The document provides a comprehensive overview of deep fascial space infections, including specifics about the masticatory space, Ludwig's angina, pharyngeal infections, and cavernous sinus thrombosis. It highlights clinical features, microbiology, diagnostic approaches, and treatment strategies for various infections, emphasizing the importance of early recognition and intervention. Attention is drawn to significant historical aspects and contemporary practices in managing these serious infections within oral and maxillofacial surgery.

1. DEEP FASCIAL SPACE
INFECTIONS
PART-2
ARJUN SHENOY
DEPT OF OMFS

2. • MASSETRIC SPACE
• LUDWIGS ANGINA
• PHARYNGEAL SPACE
• RETROPHARYNGEAL SPACE
• CAVERNOUS SINUS THROMBOSIS
• MEDIASTINITIS
• CONCLUSION
• REFERENCES

3. MASTICATORY SPACE
MASSETRIC + PTERYGOID + TEMPORAL

4. MASTICATOR SPACE
• Massetric, pterygoid and temporal- well differentiated
• Communicate with each other
• Also with
• Buccal
• Submandibular
• Parapharyngeal
• MASTICATOR SPACE CONTENTS-
• Muscles of mastication
• Internal maxillary artery
• Mandibular nerve

6. SUBDIVISION
• MASSETRIC SPACE-
• Lateral- masseter
• Medial- mandibular ascending ramus
• PTERYGOID-
• Lateral-mandible
• Medially- pterygoid muscle
• Communication-
• Superiorly- superficial and deep temporal space
• Anteriorly- buccal space
• Posteriorly- lateral pharyngeal space

7. ORGIN
molar (commonly 3rd molar)
Contaminated injections
Temporocranial flaps - neurosurgery
Nearby contiguous spaces
Circumzygomatic wiring in trauma
TMJ surgery
• Clinical hallmark- trismus
• Exception- immunocompromised
• Swelling – may not be prominent

8. • Infectious process deep to muscles -
• swelling less prominent
• contrast to buccal space infections
•

9. SICHER’S APPROACH
• Sicher suggested approach to all compartments –
incision through pterygomandibular raphae
• Feasible in cadavers - not trismus
• Oral approach-compromise airway
• purulent oozing pus
• Difficult drain - loosening

10. I & D
• MASSETRIC + PTERYGOID SPACE-
• Extra-oral – easier technically & prudent
• Sharp dissection - external angle of the mandible
• Allows dependent drainage of both spaces

11. SURGICAL INTERVENTION
• TEMPORAL SPACE –
• Intra-oral- sichers-incision
• Percutaneous-
• incision -slightly superior-zygomatic arch

12. LUDWIGS ANGINA
Wilhelm Frederick von Ludwig

13. DEFINITION
• Ludwigs angina is a firm , acute, toxic cellulitis of the
submandibular and sublingual spaces bilaterally and of
the submental space
• Three F’s
• Feared
• Not fluctuant
• Fatal

14. HISTORICAL PERSPECTIVE
• Wilhelm Frederick von Ludwig first described in 1836 a
potentially fatal, rapidly spreading soft tissue infection
of the neck and floor of the mouth

15. • Ludwig published his now-famous paper on
Ludwig's angina with no title in 1836.
• A colleague dubbed the condition "Angina Ludovici"
(Ludwig's angina) a year later
• Pre-antibiotic era- 50% mortality
• 5%- use of penicillin
• observed frequently in compromised host
• Less than 1% of all OMFS admissions
• Untreated- mortality rate 100%

16. • Compound mandibular fracture
• Puncture wounds of oral floor
• Secondary infection of oral malignancies
• Submandibular gland sialadenitis
• Oral soft tissue lacerations
• Reported in new born
• Pseudo-ludwigs angina /phenomenon- non dental

18. CLINICAL FEATURES
• Bilateral infection of sublingual and submandibular spaces
• brawny edema,
• elevated tongue
• airway obstruction
• paucity of pus

19. MICROBIOLOGY
• Streptococci or mixed oral flora are commonly
reported from cultures
• Contemporary- Ecoli ,pseudomonas and anaerobes
bacteroides and peptostreptococcus
• Prevotello melaninogenicus, prevotella oralis, prevotella
corrodens also isolated

20. DIFFERENTIAL DIAGNOSIS
• angioneurotic edema
• lingual carcinoma
• sub- lingual hematoma
• salivary gland abscess
• lymphadenitis
• cellulitis
• peritonsilar abscess

21. TREATMENT
• Establisment and maintainance of an adequate airway
are the sine qua non of therapy
• Early diagnosis,maintainance of patent airway, intense
empirical and intra-venous prolonged antibiotic
therapy, extraction of affected teeth, hydration, early
surgical drainage,
• Pencillinplus, metronidazole or clindamycin or
imipenem

22. TRACHEOSTOMY
• Death more likely to occur from airway obstruction than
sepsis
• Tracheostomy most routine during most of twentieth century
• Difficult to perform in late stage –massive neck oedema and
tissue distortion

23. BLIND NASAL INTUBATION
• Swollen tongue and glottis oedema- time consuming , unsuccessful
and fraught with danger especially if attempted by inexperienced
anaesthesiologist.
• Danger of rupturing a bulging lateral pharyngeal or
retropharengeal abscess

24. FIBRE-OPTIC ASSISTED
INTUBATION
• Cervical soft tissue plain films + CT scan
• fiberoptic laryngeoscopy- premedicated +cooperative
patient
• Tracheal intubation under deep inhalation anaesthesia
may be successful obliviating the need for
tracheostomy

26. SURGEONS PERSPECTIVE
• Sedative and narcotic agents- rapid respiratory deterioration
• Some authorities advocate high doses of antibiotic without
surgery until fluctuance develops, in most surgeons
experience prompt and deep surgical incision is required
since fluctuance is uncommon and late
• Diffuse cellulitis of deep spaces – 70% cases require surgical
intervention and drainage
• “A chance to cut is a chance to cure”

27. INCISION
• Horizontal incision midway between the chin and the hyoid
bone - classic approach to the surgical drainage - ludwigs
angina
• “cut-throat”incision unaesthetic and unnecessary

28. • Platysma and supra-hyoid fascia incised by this approach
• Fascia of submandibular gland also entered
• Mylohyoid muscle divided and sublingual space entered
• A closed clamp is inserted through the median raphae of
mylohyoid muscle and advanced to the hyoid bone at the
base of the tongue

29. NEEDLE ASPIRATION
• Needle aspiration of deep fascialspace infection has
been attempted obliviating need for open drainage
• Ludwigs angina not amenable to this technique even if
needle is CT guided
• may result in reinfection
• adequate drainage or premature closure of surgical

30. DRAIN PLACEMENT
• Bilateral incision into the submandibular spaces with
blunt dissection to the midline suffices if a through and
through drain or bilateral drains meeting in midline are
placed combined with drainage of sublingual space
• Relieves intense pressure of oedematous tissue on the
airway and provides specimen for culture

31. SCAR REVISION
• Secondary revision of scarring may be necessary for
cosmetic or to repair the stenosis of whartons duct
• Disseminated intravascular coagulation-well recognized but
fortunately uncommon sequelae of severe infection

32. PHARYNGEAL SPACE
INFECTION

33. PHARYNGEAL SPACE
• Lateral neck space shaped like a inverted cone
• Base at skull and apex at the hyoid bone
• Medial wall contiguous with carotid sheath ,lies deep to
pharyngeal constrictor muscle
• Divided into anterior and posterior compartments

34. CAUSES
• Pharyngitis
• tonsillitis
• parotitis
• otitis
• mastoiditis
• dental infection
• Herpetic gingivostomatitis involving pericoronal tissue

35. CLINICAL FEATURES
• Anterior compartment-
• Pain, fever,chills
• Medial bulging of the lateral pharengeal wall
• Deviation of palatal uvula from midline
• Dysphagia, swelling below angle of mandible
• Posterior compartment-
• Visible swelling with absence of trismus
• Respiratory obstruction
• Septic thrombosis of internal jugular vein
• Carotid artery haemorrhage - later stage

36. TREATMENT
• CT more useful than standard radiographs
• Therapy-antibiotic, surgical drainage, tracheostomy if
indicated
• Surgical approach – oral - incision of the lateral wall
• External approach- exposure of carotid sheath-lateral tip
• of sternocleidomastoid- retraction of sternocleidomastoid

37. • Blunt dissection along posterior border of digastric muscle
leads to lateral pharengeal space
• Combined intra-oral + extraoral approach – mucosal incision
– lateral to pterygomandibular raphae , large curved clamp
passed medial to medial pterygoid muscle in a posterior-inferior
direction.
• Tip of clamp delivered through skin- cutaneous incision
between the angle of the mandible and the
sternocleidomastoid muscle

38. RETROPHARYNGEAL
SPACE INFECTION

39. RETROPHARYNGEAL
SPACE
• Space lies behind the esophagus and pharynx and extends
inferiorly to the upper mediastinum and superiorly – base of skull
• Orgin- nasal or pharyngeal infection in children
• Oesophageal trauma, foreign bodies, tuberculosis
• Symptoms-
• Dysphagia
• Dyspnea
• Nuchal rigidity
• Eosophageal regurgititation
• fever

40. • Visualization of pharynx- bulging of posterior wall – more
prominent unilaterally
• Adherance of median raphae to prevertebral fascia
• Lateral soft tissue radiographs useful
• widening of retropharyngeal space
• >3-6mm adults >14mm children (2nd vertebra)
• Presence of gas in prevertebral soft tissue
• Loss of normal lordtic curvature of cervical spine
• CT- inferior extent + plain films

41. TREATMENT
• Early cases 10-40% resolve with medical management
• Prompt surgical drainage – protocol
• Tracheostomy indicated
• Transoral approach- Extreme trendelenburg position and
constant suction- under LA

42. CONTINUED
• Transoral- incision through midline of posterior pharyngeal
mucosa-blunt dissection
• Exernal approach- dependent
• Incision- anterior border of STM
• Muscle+carotid sheath retracted medially
• Blunt finger dissection deeply
• Upto level of hypopharynx
• Deep drains placed + maintained
• Overall mortality rate – approx. 10%

43. CAVERNOUS SINUS
THROMBOSIS
• Orgin- ascending rom maxillary teeth, upper teeth,
nose or orbit
• Through valveless anterior and posterior fascial veins
• Extremely high mortality rate

44. INITIAL SIGNS
• Proptosis
• Fever
• Obtunded state of consciousness
• Ophthalmoplegia
• Paresis of –
• occulomotor
• trochlear + abducens nerve

45. MEDIASTINITIS
• Extension of infection from deep neck spaces into the
mediastinum
• C/F –
• Chestpain, fever
• Severe dyspnea
• Mediastinal widening
• IV drug abusers- greater risk

46. CONTINUED
• Late complication
• Progressive septicemia-mediastinal abscess-pleural
effusion-empyema-pericarditis
• Necrotizing mediastinitis- aerobic+anaerobic
• Treatment- extensive long term antibiotic therapy and
surgical drainage of mediastinum
• Emergency neurosurgical intervention

47. CONCLUSION
• Incidence and severity have diminished with advent of
antibiotic therapy
• To be alert to the potential seriousness of these infections-never
to be dismissed as simple dental abscess
• Deep fascial infections must be recognized promptly and
treated as an emergency
• Repeat diagnostic and therapeutic measures may be
necessary until the very end point

48. REFERENCES
• R.G Topazian , Oral & Maxillofacial Infections 4th edition
• Journal of Oral and Maxillofacial Surgery, Volume 72, Issue 9,
Supplement, September 2014, Pages e83-e84
• The Journal of Emergency Medicine, Volume 43, Issue 4,
October 2012, Pages 605-611
• Journal of Plastic, Reconstructive & Aesthetic Surgery,
Volume 60, Issue 4, April 2007, Pages 372-378
• Journal of Infection, Volume 50, Issue 1, January 2005, Pages
34-40
• Emergency Medicine Clinics of North America, Volume 18,
Issue 3, 1 August 2000, Pages 481-519