Space infection /certified fixed orthodontic courses by Indian dental academy

COMPARTMENTS OF THE HEAD
AND NECK – SURGICAL
ANATOMY & APPLIED ASPECTS
INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com


“He who sees things grow from
the beginning will have the
finest view of them”

Fascial Spaces
“The facial spaces or compartments are regions
of loose C.T. that fill the areas between facial
layers”.
The concept of fascial ‘spaces’ is based on
anatomists knowledge that all ‘spaces’, exist
only potentially, until fasciae are separated by
pus, blood, drains or a surgeon’s finger.

How did the concept of facial
spaces arise?
“If I have seen further, it is by standing on the
shoulder of Gaints”.
Issac Newton”
• In the 1930s the classic anatomical studies of
Grodinsky and Holyoke established the modern
understanding of the fascial layers and the
potential anatomical spaces through which
infection can spread in head and neck.

What is fascia and its functions?
• It is a sheet or layer of more / less
condensed connective tissue.
• Fascial layers are like tissue paper
surrounding each item of clothing within a
garment box, which allows them to pass
over each other without their becoming
unfolded.

Functions of the fascia
• Acts as a musculovenous pump• Limits outward expansion of muscles as they contract.
• Contraction of muscles compress the intramuscular veins
(push the blood towards the heart).
• Prevent penetrating objects eg knife & low velocity
bullets from vital structures
• They also afford the slipperiness that allows the structures
in the neck to move & pass over one another esply during
swallowing & turning the neck.
• Determine the direction of spread of infection

CLASSIFICATION
FASCIAE IN THE NECK

SUPERFICIAL
(SCF)

DEEP
(DCF)


Superficial fascia
Superficial fascia is not a fascial sheet in the classic sense, but
rather a fatty loose connective tissue in which are embedded the
voluntary muscles of facial expression and the platysma muscle.

Superficial fascia
Skin
+
Superficial fascia
+
Platysma muscle

Complex
morphological
unit

Superficial
musculoaponeurotic
system
(SMAS)

Clinical considerations:
1. Surgeons consider SMAS most important component of
rhytidectomy / face-lift surgery / plastic surgery of the face.
2. Necrotizing fascitis – Infection of this fascia causes necrosis
of the tissues in the subcutaneous space leading to necrotizing
fascitis.

Deep fascia
Superficial layer
of deep fascia

Middle layer of
deep fascia


Deep layer of
deep fascia

Superficial layer of deep cervical fascia


Middle layer of deep cervical fascia


Buccopharyngeal fascia


Deep layer of deep cervical fascia


Schematic diagram showing the arrangement
of deep neck spaces


•

•
•

The greatest clinical implication of cervical
fascia is that it divides the neck into potential
spaces that function as a unit but are
anatomically separate.
Hyoid bone is considered the most important
structure limiting the spread of infection.
For this reason infection are classified by
dividing the potential spaces into 3 general
divisions:
1. Space of entire neck.
2. Supra hyoid spaces.
3. Infra hyoid spaces.

Classification of the spaces of Face & Neck
I Spaces of the Face
A.

Maxillary spaces
1. Buccal space.
2. Canine space.
B. Mental space.

II Spaces of neck
A.

Spaces involving the entire length of the neck.
1. Superficial space
2. Deep neck spaces (all involve only the posterior side of the
neck)
a)
b)
c)
d)

Retropharyngeal space (Space 3).
Danger space (Space 4)
Prevertebral space (Space 5)
Visceral vascular space (within carotid sheath).

B. 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 / parapharyngeal).
4) Peritonsillar space.
5) Parotid space.

C. Infrahyoid space (involves anterior side of the
neck only).
1. Pretracheal space. www.indiandentalacademy.com

Concepts about space infections
• The spaces are not empty they contain various
organs, nerves, blood vessels, salivary glands,
lymph nodes and fat surrounded by loose fibrous
connective tissue.
• The spaces of head and neck are not perfectly
enclosed they are pathways around the muscles
through which infection can spread.


Concepts about space infections
• Infections within each space has its own
diagnostic signs and tends to spread in an
orderly, anatomic fashion from one space to
another by continuous extension.
• If the surgeon understands this process, he
can anticipate the spread of infection into
dangerous spaces and abort the process by
timely incision and drainage.

Pathways of spread of dental infection

Pericoronitis of third molar area

Spread of infection from erupted and
infected third molar area


Predisposing factors
•

Primary predisposing factors leading to deep
infection of the neck were:
1. Local dental disease like dental caries or
diseases of the gums.
2. Lowered body resistance due to result of
conditions such as tuberculosis, diabetes
mellitus, syphiles, scurvy.
Primary signs & symptoms of these infections:
- Cellulitis / phlegmons.
- Localized pain.
- Tenderness.
- Redness.
- Edema of the overlying tissue.

Relationship of point of bone perforation to
spread of infection

Infection enters soft tissue through
thinnest bone

In respect

to buccinator muscle

Stages of infections
•
•
•
•

Stage I – Inoculation
Stage II – Cellulitis
Stage III – Abscess
Stage IV – Resolution


Surgical anatomy of deep facial
spaces of head and neck


Buccal space

Clinical evaluation: Examination of the patient with the buccal space infection
demonstrate swelling confined to the cheek with abscess forming beneath the
buccal mucosa and bulging into the mouth.

Canine space / Infraorbital space

• Clinical evaluation: Patient exhibits swelling lateral to the nose
obliterating the nasolabial fold, grouping at the corner of the
mouth and swelling of the upper lip, edema occurs in the
upper and lower lid that may close the eye.

Differential diagnosis of upper face
infections

Dacrocystitis with
minimal involvement
of nasolabial fold.

Odontogenic cellulitis.
The nasolabial fold is
effaced.

Suprahyoid spaces
1) Mandibular space
•
•
•
•

Submandibular space.
Submental space.
Sublingual space.
Space of the body of the mandible.


Mandibular spaces
Submandibular space

Clinical Evaluation:
Infection mostly arises from 2nd or third molar.
Induration and erythema in the submandibular area obliterating the
mandibular line and extending to the level of hyoid bone.
No trismus.

Sublingual space

Clinical evaluation: Edema and induration of the floor of the mouth on the
affected side displacing tongue medially and superiorly.
Hot potato voice.
Elevation of tongue to palate causing airway compromise.
Prevents patient from extending tongue beyond the vermilion border of upper lip.

Submental space

Boundary
Clinical evaluation
Management
Complications


Ludwig’s Angina

Ludwig’s angina is a firm, acute, toxic cellulitis of the submandibular
and sublingual spaces bilaterally and of the submental space.
Three ‘fs’ of Ludwig’s Angina
-feared
-rarely fluctuant
-often fatal

Ludwig’s Angina
•

The original description of the disease was given by Wilhelm
Friedrich von Ludwig.

•

Ludwig’s original description he emphasized that the angina

1.

Is characterized by rapidly spreading gangrenous cellulitis.

2.

Originates in the region of submandibular gland but never
involves one single space and

3.

Arises from extension by continuity and not by lymphatics
and

4.

Produces gangrene with serosanguinous, putrid infiltration
but very little or no frank pus.

Ludwig’s Angina

Clinical evaluation:
- It is characteristically aggressive and rapidly spreading.
- Patient will appear toxic with elevation of WBC count,
fever, chills.
- Airway compromise occurring quickly and with little fore
warning.
- Drooling, dysphagia, mouth pain and neck stiffness are
not uncommon.
- Physical examination.
- Anteriorly protruding tongue, induration and erythema
of the floor of the mouth and indentation of the tongue by
the teeth.
- A woody induration in the suprahyoid region of neck.
- Trismus is usually absent.

Management of Ludwig’s Angina
•
•
•
•

Hospitalization.
Airway control – tracheostomy.
Early I.v. antibiotics.
External surgical exploration with division of mylohyoid
muscle and drainage.
• Blind or nasotracheal intubation is unsafe.
• Drainage: ‘Classic’ horizontal incision midway between
chin and hyoid bone is no longer advocated.
• Bilateral through and through drainage of submandibular
space with simultaneous exploration of submental and
sublingual space is recommended.

Incision for surgical drainage of Ludwig’s Angina

X


Deep neck infections
• All involve only posterior side of neck.
a)Retropharyngeal space (space 3, posterior
visceral space).
b)Danger space (space 4).
c)Prevertebral space (space 5).
d)Visceral vascular space (within the carotid
sheath)

Principles for Rx of the deep neck spaces
•
1.
2.
3.

4.
5.

Benjamin J. Gans, in his Atlas of oral

surgery, articulated these principles:
Drain all significant deep space infections.
Do not wait for fluctuance. Fluctuance is a late
sign.
Determine incision placement, incisions
designed to avoid important anatomical
structures, provide dependent drainage and leave
cosmetically acceptable scar.
Institute definitive treatment as soon as
possible, Offending tooth to be removed.
Check for systemic disease.

Retropharyngeal space
Retropharyngeal space is the potential space sandwiched between alar
and prevertebral layers of deep layer of the deep investing fascia.
Extension

Base of the skull
Mediastinum

Most dangerous of all types of deep neck
infections

Two compartments:
Suprahyoid

Sagittal section of retropharyngeal space

Infrahyoid

1. Only fat
1. Lymph nodes and fat.

Diagnosis of the soft tissue radiograph
for retropharyngeal space infection
Step I:
• Look at the prevertebral or
retropharyngeal soft tissue
shadow.
• In the area of 2nd and 3rd CV, RP
soft tissue shadow should be less
than 7mm wide.
• In the area of 6 cervical vertebra
soft tissue shadow is behind the
trachea and includes the thickness
of esophagus making it approx.
Children – 14mm wide
adults – 22mm wide www.indiandentalacademy.com

Step II.
The second feature that
should be looked for in
this radiograph is the
presence of gas.
Anaerobic bacteria will
produce gas that can be
seen as emphysema in the
soft tissues of the neck

Areas of Emphysema in the
submandibular and lateral
pharyngeal space region

Clinical Evaluation
• Children less than 4 yrs commonly affected.
• In adults it manifests as cold abscess.
• Sore throat, dysphagia, odynophagia, difficulty handling
secretions.
• Hot potato voice.
Early signs:

Late signs

•Refusal to take food.

•Neck tilts towards involved side.

•Cervical lymphadenopathy.

•Hyperextended complete inability
to flex the neck.

•Slight neck rigidity.
•Noisy breathing due to laryngeal
edema.

•Respiratory embarssment may
occur if abscess not ruptured or
drained.


Complications of space infection
Frontal view of the patient with right cavernous sinus
thrombosis

• Venous congestion of the fundus of the left eye.
• the same patient two weeks later.
Clinically
One eye experiences early involvement than the other.

Cranial nerve most likely to be involved is abducens.

Diagnosis of cavernous sinus
thrombosis
• Eagleton’s six features.
– Known site of infection.
– Evidence of blood stream
infection.
– Early sign of venous obstruction
in retina, conjunctiva or eyelids.
– Paresis of III, IV, VI cranial
nerves resulting from
inflammatory edema.
– Abscess forms and neighboring
tissues and
– Evidence of meningeal
irritation.

Surgical incisions used to approach deep neck
infections


Diagnostic Imaging of Fascial & Neck
Spaces
Plain film.

CT.

MRI


Ultrasound

Principles of incision and drainage
• Incise in healthy skin and mucosa when possible.
• Incision placed at the site of maximum fluctuance
results in a puckered, unesthetic scar.
• Place the incision in an esthetically acceptable
area.
• When possible place the incision in a dependent
position to encourage drainage by gravity.
• Dissect bluntly with closed surgical clamp or
finger, through deeper tissues.
• Place a drain and stabilize it with sutures.

Principles of incision and drainage
• Consider use of through and through drains in
bilateral submandibular space infections.
• Do not leave drains in place for an overly
extended period.
• Remove them when drainage becomes minimal.
• Clean wound margins daily under sterile
conditions to remove clots and debris.
• Another approach to drainage is the use of
computed tomographic (CT) guided catheter.

Thank you
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