Odontogenic infections are caused by dental caries and can lead to inflammation and swelling. If the infection spreads beyond the jawbone into soft tissues, surgical incision and drainage is needed to prevent serious complications. The infection can spread to deep neck spaces through fascial planes, resulting in swelling, breathing difficulties, and systemic symptoms. Management involves determining severity, evaluating host defenses, surgical drainage to remove infection sources, medical support like antibiotics, and frequent monitoring.
2. Odontogenic infections
are primarily due to dental caries, with inflammatory periapical pathology
manifesting clinically as pain and swelling
If the infection extends outside of the alveolus and basal bone of the jaws into the
surrounding soft tissues
the most prudent management is prompt surgical incision & drainage
to prevent significant patient morbidity &airway compromise.
Moreover, if the infection extends
outside of, or distal to, the vestibule
Infections that extend to the deep fascial spaces of the neck can result in significant
edema, dysphonia, dysphagia, inability to handle secretions, systemic symptoms, and
in the most severe cases, airway compromise.
3. anatomy
In general, the regional anatomy of the head and neck can be regionalized on
classifications based upon
(1) the “triangles” of the neck
(2) those developed related to anatomy affected by penetrating neck trauma
(3) infections of the head and neck
The cervical fascial layers of the head and neck determine the boundaries of deep
space neck infections
4. anatomy
prior to spreading to the deep fascial spaces of the neck, most
oral infections will penetrate the facial cortical bone of the
maxilla or mandible leading initially to a vestibular space
abscess prior to further dissemination of the infection.
The deep spaces of the head and neck are fascia-lined spaces
containing loose areolar connective tissue.
Their purpose is to cushion and protect the nerves, muscles,
vessels, and other important structures that run through them.
These are “potential” spaces, only existing when invaded by
bacteria or other material that leads to edema opening the
space followed by a cellulitis phase and then an abscess stage.
11. Management
These principles outline management of odontogenic infections are
1. Determine the severity of infection.
2. Evaluate host defenses.
3. Decide on the setting of care.
4. Treat surgically.
5. Support medically.
6. Choose and prescribe antibiotic therapy.
7. Administer the antibiotic properly.
8. Evaluate the patient frequently
12. Primary management goals
(1) medical optimization
(2) airway protection (general endotracheal intubation or surgical airway)
(3) removal of the source of infection
(4) surgical incision and drainage
(5) adjunctive antibiotic therapy
(6) frequent assessment of response to therap
13. Severity factors
Three major factors must be considered in determining the severity of an
infection of the head and neck:
1. anatomic location
2. rate of progression
3. airway compromise
14.
15. Infection stages
1. During the (1-3) days, the swelling is soft, mildly tender, and doughy in consistency.
2.Between (2 - 5 days), the swelling becomes hard, red, very tender. Its borders are
diffuse and spreading.
3. Between (5-7) days, the center of the cellulitis begins to soften & the underlying
abscess undermines the skin or mucosa, making it compressible and shiny.
The yellow color of the underlying pus may be seen through the thin epithelial layers.
At this stage, the term fluctuance is appropriately applied.(Fluctuance implies the
palpation of a fluid wave by one hand as the abscess is compressed by the other hand)
4.The final stage of odontogenic infection is resolution, which generally occurs after
spontaneous or surgical drainage of an abscess cavity. The swelling then begins to
decrease in size, redness, and tenderness. The resolving swelling may stay firm for some
time, however, as the inflammatory process is involved in removing necrotic tissue and
bacterial debris.
19. Airway Compromise
Is the most frequent cause of death
When patency of the upper airway cannot be maintained with routine
maneuvers (e.g., head tilt, jaw thrust), immediate airway access and
patency must be established surgically
the presence of infection overlying the trachea is less important than the
absence of ventilation. Therefore, infection in the region of surgical airway
access is not a contraindication to an emergency cricothyroidotomy or
tracheotomy
In partial airway obstruction, abnormal breath sounds will be evident,
consisting of stridor or coarse airway sounds suggestive of fluid in the
upper airways.
23. Airway Compromise
The patient may assume a special posture that straightens the
airway, such as the “sniffing position,” in which the head is
inclined forward and the chin is elevated, as if one were sniffing
a rose.
Others : include a sitting patient with the hands or elbows on the
knees and the chest inclined forward with the head thrust
anterior to the shoulders (tripod position), which also
straightens the airway and pulls the tongue forward and allows
secretions to drool outward onto the floor or into a pan.
24. Airway Compromise
Occasionally, a patient with a lateral
pharyngeal space infection will incline
the neck toward the opposite shoulder
in order to position the upper airway
over the laterally deviated trachea
(Figure 38-3).
25. Airway Compromise
Trismus is an ominous sign in the patient suspected
of odontogenic infection
A maximum interincisal opening that has
decreased to 20 mm or less in a patient with acute
pain should be considered an infection of the
masticator space until proved otherwise.
pterygomandibular space infection are sometimes
missed because trismus hinders the examiner’s view
of the oropharynx. Therefore, it is important for the
examiner to position the patient’s occlusal plane
parallel to the plane of vision and to orient a light
coaxial to that plane of view.
26. Airway Compromise
Then the patient is asked to maximally open the mouth in spite of
pain, and the tongue is depressed with a mirror or tongue blade.
This should allow the examiner to get at least a glimpse of the
position of the uvula and the condition of the anterior tonsillar
pillars. The affected tonsillar pillar will usually be edematous and
reddened, and it will displace the uvula to the opposite side
If the suspected site of infection is touched with the mirror or
tongue blade, acute pain may be elicited, especially as compared
with the opposite side (The patient’s report of pain should be
distinguished from the gagging that is likely to occur)
27. The mallampati test
predicting difficult intubation.
its initial proponent, as have trismus of less
than 20 mm and decreased thyromental
distance.
These results, however, have not been
confirmed by independent examiners,
although the combination of an abnormal
Mallampati test and a thyromental distance
(7 cm IS NORMAL) less than 5 cm has been
correlates.
28. Airway Compromise
In airway obstruction, the respiratory rate may be increased or
decreased yet one functional method of assessing the effectiveness of
respiratory efforts readily available to the oral and maxillofacial surgeon
is the pulse oximeter.
An oxygen saturation of below 94% in an otherwise healthy patient is
indeed an ominous sign because it indicates insufficient oxygenation of
the tissues due to hypoperfusion or hypooxygenation.
Given the patient with clinically apparent partial airway obstruction
or abnormally low oxygen saturation is an indication for immediate
establishment of a secure airway.
29. Airway Compromise
Soft tissue radiographs of the cervical airway&chest can be quite
valuable in identifying deviation of the airway laterally on a
posteroanterior film or anterior displacement of the airway on a
lateral view.
identify“drainable pus” by the combined use of contrast-enhanced
CT and clinical examination. By “drainable pus,” the authors meant a
collection of 2 mL or more of pus.
CT and clinical examination makes this combination the method of
choice for evaluation of potential airway obstruction, characterizing
the location and quality of infections in the head and neck.
30. IndicationQs for hospital admission
(airway compromised)
Infections in anatomic spaces that have a moderate
or high severity can hinder access to the airway for
intubation by causing trismus, directly compress or
deviate the airway by swelling, or threaten vital
structures directly.
an odontogenic infection involving the masticator
space, the perimandibular spaces, or the deep neck
spaces indicates hospital admission.
systemic disease indicates hospital admission and
may even delay surgery, as in the need to reverse
warfarin anticoagulation.
32. Evalute host defenses
Diabetes have the combination of a white blood cell migration defect, which inhibits
successful chemotaxis of white blood cells to the infected site from the blood stream, &a
vascular defect that impairs blood flow to small vessel tissue beds, especially in end
organs such as the foot.
The iatrogenic use of steroids to treat asthma, skin conditions, autoimmune diseases,
cancer, and other inflammatory conditions.
Corticosteroids appear to stabilize the cell membranes of immunocompetent cells,
thereby decreasing the immune response.
Patients with organ transplants are often treated with corticosteroids, also
immunosuppressive medications such as cyclosporine, tacrolimus, and azathioprine, to
suppress organ rejection reactions
33. Evalute host defenses
most odontogenic infections are due to extracellular bacteria, which are attacked by B cells,
the white blood cells that elaborate antibodies.
Although HIV infection may damage B cells early in the course of the disease, its most
devastating effects are seen on the T cells, which explains the increased rate of cancers and
infections by intracellular pathogens in patients with acquired immunodeficiency syndrome
(AIDS) and pre-AIDS.
Although patients with HIV seropositivity may suffer a more intense and/or prolonged
hospital course than other patients, HIV seropositivity does not seem to increase the
incidence of severe odontogenic infections.
35. Systemic reverse
prolonged fever may cause dehydration, which can, therefore,
decrease cardiovascular reserves and deplete glycogen stores, shifting
the body metabolism to a catabolic state.
The surgeon should also be aware that elderly individuals are not able
to mount high fevers, as often seen in children.
increased hospital stay.
1. number of involved spaces
2. Diabetes
3. neck swelling
4. lower facial swelling
5. C-reactive protein greater than 100
6. trismus
37. Indications for hospital admission (dehydration)
Dehydration clinical signs ( dry skin, chapped lips,
loss of skin turgor, and dry mucous membranes)
dehydration can be assessed in the presence of
normal serum creatinine by an elevated urine
specific gravity (>1.030) or
an elevated blood urea nitrogen (BUN) with a
normal serum creatinine, which indicates prerenal
azotemia.(acute kidney failure)
39. airway security
definitive airway management procedure
1. The involvement of moderate- or high severity anatomic spaces
2. anatomic locations that are not amenable to profound local anesthesia.
3. An infection that is rapidly progressing through the anatomic fascial planes, as in
necrotizingfasciitis,
4. patient who is not able to cooperate, such as a young child or a mentally handicapped
individual
An infrequently used surgical technique that may aid in protecting the airway during
intubation or tracheotomy is needle decompression. In this technique, under local
anesthesia, an abscess of the pterygomandibular, lateral pharyngeal, submandibular, or
sublingual space is aspirated with a large bore needle in order to decompress the
surrounding tissues.
This maneuver may decrease the risk of abscess rupture through taut, distended
oropharyngeal tissues during instrumentation of the airway.
Additional benefits redirection of pus drainage into the oral cavity or onto the skin,
where it can easily be removed, and obtaining an excellent specimen for culture and
sensitivity testing.
40. Surgical intervention
Management of the airway, removal of the offending source of infection, and
decompression of the fluid collection (incision and drainage) are performed most
appropriately in the operating room setting with general anesthesia
The goal of surgical access to the infection site is to expose the tissues to the
aerobic environment (in the case of cellulitis, to prevent progression to an
with anaerobic bacteria)
Surgical exposure and exploration of all involved spaces, establishment of
drainage of the infection, and removal of the etiologic source of infection (tooth,
tumor, fracture, foreign body) are of paramount importance in management
41. Surgical drainage
In addition, an intraoral vertical incision over the
pterygomandibular raphe can be used to drain the
pterygomandibular and submasseteric spaces as well as the
anterior compartment of the lateral pharyngeal space, Figure(
38-8).
. A hemostat should never be blindly closed while it is inside a
surgical wound. Another important principle of surgical incision
and drainage is the need to dissect a pathway for the drain that
includes the locations where pus is most likely to be found.
This can be guided by the preoperative CT & by knowledge of
the pathways of OI.
42. Surgical drainage
For example, in drainage of the submandibular space,
if incisions are placed over the anterior and posterior bellies of the digastric muscle
at the submandibular, submental, and sublingual location and at the
submandibular, sublingual location as shown in Figure 38-7,
then the dissection must pass superiorly and medially until the medial (lingual)
plate of the mandible is contacted.
The most likely pathway for odontogenic infections to enter the submandibular
space is through the thin lingual plate of the mandible, which also approximates
the root apices of the lower molar teeth.
By exploring this location, the surgeon may find a collection of pus that would
otherwise have been missed. In order to pass a drain through the submandibular
space effectively, the surgeon should, therefore, pass a large curved hemostat from
one incision upward to the medial side of the mandible and then down to the
other incision.
A Penrose drain can then be grasped in the tip of the hemostat and pulled through
the dissected pathway from one incision to the other, thus draining the entire
submandibular space.
44. Surgical drainage
through-and-through drain. (Figure 38-9)
The advantages
1. the provision of two pathways for the egress of pus,
2. placement of the incisions in healthy tissue in cosmetically acceptable areas,
3. the ability to irrigate the infected wound with unidirectional flow from one incision
to the other.
Wound irrigation is facilitated especially by the use of a Jackson-Pratt–type drain,
which is noncollapsible and perforated.
Such unidirectional superior-to-inferior drainage of the pterygomandibular space
using intraoral and extraoral incisions and a Jackson Pratt drain is illustrated in (Figure
38-10)
46. Surgical drainage
There is little evidence to indicate that frequent wound irrigation hastens
the resolution of infection. However, it does make clinical sense to remove
by irrigation bacteria, pus, clots, and necrotic tissue from infected wounds
as they accumulate.
Similarly, the use of bulky occlusive dressings has not been shown to
substantially alter the outcome of cases of odontogenic infection.
Nonetheless, the use of such a dressing, as illustrated in Figure 38-11, may
be more comfortable over the long run than a dressing that is taped to the
skin, and it certainly helps to prevent the contamination of the hospital by
pathogenic organisms.
There is no evidence in favor of either technique. Pus usually stops flowing
from surgically drained abscesses in 24 to 72 hours, but this process may
take somewhat longer when only cellulitis has been encountered.
It should be kept in mind, however, that latex Penrose drains can be
antigenic, and after several days, they may cause exudation owing to
foreign body reaction alone.
47. Timing for incision & drainage
The alternative strategy, (Williams and Guralnick) is the immediate establishment
of airway security, as necessary, and aggressive early surgical intervention.
Identification of an abscess is not required before surgical intervention., even
when it is in the cellulitis stage.
In a prospective case series of 37 patients hospitalized with severe odontogenic
infections, (Flynn and colleagues) performed surgical drainage on all patients as
soon as possible after admission. In none of their cases did incision and drainage
seem to hasten the spread of infection
the only significant predictor of abscess formation was the negatively associated
identification of peptostreptococci in culture. Thus, peptostreptococci were
associated with cellulitis significantly more than with abscess.
48. Culture and Sensitivity Testing
most odontogenic pathogens are slow-growing species, identification can become
an expensive and time-consuming task for the microbiology laboratory
This expense is hard to justify, given the fact that, at least until recently, the oral flora
is routinely sensitive to penicillin.
Therefore, most microbiology laboratories, when given a specimen that grows out
α-hemolytic streptococci mixed with short, anaerobic, weakly gram-negative rods
will report the growth of normal oral flora, thus avoiding the necessity for species
identification and subsequent antibiotic sensitivity testing. reasons, routine culture
and sensitivity testing for minor oral infections does not appear to be justified.
49. Culture and Sensitivity Testing
Immunocompromised patients also tend to harbor unusual pathogens, such as
Klebsiella pneumoniae in diabetics, methicillin-resistant Staphylococcus aureus
in intravenous drug abusers, and intracellular pathogens, such as
mycobacteria in HIV/AIDS.
Ideally, the skin or mucosa should be prepared with antiseptic and isolated, and
the culture should be obtained by aspiration from the point of maximum
inflammation, where abscess is most likely to be found.
If this is not possible, then at surgery, a swab and culturette system can be
used, although the surgeon must be careful to avoid contamination of the
specimen by saliva or skin flora
Molecular methods using genetic material from infecting pathogens are in
development.
50. Culture and Sensitivity Testing
though the surgeon may not encounter pus during aspiration attempts or
surgical drainage, fluid aspirates and swab cultures of infected sites do
yield valid cultures with readily interpretable results. Therefore,
should be sent for culture and sensitivity testing even when (pus is not
obtained)
51. Medical support
composed of
1. hydration
2. nutrition
3. control of fever in all patients.
Maintenance or reestablishment of electrolyte balance and the control of
systemic diseases may also be a crucial part.
52. Medical support
Initial temperature has been shown to be a significant predictor of the length of
hospital stay with severe odontogenic infections.
Fever below 103°F (39.4°C) is probably beneficial. Mild temperature elevations
promote
1. Phagocytosis
2. increase blood flow to the affected area
3. raise the metabolic rate,
4. enhance antibody function.
Above 103°F, however, fever can become destructive by increasing metabolic and
cardiovascular demands beyond physiologic reserve capacity. Energy stores can be
rapidly depleted and the loss of fluid is significantly increased.
53. Medical support
Adequate hydration is the best method for controlling fever.
Daily sensible fluid loss, consisting primarily of sweat, is increased by 250 mL per
degree of fever.
Insensible fluid loss, consisting mainly of evaporation from lungs and skin, is
increased by 50 to 75 mL per degree of fever per day.
Therefore, a 70-kg patient with a fever of 102.2°F would have a daily fluid
requirement of about 3100 mL. This would translate to a required intravenous
infusion rate of approxitmately 130 mL/hr, assuming no oral intake and no other
extraordinary fluid losses.
54. Medical support
controlling fever by administration of acetaminophen or aspirin.
Fevers are often exaggerated in children and decreased in the elderly.
Thus, an older patient with a relatively mild elevation of temperature may have a fairly significant
infection. surgeon may wish to control fever in the elderly at a lower temperature level than in the
younger patient because of a fever’s increased cardiovascular and metabolic demands.
Fever reduced by
1. cool water
2. alcohol sponge baths
3. chilled drinks when practical
4. an immersion bath using tepid water.
Fever also increases metabolic demand by 5% to 8% per degree of fever per day. Therefore, it may
be necessary to supplement the infected patient’s oral intake, which is likely to be significantly
inhibited by the local effects of the infection and surgery, by using supplementary feedings or even
enteral nutrition via a feeding tube.
56. Antibiotics Coverage
respond well to the oral penicillins
a penicillin continues to be a highly effective antibiotic for uncomplicated
odontogenic infections, owing to (its low cost and low incidence of unwanted side
effects)
amoxicillin is administered orally only three times per day, compliance with the
prescribed regimen should be better than with penicillin V, at four times per day.
There was no significant difference in pain or swelling at 7 days of therapy between
penicillin and various other antibiotics, including clindamycin, amoxicillin,
amoxicillin clavulanate, and cephradine,
although these parameters improved more rapidly during the first 48 hours of
therapy with the alternative antibiotics.
57. Antibiotics Coverage
Clindamycin becomes the antibiotic of first choice for odontogenic infections. Its
resistance rates among the oral streptococci are rising recently to as high as 17% of
cases. Therefore, clindamycin has largely been replaced.
An alternative antibiotic, azithromycin, one of the newer macrolides, has been
shown to be effective in odontogenic infections in one trial, and it has a
significant safety advantage over the other macrolide antibiotics.
Erythromycin and clarithromycin, for example, are metabolized in the liver by the
cytochrome P-450 CYP3A4, which is responsible for 50% of drug intervention
For severe infections warranting hospital admission, the antibiotics of choice for
odontogenic infections do not include penicillin G or V
58. Antibiotics Coverage
Most resistance to penicillin that occurs among the oral pathogens is
due to synthesis of β-lactamase.
Approximately 25% of the strains of the Prevotella and
Porphyromonas genera are able to synthesize this enzyme.
β-Lactamase can also be found in some strains of Fusobacterium and
Streptococcus species.
oral strains of streptococci that synthesize β-lactamase are generally
among the Streptococcus mitis, S. sanguis, and S. salivarius species.
(These species are members of the Streptococcus viridans group that
are responsible for many cases of endocarditis)
59. Antibiotics Coverage
The penicillins and metronidazole have the advantage of crossing the bloodbrain
barrier when the meninges are inflamed.
Clindamycin, conversely, does not cross the blood-brain barrier.
Therefore, it is appropriate to use (penicillin plus metronidazole or ampicillin-
sulbactam) when there is a risk of an odontogenic infection entering the cranial
cavity.
60. Antibiotics Coverage
Ceftriaxone is effective against the
oral streptococci and most oral
anaerobes
Among the cephalosporins,,
ceftriaxone is an alternative
antibiotic of choice.
(Because ceftriaxone can cause
pseudocholelithiasis owing to
sludging of bile salts, it should be
used with caution or avoided in
patients with hepatobiliary disease.)
61. Antibiotics Coverage
A fourth-generation
fluoroquinolone, moxifloxacin has
great promise in the treatment of
head and neck infections. Its
spectrum against oral streptococci
and anaerobes is excellent.
The fluoroquinolones are the
antibiotics of choice for E. corrodens
Metronidazole has a disulfiram-
like reaction with alcohol; it
should be avoided in patients that
may have difficulty abstaining from
alcohol.
62. ADMINISTER THE ANTIBIOTIC PROPERLY
Some antibiotics are equally well absorbed intravenously and orally like The
fluoroquinolones, (ciprofloxacin and moxifloxacin)
For this reason, the fluoroquinolones are not given intravenously unless use of the
(oral route is contraindicated).
The minimum inhibitory concentration (MIC) is the concentration of an
that is required to kill a given percentage of the strains of a particular species,
reported as 50% or 90% of strains (MIC50 or MIC90, respectively).
The effectiveness of some antibiotics is determined by the ratio of the serum
concentration of the antibiotic to the MIC required to kill a particular organism
65. EVALUATE THE PATIENT FREQUENTLY
In outpatient infections that have been treated by tooth extraction &intraoral
I & D, the most appropriate initial follow-up appointment is usually at 2
days postoperatively becuz:
1. Usually, the drainage has ceased and the drain can be discontinued at
this time.
2. There is usually a discernible improvement or deterioration in signs
and symptoms allowing the next treatment decisions to be made.
By 2 to 3 postoperative days, the clinical signs of improvement should be
apparent, such as
1. decreasing swelling
2. defervescence(fever decreasing)
3. cessation of wound drainage
4. declining white blood cell count
5. decreased malaise
6. a decrease in airway swelling such that extubation can be considered.
Also at this time, preliminary Gram stains and/or culture reports should
be available, which may provide some guidance as to the appropriateness of
the empirical antibiotic therapy.
66. EVALUATE THE PATIENT FREQUENTLY
One of the best methods of
reevaluation is the postoperative
CT.
A postoperative CT can identify
continued airway swelling that
may preclude extubation or
further spread of the infection
into previously undrained
anatomic spaces or it may
confirm adequate surgical
drainage of all the involved
anatomic spaces by the
visualization of radiopaque
drains in all of the involved
fascial spaces.
inability to extubate a patient is
due to antibiotic resistance or
inadequate surgical drainage.
Figure 38-12
67. EVALUATE THE PATIENT FREQUENTLY
(fetid)
If there is continued chronic drainage from an infected site, diagnosis based on:
“FETID” stands for( foreign body, epithelium, tumor, infection, distal obstruction). In the
maxillofacial region, this mnemonic can be used to provide a differential diagnosis for the
chronic drainage of pus.
1. Foreign bodies may be represented by bone plates and screws or dental or cosmetic facial
implants.
2. Epithelium may cause chronic drainage simply because an epithelialized fistulous tract has
not been completely excised or because an epithelium-lined cyst has drained externally.
3. Tumors (especially malignant ones) that become infected do not heal, which may result in
chronic drainage.
4. Infection can, of course, drain chronically, which should alert the surgeon to suspect
osteomyelitis or a chronic periapical abscess that is draining onto the skin, as in Figure 38-
14
68. EVALUATE THE PATIENT FREQUENTLY(fetid)
5. Distal obstruction classically refers to
intestinal obstructions, but the concept can
still be applied to the salivary ducts and to the
natural sinus drainage pathways, such as the
ostium of the maxillary sinus.
When these openings for natural drainage of
saliva or mucus become obstructed, infection
may result and drainage may occur by an
alternate pathway, such as proximal
fistulization of the submandibular salivary duct
due to a salivary stone blocking the natural
opening of Wharton’s duct.
72. necrotizing fasciitis
The earliest signs of necrotizing fasciitis are
small vesicles and a dusky purple
discoloration of the involved skin (Figure
38-2). Soon after, the skin may become
anesthetic. Thereafter, necrosis occurs.
A suspicion of necrotizing fasciitis is a surgical
emergency requiring
1. broad-spectrum antibiotics
2. repeated surgical drainage(Repeated
surgical debridement is the rule, not the
exception)
3. antiseptic wound packing
4. intensive medical supportive care (fluids,
calcium, and possibly blood transfusion).
5. Hyperbaric oxygen therapy
73. necrotizing fasciitis
rapidly progressive infection.
Occasionally found in the head and neck, frequently due
to odontogenic sources
follows the platysma muscle down the neck and onto the
anterior chest wall.
Diabetes &alcoholism are predisposing factors, whereas
medical compromise, delay in surgery, and
mediastinitis(chest infection) are associated with increased
mortality.
Similar processes may be involved in neck descending
necrotizing progressing to the mediastinum.
74. Nectroizing fasciitis
known colloquially as (flesh-eating) bacterial infection .
Cervical necrotizing fasciitis is often polymicrobial in nature, is strikingly
destructive, and is often fatal with a mortality rate of 7% to 20%.
When the infection progresses to the thoracic region as a descending necrotizing
mediastinitis, the mortality rate rises dramatically.
the progression of cervical necrotizing fasciitis does not follow the normal fascia
planes of the head and neck. This is due to the unusually aggressive nature of the
disease process.
75. Nectroizing fasciitis
rapid spread of the infection on
the superficial surface of the
anterior (investing) layer of the
deep cervical fascia deep to the
platysma muscle.
Clinically there is necrosis of the
platysma muscle and overlying
skin due to thrombosis of the
underlying muscles , soft tissues,
dermal blood supply (Fig. 17.23)
80. Primary space
(spread of infection directly from the oral
cavity)
Secondary spaces
(spread of infection from the primary spaces)
Primary
maxillary
Primary mandibular Secondary
maxillary
Secondary mandibular
Buccal Buccal periorbital Masticator spaces
Labial
vestibular
Perimandibular spaces orbital sub_
masseteric
pterygo-
mandibula
r
Super_
Ficial
temporal
deep
temporal
Infratorbital
(canine)
Subment
al
Sub_
mandibular
Sublingua
l
Cavernous
sinus
thrombosis
Deep cervical spaces
Infra
temporal
Lateral
pharyngeal
Retro_
pharyngea
l
Prevertebral parotid
81. vestibular space
Location: Between the vestibular mucosa and the
muscles of facial expression.
Etiology: Maxillary central and canine usually have their
roots in close approximation to the buccal cortex of the
bone.
Connections: Canine and Buccal spaces.
Signs and symptoms: Vestibular fluctuation and swelling.
Surgical approach: Vestibular incision.
84. buccal space
Location:
a) The overlying skin of the face on the lateral aspect
b) the buccinator muscle on the medial aspect
c) the zygomatic arch from the superior aspect
d) the lower border of the mandible from the inferior aspect.
Content:
1. Parotid duct
2. anterior facial artery and vein
3. transverse facial artery and vein
4. buccal fat pad.
Etiology: Infection from maxillary teeth through the bone superior to the
attachment of the buccinator on the alveolar process of the maxilla.
Posterior maxillary teeth (most commonly molars and rarely premolars)
cause most buccal space infections
85. buccal space
Connections:
1. Vestibular space
2. Infraorbital (canine) space
3. Periorbital space
4. Superficial temporal space
5. Infratemporal space
6. Pterygomandibular space.
Signs and symptoms: Swelling below the zygomatic arch and above the inferior border of the
mandible.
Surgical approach: Access to the buccal space is usually intraoral (vestibular incision) for three main
reasons:
1. the abscess fluctuates intraorally in the majority of cases
2. avoid injuring the facial artery
3. for esthetic reasons.
An extraoral incision (submandibular incision: approximately 1-2 cm below and parallel to the inferior
border of the mandible) is made when intraoral access would not ensure adequate drainage, or when
the pus is deep inside the space.
86. Infraorbital or canine space
Location: Between the levator anguli oris and
the levator labii superioris muscles.
Content: Angular artery and vein, infraorbital nerve
Etiology: Maxillary canine (The canine root is often sufficiently long to
allow erosion to occur through the alveolar bone that is superior to the
origin of the levator anguli oris and below the origin of the levator labii
superioris muscle).
Connections: Vestibular and Buccal spaces.
Signs and symptoms:
Edema spreads towards the medial canthus of the eye, lower eyelid, side
of the nose as far as the corner of the mouth.
There is also obliteration of the nasolabial fold, and somewhat of the
mucolabial fold.
Surgical approach: Vestibular incision.
spontaneous drainage of infections of this space commonly occurs near
the medial or the lateral canthus of the eye because the path of least
resistance is to either side of the levator labii superioris muscle, which
attaches along the center of the inferior orbital rim.
87. infratemporal space
Location:
a) Anteriorly by the maxilla
b) bounded medially by the lateral pterygoid plate of the
sphenoid bone
c) superiorly by the base of the skull
d) Laterally, the infratemporal space is continuous with the
deep temporal space.
Content:
1) Branches of the internal maxillary artery
2) the pterygoid venous plexus.
Etiology: The infratemporal space is rarely infected, but
when it is, the cause is usually an infection of the maxillary
third molar. Also infection may spread from the
pterygomandibular space.
88. infratemporal space
Connections:
1. Deep temporal
2. Orbital spaces
3. Buccal
4. Pterygomandibular
Signs and symptoms:
1) Trismus and pain during opening of the mouth
2) lateral deviation towards the affected side
3) edema at the region anterior to the ear, which extends above the
zygomatic arch, as well as edema of the eyelids.
Surgical approach:
A. Intraoral (vestibular incision)
B. Extraoral (The incision is performed on the skin in a superior
direction, and extends approximately 3 cm, starting from the angle
created by the junction of the frontal and temporal processes of the
zygomatic bone).
90. Submental space
Location:
a) Laterally and on both sides by
the anterior belly of the digastric muscle
b) the mylohyoid muscle superiorly
c) the overlying fascia inferiorly.
Content:
1) Anterior jugular vein and
2) the submental lymph nodes.
Etiology: Isolated submental space infections are rare,
caused by infections of the mandibular incisors.
Also, spread of infection from submandibular space,
which can easily pass around the anterior belly of the
digastric muscle and enter the submental space.
91. Submental space
Connections: Submandibular space.
Signs and symptoms:
Indurated and painful submental edema,
which later may fluctuate.
Surgical approach: Extraoral approach
(incision on the skin, beneath tbeneath the
chin, in a horizontal direction and parallel to
the anterior border of the chin).
92. Sublingual space
Location:
a) superiorly by the oral mucosa of the floor of the mouth
b) Inferiorly by mylohyoid muscle
c) Anteriorly and laterally by the inner surface of the body of the mandible
d) medially by the midline genioglossus/geniohyoid muscle complex.
The posterior border of sublingual space is open, therefore,
it freely communicates with the submandibular space.
Content:
1. Submandibular duct (Wharton’s duct)
2. part of the submandibular gland.
3. the sublingual gland
4. the sublingual & lingual nerve
5. terminal branches of the lingual artery
93. Sublingual space
Etiology:
The factor that determines whether the infection is
submandibular or sublingual is the attachment of the
mylohyoid muscle on the mylohyoid ridge of the medial aspect
of the mandible.
If the infection erodes through the medial aspect of the
mandible above this line, the infection will be in the sublingual
space. This is most commonly seen with premolars and the first
molar.
The second molar may involve the sublingual or
submandibular space, depending on the length of individual
roots.
The mandibular third molar is the tooth that most commonly
involves the submandibular space directly.
94. Sublingual space
Connections: Submandibular &
Lateral Pharyngeal spaces.
Signs and symptoms:
1. Swelling of the mucosa of the floor of the
mouth, resulting in elevation of the tongue
towards the palate and laterally (little or no
extraoral) swelling.
2. The mandibular lingual sulcus is obliterated
and the mucosa presents a bluish tinge.
3. The patient speaks with difficulty, because of
the edema,
4. movements of the tongue are painful.
95. Sublingual space
Surgical approach:
Intraoral approach (incision is
lateral & along
Wharton’s duct and the lingual
nerve)
extraoral approach
(submandibular incision:
approximately 1-2 cm below and
parallel to the inferior border of the
mandible).
96. Submandibular space
Location: Lies between the mylohyoid muscle and the overlying superficial layer of the
deep cervical fascia.
1. laterally by the inferior border of the body of the mandible
2. medially by the anterior belly of the digastric muscle
3. posteriorly by the stylohyoid ligament &
posterior belly of the digastric muscle
( The posterior extent of the submandibular space communicates with
the deep fascial spaces of the neck)
Content:
1. Facial artery and vein
2. the submandibular salivary gland
3. submandibular lymph nodes.
97. Submandibular space
Etiology: originate from mandibular third molars (and second molar if their apices lies
beneath the attachment of the mylohyoid muscle).
result of spread of infection from the sublingual or submental spaces.
Connections: Submental, Sublingual, Lateral pharyngeal and Buccal spaces.
Signs and symptoms:
1. Moderate swelling at the submandibular area
2. edema that is indurated
3. redness of the overlying skin.
4. angle of the mandible is obliterated
5. pain during palpation
6. moderate trismus due to involvement of the medial pterygoid muscle
Surgical approach: Extraoral approach (submandibular incision:
approximately 1-2 cm below and parallel to the inferior border of the mandible).
100. Ludwings angina
infections from one submandibular space may pass
through the submental space to then involve the
contralateral submandibular space.
It is Involvement of sublingual, submandibular, and
submental spaces
This is a wrong term for any (perimandibular space)infection
airway may be compromised When a cellulitis or abscess
involves all three of these spaces (actually, five spaces: two
submandibular spaces, two sublingual spaces, and one
submental space), the airway should be the primary
consideration and be secured (e.g., tracheal intubation of
tracheostomy).
101. Ludwings angina
The clinical findings
1. elevation of the floor of the mouth and tongue intraorally (sublingual space)
2. firm induration of the skin in the submental and submandibular regions extraorally
3. fluctuant swellings (abscess cavities) bilaterally from the inferior border of the mandible to the
hyoid bone.
4. The inferior border of the mandible is often not palpable due to significant firm swelling.
Other clinical findings include
1. dysphagia, dysphonia
2. Trismus
3. floor of mouth, tongue elevation (causing inability to visualize and evaluate the posterior
oropharynx),
4. cervical immobility
5. globus sensation (feeling of a lump in throat) in the late stages
6. inability to handle oral secretions, head held in a forward “sniffing” position, a “hot potato” voice,
7. increased work of breathing due to upper airway obstruction.
102. Ludwings angina history
In the early and mid-1900s, Ludwig angina was
associawith high morbidity and mortality, and it
was determined that securing the airway as early
as possible, with early surgical intervention in the
form of incision & drainage, significantly reduced
patient morbidity
104. periorbital or orbital space
(secondary maxillar space)
Periorbital cellulitis is an infection of the eyelid and the periorbital soft tissues;
orbital cellulitis is an infection of the eyeball and tissues around it.
Rarely occurs as the result of odontogenic infection.
The presentation is typical: redness and swelling of the eyelids and involvement of the vascular
and neural components of the orbit.
This is a serious infection and requires aggressive medical and surgical intervention from an oral-
maxillofacial surgeon and other specialists
105. Cavernous sinus thrombosis
One of the most severe complications of a maxillary
odontogenic infection
intracranial compartments (serve as bilateral venous
drainage channels for the middle cranial fossa)
These cavities (or “sinuses”) absorb secretory fluid from
the pituitary gland and are bordered by the superior
orbital fissure anteriorly that contains the ophthalmic
vein (Fig. 17.21)
The superior and inferior ophthalmic veins drain the
orbital region, and it is via these veins that orbital
abscesses may spread to the cavernous sinus.
107. Cavernous sinus thrombosis
It is bordered laterally and superiorly by the dura mater.
It is drained by the superior and inferior petrosal sinuses.
The contents include cranial nerves II, III, IV, VI; the second
division of cranial nerve V; and the internal carotid artery (see
Fig. 17.21B).
On clinical exam, any of the structures that receive innervation from
these nerves may be affected, but (CN6) is most likely to be affected
(lateral rectus muscle palsy) because its exposure in the cavernous
sinus is greatest in the lateral compartment.
Another early finding in cavernous sinus thrombosis is : congestion
of the retinal veins of the eye on the unaffected side that may be
noted on a detailed ophthalmologic exam
109. Submasseteric space(secondary
mand)
The masticator spaces: It is formed by the splitting the superficial
layer of the deep cervical fascia to surround the muscles of
mastication.
Location:
1. Between the masseter muscle laterally
2. the lateral surface of the ascending ramus of the mandible
medially.
3. The zygomatic arch superiorly
4. the lower border of the mandible inferiorly.
Content: Masseteric artery and vein.
Etiology: Infection most commonly as the result of spread
from the buccal space or from soft tissue infection around the
mandibular third molar (pericoronitis).
Occasionally, an infected mandibular angle fracture causes
a submasseteric space infection.
110. Submasseteric space
Connections: Buccal space, parotid space , the rest
of the masticator space.
Signs and symptoms:
1. The masseter muscle becomes inflamed and
swollen.
2. The patient also has moderate to severe trismus
(due to the involvement of the masseter muscle).
Surgical approach: Intraoral approach (incision
begins at the coronoid process and runs along the
anterior border of the ramus towards the
mucobuccal fold as far as the second molar)
111. pterygomandibular space
It is the space into which local anesthetic is injected during inferior alveolar nerve block.
Location:
1. Medially by medial pterygoid m.
2. laterally by medial surface of the ascending ramus.
3. Anteriorly by buccal space
4. Posteriorly by parotid gland
5. Superiorly by lateral pterygoid m.
6. inferiorly by inferior border of the mandible
Content: Mandibular division of trigeminal n.
Inferior alveolar artery and vein.
Etiology: The mandibular third molar is the most commonly associated tooth.
Also may caused by needle track infection from inferior alveolar nerve block.
112. pterygomandibular space
Connections:
1. Buccal
2. Submasseteric
3. Deep temporal
4. Lateral pharyngeal,
5. Parotid
6. Peritonsillar spaces.
Signs and symptoms:
Little or no facial swelling is observed extraorally
the patient almost always has significant trismus.
Therefore, trismus without swelling is a valuable
diagnostic clue for pterygomandibular space
infection.
113. pterygomandibular space
Surgical approach:
A. Intraoral approach (vertical incision, lateral and parallel to the
pterygomandibular raphe)
B. extraoral submandibular approach.
114. Superficial temporal space
Location: Bounded laterally by the temporal
fascia and medially by the temporalis muscle.
Content: Temporal fat pad, Temporal branch of
facial nerve.
Etiology: Rarely become infected and usually
only in severe infections due to spread of
infection from the infratemporal space, with
which it communicates.
Connections: Buccal and Deep temporal spaces.
115. Superficial temporal space
Signs and symptoms: Swelling over the
temporal region, superior to the zygomatic
arch and posterior to the lateral orbital rim.
Surgical approach: Extraoral approach
(incision made horizontally, at the margin
of the scalp hair and approximately 3 cm
above the zygomatic arch).
116. deep temporal space
Location: Between the medial surface of the
temporalis muscle and the temporal bone.
Content: Mandibular division of trigeminal
nerve, Skull base foramina.
Etiology: same as superficial temporal
Connections: Infratemporal space, Superficial
temporal space, Inferior petrosal sinus.
Signs and symptoms: same as superficial
temporal
Surgical approach: same as superficial temporal
119. Lateral pharangeal space
Location:
Extends from the base of the skull at the sphenoid bone superiorly
the hyoid bone inferiorly.
The space is bounded laterally by the medial pterygoid muscle and the ramus of the mandible
medially by the superior pharyngeal constrictor muscle
bounded anteriorly by the pterygomandibular raphe
extends posteriorly to the prevertebral fascia.
Content: The styloid process and associated muscles and
fascia divide the lateral pharyngeal space into
anterior compartment, which contains primarily loose connective tissue
posterior compartment, which contains the carotid sheath and cranial nerves IX
(glossopharyngeal), X (vagus), and XII (hypoglossal).
Etiology: Lower third molars, Tonsils, Infection in neighboring spaces.
Connections: Pterygomandibular, Submandibular, Sublingual, Peritonsillar, and
Retropharyngeal spaces.
120. Lateral pharangeal space
Signs and symptoms:
1. Trismus (as the result of inflammation of the medial pterygoid m)
2. lateral swelling of the neck (especially between the angle of the
mandible and the sternocleidomastoid muscle), swelling of the lateral
pharyngeal wall causing it to bulge toward the midline
3. difficulty swallowing
4. fever.
Complications: the odontogenic infection is severe, may be
progressing at a rapid rate, and has a direct effect on the contents of
the space, especially those of the posterior compartment. include
1. thrombosis of the internal jugular vein
2. erosion of the carotid artery or its branches
3. interference with cranial nerves IX, X, and XII
4. Other serious complication may arises if the infection progresses from
the lateral pharyngeal space to the retropharyngeal space or beyond.
121. Lateral pharangeal space
Surgical approach:
Extraoral approach (submandibular incision)
intraoral approach (incision in the lateral
pharangyal wall)
122. Lateral pharangeal space
Other terms
1. Para-pharyngeal space
2. Pharyngo-maxillary space,
3. less commonly pterygo-maxillary space,
4. Pterygo-pharyngeal space,
5. Peri-pharyngeal space,
6. Pharyngo-masticatory space
123. retro pharangeal space
Location: Lies behind the soft tissue of the posterior aspect of the
pharynx. It is bounded
A. anteriorly by the pharyngeal constrictor muscles and the
retropharyngeal fascia
B. posteriorly by the alar fascia
C. superiorly by the base of the skull
D. ends inferiorly by the fusion of alar and prevertebral fascia
(between the sixth cervical (C6) and fourth thoracic (T4) vertebrae.
Content: Loose connective tissue and lymph nodes.
Etiology: Spread of infection from lateral pharyngeal space.
Connections: Lateral pharyngeal space, mediastinum.
124. retro pharangeal space
Connections: Lateral pharyngeal space,
mediastinum.
Signs and symptoms: same as lateral
pharyngeal space appear clinically, with even
greater difficulty in swallowing though, due to
edema at the posterior wall of the pharynx.
Complication: Obstruction of the upper
respiratory tract (due to displacement of the
posterior wall of the pharynx anteriorly), rupture
of the abscess and aspiration of pus into the
lungs with asphyxiation and spread of infection
into the mediastinum.
Surgical approach: Drainage through the
lateral pharyngeal space.
125. Prevertabral space
it is rarely involved in odontogenic infections because the prevertebral
fascia fuses with the periosteum of the vertebral bodies.
Location:
a) from the skull base to the coccyx.
b) It is located anterior to the vertebral bodies, behind the prevertebral
fascial layer of the deep layer of deep cervical fascia.
c) Laterally it is limited by the fusion of the prevertebral fascia with the
transverse processes of the vertebral bodies.
Etiology: Infection may be caused by osteomyelitis of the vertebrae,
trauma, or may originate from the cervical or thoracic spine.
Signs and symptoms: The diagnosis is difficult to make.
neck and/or back pain,
fever
and/or neurologic dysfunction ranging from nerve root pain to paralysis.
MRI is the imaging modality of choice to assess epidural or spinal cord
involvement.
126. parotid space
Location:
a. Bound by the superficial layer of deep cervical fascia.
The space extends from the external auditory canal to
the angle of the mandible.
b. It is located lateral to the carotid and parapharyngeal spaces
c. posterior to the masticator space.
Content:
Parotid gland and its duct
the external carotid artery
the superficial temporal
facial artery
the retromandibular vein
the auriculotemporal nerve,
the facial nerve.
Etiology: spread of infection from
lateral pharyngeal, parotitis, and sialadenitis.
127. parotid space
Connections: Lateral pharyngeal,
Pterygomandibular, Submasseteric space.
Signs and symptoms:
Edema of the retromandibular and parotid
region,
trismus
difficulty in swallowing and pain mainly
during chewing, which radiates to the ear and
temporal region.
In certain cases, there is redness of the skin
and subcutaneous fluctuation. Also, a purulent
exudate may be noted from the papilla of the
parotid duct after pressure is applied.
Surgical approach: Extraoral approach
(broad incision posterior to the angle of the
mandible)
131. Danger space vs danger zone(death
traingle)
Danger space
Borders: Base of skull, diaphragm, fusion of alar
and prevertebral fascia
Source of infections: pharyngeal spaces,
visceral space
Contents: Areolar connective tissue
Connections: Posterior mediastinum
Incision: Extraoral
Danger traingle
Borders: bridge of your nose to the corners of your mouth
Source of infections: it’s one place where you should never
pop a pimple, as it can lead to an infection in your brain .
Others like a picked pimple, or a wrong nose piercing.
Routes: veins superior ophthalmic, & deep facial veins
(pterygoid plexuses & emissary)
Connections: Think of this small segment of your face as a
direct line to your brain. Through your cavernous sinus, a
network of large veins located behind your eye sockets.
145. sources
((Contemporary of maxillofacial surgery))
Complex Odontogenic Infections
Deep Fascial Space Infections, 343
Infections Arising From Any Tooth, 343
Infections Arising From Maxillary Teeth, 343
Infections Arising From Mandibular Teeth, 345
Deep Cervical Fascial Space Infections, 348
Management of Fascial Space Infections, 348
Airway Management, 348
Surgical Management, 349
Specific Infections, 352
Cavernous Sinus Thrombosis, 352
Necrotizing Fasciitis, 353
((Petersson of maxillofacial surgery))
Chapter 38 Principles of Management of Maxillofacial Infections
841 Thomas R. Flynn
((Almustansiriya lectures of oral surgery))
MANAGEMENT OF ODONTOGENIC INFECTIONS
Dr noor sahban
