This document provides an overview of odontogenic infections and the fascial spaces of the head and neck region that can become infected. It defines odontogenic infection as originating from dental pulp, periodontium or jawbones. Types of odontogenic infections are described including periapical/dentoalveolar abscesses and cellulitis. The document outlines the etiology, clinical features, stages, pathogenesis and routes of spread of odontogenic infections. It then describes the classification and contents of cervical fascia and various classifications of fascial spaces in the head and neck region. Specific primary and secondary fascial spaces are defined, including the canine, buccal, infratemporal, submental, sub

1. HEAD AND NECK
SPACE INFECTION
Dr. Ashish,
Sr.Lecturer

2. CONTENT-
• Odontogenic infection
• Definition of odontogenic infection
• Types of odontogenic infection
• Physiology of infection and inflammation
• Etiology of odontogenic infection
• Clinical feature of odontogenic infection
• Stages of odontogenic infection
• Pathogenesis of odontogenic infection
• Routes of spread of odontogenic infection
• Management of odontogenic infection
• Potential fascial spaces
• Classification and content of cervical fascia
• Classification of fascial spaces
- Topazian classification
- Grodinsky and Holyoke classification
- Based on mode of involvement
- Based on clinical significance
- Based on etiology
- Based on causative organism

3. • Suprasternal space (of burns)
• I) Primary fascial spaces
- Canine space
- Buccal space
- Infratemporal space
- Submental space
- Submandibular space
- Sublingual space
II) Secondary fascial spaces
- Temporal space
- Parotid space infection
- Submasseteric space
- Pterygomandibular space
- Lateral pharyngeal space
- Retropharyngeal space
- Peritonsillar abscess (quinsy)

4. • Life threatening complication of orofacial infections
A) Mandible-
- Ludwig’s angina
- Mediastinitis
- Carotid space infection
B) Maxilla-
- Cerebral abscess
- Meningitis
- Cavernous sinus thrombosis
- Necrotising fasciitis of the head and neck

5. ODONTGENIC INFECTION-
DEFINITION-
Infection that originates from the dental pulp, periodontium and jawbones
or in tissues that closely surround it is called odontogenic infection.
TYPES OF ODONTOGENIC INFECTION-
1) PERAPICAL INFECTION / ABSCESS-
Dental infection that spreads across the pulp to the area extending
beyond apex of the tooth and is localised at that site is periapical
infection. When the localised periapical infection undergoes an acute
exacerbation with pus formation within the bony confines, it becomes
periapical abscess.
Periapical abscess refers to an abscess of odontogenic origin that
occurs mainly in relation to root apices. It may be confined to the alveolar
bone, perforate through the bone reaching the surface or invade the soft
tissues subperiosteally or supraperiosteally.

6. 2) DENTOALVEOLAR ABSCESS-
The infection that has extended beyond the alveolar bone and comes into
the adjacent soft tissues as a localised form is known as dentoalveolar
abscess.
3) CELLULITIS-
Cellulitis is defined as ‘diffuse, nonsuppurative inflammatory reaction of
the fascial tissue planes (submucosal or subcutaneous) or loose
connective tissues usually as a result of bacterial odontogenic infections’.

7. PHYSIOLOGY OF ODONTOGENIC INFECTION-

8. ETIOLOGY OF ODONTOGENIC INFECTION-
1. Dental caries
2. Pericoronitis
3. Traumatic root fracture or pathological exposure due to tooth
wear.
4. Traumatic pulpal exposure due to dental treatment.
5. Through periodontal membrane and accessory root canal.
6. Rarely by anachoresis, i.e. seeding of the organisms directly into
the pulp via pulpal blood supply during bacteraemia.
7. Periapical abscess
8. Periodontal abscess

9. CLINICAL FEATURES OF ODONTOGENIC INFECTION-
1) Nonvital tooth with or without a carious lesion,a large restoration,
or evidence of trauma
2) Swelling
3) Trismus
4) Local lymph node enlargement / lymphadenopathy
5) Sinus formation
6) Malaise
7) Rubor or redness
8) Tumour or swelling
9) Calor or heat
10) Dolour or pain.
11) Loss of function
12) Pyrexia
13) Presence of halitosis

10. STAGES OF ODONTOGENIC INFECTION-
Odontogenic infections generally pass through three stages before they
undergo resolution-
1) During 1–3 days—the swelling is soft, mildly tender and doughy in
consistency.
2) Between 5 and 7 days—the centre begins to soften and the underlying
abscess undermines the skin or mucosa making it compressible. The
underlying pus may be seen through the epithelial layers making it
fluctuant.
3) Finally, there is a resolution of the abscess that may be spontaneous or
after surgical drainage. During the resolution phase the involved
region is firm on palpation due to the process of necrotic tissues and
bacterial debris removed by the macrophages and alternating repair
mechanism.

11. PATHOGENESIS OF ODONTOGENIC INFECTION-

12. ROUTE OF SPREAD OF ODONTOGENIC INFECTION-
1) DIRECT SPREAD-
A) Spread into the superficial soft tissues may:
- Localise as a soft tissue abscess.
- Extend through the overlying oral mucosa or skin, producing
a ‘sinus’ connecting the main abscess cavity to the exterior.
- Extend through the soft tissue to produce cellulitis.
B) Spread may occur into the adjacent fascial spaces, following the
path of least resistance resulting in space infection, which can
further lead to life-threatening septicaemia.Occasionally, it may
cause severe respiratory distress as a result of occlusion of the
airway by oedema.
Sequelae- Odontogenic infection
Space infections
Septicaemia.
C) Infection may extend into deeper medullary spaces of alveolar
bone producing a osteomyelitis.

14. MAXILLA
MANDIBLE

15. 2) INDIRECT SPREAD-
A) Lymphatic routes to regional nodes in the head and neck
region (submental, submandibular, deep cervical, parotid
and occipital).
Usually involved nodes are tender, swollen and rarely maY
suppurate requiring drainage.
B) Haematogenous routes to other organs such as brain is
possible through deep facial vein and pterygoid venous
plexus that communicate intracranially with cavernous
venous sinuses.

16. SUMMARY
OF
ROUTE

17. MANAGEMENT OF ODONTOGENIC INFECTION-
1) Incision and drainage
2 ) Excision of sinus
3) Antibiotic therapy
4) Supportive therapy

18. POTENTIAL FASCIAL SPACES-
The head and neck region has structures separated
from each other through specific natural connective
tissue barriers called fascia. Fascia means fibrous
connective tissue which binds together various
structures of the body.
Shapiro defined fascial spaces as potential spaces
between the layer of fascia. These spaces are normally
filled with loose connective tissues and various
structures like veins, arteries, glands, lymph nodes,
etc.
Space is a misnomer. There are no voids in the tissues
in actual reality.
Purulent exudate accumulates in these potential tissue
spaces, which are not actual spaces till purulent
exudate is formed. This exudate (pus) destroys the
loose connective tissue and separates the anatomical
boundaries of the compartment thus forming space

19. CLASSIFICATION AND CONTENT OF CERVICAL FASCIA -
(According to Hollinshead’s Classification {1958})
1) SUPERFICIAL CERVICAL FASCIA-
- Platysma
- Facial Muscles
2) DEEP CERVICAL FASCIA-
- Anterior layer
i) Investing
ii) Parotideomasseteric
iii) Temporal
- Middle layer
i) Sternohyoid-omohyoid division
ii) Sternothyroid- thyrohyoid division
- Visceral layer
i) Buccopharyngeal
ii) Pretracheal
iii) Retropharyngeal
- Posterior layer
i) Alar division
ii) Prevertebral division

21. CLASSIFICATION OF FASCIAL SPACES -
1) TOPAZIAN CLASSIFICATION-

22. 2) GRODINSKY AND HOLYOKE CLASSIFICATION-
- Space 1 - Superficial fascial compartment
- Space 2 - Potential space between the superficial layer of deep fascia and
the deep layer of the sternothyroid–thyrohyoid sheath.
- Space 2A - Space between the superficial layer of deep fascia and the
sheath of the posterior belly of the omohyoid muscle.
- Spaces 3 - Visceral compartment and space within carotid sheath, respectively
- Space 3A - Potential space within the carotid sheath, which extends from jugular
foramen and carotid canal to the mediastinum. ( aka Lincoln’s
Highway)
- Space 4 - Space between two laminae of prevertebral fascia.( aka danger space)
- Space 4A - The potential space between the superficial layers of deep
fascia and the scalenus fascia.
- Space 5 - This is a potential space between prevertebral fascia and
vertebral bodies limited laterally up to transverse processes of
vertebrae.
- Space 5A - This lies in the posterior triangle deep to scalenus fascia. This
space, posterior to the scalenus fascia, lies between the deep
muscles of the back of the neck

23. 3) BASED ON MODE OF INVOLVEMENT-
A) Direct involvement / Primary spaces
- Maxillary spaces
- Mandibular spaces
B) Indirect involvement / Secondary spaces

24. 4) BASED ON CLINICAL SIGNIFICANCE-
Primary Maxillary Spaces Canine (infraorbital)
Buccal
Infratemporal
Primary Mandibular Spaces Submental
Submandibular
Sublingual
Buccal
Secondary Fascial Spaces Masseteric
Pterygomandibular
Superficial and deep temporal
Lateral pharyngeal
Retropharyngeal
Prevertebral

25. 5) BASED ON ETIOLOGY-
A) Traumatic
B) Implant Surgery
C) Reconstructive Surgery
D) Infection from contaminated needle puncture
E) Secondary to oral malignancies
F) Others
- Infected antrum
- Salivary gland afflictions
6) BASED ON CAUSTIVE ORGANISM-
A) Bacterial infection
B) Odontogenic infection
C) Non-Odontogenic infection
- Tonsillar infection
- Nasal infection
- Furuncle over skin

26. SUPRASTERNAL SPACE (OF BURNS)-
The Suprasternal Space (of Burns) is a space of the inferior neck.
Superficial fascia splits below the level of the hyoid bone to form two
spaces-
1) It forms the lower part of the root of the posterior triangle, the fascia
splits into two layers, both of which are attached to the clavicle.
2) It forms the lower part of the roof of the anterior triangle and the
fascia splits in form the suprasternal space or the space of the
‘burns’. The layers pass down to get attached one to the anterior,
the other to the posterior border of the manubrium sterni.
Contents
• Sternal head of sternocleidomastoid muscle
• Anterior Jugular vein anastomoses
• Lymph nodes
• Interclavicular ligament

27. I) PRIMARY FASCIAL SPACES-
CANINE SPACE-
Boundaries of canine space-
Superficial and superior—Quadratus labii superioris
Inferior—Orbicularis oris
Deep—Levator anguli oris, anterior surface of maxilla
Medial—Levator labii superioris alaeque nasi
Lateral—Zygomaticus major
Contents-
• Angular artery and vein
• Infraorbital nerve
Teeth involved-
•Maxillary canine
•1st premolar
•Rarely mesiobuccal root of first molars
Maxillary primary spaces

28. Clinical features-
• Periapical abscess of canine usually present as labial sulcus swelling
and less commonly as palatal swelling
• Swelling of the cheek and upper lip (vestibular abscess)
• Obliteration of the nasolabial fold (pus accumulation in the nasolabial fold)
• Oedema of the lower eyelid.
• Marked periorbital oedema forcing the eyelid to close.
• Marked tenderness and redness in the facial tissue.
Surgical Management-
The incision is made intraorally high in the maxillary labial vestibule. Insert a
small haemostat through the levator anguli oris into the abscess cavity, place
a rubber drain and suture into the lower margin of the vestibular incision.

29. BUCCAL SPACE-
Boundaries of buccal space-
Superior—Zygomatic arch
Inferior—Inferior border of mandible
Anterior—Posterior border of the zygomatic bone above
and depressor angulioris below
Posterior—Anterior border of the masseter muscle
Medial—Buccinator muscle and its fascia
Lateral—Skin and subcutaneous tissue.
Contents-
• Space filled with buccal pad of fat (adipose tissues)
• Parotid duct
• Anterior and transverse facial artery and vein
Teeth involved-
•Maxillary molars
•Maxillary premolars
•Mandibular molars
•Mandibular premolars

30. Clinical features-
•Dome-shaped swelling on the anterior aspect of the cheek beginning at the
lower border of the mandible, extending upwards to the level of zygomatic arch.
Surgical Management-
Two stab incisions is made for buccal space abscess with No. 11 scalpel blade.
A curved haemostat is inserted through the anterior incision into the abscess
cavity; exited through the posterior incision providing dependent drainage.

31. INFRATEMPORAL / RETROZYGOMATIC SPACE-
Boundaries of infratemporal space-
Superior—Skull base-sphenoid crest
Inferior—Lateral pterygoid muscle
Medial—Lateral pterygoid plate
Lateral—Temporalis muscle and tendon
Anterior—Maxillary tuberosity
Posterior—Mandibular condyle
Contents-
• Internal maxillary artery (second part)
• Pterygoid venous plexus
• Mandibular division of trigeminal nerve
• Medial and lateral pterygoid muscles
Neighbouring spaces-
• Buccal space
• Superficial temporal space
• Inferior petrosal sinus space

32. Involvement-
Infratemporal fossa
Clinical features-
• Swelling
• Severe trismus
• Pain
• Optic neuritis
• Cavernous sinus
• Headache
• Irritability
• Photophobia
• Vomiting
• Drowsiness
Surgical Management-
Infratemporal space can be reached either -
i) Internal approach
-Kruger
- Laskin
ii) External approach (in case of trismus)

33. Mandibular primary spaces
SUBMENTAL SPACE-
Boundaries of submental space-
Superior—Mylohyoid muscle
Inferior—Skin and subcutaneous tissue, platysma
and deep cervical fascia
Medial—Single midline space with no medial wall
Lateral—Anterior belly of digastric (bilateral)
Anterior—Mandible
Posterior—Hyoid bone
Contents-
• This space has no vital structures
• Lymph nodes and anterior jugular
veins
Neighbouring spaces-
• Submandibular space

34. Involvement-
Infection from lower incisors, lower lip, chin, tip of the tongue and anterior
part of floor of the mouth can spread to the submental lymph nodes and
subsequently cause infection of the submental space.
Clinical features-
• Swelling in the midline, in the region of the chin and the region just beneath
it.
Surgical Management-
The incision for drainage is made bilaterally through the skin, subcutaneous
tissue and platysma muscle at the most inferior aspect of the swelling. Rubber
drain is inserted through one incision, exited through the other and secured

35. SUBMANDIBULAR SPACE-
Submandibular space is enclosed by the investing layer of deep cervical
fascia and lies lateral to the sub-mental space.
Boundaries of submandibular space-
Lateral—Skin, superficial fascia, investing fascia, platysma
Medial—Mylohyoid, hyoglossus, superior constrictor, styloglossus muscles
Superior—Inferior and medial surface of the mandible and attachment of
mylohyoid muscle
Inferior—Anterior and posterior belly of digastrics muscle
Contents-
• Submandibular salivary gland and
lymph nodes
• Facial artery
• Lingual nerve
• Lymph nodes
Neighbouring spaces-
• Sublingual space
• Submental space
• Lateral, pharyngeal space
• Buccal space

36. Involvement-
• Infection from the mandibular molars, most commonly second and third
molars
• Infection from submental and sublingual spaces can pass backwards via
lymphatics.
• Infection from the submandibular salivary gland may pass via lymphatics
• Infection from the middle third of the tongue, posterior part of the floor of
the mouth, maxillary teeth, cheek, maxillary sinus and palate
Clinical features-
• Swelling
• Trismus

37. Surgical Management-
The two stab incisions are made at the inferior aspect of the swelling in the
shadow of the mandible. The dissection is carried out through one of the
incisions with the curved haemostat in the abscess cavity. Blunt dissection
avoids the risk of injuring the facial artery, anterior facial vein and facial
nerve.
The haemostat is passed through one incision and out through the other. A
thin rubber drain is passed through the stab incisions with the help of the
haemostat. The ends of the drain are sutured to prevent dislodgement.

38. SUBLINGUAL SPACE-
Boundaries of sublingual space-
Superior—Mucosa of the floor of the mouth
Inferior—Superior surface of mylohyoid muscle
Medial—Midline raphae
Lateral—Medial surface of mandible
Contents-
• Deep part of submandibular gland,
sublingual gland and their draining
ducts (Wharton’s duct and ducts of
Rivinus)
• Lingual nerve
Neighbouring spaces-
• Submandibular space
• Lateral pharyngeal space

39. Involvement-
• Mylohyoid Muscle
• Mandibular premolars or molars
Clinical features-
• Swelling is seen on the anterior part of floor of the mouth,
• Difficulty in swallowing tenderness.
• Difficulty in speaking.
• Floor of the mouth is raised and the tongue may be pushed superiorly
causing airway obstruction.
Etiology-
• Chronic Decayed mandibular anterior teeth
• Infected ranula
• Infected lymph node with purulent discharge—lymphadenitis
• Extension of infections of the submandibular space.

40. Surgical Management-
1. Extra oral approach—an external transverse skin incision between the
hyoid bone and the inferior border of the mandible.
2. Intra oral approach—Drainage can be obtained transorally by incising
the mucosa in the anterior part of the floor of the
mouth, the incision should be placed parallel to the
submandibular duct. Blunt dissection is indicated so
as to not injure the lingual nerve or the submandibular
ducts.

41. II) SECONDARY FASCIAL SPACES-
TEMPORAL SPACE-
Temporal space has two compartments: superficial and deep.

42. Boundaries of temporal space-
Superficial compartment-
Laterally—Temporal fascia
Medially—Lateral surface of the temporalis muscle
Deep compartment-
Laterally—Medial surface of the temporalis muscle
Medially—Temporal bone
Contents-
• Superficial temporal vessels
• Auriculotemporal nerve
• Temporal fat pad.
Clinical features-
• Swelling
• Severe trismus
• Pain

43. Surgical Management-
Intraoral incision for drainage of the temporal abscess is same as that of
infratemporal space. The haemostat is passed superiorly along the lateral
aspect of the coronoid process to enter the superficial compartment. If
haemostat is passed superiorly along the medial aspect of the coronoid
process, it will enter the deep temporal compartment. In case of severe
trismus, an extraoral approach can be used to gain access into the temporal
space. This incision is also same as that used for extraoral incision of
infratemporal space. At first, the haemostat is passed medially to enter the
superficial space and later on blunt dissection is done through the temporalis
muscle to enter into the deep temporal space. Intraoral approach is preferred
over extraoral since intraoral approach provides more dependent drainage
over the entire area whereas the extraoral approach does not enter the
inferior aspect of the temporal space. Moreover, intraoral approach prevents
the fibres of the temporalis muscle from contracting against the drain and
affecting the flow of pus from the deep temporal space.

44. PAROTID SPACE-
Boundaries of parotid space-
Parotid space is enclosed by the superficial layer of
the deep cervical fascia surrounding the parotid
gland.
Clinical features-
• Swelling extends from the zygomatic arch to the
lower border of the mandible anteriorly and from
the anterior border of the mandible to
retromandibular region posteriorly.
• Swelling everts the lobule of the ear and presents
with severe pain especially while eating.
• Intraorally pus may be milked from the parotid
duct.
• Trismus is NOT a sign of this space infection.
Differential Diagnosis-
Submasseteric space infection (Trismus is present
here).

45. Management-
The pus within the parotid space is present in different loculations, which
necessitates for a wide area of approach. Large incision is made in the
retromandibular area from lower aspect of lobule of the ear to angle of the
mandible. Blunt dissection with a haemostat is done avoiding injury to the
branches of the facial nerve. Multiple drains are used for drainage of the pus.
A curved incision at the angle of the mandible can also be made; blunt
dissection is done with a haemostat and a drain is placed.

46. SUBMASSETERIC SPACE-
Boundaries of submasseteric space-
Anterior—Buccal space, parotidomasseteric fascia
Posterior—Parotid gland and its fascia
Superior—Zygomatic arch
Inferior—Inferior border of mandible
Superficial or medial—Ascending ramus
Deep or lateral—Masseter muscle

47. Etiology-
Pericoronitis
Contents-
• Masseteric artery and vein
Neighbouring spaces-
• Buccal space
• Pterygomandibular space
• Superficial temporal space
• Parotid space
• Infratemporal space
Differential Diagnosis-
Peritonsillar abscess ( NO trismus or
dental involvement).

48. Clinical features-
• Swelling
• Severe trismus
• Throbbing pain
• Ischemia
• Osteomyelitis
• Sequestrum Formation
• Subperiosteal new bone deposition

49. Surgical Management-
A vertical incision is made intraorally along the external oblique line of the
mandible. A haemostat is inserted through this incision and passed posteriorly
along the lateral aspect of the ramus beneath the masseter muscle and the
beaks are opened for free escape of the pus. A rubber drain is inserted and
sutured to the incision margin. Extraoral approach involves a small incision
beneath the angle of the mandible and blunt dissection is done with the help
of the haemostat. A rubber catheter is inserted in the wound for drainage.

50. PTERYGOMANDIBULAR SPACE-
Boundaries of pterygomandibular space-
Anterior—Buccal space
Posterior—Parotid gland with lateral pharyngeal space
Superior—Lateral pterygoid muscle Inferior—Inferior border of mandible
Superficial or medial—Lateral surface of medial pterygoid muscle
Deep or lateral—Medial surface of ascending ramus of mandible
Contents-
• Mandibular division of trigeminal nerve
• Inferior alveolar artery and vein
Neighbouring spaces-
• Buccal space
• Lateral pharyngeal space
• Submasseteric space
• Deep temporal space
• Parotid space
• Peritonsillar space

51. Etiology-
• Pericoronitis
• Contaminated needle
Clinical features-
• Swelling of the soft palate on the same side
• Swelling of the anterior tonsillar pillar
• Deviation of the uvula to the opposite side
• Severe trismus
• Dysphagia
Surgical Management-
Because of the severe trismus either general anaesthesia is used or the
mandibular nerve is blocked extraorally with local anaesthetic. The incision for
drainage is made between medial aspect of the ramus of mandible and the
pterygomandibular raphe, and the abscess cavity is opened by blunt dissection
using a haemostat. Rubber drain is placed and sutured to one of the margins
of the incision to prevent dislodgement. This would help in sufficient
drainage.

52. LATERAL PHARYNGEAL SPACE-
Boundaries of lateral pharyngeal space-
Anterior—Superior and middle pharyngeal constrictor
Posterior—Carotid sheath, stylohyoid, styloglossus and stylopharyngeus
Superior—Skull base
Inferior—Hyoid bone
Superficial or medial—Superior pharyngeal constrictors and retropharyngeal space
Deep or lateral—Medial pterygoid muscle and capsule of parotid gland
Contents-
• Carotid artery
• Internal jugular vein
• Vagus nerve
• Cervical sympathetic chain
Neighbouring spaces-
• Pterygomandibular
• Submandibular
• Peritonsillar
• Sublingual
• Retropharyngeal

53. Clinical features-
• Severe pain on the affected side of throat
• Dysphagia are present.
• Tonsil, tonsillar pillar and uvula are seen to be displaced to the medial side.
• Trismus
• Induration and swelling of angle of the jaw,
• Fever
• Pharyngeal bulging.
• Rotation of the neck away from the side of the swelling
• Severe pain
Complications-
• Septic jugular thrombophlebitis
• Carotid artery erosion.
• Inequality of the pupils due to involvement of cervical sympathetic
• Bleeding from nose, mouth or ear
• cavernous sinus thrombosis
• Meningitis
• Brain abscess.

54. Surgical Management-
There are multiple approaches to the lateral pharyngeal space-
1) Intraoral- Intraoral incision can be either-
i) Transpharyngeal - The transpharyngeal approach is made through the
tonsillar fossa, but this approach is not recommended
since adequate drainage is very difficult to obtain.
ii) Lateral- The incision is made between the ramus and medial pterygoid
and dissecting bluntly with a haemostat medial and posterior to
the medial pterygoid muscle into the parapharyngeal space.
2) Extraoral- An incision is made anterior and inferior to angle of the mandible and
blunt dissection with haemostat is carried superficially and medially
along the medial pterygoid muscle into the pharyngeal space.
3) Combination of both- The lateral mucosal incision is made and a large curved
haemostat is passed lateral to the superior constrictor
and medial to the medial pterygoid muscle. A blunt
dissection is carried out posteroinferiorly below the angle
of the mandible. The tip of the instrument is palpated
extraorally anterior to the sternocleidomastoid and a
cutaneous incision is made over the tip. A drain is inserted
and sutured to the wound margin to allow drainage.

55. RETROPHARYNGEAL SPACE-
Boundaries of retropharyngeal space-
Anterior—Superior and middle
constrictors
Posterior—Alar fascia
Superior—Skull base
Inferior—Fusion of alar and
prevertebral fascia at T4
Superficial or medial—Common
space, no wall
Deep or lateral—Carotid sheath and
lateral pharyngeal
space
Contents-
• Lymph node, no major structures.

56. Clinical features-
• Pain
• Fever
• Stiffness of the neck
• Dyspnoea
• Drooling
• Dysphagia
• Bulging of the posterior pharyngeal wall
• Retropharyngeal abscess
• Mediastinitis
• Empyema
• Pericardial effusion
• Chest pain

57. Surgical Management-
In most of the cases, the retropharyngeal space abscess will result from an extension
of lateral pharyngeal space infection and therefore will not be drained independently.
In conditions where independent drainage is necessary, an intraoral approach is made.
A vertical incision is made on the pharyngeal wall lateral to the midline. Using a
haemostat, abscess cavity is opened by blunt dissection while the patient is in
Trendelenburg position to avoid aspiration of the pus.
In case of concern about the rupture of the abscess, extraoral approach is used for
drainage. An incision is made along the anterior border of the sternocleido-mastoid
inferior to hyoid bone and the muscle and carotid sheath retracted laterally. Dissection
between the carotid sheath and the inferior constrictor helps in the drainage of
retropharyngeal space.
Danger space- It is the potential space between the alar and
prevertebral division of the deep layer of the deep cervical fascia.
Why is it danger?
The danger space at its inferior border it is continuous with the
posterior mediastinum containing vena cava, arch of aorta, thoracic
duct, tracha and oesophagus. Erosion of the major blood vessels,
lower airways and upper digestive tract leads to death of the
patient.

59. PERITONSILLAR ABSCESS
(QUINSY)-
Peritonsillar abscess or quinsy is a deep
neck infection that is usually secondary
to contiguous spread from the local sites
or as a complication of acute tonsillitis
that is rarely life threatening in itself. It
can spread to involve the lateral
pharyngeal space. The peritonsillar
space is a potential space of loose
areolar tissue that surrounds the tonsil.
Boundaries of retropharyngeal space-
Laterally—Superior constrictors

60. Clinical features-
• Swelling of the tonsils
• Uvular displacement
• Trismus
• Muffled voice
• Fever
• Sore throat
• Dysphagia
Complications-
• Spontaneous rupture and aspiration
• Contiguous spread to pterygomaxillary space
• Airway obstruction
• Aspiration pneumonitis
• Hemorrhage or septic necrosis into carotid sheath
• Poststreptococcal sequelae -
- Glomerulonephritis
- Rheumatic fever

61. Surgical Management-
If the patient is not seen until the pus is formed or if the antibiotic therapy
fails, the abscess must be drained. But since peritonsillar abscess often tends to
recur, tonsillectomy should be performed 6–8 weeks after formation of the
abscess.

63. LIFE THREATENING COMPLICATIONS
OF OROFACIAL INFECTIONS-
Maxilla
LUDWIG’S ANGINA-
Ludwig’s angina is a form of a firm, acute, toxic and severe diffuse cellulitis/induration
that spreads rapidly, bilaterally affecting the submandibular, sublingual and submental
spaces.
Etiology-
1) Odontogenic infection
2) Traumatic injuries of orofacial region
3) Submandibular and sublingual sialadenitis
4) Secondary infections of oral malignancies
5) Pharyngeal infection or tonsillitis.
6) Iatrogenic (Use of contaminated needle for giving local anaesthesia)
7) Cervical lymphoid tissues
8) Miscellaneous

64. Clinical features-
General examination-
• Patient looks very ill
• Dehydration
• Chills
• Malaise
• Marked pyrexia
• Difficulty in swallowing (dysphagia)
• Impaired speech and hoarseness of voice
Regional examination-
Extraoral examination-
• Bilateral suprahyoid swelling is observed, with a hard, cardboard-like consistency.
• Swelling is firm/hard brawny involving bilateral submandibular and submental regions
• Airway obstruction and cyanosis may occur due to progressive hypoxia
•Mouth remains open due to the oedema of sublingual tissues and there is aresultant raised
tongue
• Fatal death may occur in untreated case of ludwig’s angina within 10– 24 h due to asphyxia.
Intraoral examination-
• Swelling develops rapidly and involves sublingual spaces causing elevation of tooth against the
palate.
• Increased salivation, stiffness of tongue,,restricted tongue movements and inability to close the
mouth, difficulty in swallowing with hot potato speech is noted.
• Drooling of saliva due to reduced control of muscles and jaw posture.
• Backward spread of infection leading to oedema of the glottis, which leads to obstruction of
airway.
• Development of Stridor being the alarming sign for fatal extension necessitating emergency
intervention to keep airway patent.

65. Treatment-
Ludwig’s angina should be considered as the life-threatening emergency.
Treatment must be vigorous and initiated early with administration of
antibiotics as for any odontogenic infections and prophylactic incision and
drainage of the spaces involved, without waiting for fluctuation to appear. The
airway must also be controlled, often requiring tracheostomy.
Surgical management-
Surgical management is necessary in case of rise of tissue tension and as a
provision for drainage. In a classic case of Ludwig’s angina, little amount of
pus is evacuated. Bilateral drainage of submandibular spaces along with the
drainage of sublingual and submental spaces is the recommended therapy.
It is preferable to drain sublingual and submental spaces separately to avoid
perforation of the mylohyoid muscle.

68. MEDIASTINITIS-
In the neck, the muscles and aponeurosis are oriented in the vertical plane,
creating a space that joins the posterior part of the mouth with the
mediastinum, in a chimney-like manner. This is where the major structures,
the carotid artery, vagus nerve and internal jugular vein covered by
perivascular fascia pass through. When this area becomes infected, it can
lead to mediastinitis, also known as descending necrotising mediastinitis.
Clinical features-
• Dysphagia
• Dyspnoea
• Stiff neck
• Oesophageal regurgitation.
• Swelling appears on the side of the neck
• Retrosternal pain
• Nonproductive cough
• Oedema and crepitation in the upper thorax.
• Fever and chills.

69. Complication-
• Septicemia
• Abscess formation
• Pleural effusion
• Rise in temperature, chills, sweat and shocks
• Empyema
• Compression of the local blood vessels
• Pericarditis
• Death
Management-
Intravenous administration of antibiotics at maximum doses and support measures that
can only be given in intensive care units (ICU) are mandatory. The association of
penicillin G and metronidazole or chloramphenicol against the anaerobes is often
considered shock therapy; when the Gram-negative microorganisms are also involved,
gentamicin or tobramycin is added.
Surgical Management-
Surgical intervention is aimed at incision and drainage. A transcervical approach has been
recommended, performing a wide incision in the area of the anterior edge of the
sternocleidomastoid muscle and reaching all the way to the mediastinum by means of
blunt, finger dissection through the pretracheal space. This procedure reduces the risk of
injuring vascular structures. After abundant irrigation of the affected spaces, continuous
suction
drains are placed. During the postoperative period, the patient must be placed in the

70. CAROTID SPACE INFECTION-
Carotid space infection produces a
tender swelling in the lateral aspect of
the neck under the
sternocleidomastoid muscle. Patients
will experience pain on palpation while
rotating the head laterally. Usually
there will be torticollis towards the
unaffected side.
Surgical Management-
An incision is made along the middle
third of the anterior border of the
sternocleidomastoid muscle. Through
a vertical incision, carotid sheath is
exposed carefully after retracting the
muscle posteriorly. Internal jugular
vein should be ligated to prevent
infection if it is thrombosed.

71. Mandible
CAVERNOUS SINUS THROMBOSIS-
When a thrombus is formed at some point in the facial venous system, it can
undergo retrograde spread towards the cavernous sinus, giving rise to thrombosis.
Routes-
• Danger area of face (external route)
• Pterygoid plexus of veins (internal route)
• Emissary veins

72. Clinical features-
• Eye pain
• Sensitivity of the eyeball to pressure
• Sgns of severe toxic infection, high fever, chills, tachycardia and sweating.
• Pulsatile exopthalmos with retrobulbar oedema.
• Palpebral oedema
• Ptosis
• Tearing of the eye
• Chemosis
• Retinal bleeding
• Ophthalmoplegia and palpebral ptosis
• Corneal reflexes are decreased or absent
• Mydriasis
• Thrombophlebitis
• Toxemia, meningitis, stiffness of neck with positive Kernigs and Brudzinski’s sign and
Biot’s respiration
Eagleton criteria-
1) A known site of infection or septicaemia.
2) Early destructive signs (such as full retinal veins, proptosis, exophthalmos, collateral
venous circulation).
3) Oculomotor pareses and trigeminal nerve involvement.
4) Neighbourhood abscesses from the thrombophlebitis situated in the orbit,
nasopharynx, occiput or neck.
5) Symptoms of complication such as headache, papilloedema and meningeal signs

73. Treatment-
• Early diagnosis is necessary for prompt
treatment and favourable prognosis.
• Treatment involves therapy with antibiotics
and steroids.
• Heparinisation—to prevent the extension of
thrombosis.
• Heparin 20,000 units in 1.5 L of 5% dextrose
or Dicumarol 200 mg may be given orally for
first day and 100 mg daily.
• Mannitol—to reduce oedema
• Surgical drainage

74. CEREBRAL ABSCESS-
Brain abscesses have been associated with oral manipulations such as dental
extractions, dental and periodontal surgery and injection of local anaesthetics or
dental prophylaxis, which suggests that the mechanism responsible for producing
septicaemia. It consist of localised suppurative areas inside the cerebral parenchyma,
followed by cerebellum.
Clinical features-
• Intense headache
• Nausea
• Projectile vomiting
• Convulsions
• Asphyxia
• Changes in character and behaviour
• Disorientation
• Hemiplegia
• Papilloedema
• Hemisensory deficit
• Abducent nerve palsy
Management-
The main line of management is antibiotics, antiinflammatory drugs, steroids
and mannitol to reduce cerebral oedema as well as surgical drainage.

75. MENINGITIS-
Meningitis is the most commonly occurring neurological complication, albeit it is rare.
It may develop from metastatic spread or it may be due to nearby thrombophlebitis.
Clinical features-
• Intense headache
• mental confusion
• Irritability
• Stupor
• High fever with chills
• Vomiting and stiff neck (Brudzinski’s sign).
• Convulsions may occur
• Kernigs sign- Flexing the patient’s hip 90 degree then extending the patient’s knee
causes pain
• Brudzinski’s sign- Flexing the patient neck causes flexion of the patient’s hip and
knees.
Management-
Neurological complications require hospital care. Initiating treatment with chloramphenicol
4 g/day IV because of its broad-spectrum activity, associated with penicillin G at a dose of
24 million units/day IV, while the microorganism is being identified through culture and
sensitivity, and its sensitivity profile is being determined. The maintenance of
hydroelectrolytic balance is also recommended in addition to controlling cerebral oedema
and preventing collapse and shock.

76. NECROTISING FASCIITIS OF THE HEAD AND NECK-
Necrotising fasciitis of the head and neck is a multimicrobial, uncommon soft tissue
infection characterised by formation of large necrotic lesions and gas formation,
located in the subcutaneous tissue and in the superficial fascia. As the disease
progresses, muscle and skin involvement develops, giving rise to myonecrosis and
spots in the area, as a consequence of the feeder vessels that pass through the
infected fasciae and if left untreated the generalised toxicity leads to multisystem
organ failure.Dental infections comprise the most frequent cause in the head and
neck although it can also be due to pharyngeal infections.
Clinical features-
• Gangrene of the subcutaneous cell tissue and muscular aponeurosis.
• Intense pain
• Paraesthesia
• The skin turns purple or dark with poorly defined edges.
• Vesicles later appear with a foul-smelling, purulent exudate.
• Cutaneous necrosis is detected on the fourth or fifth day with suppuration
approximately on the eighth day.
• Pneumonia
• Pulmonary abscess
• Vascular erosion
• Venous thrombosis
• Cranial neuropathies
• Fever, crepitation and sepsis may be present.

78. Management-
Treatment is based on antibiotic therapy, dental treatment of affected teeth
and surgical drainage of the lesion. Initially, broad-spectrum antibiotics are
administered intravenously.
Immediate surgical treatment is obligatory, with incisions and drainage, in
addition to vigorous debridement of the fasciae, subcutaneous tissue, muscles
and necrotic skin, requiring general anaesthesia in most cases. It is important
that the airway be maintained open, since they may be compromised as a
result of the oedema and necrosis produced by the necrotising fasciitis.
Intubation is difficult in these patients and tracheostomy is often needed.
Surgical Management-
An intraoral incision is placed at the base of the alveolar process in the lingual
sulcus. Care should be taken not to injure the sublingual gland, lingual nerve
and submandibular duct. To evacuate the pus a haemostat is inserted in the
anterior and posterior direction and beneath the sublingual gland. A rubber
drain is placed and sutured to avoid displacement. When infection crosses the
midline there will be a bilateral swelling of the sublingual space, in which case
a bilateral incision is made to drain the pus.

79. REFERENCE-
• Textbook of Oral Maxillofacial Surgery, Dr. S.M.Balaji, 3rd edition.
• https://www.slideshare.net/smijalgopalan/fascial-space-infections-70262438
• https://www.indmedica.com/journals.php?journalid=8&issueid=76&articleid=99
6&action=article