: levator labii superioris
 Laterally: zygomaticus major
Contents:
 Infraorbital nerve, Angular artery and vein
52

53. 53

54. Etiology-
 The canine space is involved in odontogenic and is implicated
even less frequently in nasal infections. Canines & rarely
premolars
 Rarely nasal infections, upper lip infections
Clinical Features:
 Swelling of affected side, upper lip, cheek up to medial canthus
of the eye.
 Obliteration of the nasolabial fold.
 Drooping of mouth.
 Oedema of lower eyelid
 Offending tooth mobile & tender on percussion
54

55. • Enlargement of the upper lip
• Redness & tenderness of the
facial tissues
• Infection may burrow toward
skin on either side of quadratis
labii superioris, & may point
through medial or Lateral
aspect of lower eyelid.
55

56. Surgical Management-
Drainage is accomplished best through an intraoral
approach, high in maxillary labial vestibule for sharp
and blunt dissection.
56

57. Buccal Space
Boundaries:
 Superiorly: Zygomatic arch
 Inferiorly: Lower border of
mandible
 Anteriorly: Posterior border of
zygomaticus major above and
Depressor anguli oris below.
 Posterior: Pterygomandibular raphe
and anterior edge of masseter muscle.
 Medially: Buccinator muscle and buccopharyngeal fascia.
 Laterally: Skin of cheek and subcutaneous tissue
57

58. Contents:
 Buccal pad of fat
 Parotid duct
 Facial artery
 Transverse facial artery
58

59. Clinical Features:
 Obvious dome shaped swelling at lower aspect of the cheek.
 Associated with a diseased molar or premolar tooth.
 Associated pain
 Oedema of the lower eyelid seen
 No trismus.
59

60. Surgical treatment-
Cutaneous drainage should be performed with submandibular
incision into the depth of the space for aesthetic purpose.
 Branches of facial nerve avoided.
 Intraoral drainage through mucosa, submucosa, and
buccinator muscle , difficult.
 Intraorally- horizontal incision placed just above the depth of
vestibules.
 This prevents damage to the parotid duct, and also provides
dependent drainage.
60

61. SUBMENTAL SPACE
Boundaries:
 Anterosuperiorly: Symphysis menti
 Posteroinferiorly: Hyoid bone
 Superolaterally: Anterior bellies of digastric
 Superficially: Skin, Superficial fascia containing platysma
61

62. Contents:
 Anterior Jugular vein
 Submental lymph nodes
Communications: It communicates with submandibular
space posteriorly
62

63. CLINICAL FEATURES---
 Dysphagia, swelling below chin, skin overlying swelling
board like and taut, and fluctuations present.
63

64. Surgical Management-
 Percutaneous surgical drainage is the most effective
approach.
 A horizontal incision is given in the inferior portion of
chin, in a natural skin crease.
 It provides dependent drainage and the most cosmetically
accepted scar
64

65. SUBMANDIBULAR SPACE
Boundaries:
 Superiorly: Myelohyoid and
genioglossus
 Inferiorly: Skin, Superficial
fascia containing platysma,
deep fascia
 Laterally: Lingual aspect of
mandible below, myelohyoid line
 Medially: Mylohyoid, Hyoglossus, Styloglossus
 Anteroinferiorly: Anterior belly of digastric
 Posteroinferiorly: Posterior belly of digastric
65

66. 66

67. Contents:
 Superficial part of submandibular
salivary gland
 Submandibular lymph nodes
 Myelohyoid vessels and nerves
 Lingual nerve
Communications:
 Superficial fascial compartment
 Parotid compartment
 Sublingual space from posterior border of
myelohyoid
 Pterygoid space
 Lateral Pharyngeal space
67

68. Spread of infection:
 Mandibular second and third molar
 Sometimes first molar
 Secondary to adjoining spaces- sublingual or submental
68

69. Submandibular Space
69

70. CLINICAL FEATURES:-
 Firm swelling in the submandibular region below the inferior
border of mandible and extends to the level of the hyoid bone
 Tenderness and redness of the overlying skin
 Generalized constitutional symptoms
 Moderate trismus and dysphagia
 Abscess is triangular (swelling)
70

71. TREATMENT
 I & D through Extra-oral incision
 Incision – 2 stab incision over the dependent part below the
lower border of mandible in the neck (shadow) of the
mandible
 Drainage – drain placed & dressing given
 Blunt dissection through subcutaneous fat not to damage
facial artery, anterior facial vein and the facial nerve
71

72. SUBLINGUAL SPACES
Boundaries:
 Superior: Sublingual mucous
membrane
 Inferiorly: Mylohyoid muscle
 Anterior: Lingual surface of
mandible
 Posterior: Body of hyoid bone
 Medial: Genioglossus and Geniohyoid
 Lateral: Alveolar process of mandible above mylohyoid line
72

73. Contents:
Deep part of submandibular salivary gland
and duct, Sublingual salivary gland
Lingual vessels and nerve
Hypoglossal nerve
Communications:
Anteriorly: Submental space
Posteriorly: Submandibular space
73

74. Sources of infection:
 Premolars
 Periodontal infection of lower incisors
 Infection of Wharton’s duct
74

75. Clinical Features:
 Raised tongue
 Brawny, erythematous swelling on floor of the mouth
 Drooling of saliva
 Dysphagia
 Dyspnoea
75

76. TREATMENT
 Intraorally - incision through the mucosa parallel to
Whartson’s duct bilaterally
76

77. INFRATEMPORAL FOSSA SPACE
BOUNDARIES:-
 Medially – lateral pterygoid plate, inferior portion of the
lateral pterygoid muscle, lateral pharyngeal wall
 Superiorly - infratemporal surface of the greater wing of
sphenoid
 Laterally –temporal tendon and the coronoid process
 Postero laterally-mandibular condyle, temporalis, lateral
pterygoid muscle, medial aspect of the parotid capsule
77

78. Anteriorly-infratemporal surface of maxilla & posterior surface
of the zygomatic bone
Inferiorly-communicate with the pterygomandibular space
78

79. CONTENTS:-
 Origins of medial and lateral Pterygoid muscles
 Pterygoid plexus of vein
 Traversed by maxillary Artery, mandibular nerve, middle
meningeal Artery
ETIOLOGY:- From
 Buccal space
 Maxillary molars, distoangular impacted third molar
 Pterygomandibular space
 Contaminated needle injection in the tuberosity area
79

80. Clinical features
 Swelling of cheek, upper lip
 Obliteration of nasolabial fold
 Drooping of angle of mouth.
 Edema of lower eyelid
Extraoral early phase
 Inflammatory enlargement of upper lip, and angle of the
mouth is seen to drop. Periorbital edema.
80

81. Late phase on 2nd or 3rd day
Minimal swelling partly above and partly below the
zygomatic arch. Jaw deviates to affected side
Intraorally
the offending tooth is mobile or is tender on percussion
81

82. TREATMENT:-
 Incision  extraorally (in severe trismus pts.)
 Horizontal incision parallel to the zygomatic branch of facial
nerve.
 Haemostat in an inferior and medial direction
 Intraorally incision made all along the anterior border of ramus
of the mandible
82

83. Masticatory spaces
Comprise of the following spaces:
(i) pterygomandibular,
(ii) submasseteric,
(iii) temporal-superficial temporal and deep temporal
Masticatory spaces are formed by splitting of investing fascia into
superficial and deep layers around the masticatory muscles which
define the lateral and medial extent of space
83

84. TEMPORAL SPACES-
 Superficial temporal space is between superficial temporal
fascia and lateral aspect of the temporalis muscle.
 Deep temporal space is present between the medial surface of
temporalis muscle and the periosteum of temporal bone.
84

85. 85

86. Contents:
 Vessels supplying the temporal muscle
Neighboring spaces:
 Buccal space
 Submandibular space
 Parapharyngeal spaces
86

87. Clinical Features:
Swelling present in
temporal area.
Buccal space infection
is associated with it and
has characteristic dumbell shape
swelling.
87

88.  Deep temporal space infection produces less swelling
comparatively.
 Throbbing pain
 Associated trismus
88

89. Surgical Management
 intraoral - incision along the pterygomandibular raphae.
 Also drained percutaneously through an incision slightly
superior to the zygomatic arch.
 Incision parallel to zygomatic arch , therefore parallel to the
zygomatic branch of facial nerve
89

90. SUBMASSETERIC SPACE
Boundaries:
 Superiorly: zygomatic arch
 Inferiorly: attachment of masseter
onto lower border of mandible
 Anteriorly: buccal space,
parotidomasseteric fascia
 Posteriorly: parotid gland,
Parotid fascia
 Medially: lateral aspect of
Mandibular ramus
 Laterally: masseter muscle
90

91. CONTENTS
• Masseteric nerve
• Superficial temporal artery
• Transverse facial artery
91

92.  It contains muscles of mastication
o Masseter
o Lateral and medial pterygoids
o Temporalis muscle insertion .
Spread of infection:
 Lower third molar (pericoronitis of vertical and distoangular
impacted third molar)
 Presence of buccinator attachment and position of third
molar determines the extension of backward pericoronal pus
92

93. Neighboring Spaces:
Communicates freely with
 Temporal space
 Buccal space
 Pterygoid space
 Superficial temporal space
 Parotid space
 Infratemporal space
93

94. 94

95. Clinical features:
 External fascial swelling extending from the lower border of
the mandible to the zygomatic arch; and anteriorly to the
anterior border of masseter; and posteriorly to the posterior
border of the mandible.
 Tenderness over the angle
of mandible.
 Limitation of mouth
opening, trismus is
characteristic feature
with minimal swelling.
 Pyrexia and malaise.
95

96. 96

97. TREATMENT:-
 Incision  Intra oral : vertical incision along the external
oblique line of the mandible , level of the occlusal plane ,
extending downward and forward in buccal sulcus opposite
second molar.
97

98. PTERYGOMANDIBULAR SPACE-
Boundaries:
 Superiorly: lateral pterygoid
 Inferiorly: attachment of
Medial pterygoid
to the mandible.
 Posteriorly: deep lobe of parotid
gland
 Medially: medial pterygoid
 Laterally: medial surface of ramus
98

99. Contents:
 Lingual nerve, mandibular nerve
 Inferior alveolar or mandibular artery
 Myloyoid nerve and vessels
 Loose areolar connective tissue
Neighboring spaces:
 Buccal space
 Lateral pharyngeal space
 Submassetric space
 Deep temporal space
 Parotid space
 Peritonsillar space
99

100. 100

101. ETIOLOGY:-
 Periapical and pericoronal conditions, mandibular third
molars
 Third molars, mesio angular / horizontal impacted teeth
 Contaminated needle during Inferior Alveolar Nerve Block
 Fracture of mandible
101

102. 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.
Complications
 Spread to infratemporal spaces
 Lateral pharyngeal spaces
 Retropharyngeal spaces
 Buccal submandibular spaces
102

103. Surgical treatment-
 Extraoral mandibular nerve block is given.
 Incision and drainage - medial aspect of ramus of mandible
and pterygomandibular raphae.
103

104. PAROTID SPACE
BOUNDARIES:-
 Above  zygomatic arch
 Below  lower border of mandible
 Anteriorly  anterior border of the mandible
 Posteriorly  retromandibular region
CONTENTS:-
 Parotid gland with structures (facial nerve, external carotid
artery, retromandibular vein) within its substance.
 Superficial parotid lymph nodes on lateral aspect of the gland.
 Deep parotid lymph nodes within the gland
104

105. Parotid Space
105

106. ETIOLOGY:
 From extension of infection from submasseteric,
pterygomandibular, lateral pharyngeal spaces
 Blood-borne infection or retrograde infection through the
stensons duct
106

107. CLINICAL FEATURES:
 Severe referred pain to ear
 Pain on eating and dehydrated
 Eversion of lobule of the ear
 Escape of pus from the parotid duct on gland milking
 Swelling present.
107

108. TREATMENT:-
Incision
 Extraoral- retromandibular incision extending from inferior
aspect of the lobule of the ear till just above the angle of the
mandible
 Curved extraoral incision at the angle of the mandible multiple
drains placed
108

109. Deep Neck Spaces:
109

110. Superficial Space-
 Entire length of neck
 Surrounds platysma
 Contains areolar tissue, nodes, nerves and vessels
 Involved with cellulitis and superficial abscesses
 Incision along langer’s lines, drainage and antibiotics
110

111. PARAPHARYNGEAL SPACES:
 Lateral pharyngeal space
 Retropharyngeal spaces
111

112. LATERAL PHARYNGEAL SPACE
BOUNDARIES:-
 Superiorly  base
of skull
 Inferiorly  level of
hyoid bone
 Medially  superior
pharyngeal constrictor
 Laterally  fascia of the
medial pterygoid muscle & Deep capsule of the parotid gland
 Posteriorly  carotid sheath contents, styohyoid,
styloglossus, & stylopharyngeus.
112

113. Contents:
The Internal Jugular Vein
divides the space into two
parts:
 Anterior compartment
 Posterior compartment
Anterior
compartment contains:
 Lymph nodes
 Ascending pharyngeal and
facial and maxillary arteries
 Inferior alveolar, lingual
nerve
 Auriculotemporal nerve and
 Loose areolar tissue. 113

114. Posterior compartment contains:
 Carotid sheath with its contents,
 9, 11, 12th cranial nerves and
 Cervical sympathetic chain
Etiology-
 Mandibular third molars
 Tonsillar infections
 Parotitis
 Pharyngitis
 Backwards from sublingual, submandibular or
ptrygomandibular space.
 Herpetic gingivostomatitis involving pericoronal tissues.
114

115. Communicates with
several deep neck
spaces.
 Parotid
 Masticator
 Peritonsillar
 Submandibular
 Retropharyngeal
115

116. Clinical Features:
 Trismus
 Induration and swelling of angle of jaw intraorally
 Pharyngeal bulging
 Rotation of neck away from site of swelling causes severe pain
due to tension on ipsilateral sternocleidomastoid.
 Severe pain on affected side on swallowing
 Displacement of tonsillar
pillars
116

117. Complications:
 Septic jugular vein thrombophlebitis.
 Cavernous sinus thrombosis
 Meningitis
 Brain abscess
 May spread into the retropharyngeal space.
 Invade the carotid sheath and towards the mediastinum that is
Moschers “ lincoln’s highway” of the neck.
117

118. Surgical management-
 Intraoral - incision between the ramus and medial pterygoid.
 Extraoral - submandibular incision, in involvement of
posterior compartment.
 Incision - anterior and inferior to angle of mandible.
 Haemostat - carried superiorly and medially along the medial
pterygoid muscle into pharyngeal space.
118

119. RETROPHARYNGEAL SPACE
 It is the area of loose connective tissue lying behind the
pharynx and in front of prevertebral fascia.
Boundaries:
 Superiorly: Base of skull
 Inferiorly: Communicates with superior
mediastinum
 Anteriorly: Posterior wall of pharynx
 Posteriorly: Pre vertebral fascia
119

120. Retropharyngeal
Space
120

121. Spread of infection:
 Odontogenic infection from contiguous spaces.
 Nasal and pharyngeal infections
 Esophageal trauma
 Tuberculosis of retropharyngeal lymph nodes
121

122. 122

123. Clinical features:
 Pain, dysphagia, dyspnoea
 Fever
 Stiffness of the neck
 Bulging of the posterior pharyngeal
wall(more prominent on one side.
Adherence of medial raphae, of
the prevertebral fascia)
 Unilateral cervical adenitis seen
 Anorexia present.
123

124. COMPLICATIONS:
 Mediastinitis present
 Laryngeal spasm, internal jugular vein thrombosis
124

125. Surgical Management-
 Incision and drainage - transorally under general anesthesia
 The incision - midline of the posterior pharyngeal mucosa, ,
abscess opened by blunt dissection
 Incision - anterior border of the sternocleidomastoid muscle
and parallel to it inferior to the hyoid bone.
 The muscle and the carotid sheath are retracted laterally
avoiding the hypoglossal nerve.
125

126. PERITONSILLAR SPACE-
 Potential space of loose areolar tissue that surrounds the tonsils
and bounded laterally by the superior constrictor muscles
Boundaries :
 Laterally: superior pharyngeal constrictor
 Medially: mucous membrane of anterior and posterior pillar of
fauces
 Superior—anterior tonsil pillar
 Inferior—posterior tonsil pillar
126

127. Peritonsillar Space
127

128. Etiology-
 Infection starts in the intratonsillar fossa, situated between the
upper pole and body and eventually extends around the
tonsils.
 Quinsy is unilateral but rarely can occur bilateral.
Clinical features-
 Fever, malaise
 Dysphagia, odynophagia
 “Hot-potato” voice, trismus, bulging of superior tonsil pole
and soft palate, deviation of uvula
128

129. Complications:
 Spontaneous rupture
 Spread into pterygomaxillary space
Surgical Management-
 In delayed cases or where antibiotic does not work,
tonsillectomy is preferred 6-8 weeks after the abscess is
formed.
129

130. INFRAHYOID SPACES
130

131. Visceral Compartment
 Around the upper parts of trachea, esophagus and thyroid
gland, this compartment surrounds these structures
completely while below the level where inferior thyroid artery
enters the thyroid gland, it is divided into 2 portions by a
dense connective tissue layer.
131

132.  The anterior part of the compartment surrounds the trachea
and lies against the anterior wall of esophagus - previsceral or
pretracheal space.
 The posterior part of the compartment lying behind the
pharynx and esophagus - retrovisceral, retroesophageal or post
visceral space or retropharyngeal space.
132

133. 133

134. PRE- TRACHEAL SPACE-
 Also called Anterior Visceral Space
Boundaries :
 Superiorly : attachment of strap muscles and their fascia to
thyroid cartilage and hyoid bone.
 Inferiorly : superior mediastinum and extends up to upper
border of arch of aorta .
 Laterally : it is blind at root of the neck because of dense
adhesions between alar and visceral fasciae.
134

135. Contents:-
Thyroid glands,
Trachea
Esophagus
Communicating spaces:
Retrovisceral space
135

136. Spread of Infection:
 Directly by anterior perforation of esophagus.
 This space can get infected from retrovisceral space, around
the sides of esophagus and thyroid gland.
 Rarely odontogenic infection.
Surgical Management-
 Incision anterior to sternocleidomastoid, carried medially
behind the carotid sheath.
136

137. Visceral Space
 The esophagus is enclosed in a connective tissue sheath
continuous above with buccopharyngeal fascia, posterior
surface of pharynx and adjacent to surface of thyroid gland
and trachea.
137

138.  Potential space which may be imagined to exist between
visceral fascia and the organs themselves (may these be
trachea or esophagus).
 Firmly united to structures it covers.
138

139. CAROTID SHEATH SPACE
 Space with in the carotid sheath extends between base of
skull at jugular foramen and carotid canal through the
thoracic inlet to the pericardial sac of the middle
mediastinum.
 This along with visceral space is grouped under visceral
vascular space by Coller and Yglesias (1935)
139

140. Contents:
 Carotid artery
 Internal Jugular vein
 Vagus nerve
 Sympathetic plexus
 Lymph nodes (level 2-4)
140

141.  It forms a pathway for the spread of infections from upper to the
lower part of the neck and into the mediastinum (lincoln’s
highway).
ETIOLOGY:-
a)Secondary to odontogenic infections from
 Submandibular space
 Infra temporal space
 Parapharyngeal space
b) Parenteral - via Internal jugular vein
141

142. CLINICAL FEATURES:-
 Local pain & swelling
 Bleeding  through nose, pharynx (intestine) due to erosions
of carotid artery/internal jugular vein
 Palsies of C.N. X, XI, XII  Horners syndrome.
 Septic shock  malaise, chills, pyrexia, anorexia
 Ecchymosis in neck and surrounding tissues
 Carotid Artery involvement  Arteritis  aneurysm formation
142

143.  Trismus, less / absent
 Vocal cord paralysis, septicemia positive
 Metastatic abscess involving lung, bones, joint or other sites
 Cerebral abscess or meningitis (retrograde spread)
 Swelling extends down the neck with localized pain along the
course of the vessels.
143

144. COMPLICATIONS :-
 Septic venous thrombosis
 Mediastinitis
 Suppurative jugular
thrombophlebitis
 Erosion of Common carotid
artery
 Inequality of pupils
due to involvement of
cervical sympathetic nerve
144

145. TREATMENT: -
 I & D
 INCISION  along middle 1/3rds of the anterior border of SCM
muscle
 Retracted posteriorly  Expose carotid sheath  through
vertical incision carotid sheath opened and drained
 Thrombosis of IJV noted, ligate above & below that to prevent
further spread.
145

146. DANGER SPACE
 Potential space between alar fascia & prevertebral fascia
 Extends from base of skull to sacrum
 Infection can extend entire length of vertebral from cervical
vertebrae and to sacral vertebrae.
146

147. 147

148. ETIOLOGY:-
 Posterior extension of infection in retropharyngeal space
through dents in the alar fascia into the danger space
 Vertebral osteomyelitis
CLINICAL FEATURES:-
 Pain, fever, leukocytosis, dysphagia, odynophagia, hot potato
voice.
 Unilateral bulging of the posterior pharyngeal wall
 Stiff neck – irritation of paraspinous muscle.
 Features similar to a retropharyngeal space infection
148

149. TREATMENT –
 Incision and drainage
149

150. PREVERTEBRAL SPACE
Potential pocket existing between the
prevertebral fascia and the vertebral bodies.
150

151.  Extends along entire length of vertebral column
 Intervertebral discs exist between vertebrae and are
vulnerable to an infection traveling in this space
 It extends from skull base to coccyx, allowing for infection
from the neck to the psoas muscle.
Routes of entry:
 infection of the vertebral bodies and penetrating injuries
151

152.  Fascia 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.
152

153. 153

154. Space Of The Body Of The Mandible
 Potential space between the mandible and the periosteum.
Signs, symptoms, and treatment, similar to those for
vestibular space infection.
 Difference is abscess remains sub periosteal in the space of
the body of the mandible, whereas in the vestibular space,
the abscess may perforate the periosteum
154

155. KEY FEATURES
 Canine Space:
*Location- upper lip, lower eyelid
* Obliteration of nasolabial fold
 Buccal Space:
*Location- below the zygomatic arch, above inferior border
of mandible
*Bulging in nature
155

156.  Infratemporal space:
*Location- sigmoid notch, over temporomandibular joint
*Bulging of temporalis muscle
*Intraorally- swelling in tuberosity
 Temporal:
*Location- limited by zygomatic arch
*Trismus
156

157.  Submassetric Space:
*Location- angle of jaw, and ramus of mandible
*More prominent on clenching
*Trismus
 Pterygomandibular Space:
*Location- no extraoral swelling
*Trismus
*Intraorally- swelling over retromolar region
157

158.  Parotid Space:
*Location- swelling extends beyond retromandibular
region
*Elevation of ear lobule
158

159. COMPLICATIONS:
RELATED TO UPPER JAW: -
1.Intracranial complications
 Cavernous sinus thrombosis
 Brain abscess
 Dural meningitis
2.Retrobulbar cellulitis with possibility of blindness
RELATED TO LOWER JAW:-
 Ludwig's Angina
 Descending deep cellulitis of neck resulting in mediastinitis
 Carotid sheath invasion
159

160. BRAIN ABSCESS
ETIOLOGY:
 Bacteremia
 Due to ear & PNS diseases
 Odontogenic infection, orbital infection, congenital heart
disease, malignancies, septic thrombi from SABE, previous
cranial surgery.
160

161. CLINICAL FEATURES:-
 Headache, Nausea, vomiting, Low-grade fever
 Frontal lobe abscess – causes stupor, confusion & Subtle
changes in personality.
 Hemiplegia, papilloedema, aphasia, convulsion,
hemianopia, abducens palsy.
TREATMENT:
 Antibiotics, steroids, mannitol
 Surgical Drainage
161

162. MENINGITIS
ETIOLOGY:-
 Common after orofacial infections
CLINICAL FEATURES:-
 Headache, Fever, Stiffness of the neck, Vomiting, confused
orientation, Convulsions
 Positive kernig’s & Brudzinski’s signs
162

163.  Kernig’s sign: strong passive resistance when attempt made to
extend knees from flexed position
 Brudzinski’s sign: neck flexion in supine position resulting in
involuntary flexion of knees
163

164. Diagnosis : -
 CSF Study through Lumbar puncture.
 Fluid is opalescent or cloudy. Contains polymorphonuclear
cells, protein is increased, glucose is reduced
TREATMENT:-
 Medical than surgical
 Chloramphenicol & Penicillin G,
 Control of cerebral edema & avoid vascular collapse & shock.
164

165. MEDIASTINITIS
 Infection involving the connective tissue (mediastinal) that
fills the interpleural space and surrounds the median thoracic
organs.
BOUNDARIES:-
 Superiorly – inlet
 Inferiorly – diaphragm
 Anteriorly – sternum
 Posteriorly - vertebral column
 Laterally – parietal pleura
165

166. ETIOLOGY:-
 By dissection of abscess from deep anterior neck infections,
primarily via carotid sheath through the thoracic inlet into the
mediastinum.
 Esophageal perforation
 Tracheobronchial perforation
 Extension of infections in pulmonary parenchyma, chest wall,
vertebral vessels
166

167. CLINICAL FEATURES:-
 Fever, tachycardia, pain in chest, back, neck.
 Leucocytosis,tachypnoea, decreased blood pressure, dyspnea,
retrosternal discomfort, Brawny edema, induration of neck,
chest & crepitus
 X-Ray:- A-P & lateral chest film –
 Mediastinal widening > 10cms is abnormal
 CT Scan of neck & chest – pus present
167

168. TREATMENT:-
 Correction of underlying cause
 Debridement of necrotic tissue
 Surgical Drainage
 Antibiotics
 Drainage through Cervico mediastinal route
 Incision anterior to the Sternocleidomastoid muscle ,
access to retropharyngeal space & posterior mediastinum.
Below 4th thoracic vertebral through left transthoracic
approach drainage of posterior mediastinum achieved.
168

169. CAVERNOUS SINUS THROMBOSIS
ETIOLOGY:
 Septic Thrombosis from odontogenic inf. in anterior maxilla &
skin lesions that travel to the sinus via angular vein.
 Ethmoidal and sphenoidal sinusitis through venous channels
or directly through sinus walls.
 Posterior maxilla infections through pterygoid plexus of veins.
 Otitis media through petrosal sinuses & mastoiditis.
169

170. Infection spreads by 2 routes:-
 External or facial route through superior ophthalmic veins
 Internal or through pterygoid plexus of veins via inferior
ophthalmic veins
170

171. 171

172. Etiology and Pathogenesis :-
 Include facial furuncles, erysipelas, sinusitis, Osteomyelitis,
optic infection and odontogenic infection.
 The upper lip, ala of nose, and
nasal septum are considered the
danger area of face as infection
from here spread to anterior facial
vein and from there to superior
ophthalmic vein and to
Cavernous sinus
172

173. CLINICAL FEATURES
 Ptosis, proptosis, oculomotor palsy
 Diplopia (early symptom.
 Headache, Sepsis (Generalized)
 Photophobia, eye pain, decreases visual activity
173

174.  Septic thrombi to general circulation.
 Loss of extra ocular movements, convulsions, coma, & death
 Positive kernigs signs, Positive Brudunskis, Positive Bitots
respiration
 Generalized sepsis with swinging temperature curve (Picket
Fence Fever)
174

175. TREATMENT:-
 Heparinisation
 Mannitol
 Anticoagulants
 Rarely surgical drainage done
175

176. NECROTISING FASCITIS
 An aggressive superficial bacterial infection that directs along
the plane of superficial fascia causing thrombosis, compromise
of subdermal blood supply & necrosis & loss of large areas of
skin
ETIOLOGY: -
 Common in Immuno compromised patients
 Surgery & trauma patients
 Odontogenic, peritonsillar infections, Burns, superficial cuts &
abrasions, contusions, pyogenic skin lesions.
176

177. CLINICAL FEATURES:-
Smooth, tense, shiny skin
Dusky, purplish discoloration of the skin
Bullae or Blisters
Purulent exudate
Cutaneous gangrene with necrosis liquefaction
of subcutaneous fat & fascia
 In Head & Neck region the superficial musculoaponeurotic system is
the facial plane commonly involved.
177

178. 178

179. TREATMENT
 Aggressive early Surgical drainage & Debridement
 Irrigation of wound with H2O2, Betadine
 I.V. Antibiotics
 Supportive Medical management with Hydration, Fluid &
electrolyte balance, Hyperbaric O2 therapy
 Control skin infection & place soft tissue grafts.
179

180. ORBITAL COMPLICATIONS
ETIOLOGY:-
 Odontogenic infection
 PNS infection
 Trauma
 Dissemination (Haematogenous from distant sites)
180

181.  Maxillary odontogenic infection  Infratemporal &
Pterygopalatine fossae  Pterygoid plexus  inferior
ophthalmic veins  orbit.
 Via. Angular & facial veins
 Infection Across Maxillary sinus into orbit through inferior
orbital tissues.
CLINICAL FEATURES:-
 Proptosis, visual acuity loss, painful eye movements –
pailloedema, internal and external opthalmoplegia, pain,
decreases extra-ocular mobility.
 Optic Nerve atrophy, keratitis, meningitis, brain abscess,
cavernous sinus thrombosis, seizures, and death.
181

182. TREATMENT –
 IV antibiotics, Eg., Ampicillin
 Invasive sinus procedures, extraction of teeth
 I & D for subperiosteal, orbital abscess
 Drainage & decompression done
182

183. LUDWIGS ANGINA
 Bilateral involvement of submandibular, sublingual and sub
mental spaces, simultaneously
 ‘’Angina maligna’’,
 ‘’Morbus strangulatorius’’,
 ‘’Garotillo’’
183

184. CLINICAL FEATURES:-
 Massive, firm, brawny cellulitis / induration
 Rapid onset of swelling within 24hrs.
 Edema of neck, floor of mouth, epiglottis
 Dyspnoea with loss of patent airway
 Dysphagia, dehydration, fever
 Hoarseness of voice, odynophagia, Dysphagia
 Anorexia, chills, malaise, toxic.
 Raised tongue touching palatal vault
 Stridor
 Death if untreated within 10 – 24hrs due to asphyxia.
184

185. COMPLICATIONS:-
 Septicemia & shock
 Mediastinitis
 Aspiration pneumonia
 Osteomyelitis
 Maxillary sinusitis
 Resp. & digestive tract disturbances
 Pericarditis
 Internal jugular vein thrombosis
 Meningitis
 Cavernous sinus thrombosis, death.
185

186. TREATMENT GOALS:-
 Early diagnosis
 Patent airway
 Antibiotics
 Extraction of offending tooth / teeth
 Surgical drainage / decompression
186

187. IMAGING OF FASCIAL SPACES
 Evaluation of patients with acute widespread odontogenic
infections can be difficult for the dental surgeons
 Multiple spaces involvement and their complications or deep neck
infections requires immediate surgical intervention.
 Provisional diagnosis needs to be supplemented by advanced
imaging modalities in such cases
187

188.  Magnetic Resonance Imaging
 Computerized Axial Tomography
 Ultrasonography
 Lateral neck films
188

189. MAGNETIC RESONANCE IMAGING
 Excellent soft tissue resolution to help localize the region of
involvement and spread.
 Advantages
• excellent tissue contrast
• depiction of all anatomic planes.
189

190.  Disadvantages
* prolonged time
* effect of patient motion
* danger to individuals with cardiac pacemakers
* expensive
190

191. COMPUTERIZED AXIAL TOMOGRAPHY
 Localized area of infection- more radiolucent , either
lobulated or multifocal
 Spread of infection – appear as massive swelling of the involved
muscle , obliteration of the fat spaces between the neighboring
muscles
 Detects gas accumulation
 Fast, relatively inexpensive, and fairly widely available
 Disadvanages- High cost, radiation exposure, artifacts
191

192. 192

193. ULTRASONOGRAPHY
 Useful in detecting stages of infection: edematous changes,
cellulitis and complete abscess formation.
 No echoes are returned by fluids. Pus localization is shown
as, well demarcated hypoechoic area
 Gives information about the condition of surrounding
vessels
193

194.  Color Doppler may show hyperemia adjacent to the abscess
cavity and absence of flow within it
 No reliable data for detecting infections in the deeper fascial
spaces
 Low cost, adjunct therapy
194

195. Lateral neck film
 Normal:
 7mm at C-2
 14mm at C-6 for kids
 22mm at C-6 for adults
 Enlargement from the normal
values indicative of deep neck
infections
195

196. MANAGEMENT
 Remove the etiology
 Establish drainage
 Pharmacological management
 Supportive care
196

197.  Oral infections are typically polymicrobial
 Effectiveness dependent upon adequate tissue concentration
for appropriate amount of time
 Antibiotics should be prescribed for at least one week
197

198.  Penicillin- Cap Amox, 500 mg , Cap Augmentin 625 mg
T.D.S, children- 20-40 mg/kg/day in 3 divided doses
 Clindamycin- Cap Daclinex, Cap Daclin, 300mg, Q.D.S,
children- 20-40 mg/kg/day in 3-4 divided doses
 Azithromycin- Tab Azithral, Tab Azithrex, 500 mg, O.D,
children – 10mg/kg/day
 Metronidazole- Tab Flagyl, Tab Metrogyl, 400mg, T.D.S,
children- 35-50 mg/kg/day in 3 divided doses
 Selection, combinations and frequency depends o the
severity of infection and immune status of patient
198

199.  Analgesics- Tab Duoflam Plus, Fenac Plus, 150 mg, B.D,
children- 1-3 mg/kg/day in divided doses
 Seratiopeptidases- Tab Chymoral Forte, Tab Afdase, 150
mg, B.D
 Vitamin supplements- Cap Vizylac, Cap Becomex, O.D
 Muscle Relaxants- Tab Mobizox, Myospaz, 250 mg, T.D.S,
children- 125 mg T.D.S
199

200. SUPPORTIVE CARE
 To ensure patients maximum immune response
* Increased fluid intake
* Improve nutritional intake
* Proper rest
* Encouraging environment
 Daily observation needed until resolution of infection
200

201. CONCLUSION
 Odontogenic infections are the most common of all infections
of the head and neck.
 The key to successful management is prompt therapy.
 Early extraction of the offending tooth and incision and
drainage tend to shorten the usual course of the infection and
minimize the chances for development of further
complications
201

202. 202