DR Adil Sulieman Mohammed OMF surgeon Khartoum Sudan

1. Tissue space infection
Mr.adil Suliman
OMF surgeon 2005
Khartoum dental hospital

2. Tissue space infection

Space is misnomer so it is clefts
(apotential space between the fascial
layers which contain CT AND Various
anatomical structures ) there is no voids in
the tissue.

3. abcess

Def.is apthological cavity which contain
pus and covered by pyogenic membane

4. why

Abcess should be drain before sun set

7. WHY WE STUDY THE TISSUE SPACE
INFECTIONS

8. Tissue space infection

1.Fatal :ludwig angina sophocation or
asphexia

Lateral pharyngeal space :erosion of
internal cartid A.

Canine space : Cavernous sinus
thrombosis

2.Comlications brain abcess meningitis
,septicemia ,blindness fistula,osteomyelitis

9. aetiology

Odontogenic instrumentation of
RCT,chemical,caries,deep pero.poccket

Trauma

post surgery ie reconstructive

Contaminated needle

Secondary to cyst or neoplasm

Microbial bacterial ,viral fungal

10. bacteriology

Aerobes and anaerobes are the causative
agents

Aerobes account for 5%

Anaerobes account for 35%

Both or both account for 60%

11. Life threatening features

Respiratory impairment

Difficulty in swallowing

Impaired vision

Change in voice (hot potato)

Lethargy

Decrease level of consciousness

Agitation, restlessness due to hypoxia

12. Toxicity features

Pallor

Rapid respiration

Throbbing pulse

Fever, shivering

Lethargy

Appear ill

13. Natural barriers against infection

Muscles

Fasiae

bone

14. Muscles containing infection

1.mylohoid

2.masseter

3.buccinator

4.M&L. Ptregoid muscles

5.temporalis

6. the superior constictors

15. The fascial layers

A.Deep cervical

Pretracheal

Prevertebral

Carotid sheath (vagus,internal jugular
v.,inernal carotid A.)

B.Superficial or investing layer

16. Bones containg abcess
Maxilla
mandible
Superaperioseal
Subperioseal


17. Masticator space infection

It is space lie along the lower border of the
mandible,ramus of the mandible and the mscles
of mastications

Outer sheath (masseter ,temporalis muscles)

The inner sheath cover (mylohoid m.)

Poteriorly cover the m.ptregoid m

Parotid space laterally,parapharyngeal space
medially ,it attach to temporal m. superiorly

18. The space of burns (suprasternal )

The superficial layer split below the level
of hyoid to form 2 spaces

The lower part of ant. Triangle (2layers
attach to) sternum

The lower part of post.Triangle (2layers
attach to manibrum of the clavicle

19. The space of burns (suprasternal )

Contents

The sternal head of sternocliedomastoid

Communication between the anterior
jugular v.

Lymph gland

The interclavicular ligament

20. Stages of infection

Periapical osteitis

Cellulitis

abcess

21. Stages of infection

Periapical abcess

A.infection confined within bone

B.tooth extruded from socket

C.painful tooth to biting and percussion

22. Stages of infection

Cellulitis

A.swelling not shaply demarcating

B. tissue has daughy consistency

C.no fluctuation

23. Stages of infection

Abcess

A.swelling distinctly outlined

B.tissue has firm consistency

C.fluctuation can usually be elicited

24. Site of dental infection and direction
of sread from jaw bones

Upper and lower central incisors and
canines and lower premolars the abcess
exit labially

Lower third molars it exit lingually from
bone

From other teeth it exit labially and
occasionally exit palataly or lingually

25. Clincal feature

Rubor (Redness)-calor (heat)-dolar (pain)-
tumor (swelling),fever
(pyrexia),headache,lymphadenopathy,diffi
culty inopening the mouth or swallowingor
brathing,increase salivation, change in
phonation ,bad breath

26. cellulitis

Def.oedematus swelling with all cardinal
signs of inflammation ,it is spreading
infection of loose connective tissue it
caused by streptococcus infection it does
not produce alarge collection of pus.

30. Cellulitis Vs abcess

Duration acute phase

Pain severe generalise

Size large

Localization diffuse
border

Palpation douphy to
induration

Pus No

Seriousness degree
greater

Bacteria aerobic

Chronic phase

Localized

Small

Well circumscribed

Fluctuant

Yes

Less

Anaerobic-mixed

31. periapical Vs periodontal

periapical abcess

1.non vital tooth

2. severe pain

3.sinus formation is
usual

4.tooth tender to
periapical percussion

5.swelling in the apex

Periodontal abcess

1.vital tooth

2.dull pain

3.no sinus formation
4.Tooth tender to
horizontal percussion
5. Swelling in the
middle third of
alveolar process

32. Factors affecting the spread of
infection

1.type and virulance of microorganism

2.the state of pt. Health

3.the efficiency of pt,s immune system

4.failure of pus drainage

33. Anatomical factors influencing the
direction of spread of infection

1.site of the source of infection ;lower or
upper jaw molar region or premolar
,incisor ,canine .anterior or posterior

2.point at which pus escape from bone to
soft tissues ;labiolingual or buccopalatally

3.the natural barrier to spread ;fascia
,muscle ,bone.

34. The spread of infection can be

1.direct depend on the anatomical
barriers

2.by lympatic

3.by blood (haematogenus)

35. pericoronitis

It is inflammation of the soft tissues
covering the crown of partially erupted or
unerupted tooth.it can be

1.unilateral

2.bilateral (infectious mononucleosis or
vincient ulcerative gingivitis

36. pericoronitis

Aetiology unknown

But the causes could be food collection
which is good media for bacteria to florish
due to 1.darkness,moist,food
(nutrition),absence of oxygen (anaerobic
conoization)

37. pericoronitis

2.trauma of overlaying gum

Factor influence the process of
pericoronitis

1.virulence of microorganisms

2.the host resistance

38. pericoronitis

Classifications

Subacute

Acute

chronic

39. Subacute

Localized dull pain

Swelling,red,tnder gum

Foetor oris

Submandibular
LN,tender,palpable,enlarged

40. Acute type

Throbbing pain intrfere e sleeping

Facial swelling

Fever,malaise

Trismus,

Discomfort e swallowing

Enlarged ,tender regional LN

41. Chronic type

Asymptomatic

Discomfort

Foeter oris

Change to acute or subaute

42. treatment

Irrigtion e normal saline

Antiboitic

Analgesics

Removal of the cause

Rehydration

Nutrition

Bed rest

Reduction or extaction of opposing tooth or offender
tooth

Operculectomy

Incision and drainage and culture and sensitivity test

43. Sublingual space

Firm painfull swelling in the ant. Part of
floor of the mouth

Raise the tongue

Little not exetnded swelling

45. Sublingual space

Boundery

V-shaped space

Medially the muscles of tongue
(genio,hyoglossus m.)

Inferiorly mylohoid m.

Laterally the lingual aspect of the
mandible

Superiorly the mucosa of the floor of the
mouth.

47. 
Surgical therapy aim

1.toget rid of toxic purulent material

2.to decompress the abcess

3.to allow better perfusion of
blood,containing antiboics and defense
elements

To increase the oxygenation of infected
area

48. Submental space

Surgical anatomy it lies between the
anterior and posterior bellies of diagastric
muscle

49. Submental space

Boundry :Superiorly ;the mylohoid m.

Inferiorly ;skin,platysma, deep cervical
fascia

Laterally; the anterior belley of daigasric
m.

Anteriolaterally ;lingual surface of the
body of the mandible

Posterioly ;the hyoid bone

50. Submental contents

Submental LN embbeded in adipose tissue

The source of infection:tip of the tongue

Lower incisors,anterior part of floor of the
mouth,lower lip skin or infection from the
submandibular space

51. Submandibular space

Surgical anatomy between the anterior
and posterior belly of diagastric m.

Medially the mylohyoid &hyoglossus m.

Inferiorly the investing layer of deep
cervical fascia

Laterally the medial aspect of the
mandible

55. Submandibular space
Contents
The submandibular gland ,LN,duct
Facial a.n, common facial v.n
Mylohyoid n.vessels
Causes
Infection from teeth ,LN
Truma in the angle of the mandibule

56. Submandibular space

CF

Swelling of the submandibular region

Pain tenerness,dysphagia

Systemic toxic effect

Discomfort

Difficult opening of the mouth

57. HILTON METHOD

THE METHOD OF OPENING THE ABCESS
ENSURES THAT NO BLOOD VESSELS OR
NERVE IN THE VICINITY IS DAMAGE

58. HILTON METHOD

TOPICAL ANAESTHESIA

STAP INCISION IN MORE FLUCTUATION
REGION

CLOSED FORCEP PUSH TO DEEP FASCIA

OPEN FORCEPS TO DECOMPESS

PLACEMENT OF DRAIN UNTIL SOPP
DRAININD

DRESSING

61. Ludwig angina

Apotential life threatining Bilateral massive
diffuse septic gangernous cellulitis of
submental , sublingual ,submandibular
region

Surgical anatomy of sublingual space

Surgical anatomy of submental space

Surgcal anatomy of submandibular space

62. Ludwig angina

Aetiology

Dental (odontogenic)

Foreign body

Sailadentits

Purulent tonsilitis

63. Ludwig angina

Bacteriology

Strepto staph.cocci aureus,albus

Spirocheats ,fusiform ,colli form bacteria

64. Ludwig angina

CF

Fever,malaise,pyrexia
,dysphonia,dehydration ,oedema of
epiglotis,drooling of saliva ,dynoea,

Raise tonue

Nonfluctuant ,brawny ,hard,in the 3
spaces,asphyxia or souphication in late
stage

67. Ludwig angina

Diagnosis

1.deep tender,bilateral swelling

2.It must be swelling of floor of the
mouth

3.Raise the tongue

69. Ludwig angina

Ttt

massive Antiboitics

Early intubation to control the airway

Nasotracheal intubation,cricotherodotomy and tracheostomy (late
stage)

Surgical drianage

Culture &sensetivity test

Bed rest fluid and electrolytes balance
Monitring of vital signs

Nutrition (multivitamines ,high protein diet (forceval)

analgesics

Folow up


71. Ptregomandibular space

Surgical anatomy :between the medial
surface of the mandiblar ramus &the
medial ptregoid m.

72. Pterygomandibular space

Boundries

superiorly: the latral ptregoid m.

Laterally :the ramus of the mandible

Medially :the medial ptregoid m.

73. Pterygomandibular space

contents:

Inferior dental v.a.n.

Lingualn.

Maxillary a.

Ptergoid venous plexus

74. Pterygomandibular space

Causes

1.pericoronitis

2.apical infection of mandibular molar

3.trauma at the angle of mandible

4.infected odontoma or cyst

75. Pterygomandibular space

Fever malaise,dysphagia

Intraoral swelling in the anterior border of
the ramus

Severe trismus

76. Submassetric space

The masseter muscle has 3heads e
insertion into the ramus seprated from
each other by bare areas the space
beteen the middle &deep head called
(submasseteric space) the origin the lower
border and medial surface of zygomatic
arch insertion in the lateral aspect of the
ramus of mandible.

77. Submassetric space

Aetiology

Pericorinitis vertical distoangular wisdom
tooth

Periapical infection of mandibular molar
extend distally.

78. Submassetric space

CF

Facial swelling outline the masseter m.

Swelling does not extend beyond the
posterior border of ramus or lift the lobe
of ear (DD.Acute parotitis)

Trismus

Pyrexia,malaise

79. Submassetric space

Complication

Osteomylitis

Misdiagnosed as sarcoma

80. Buccal space

Boundries

Anteriomedially the buccinator m.

Posteriorly :the masseter m.

Laterally ;paotid fascia covered by platysma

Limited below by the attachement of deep
cervical fasciato the mandible &depressor
angularis oris

Limted above by zygomatic process of maxilla
&zygomaticus major and minor.

83. Parotid space

Deep cervical fascia at the angle of the
mandible covere it large swelling posterior
to masseter m.

It raise the lobe of the ear

Doesnot cause trismus

84. Parotid space

Contents

Parotid lobes superfacial ,deep,LN,Duct

Facial n

Auriculotemporal n.

85. Infratemporal space

it form the upper exteremty of the
pterygoid space

Boundry

Laterally the ramus of the mandible
&the temporalis

Medially the lateral ptregoid m plate

Superiorly infratemporal surface of
the greater wing of sphenoid

86. Infratemporal space

Causes

Infection of upper third molar

Conamined LA Injection

CF

Trismus

Bulging of temporalis m.

Complication cavernous sinus thrombosis

87. Infratemporal space

Contents

The origin of the L&Medial ptregoid

The maxillary

The ptregoid venous plexus

88. Peritonsillar (QUINSY)

It is locaized infectionin the CT between
the tonsil& superior constrictor m.between
the ant. And pos. pillar of fauces.

Aetiology

Tonsillar cyrpts and supratonsillar fossa
infection

Pericoronal infection.

89. Peritonsillar (QUINSY)
CF
Ill,toxic,dehydrated,pain radiated to ear,hot
potato mouth,drooling of saliva,
trismus,intra oral tense swelling in the
anterior pillar facues

90. Parapharyngeal space

Lateral pharyngeal space+retrophayngeal
space (Prevertebral spce)

Space form ring around the pharynx
extended to mediastinum and
communicate e submandibular space
anterinferiorly and retromandibular space
posteriorly

91. Lateral pharyngeal space

Surgical anatomy it is cone shape space it
is base at the base of skull and it is apex
at the hyoid bone

92. Lateral pharyngeal space

The medial wall is superior constrictor

The laterl wall the medial ptregoid
m.,down to the angle of the mandible
&Submandibular gland

The posterior border is prevertebral fascia

It consists of 2 components

1.anterior component (muscular)

2.posterior component (vascular )

93. Lateral pharyngeal space

Aetiology

Lower third mlar infection

Tonsillar abscess

Sublingual,submandibular infection

CF

Prexia,malaise,swelling below the angle of
mandible,intraoral swelling in the lateral
wall of pharynx.

94. Retropharyngeal space

Laterally carotid sheath,the space is
continous e retro-oesophageal space into
posterior mediastinum to level of 6th
thoracic vertebra

95. Lateral pharyngeal space

The vascular components

1.the carotid sheath

2. the sympathetic trunk

3.cranial nerves ;9,10,11,12

96. Lateral pharyngeal space

Complications

1.thromophelibitis of the internal jugular v.

2.erossion of common carotid
a.(haemrraghe)

3.tongue paresis

97. Retropharyngeal space

Midlinespce between the pharyngobasillar
fascia which attach the pharyngeal
constrictor to base of skull and
prevertebral fascia

Aetiology

Lateral pharyngeal space infection

98. Retropharyngeal space

CF

Recurent sore throat,snoring
choking,dyspnoea,cervical adentis

Hot potatoes voice

99. Canine space

Lie deep into muscles of facial expression
involve upper lip (levator labii
superioris,levator angularis oris ,labii
superioris alaeque nasi )

Levator anguli oris below the infraorbital
n.levator labii superioris above it

Short canine level below levator angulii
oris.

100. Canine space

CF

Oedema of upper lip & cheek

Obliteration of nasolabial fold

Drooping of the angle of the mouth

Swelling of medial corner of lower eyelid

Complication cavernous sinus thrombosis

101. Cavernous sinus thrombosis

It is serious condition consisting formation of
thrombus in the cavernous sinus or it is
communicating branches

2routes

External route face,lip –facial –angular vein-
opthalmic v.-superior orbital fissure –cavenous
sinus

Internal route ;dental infection –ptregoid
v.plexus-inferior opth. V. inferior orbital fissure –
cavernus sinus

102. Cavernous sinus thrombosis

Crainal nerves involved

Occulomoter,trochlear, adbucent,optlamic
(trigeminal),carotid venous plexus

Microbilogy common bacteria sreptococci,
staph.cocci,and GM-VE Bcteria

103. Cavernous sinus thrombosis

Facial swelling (venous obstuction)

Pulsating exopthalmus (carotid pulse
transmitted to retrobublar oedema)

Opthalmoplegia ,absence of corneal
reflex,ptosis ,dilatation of pupil
,exopthamus ,profuse lacrimation
,chemosis , epistaxis (parlysis of cranial
nerves 3,4,5a ,carotid sympathetic plexus

104. Cavernous sinus thrombosis

Late CF

TOXIMIA ,MENINGITIS,KERING
SIGNS,BRUDZINSKI SINGN
,SEPTICEMIA,BLINDNESS

105. Cavernous sinus thrombosis

Or ptregoid v. plexus –emissary v.-foramen
ovale –cavernous sinus

Rapid complications lead to death because

Short distance from facial region to the
sinus

Frequent anastomosis of vein(direct
communication)

Valveless vessels (no protection )

106. Cavernous sinus thrombosis

TREATMENT

Antiboitics (chlormaphenicol 1g 6h)

Mannitol (reduce oedema)

Anticoagulants (heparin 20000 unit in
1500 ml 5% dextrose)

Surgical drinage

Culture &sensitivity ,bed rest ,fluid
,nutrition,follow up of general heath.

107. management

Drainage

Culture &sensetivity test

Antibotics

Analgesics

Fluid and electolytes balance

Nutrition

Bed rest

Monitring the vital signs and general health

Follow up

108. MERCI BEACOUP

THANKS