Serious Life-threatening conditions Copyright (c) Department of Oral and Maxillofacial Surgery University of Dental Medicine, Yangon

1.  Ludwig’s angina
 Cervical fascial space infection
 Cavernous sinus thrombosis
 Acute necrotizing fascitis

2.  Bilateral submandibular , sublingual and submental
spaces = 6 spaces
 Impending Ludwig ( close to )
 Rapidly and aggressively spreading cellulitis involving
bilateral submandibular, sublingual and submental
spaces

4.  extension of infection from the the mandibular teeth
usually second and third molars
 infection erodes through the medial aspect of the
mandible inferior to the mylohyoid line
 as a result of haemolytic strepto cocci , aerobic and
anaerobic organism
 virulence property - hyaluronidase , collagenase ,
fibrinolysin , enzyme that cause tissue destruction or
promote bacterial spread

5.  Submental space lies between the anterior bellies of
the digastric and between the mylohyoid muscle and
overlying skin , by mandibular incisors

6.  Sublingual space lies between the oral mucosa of the
floor of the mouth and the mylohyoid muscle , most
commonly seen with premolars and first molar , its
posterior border is open and communicate with
submandibular space ,

7.  Submandibular space liesbetween the mylohyoid
muscle and overlying skin and superficial fascia ,
posterior boundary communicates with the secondary
spaces

8.  chill , fever , increased pulse rate and respiratory rate
 - toxic appearance - fatigue , feverish , malaise
 - painful brawny swelling of the upper part of the
neck and the floor of the mouth on both sides
 - induration , board like and do not pit on pressure , no
fluctuation , tissue may become gangrenous , when
cut - lifeless , sharp demarcation from the surrounding
normal tissue
 - typical open mouthed appearance , tongue is
protruded and elevated - sublingual space
involvement , limited tongue movement
 - drooling of saliva , increased salivation

9.  may has severe trismus ( < than 10mm )
 - difficulty in swallowing ( dysphagia )
 -respiratory obstruction due to odema of the glottis
,noisy breathing ( stridor ) , restlessness, respiration
using acessory muscles , cyanosis , asphyxiation
 - die from asphyxia , toxaemia , septicaemia , infection
to the mediastinum

10.  Surgical intervention - surgical incision should be
under taken early before respiratory obstruction
develops ,
 Aim to release of tissue tension , adequate exposure of
deep compartment , to provide drainage primary as
well as secondary spaces , more than one drain (
antibiotic alone cannot eleminate the pus ) , pus for C
& S ,
 G.A. is hazardeous ,
 Local anaesthesia is more safer

11. Incision in the submental area should be extended
through the mylohyoid muscle to the mucous
membrane
Emergency tracheostomy if respiration becomes
embrassed ,
Gross swelling may distort the normal anatomy of the
face and neck
Parallel incision medial to the lower border of
the mandible which extended upward to the
base of the tongue in the submandibular area

12.  Pretracheal space
 Lareral pharyngeal space
 Retropharyngeal space
 Danger space
 Prevertebral space

13.  Ant; Sup. and mid. pharyngeal
constrictor m.
 Post; Carotid sheath and scalene fascia
 Sup; Skull base
 Inf; Hyoid bone
 Likely cause; Lower third molars,
Tonsillar infection in neighboring
spaces
 Contents; Carotid a., Internal jugular
v., Vagus n., Cervical sympathetic chain
 Neighbouring space;
Pterygomandibular, Submandibular,
Sublingual, Peritonsillar,
Retropharyngeal

14.  Severe trismus – involvement of the lateral pterygoid
muscle
 Difficulty in swallowing
 Lateral swelling of the neck
 Direct effect of the infection on the contents of the
space; grave problems ; Thrombosis of the IJV
Erosion of the carotid artery or its branches
Interference with IX, X & XII CN
 Infection progresses to retropharyngeal space

15.  Ant; Sup. And mid.
Pharyngeal constrictor
m.
 Post; Alar fascia
 Sup; Skull base
 Inf; Mediastinum
(Fusion of alar and
prevertebral fasciae at
variable level between
C6-T4)

16.  Xray - Retropharyngeal soft tissue shadow is narrow (3-
4mm ) and located at C2 and at C6
 when retropharyngeal space is involved , soft tissue
becomes substantially thicker , space enlarge and
compromising the airway
 No important contents
 Posterosuperior mediastinum may also become involved
secondarily
 Mediastinum ; the space in the thorac between two
pleural sac , contains heart , aorta, trachea , oesophagus
and thymus
 Progressive involvement of the prevertibral spaces

17.  Ant; alar fascia
 Post; prevertibral fascia
 Sup; cranial base
 Inf; diaphragm
 Mostly risk to the involvement of
entire mediastinum

18.  Three greatest potential complications
 Serious possibility of upper airway obstruction as a
result of anterior displacement of the posterior
pharyngeal wall into the oro pharynx
 Rupture of the retropharyngeal space abscess with
aspiration of pus into the lungs and subsequent
asphyxiation
 Infection spread into the mediastinum which results
in severe infection in the thorax

19.  Ant; Sternothyroid-
thyrohyoid fascia
 Post; Trachea
 Sup; Thyoid cartilage
 Inf; Superior
mediastinum

23. An extension of the infection into the area not detected at first treatment may have to be I&D

25.  Cavernous sinus contents
 O TOM CAT:
 O TOM are lateral wall components, in order from
superior to inferior.
 CA are the components within the sinus, from
medial to lateral. CA ends at the level of T from O
TOM.
 See diagram.
 Occulomotor nerve (III)
 Trochlear nerve (IV)
 Ophthalmic nerve (V1)
 Maxillary nerve (V2)
 Carotid artery
 Abducent nerve (VI)
 T: When written, connects to the T of OTOM.

26.  Cavernous sinus is so called
because it is divided into caverns
by fibrous septa , sponge like
appearance. It lies along side the
body of the sphenoid bone in the
middle cranial fossa and it is
formed in between the outer
layer of the dura covering the
body of the sphenoid bone and
inner layer of dura , two
cavernous sinuses are connected
by anterior and posterior
intercavernous sinus , may
readily spread from one sinus to
other

28.  high mortality even today
 - superior spread of infection via a haematogenous
route , septic thrombosis of the cavernous sinus
 - veins of the face and orbit lack valves which permits
blood flow in either direction
 -

29.  posteriorly via - pterygoid
plexus and emissary veins (
are communications
between intracranial
venous sinuses and
extracranial vein , foramen
ovale and or sphenoidal
foramen / Vesalires)
 pterygoid plexus also
anastomoses with the
inferior opthalmic vein by a
vein treansversing the
inferior orbital fissure ,

30.  anteriorly via angular vein and
inferior or superior opthalmic
veins ( supratrochlear and
supraorbital unite at the medial
corner of the eyelid ) angular
vein which then continue as
across the face as a facial vein ,
communication of the angular
vein with the superior opthalmic
vein often called nasofrontal
vein , superior opthalmic vein is
tha main tributary of the
cavernous sinus , large
communication from the facial
vein via the deep facial vein to
the pterygoid plexus

32.  ; six features
 (1) known site of infection-
 boils , furunculosis and infected hair follicles
(staphylococci infection) of the face that is drained by
the facial vein ( danger trigone ) hardening along the
course of vein , odontogenic infection , infections from
eyes ( via the superior , inferior opthalmic vein - direct
and

33.  indirect through pterygoid plexus ), ears ( through
petrosal sinus ), paranasal sinuses , pharynx ( pharyngeal
plexus communicate with cavernous sinus by emissary
veins ) , tonsillar and paratonsillar abscesses
 (2) evidence of blood stream infection - signs of systemic
involvement - fever, increased pulse rate & respiratory
rate , toxic appearance , blood culture positive of
Staphylococcal aureus
 (3) early sign of venous obstruction in the retina
conjuntiva or eyelid- papillodema (Ophthalmoscope)
chemosis ( odema of the occular conjuntiva ) , orbital
cellulitis and abscess , 50 % motality loss vision , one or
both eyes , impairment of the vision is due to odema of the
optic nerve with congestion of the central vein of the retina

34.  Superior Orbital syndrome - is characterized by
opthalmoplegia , ptosis , proptosis of the eyes , dilated
and fixity of pupil , sometime blood stained tear
trickled down the cheek , anaesthesia of the eyelid
and forehead
 Orbital apex syndrome - involvement of the optic
nerve , blindness
 (4) paresis of the 3,4 & 6 CN resulting from
inflammatory edema - voluntary movement of all
extrinsic occcular muscles are abolished (
opthalmoplegia ) , early one eye involvement , later
other one

35.  6 CN being the more exposed position within the sinus
and often the first to be involved
 loss of abduction ( away from the midline - lateral
rectus )
 - 4 C N - supplies superior oblique - impairment leads to
loss of downward movement of the eyeball if it is
adducted(move toward the midline)
 - 3 C N - supplies all muscles except lateral rectus and
superior oblique , 3 C n involvement leads to loss of
adduction ( toward midline - medial rectus ) , elevation (
superior rectus , depression (inferior rectus ) , elevation
abduction ( inferior oblique ) ,elevation of upper eyelid (
levator palpebra superioris)

36.  (5) abscess formation in the neighbouring soft tissue
 (6) evidence of meningeal irritation - head ache ,
vomitting , photophobia , irritable , evokes reflex
spasm in the paravertebral muscles resulting in neck
stiffness in the cervical area and positive Kernig’s sign
in lumbar area muscle spasm

37.  Signs of meningitis – Neuchal rigidity (unable to do
flexion of the neck) due to spasm of paravertebral
muscles
 Kernig’s sign (in supine position when the thighs are
held at 90 degree, the legs are unable to extend at the
knees) due to stiffness of hamstring muscles at the
legs
 Brudzinski’s sign( at supine position, when flexion of
neck, the hips and knees also flex involuntarily)

38.  patient in supine , flex
the neck until the chin
touches the chest
 Brudzinski’s sign -
flexion of hips and knees
in response to passive
neck flexion

39.  Kernig’s sign - patient in
supine , both legs
extended , contraction of
hamstrings in response
to knee extension while
hip is flexed

40.  die from , septicaemia , meningitis , enchephalitis
 - Treatment - antibiotic therapy ,corticosteroid are
recommended to prevent circulatory collapse
secondary to pituitary dysfunction , controversy - use
of anticoagulant because of spread of infection ,
surgical access through eye enucleation , neuro
surgical management

41.  is a rapidly spreading soft-tissue infection that involves
the subcutaneous tissues
 produces morbidity and in some instances mortality
 Most cases occur in the extremities, abdomen and
perineum
 a rare complication from dental infection
 Sometimes as a result of minimal skin trauma or a
simple tooth extraction

42.  polymicrobial
 bacteria involved are the same species as those that
cause chronic dental infections in the gingival crevice
or periapical infections of the jaw
 immunocompromised, but also can occur in healthy
people
 Obesity????

43.  typically is febrile
 elevated WBC counts
 also might be hypotensive and tachycardia
 pain is severe and out of proportion to the clinical
findings
 can be hypo aesthetic or anesthetic

44.  within 24 - 48 hours , the area become red ,
edematous and painful , but soon becomes anaesthetic
, well or ill demarcated , becomes dusky , purplish and
black
 4- 5 days necrosis of the skin appears , release of
brownish exudate with gas bubbles
 the necrotic tissue starts to separate within 8 - 10 days

45.  Rapid surgical debridement is warranted to stop the
necrosis from spreading
 radical surgical debridement of necrotic tissue
 definitively by inspecting the tissue and performing a
biopsy
 incision in advance of the line of necrosis to prevent
subcutaneous spreading along fascial planes
 . The practitioner should make incision into the
affected tissue produces virtually no bleeding
 Drainage appears dishwater like
 Blood vessels are thrombosed
 Fetor odor indicating necrotic tissue is characteristic

46.  tracheostomy or endotracheal intubationto protect the
patient’s airway owing to severe neck swelling
 Ventilator support is required in patients with severe
cases of CNF, owing to acute respiratory failure
 Skin graft may be necessary later in case of large skin
defect

47. A delay in seeking treatment for odontogenic infection is a common finding
early stages may resemble odontogenic cellulitis or as abscess

50. transcervical neck incision to create a wide exposure

51. can lead to involvement of the neck, mediastinum and chest wall

54. in the submandibular
region to open the
fascial planes from the
mandible to the clavicle

55.  Cardiovascular intensive measures such as intravenous
(IV) fluids and medication to support the patient’s
blood pressure and heart rate.
 Hyperbaric oxygen therapy(HBO) is an adjunctive
treatment for CNF. It has shown a beneficial effect.

56.  Overwhelming sepsis, mediastinitis and
multiple organ failures
 If mediastinum involvement occurs, the mortality rate
is approximately 50 percents.

57.  Must be hospitalised
 Surgical and medical management require more
extensive and aggressive treatment

58.  Medical support of the patient with special attention
to correcting host defense compromises where they
exist
 Administration of the proper antibiotics in appropriate
doses
 Surgical removal of the source of infection as early as
possible
 Surgical drainage of the infection with placement of
proper drains
 Constant reevaluation of the resolution of the
infection

59.  Surgeon must not wait for unequivocal evidence of
pus formation
 I&D must be extensive , various sites
 At OTh
 Aggressive exploration of the involved fascial space
 One or more drain require to provide adequate
drainage and decompression of the infected area
 Removal of the source of infection as early as possible ,
removal of drain should not be done prior to the
extraction of the causative tooth

60.  Support host defense mechanism including analgesics
, fluid requirements and nutrition
 High dose bacteriacidal antibiotics
 Almost always administered intravenously
 Mouth rinses - 0.02 % Chlorhexidine gluconate, bland
M/W
 Mouth opening exercise - active and passive

61.  Airway continually monitored
 If respiration becomes embrassed surgical airway
established if warranted
 Emergency tracheostomy , gross swelling may distort
the normal anatomy of the face and neck