Head and Neck Infections

PRESENTED BY: DR MOHAMMED HANEEF

Index
 Introduction
 Classification of infection
 Stages of infection
 Microbiology of odontogenic infections
 Management of odontegic infections
 Classification of fascial planes
 Progression of infection
 Space infections of maxilla
 Space infections of mandible
 Space infections of neck
 Principles of treatment
 Management
 Refrences

Introduction
 Potential or actual space between fascia and muscles containing
nerves, blood vessels and connective tissue but this becomes
pathway of infection in presence of infection
 Infection may be defined as invasion and multiplication of
microorganisms in body tissues, especially that causing local
cellular injury due to competitive metabolism, toxins,
intracellular replication, or antigen-antibody response
 Fascial space infections are a relatively common presentation to
both general medical and dental practitioners.
 Infections originating in deeper structures can be severe, rapidly
progressive and may cause prolonged morbidity, long term
complications as well as potentially endanger life.

Classification of infections
 According to the clinical appearance:
a) Acute infections
b) Chronic infections
c) Acute exacerbation of a chronic infection
 Depending on the etiological agent:
a) Bacterial
b) Viral
c) Fungal
 According to source of infection:
a) Odontogenic
b) Secondary infections of lesions such as cyst or tumors
c) Infections arises from contaminated wound/trauma
d) Iatrogenic infections

Stages of infections
 Stage I: Initiation of infection
• Mostly odontogenic in origin,
• Periapical/periodontal/pericoronal infection
• Mildly symptomatic or asymtomatic.
 Stage II: Entry of infection in medullary bone
• Symptomatic, patient seeks treatment
• Tender on percussion
• No space for pus to drain starts effecting the medullary bone
 Stage III: Path of drainage
• Pus follow path of least resistance
• Perforates cortex that is thinner
• Appears in soft tissues, extra oral swelling
• May lead to cellulitis or abscess formation
 Stage IV: Spread of infection
• Spreads to another space along anatomical barriers
• May perforate the skin to form sinus

Microbiology of odontogenic infections
 Bacterial composition
1. 5%-aerobic bacteria
2. 60%-anaerobic bacteria
3. 35% mixed aerobic and anaerobic bacteria
 Commonly cultured organisms: alpha-
hemolytic Streptococcus, Peptostreptococcus,
Peptococcus, Eubacterium, Bacteroides
(Prevotella) melaninogenicus, and
Fusobacterium.
 Quantitative estimations of the number of
microorganisms in saliva and plaque range as
high as 1011/ml.

Microbiology – aerobic
 Gram-positive cocci 85%
 Streptococcus spp.
 Streptococcus (group D) spp.
 Staphylococcus spp.
 Eikenella spp.
 Gram-negative cocci
 (Neisseria spp.) 2%
 Gram-positive rods
 (Corynebacterium spp.) 3%
 Gram-negative rods
 (Haemophilus spp.) 6%
 Miscellaneous and
undifferentiated 4%

Microbiology- Anaerobic
 Gram-positive cocci 30%
 Streptococcus spp.
 Peptostreptococcus spp.
 Staphylococcus spp.
 Gram-negative cocci
 (Veillonella spp.) 4%
 Gram-positive rods 14%
 Eubacterium spp.
 Lactobacillus spp.
 Actinomyces spp.
 Clostridia spp.
 Gram-negative rods 50%
 Bacteroides spp.
 Fusobacterium sp.

Management of odontogenic infections
 Determine the severity of the infection
 Complete history
 Physical examination
 State of the patients host defense
 Treat the infection surgically
 Support the patient medically
 Choose the appropriate AB
 Re-evaluate the patient frequently

Severity of infection
 How the patient feels
 Previous treatment
 Self treatment
 Past Medical History
 Complete History
 Chief Complaint
 Onset
 Duration
 Symptoms

Clinical presentation
 History-previous toothaches (onset,
duration), presence of fever, and previous
treatments (antibiotics ) important
 Patients may complain of trismus, dysphagia
and have shortness of breath should be
investigated.
 Findings vary from mild swelling and pain
to life-threatening airway compromise and
CNS impairment

 Inspection, palpation, and percussion are
integral parts of the exam
 Begin extraorally and then move intraorally
 Skin of the face, head, and neck for
swelling, erythema, sinus or fistula
formation.
 Assess for cervical lymphadenopathy and
fascial space involvement
 Assess for the presence and magnitude of
trismus

 Examine quality and consistency:
 Soft to fluctuant (fluid filled) to hard (indurated)
 Normal vs abnormal tissue architecture:
 Distortion of mucobuccal fold
 Soft palate symmetric with uvula in midline
(deviation → involvement of lateral pharyngeal
space)
 nasolabial fold, circumorbital areas

 Identify causative factors:
 Tooth, root tip, foreign body, etc.
 Vital signs should be taken:
 Temperatures > 101 to 102°F
accompanied by an elevated heart rate
indicate systemic involvement of the
infection and increased urgency of
treatment.

 Imaging studies can further substantiate
diagnosis – Panorex, Plain Films , CT , MRI
 Computerized tomograms should be
obtained when infection has spread into
fascial spaces in the orbit or neck
 Infections, well-localized to oral cavity do
not require special imaging studies with a
panorex being sufficient for diagnosis and
treatment

Host – Defense mechanisms
 Local defenses
 Intact anatomic barrier
 Indigenous bacteria
 Humoral defenses
 Immunoglobulins
 Complement
 Cellular defenses
 Phagocytes
 Lymphocytes

Medically compromised patients
 Uncontrolled metabolic diseases
 Diabetes
 Alcoholism
 Malnutrition
 Suppressing diseases
 Leukemia
 Lymphoma
 Malignant Tumors
 Suppressing drugs
 Chemotherapeutic agents
 Immunosuppressives

 One of the most common & difficult
problems
 Range from low-grade to severe, life-
threatening
 Most are easily managed with minor
surgery and antibiotics

Common types of infection:
 Periapical, periodontal, postsurgical,
pericoronal
May begin as well-delineated, self-limiting
condition with potential to spread and result in
a major fascial space infection.
Life-threatening sequelae can ensue:
 Septicemia, cavernous sinus thrombosis,
airway obstruction, mediastinitis

Progression of Odontogenic Infections
 Periapical
 Periodontal
 Soft tissue involvement
Determined by perforation of the cortical
bone in relation to the muscle attachments
 Cellulitis- acute, painful, diffuse borders
 Abscess- chronic, localized pain, fluctuant,
well circumscribed.

Cellulitis: initial stage of infection
 Diffuse, reddened, soft or
hard swelling that is tender
to palpation.
 Inflammatory response not
yet forming a true abscess.
 Microorganisms have just
begun to overcome host
defenses and spread beyond
tissue planes.

True abscess formation
 As inflammatory
response matures,
may develop a focal
accumulation of pus.
 May have
spontaneous drainage
intraorally or
extraorally.

Differences between cellulitis & abscess
Cellulitis Abscess
Duration Acute Chronic
Pain Severe generalized Localised
Size Large Small
Localization Diffuse borders Well circumscribed
Palpation Doughy indurated Fluctuant
Presence of pus No Yes
Degree of seriousness Greater Less
Bacteria Aerobic anaerobic

Classification of fascial spaces
 Based on mode of involvement
I. Direct involvement (Primary spaces) – maxillary
spaces , mandibular spaces
II. Indirect involvement (Secondary spaces ) – Lateral
pharyngeal space
 Based on clinical significance by Topazian
I. Face – buccal, canine, masticatory, parotid
II. Suprahyoid – sublingual, submandibular
(submaxillary, submental) pharyngomaxillary
(lateral pharyngeal) peritonsillar
III. Infrahyoid – anterovisceral (pretracheal)
IV. Spaces of total neck – retropharyngeal, space of
carotid sheath

 BASED ON FASCIA
I. Superficial fascia
II. Deep cervical fascia
1. Anterior layer
• Investing fascia ( over the neck)
• Parotidomasseteric
• Temporal
2. Middle layer
• Sternohyoid - omohyoid division
• Sternothyroid - thyrohyoid division
• Visceral division –
• Buccopharyngeal
• Pretracheal
• Retropharyngeal
3. Posterior layer
• Alar division
• Prevertebral division

 According to Grodinsky & Holyoke in 1938
I. Space 1 – potential space superficial and deep to the
platsyma muscle
II. Space 2 – space behind the anterior layer of deep
cervical fascia
III. Space 3 – pretracheal space, ant to layer of deep
cervical fascia
IV. Space 3A – viscerovascular space; is the carotid
sheath from the jugular foramen and carotid canal at
the base of skull to the pericardium (lincoln’s
highway)
V. Space 4 – ‘Danger space’ potential space b/w alar
and prevertebral fascia. Extends from base of skull to
the prevertebral fascia
VI. Space 5 – it is the space enclosed by the prevertebral
fascia posterior to transverse processes of vertebrae

 According to killey and kay
1. In relation to lower jaw:
1. Submental
2. Submandibular
3. Sublingual
4. Buccal
5. Submassetric
6. Parotid
7. Pterygomandibular
8. Lateral pharygeal
9. Peritonsillar
2. In relation to the upper jaw:
a) Canine space
b) Palatal space
c) Maxillary antrum
d) Infratemporal space
e) Subtemporal space

SPACE OF BURNS : The Suprasternal
Space
The superficial fascia splits below the level of
the hyoid bone to form 2 spaces
- Forms lower part of the roof of the post
triangle, the fascia splits into two layers,
attached to clavicle
- Forms lower part of the roof of the ant
triangle and fascia splits to form the
suprasternal space

Spaces involved in odontogenic infections
 Primary maxillary spaces – canine, palatal, and
infratemporal spaces
 Primary mandibular spaces – submental, buccal,
submandibular and sublingual spaces
 Secondary fascial spaces – masseteric,
pterygomandibular, superficial & deep temporal,
lateral pharyngeal, retropharyngeal, prevertebral
, parotid

Maxillary Odontogenic Infections
 Canine space
 Palatal space
 Infratemporal space
 Subtemporal space

Canine space infection/ Infraorbital space
infection
 This is a potential space present on the
anterior surface of the maxilla in the region
of canine fossa
 Appear commonly as labial sulcus swelling
 Levator anguli oris and levator labii
superioris muscle overlies apex of canine
root
 Origin: canine fossa.
 Insertion: angle of mouth

 Boundries:
• superiorly:
a) Levator angulii oris
b) Levator labii superioris
• Posteriorly:
a) Buccal space
• Inferiorly:
a) Orbicularis muscle
Contents: infrorbital nerve and its branches

Canine space infection
Signs:
• Obliteration of the nasolabial
fold
• Drooping of angle of mouth
• Superior extension can
involve lower eyelid
• Open in relation to medial
canthus of eye

Incision for canine space infection
 Intra-oral approach, high in labial vestibule
by sharp and blunt dissection
 Percutaneous drainage – lateral to the nose

 Differential diagnosis:
a) Maxillary sinusitis
b) Dacryocystitis

 Palate is covered by tightly
adherent mucoperiosteum
 Periosteum is tightly bound to
the mucosa, periodontal
membrane of the adjacent teeth
and to the suture in the midline
 Pus tends to accumulate
between periosteum and bone
 Infections begin in lateral
incisor or upper post tooth
 It is in the subperiosteal space
of palate
 Exquisitely painful due to rich
innervations of the periosteum
Palatal space infection

 Signs and symptoms
 circumscribed fluctant swelling confined to one
side
 May discharge from the gingival sulcus
 Infection does not cross midline
 Infection from:
• Upper lateral incisor
• Palatal pocket in premolars or molars
• Infection of palatal root

 Management:
 Incision should be in AP direction to avoid
injury to anterior palatine nerve
 Treatment of offending tooth
 Differential diagnosis:
 Extravasation cyst
 Gumma
 Pleomorphic adenoma
 Carcinoma of maxillary antrum

Infratemporal space infection
 Odontogenic infections of maxillary posterior teeth
 Odontogenic infections involving the
pterygomandibular space or infection from buccal
space coursing along the masticatory fat pad.
 Anatomical boundries:
a. laterally: ramus of mandible, temporalis muscle and
temporalis tendon
b. Medially: lateral pterygoid plate
c. Superiorly: infratemporal surface of the greater wing of
sphenoid
d. Inferiorly: lower head of lateral pterygoid muscle

 Contents:
a. Origin of pterygoid muscles
b. Pterygoid venous plexus
c. Internal maxillary artery
d. Mandibular nerve and its branches
 Signs and symptoms:
a. Infected upper molar teeth
b. Severe trismus is universal finding
c. extraoral swelling over the sigmoid notch, intra
oral swelling in the tuberosity area

 Management:
a. Intravenous antibiotics
b. Incision in upper buccal sulcus in third molar
region
c. Use of sinus forceps along medial surface of
coronoid and temporalis upwards and
backwards

Mandibular Space Infections
 Sublingual space
 Submental space
 Submandibular space
 Ludwigs angina
 Masticator space
 Lateral pharyngeal space
 Temporal space

Submental space
 Potential space present just below the chin
region on the medial surface of the mandible
 It is a midline structure bordered laterally by
the anterior bellies of digastric muscle
 Infections begin in the anterior mandibular
teeth
 Secondarily Infected skin wounds or
anterior mandibular fractures may also cause
infections

 BORDERS:
• Anterior – inf border of mandible
• Posterior – hyoid bone
• Superior – mylohyoid muscle
• Inferior – investing layer of deep cerical fascia
• Deep/Lateral - ant. bellies of digastric muscle
Contents:
• Submental lymphnodes
• Anterior juglar veins
• Adipose tissue

• Firm circumscribed swelling beneath the
chin
• Patient complains of discomfort and
difficulty in swallowing
 Management:
• Incision is made bilaterally through the skin,
subcutaneous tissue and platsyma muscle at the
most inferior aspect of swelling
• A hemostat is inserted through one incision and
then exited through the second incision

Incision for submental abscess

Sublingual space
 It is a potential space present in the anterior part of
the floor of the mouth
 It almost always involved with submandibular
space
 Only loose connective tissue separates right and left
sublingual spaces and infection spreads easily from
side to the other
 Boundries:
• Anteriorly and laterally– medial surface of mandible
• Posteriorly – submandibular space
• Superiorly – sublingual mucosa
• Inferiorly – mylohyoid muscle
• medially - genioglossus, geniohyoid, styloglossus muscles
• Superficial – muscles of tongue
• Deep – ant.bellies of digastric muscle

 The styloglossus muscle passes b/w superior
& middle pharyngeal constrictor muscles in
this region to enter the tongue
 The seperation b/w these pharyngeal
constrictors formed by the styloglossus
muscle is termed BUCCOPHARYNGEAL GAP

Sublingual space
Elevation of floor of mouth
Tongue raised
Respiratory difficulty

 Incision is placed at the
base of the alveolar
process in the lingual
sulcus so that the
sublingual gland, lingual
nerve & submandibular
duct are not injured
 A hemostat is inserted
through the incision in
an ant & post direction
& beneath the sublingual
gland to evacuate the
pus
Incision for Sublingual space
infection

Submandibular space
 It is a potential space present on the medial surface of the
posterior aspect of the mandible
 Anatomical boundries:
• Anteriorly – ant. belly of digastric muscle
• Posteriorly - post. belly of digastric muscle, stylohyoid muscle,
stylopharyngeus muscle
• Superior – inf & medial surfaces of mandible
• Inferior – digastric tendon
• Superficial – platsyma muscle, investing fascia
• Deep – mylohyoid, hypoglossus, sup constricting muscles
• Laterally – bounded by skin, superficial fascia, platysma
 Contents:
• Submandibular salivary gland
• Lymph nodes
• Facial artery
• Lingual and hypoglossal nerves

Submandibular space
 Triangular swelling
 Begins at the lower
border of mandible,
extends to level of
hyoid bone
 Brawny induration
 Usually associated
with lowermolar
infection

 Two stab incisions are placed at the inf
aspect of swelling in the shadow of the
mandible
 Extended through the skin &
superficial fascia
 Dissection is bluntly done through one
incision with a curved hemostat, which
is inserted through the platsyma
muscle & deep fascia in abscess for
drainage
Submandibular incision

 A hemostat is passed thru the
cavity and out the other incision
 A thin rubber drain is inserted through the
wound beaks of the hemostat & withdrawing
the Instrument Dressing is placed

Ludwig’s angina
 First described by wilhelm fredreich
von ludwig in 1836.
 Its rapidly spreading in nature
 Ludwig’s angina is a form of firm,
acute, toxic and severe diffuse
cellulitis that spreads rapidly,
bilaterally, affecting the
submandibular, sublingual and
submental spaces and resulting in a
woody swelling

Clinical features
 Bilateral suprahyoid swelling with hard cardboard like
consistency, non fluctuating & painful on palpation
 Swelling is characterized by rapid onset
 Difficulty in breathing (dyspnea),
 Difficulty in swallowing (odynophagia)
 Restricted tongue movements, elevated tongue ,inability to
open the mouth, salivation
 Patients may exhibit muffled voice due to edema of vocal
apparatus (hot potato voice)

 Eitiology
 Odontogenic infections
 Traumatic injuries
 Infective conditions like osteomyelitis
 Pathology:
 Infection from the source reaches the submandibular
space
 The submental spaces gets involved via the lymphatics
 It’s a cellulitis it rapidly spreads reaches the epiglottis
producing edema and inflammation of laryngeal inlet.
 Spreads to pterygomandibular, massetric and lateral
pharyngeal spaces
 Patient may die with in 24 hours due asphyxia if not
treated
 May die from septic shock, aspiration of pus or
mediastinitis

a. Pyrexic
b. Dehydration
c. Dysphagia
d. Rapid shallow breathing
e. Hoarseness of voice
 Extra oral features:
a. Hard to firm brawny, board like swellin
b. Skin is shiny stretched and erythmatous
c. Tender swelling with local rise in temperature
d. Unable to close the mouth and drooling of saliva
e. Evident respiratory distress, use of accessory muscle of respiration
f. Trismus
 Intra oral features:
a. Floor of mouth is raised
b. Tongue appears swollen and raised upwards towards the palate
c. Increased salivation

The cardinal signs of Ludwig’s angina are:
1. Bilateral involvement of more than a single deep tissue space
2. Gangrene with serosanguinous, putrid infiltration but little
or no frank pus
3. Involvement of connective tissue, fascia, and muscle but not
glandular structures
4. Spread via fascial space continuity rather than by lymphatic
system
Danger signs:
1. Dysapnoea
2. Dysphagia
3. Hoarseness of voice
4. Stridor
5. Swelling below the clavicles

Diagnosis & investigations
 UltraSonography: Used to identify fluid
collection in the soft tissues.
 C.T. Scan
 M.R.I

UltraSonography:
 Effective diagnostic tool in treatment of acute
odontogenic fascial space infections and cellulitis
 Micro convex probe of 6.5Mhz is used
 Probe is applied over skin, covering the swelling
in transverse and axial sections
 Echoing of sound from the fluids is absent
thereby detecting the fluid collection

Differential diagnosis
 Angioneurotic edema
 Lingual carcinoma
 Sub lingual hematoma
 Salivary Gland abscess
 Peri-tonsillar abscess

Complications
 Septicemia
 Carotid blow out
 Obstruction of upper respiratory airways
 Aspiration pneumonia
 Spread of infection into Para pharyngeal
spaces-mediastinum-produce thoracic
empyema
 Death due to airway compromise

 TREATMENT :
 Early diagnosis of incipient cases
 Maintenance of patent airway
 Intense & prolonged antibiotic therapy
 Extraction of affected teeth
 Hydration
 Early surgical drainage

“ A chance to cut is a chance to cure ”
Classic approach / Cut- throat approach:
Horizontal incision midway b/w chin & hyoid
bone.
Bilateral incision into the submandibular
spaces with blunt dissection to the midline
Through and through drain or bilateral drains
meeting at the midpoint

Buccal space infection
 Buccal space occupies portion of
subcutaneous space b/w facial skin
& buccinator muscle
 Maxillary & mandibular premolar
and molar teeth tend to drain in
lateral & buccal direction
 Relation of root apices to
buccinator muscle determines path
of infection : intraorally in buccal
vestibule or deeply in buccal space

 BORDERS:
 Anterior – corner of mouth
 Posterior – masseter muscle, pterygomandibular
space
 Superior – maxilla, infraorbital space
 Inferior – mandible
 Medial – subcutaneous skin
 Lateral – buccinator muscle

BUCCAL SPACE INFECTION
Signs and symptoms:
•Dome shaped swelling
beginning at lower border of
mandible
• extending upwards to level of
zygomatic arch
•Diagnosed because of marked
cheek swelling associated with
diseased molar/premolar tooth
•Not associated with trismus

Management
 Intra – oral drainage:
 Is done with the incision made through the buccinator muscle
 It is difficult in maintaining a patent opening for drainage
because contraction of muscle fibres tend to close it off
 Hence a horizontal rather than a vertical incision is made just
above the depth of the vestibule
 Extra oral drainage:
 Inferior to point of fluctuance with blunt dissection
 Incisions are placed below the lower border of mandible
 2 stab incisions are made with a no.11 blade through the skin &
subcutaneous tissue
 A curved hemostat is inserted thru the anterior incision into the
buccal space and then turned & exited through the posterior
incision
 Beaks of hemostat are opened, strip of rubber drain is grasped.
Hemostat is withdrawn carrying drain through the tissues
 Ends are fastened, dressing placed

Submasseteric space
 Earliear this space was considered to
between masseter and the lateral aspect
of the ramus of the mandible.
 Now it is found to be between three
layers of the masseter muscle itself
 Submasseteric swellings can be
differentiated from parotid swellings as
these produce marked Trismus
overlying masseter muscle
 Obscure earlobe or elevation of ear lobe
in frontal view

 BORDERS:
 Anterior– buccal space
 Posterior – Parotid gland
 Superior – zygomatic arch
 Inferior – pterygomassetric sling
 Medial – ascending ramus of mandible
 Lateral – masseter muscle
 Infection can spread from lower third molars
• External facial swelling confined to masseter
muscle
• Swelling usually does not extend beyond the
posterior border of the masseter into the
postauricular area
• Swelling acutely tender
• Almost complete trismus
• Overlying skin reddened and stretched
• Pus may drain at the angle of the mandible

Management:
 Intraorally:
 Drainage is done through a vertical incision along the ext
oblique line of the mandible
 Starting at the level of the occlusal plane and extending
downward & forward in the buccal sulcus to a point opp
the second molar
 A hemostat is inserted and passed posteriorly along the
lateral aspect of the ramus to point beneath masseter
muscle
 Beaks are opened
 Rubber drain is inserted & sutured
 Extraorally:
• Incision is made behind the angle of the mandible
(retromandibular incision)
• Hemostat is inserted and passed along the lateral aspect of
the ramus
• Rubber drain is inserted

Pterygomandibular space
Most frequently affected anatomical compartment
Correlated highly with pericoronitis & mandibular
third molar
secondary infection results from spread from the
sublingual and submandibular spaces
Symptoms:
• Trismus – due to edema & inflamm of med pterygoid
• Swollen ant tonsillar pillar
• Deviation of uvula to opposite side

 Communications:
• Deep temporal space: By passing around the
lateral pterygoid muscle superiorly, running from
the mandibular condyle neck and the articular
disc to the medial pterygoid plate.
• Lateral pharyngeal space:by along the anterior
border of medial border of medial pterygoid
muscle following postereolateral surface of the
buccinator and the superior pharyngeal
constrictor muscles

Rt.Pterygomandibular Space
Infection

 BORDERS:
• Anteriorly – pterygo mandibular raphae,buccal space
• Inferior – inf border of mandible upto attachment of
medial pterygoid muscle, pterygomassetric sling
• Superior – Lateral pterygoid muscle
• Posterior – deep lobe of parotid gland
• Superficial – lateral pterygoid muscle
• Deep – ascending ramus of mandible
• Medially – medial pterygoid muscle
• Laterally – ascending ramus of the mandible
 Contents:
• Inferior alveolar nerve
• Lingual nerve
• Nerve to mylohyoid
• Inferior alveolar artery and vein

NOTE : DANGER SPACE 4 IS THE SPACE BETWEEN
PREVERTIBRAL AND ALAR FASCIA
PTERYGOMANDIBULAR SPACE
PTERYGOID SPLEXUS
EMISSERY VEINS
CAVERNOUS SINUS
THROMBOSIS
LATERAL PHARYNGEAL SPACE
RETROPHARYNGEAL SPACE
MEDIASTINUM
CAROTID SHEATH
DANGER SPACE 4

Management
 Extra oral mandibular block
is given
 Incision is placed through
the mucosa in the area b/w
medial aspect of the ramus &
pterygomandibular raphe.
 Abscess is opened by blunt
dissection and Drain is
placed

Temporal space
 Two divisions:
a. Superficial – It is between superficial temporal
fascia and lateral aspect of temporalis muscle
b. Deep – It is between the medial surface of the
temporalis muscle and periosteum of temporal bone.
 Inferiorly the temporal space is limited to the
attachments of the temporalis muscle and fascia.
Inferiorly, it communicates with the pterygomandibular
space
 Its contains loose connective tissue and vessels
supplying the temporalis muscle

• Swelling confined to the shape of the muscle extending from the
lateral orbital rim, above the zygomatic arch, covering the lateral
aspect of tempral bone.
• swelling more prominent in a superficial temporal space infection.
• severe trismus
 Deep temporal abscess
 Produce less swelling
 Lies deep to temporalis muscle
 Less fluctuant
 Management:
 Intra oral sicher’s incision along the anterior border of the ramus of
the mandible
 Extra oral cutaneous incision slightly above the zygomatic arch made
parallel to zygomatic arch followed by blunt dissection and placement
of drain

Lateral pharyngeal space
 Also known as Pharyngomaxillary/
parapharyngeal space
 Lateral neck space shaped like an inverted
cone
 Base is uppermost at the base of the skull
 Apex is at the greater horn of the hyoid
bone
 Infections may result from – pharyngitis,
tonsilitis, parotitis, otitis, mastoiditis and
dental infection

Pharyngomaxillary space
 Suprahyoid
• superior—skull base
• Inferior—hyoid
• Anterior—ptyergomandibular raphe
• Posterior—prevertebral fascia
• Medial—buccopharyngeal fascia
• Lateral—superficial layer of deep fascia
• Prestyloid
 Muscular compartment
 Medial—tonsillar fossa
 Lateral—medial pterygoid
 Contains fat, connective tissue, nodes
 Poststyloid
 Neurovascular compartment
 Carotid sheath
 Cranial nerves IX, X, XI, XII
 Sympathetic chain
 Stylopharyngeal aponeurosis of Zuckerkandel
and Testut
 Alar, buccopharyngeal and stylomuscular
fascia.
 Prevents infectious spread from anterior to
posterior.

 Borders:
 Anterior – sup & middle pharyngeal constrictor muscles
 Medially – superior constrictor, styloglossus muscle,
stylopharyngeus and middle constrictor muscle
 Posterior – carotid sheath & scalene fascia
 Superior – skull base
 Inferior – hyoid bone
 Superficial – pharyngeal constrictors, retropharyngeal space
 Deep – medial pterygoid muscle
 For surgical & anatomical purposes, it is divided into anterior &
posterior compartments
 Ant comp infection pt exhibits pain, fever, chills, medial
bulging of lat pharyngeal wall with deviation of palatal uvula
from midline, dysphagia, swelling below the angle of the
mandible
 Post comp has absence of trismus & visible swelling, BUT resp
obstruction, septic thrombosis of int jugular vein and carotid
artery hemorrhage

 Severe trismus
 Lateral swelling of the
neck
 Bulging of the lateral
pharyngeal wall
pushed to midline
 Usually no extra oral
swelling
 Rapid progression of
infection in this space
is common
Lateral pharyngeal space infection

Management
 Aggressive antibiotic therapy
 If the mouth can be opened, intra oral incision
medial to the anterior border of the ramus
 Extra orally
 The incision is placed 1cm below and behind the
angle of the mandible. Sinus forceps are inserted into
the space between submandibular and parotid gland
and passed medial to mandible and upwards along
the inner aspect of medial pterygoid muscle.drain is
inserted

Peritonsillar Space
 The peritonsillar space consists of
loose connective tissue between the
capsule of the palatine tonsil and the
superior constrictor muscle. The
anterior and posterior tonsillar
pillars contribute to its anterior and
posterior borders, respectively. The
posterior tongue forms the inferior
boundary. Peritonsillar infections
may readily spread to the
parapharyngeal space.

Peri-tonsillar space
Clinical evaluation:
 3-7 days H/o pharyngitis .
 Severe sore throat, dysphagia, Odyonophagia and referred
otalgia.
 The speech is muffled and classically described as hot potato
voice.
 Trismus is not present
 In recent literature,needle aspiration instead of open incision
and drainage (JOMS,Vol 51,1993)

Parotid Space
 Formed by the superficial layer of deep
cervical fascia surrounding the gland
 Boundaries :
Swelling extends from level of zygomatic
above to lower border of mandible
Anteriorly it ends at the anterior border of
mandible
Posteriorly it extends into the
retromandibular region

Parotid space
 Superficial layer of deep fascia
 Dense septa from capsule into gland
 Direct communication to parapharyngeal space
 Contains
 External carotid artery
 Posterior facial vein
 Facial nerve
 Lymph nodes

 C/F
 Everted ear lobule
 Severe pain referred to the ear, accentuated
by eating
 Trismus

Spaces of the neck
1. Retropharyngeal space
2. Prevertebral space
3. Mediastinitis

 Retropharyngeal ,danger space and
prevertebral spaces lie between deep
cervical fascia the surrounds the pharynx
and oesophagus anteriorly and vertebral
spine with its muscle attachments
posteriorsly

 Retropharyngeal space
Anatomical boundries:
1. anteriorly: constrictor muscles of the neck and their
fascia
2. Posteriorly: alar layer of deep cervical fascia which
extends from the base of the skull to the superior
mediastinum
A midline septum exists between the right and left
retropharyngeal spaces that is crossed easily.
Contents
1. Adenoidal tissues draining posterior pharyngeal wall
2. Lymphnodes draining waldeyers ring

 Prevertebral space:
 extends from base of the skull to the coccyx
 anteriorly bounded by prevertebral fascia
 For spaces of the neck the infections may
arise from nasal, pharyngeal, dental
infections

Clinical features of space of neck
 Drooling
 Fever
 Irritatibility
 Nuchal rigidity –
 neck siffness
 Irritability light
 Head ache
 Dyapnoea
 Dysphagia
 Bulging in the posterior pharyngeal wall may be
there

 Dangers involves
 severe laryngeal edema
 Rupture of abscess leading to aspiration
pnemonia or asphyxia
 Mediastinitis

Management
 Tracheostomy
 Extreme trendelburg position
 Surgical intervention
 Intra oral: through posterior pharyngeal wall
 Extra oral:
 inferior to hyoid parallel to sternocleidomastoid,
retraction of muscle and carotid sheath, blunt
dissection till hypopharynx.
 Deep dissection to carotid sheath between it and
inferior constrictor muscles rupture retropharyngeal
abscess
 Deep drains inserted

Principles in Treatment of Oral and
Paraoral Infections
a) Remove the cause.
b) Establish drainage.
c) Institute antibiotic therapy.
d) Supportive care, including proper rest and
nutrition.

Management of Odontogenic Infections
General principles
 Goals of management of odontogenic
infection:
1. Airway protection
2. Surgical drainage
3. Medical support of the patient
4. Identification of etiologic bacteria
5. Selection of appropriate antibiotic therapy

 Airway protection
1.Floor of mouth and tongue elevation or
narrowing can cause respiratory
distress
2.Expedient assessment and diagnosis of
airway compromise is the most
important initial step in managing
odontogenic infections
3.Airway loss is primary cause of death
in these patients

• Initially intact airway must be
continuously reevaluated during
treatment
• Signs and findings of airway
compromise: inability to assume a
supine position, stridor, and
restlessness etc.
• Surgeon must decide the need, timing
and method to establish an emergency
airway

 Surgical drainage
1. Administration of intravenous antibiotics
without drainage of pus may not allow for
resolution of an abscess
2. Starting antibiotic therapy without Gram's
stain and cultures may result in failure to
identify pathogens
3. Important to drain all primary spaces as well
as explore and drain potentially involved
secondary spaces

• CT scans may help identifying spaces
involved
• OPG can help identify putative teeth
involved

• Canine, sublingual and vestibular
abscesses are drained intraorally
• Masseteric, pterygomandibular, and
lateral pharyngeal space abscesses can
be drained with combination intraoral
and extraoral drainage
• Temporal, submandibular, submental,
retropharyngeal, and buccal space
abscesses may mandate extraoral
incision and drainage

 Technique:
1. Small incision are made in a dependent
area
2. Placement of a hemostat in the abscess
cavity with entry into all loculations of
the abscess
3. drains inserted into cavity to allow for
postoperative drainage of the abscess

PURPOSES OF SURGICAL DRAINAGE & INCISION
 Rid the body of toxic purulent material
 Decompress the tissues
 Allowing better perfusion of blood containing
antibiotics and defensive elements
 Increased oxygenation of the infected area

Dependent drainage of
the space is
performed by
placing a horizontal
incision in the most
dependent area of
the swelling
extraorally /
intraorally with a
cosmetic scar being
the result

 Medical support of the patient
1. Rehydrate patient as dehydration may
be present
2. Treat conditions that predispose
patient to infection (DM)
3. Oral pain, trismus , and swelling can
be addressed by appropriate analgesia
and treatment of underlying infection

 Identification of etiologic bacteria
1. Expected causes are alpha hemolytic
streptococci and oral anaerobes
2. Cultures should be performed on all
patients undergoing incision and drainage
and sensitivities ordered if patient is not
progressing well (possible antibiotic
resistance)
3. An aspirate of the abscess can be performed
and sent for culture and sensitivities if
incision and drainage delayed

Antibiotic Therapy
 Removal of the cause, drainage, and supportive
care more important than antibiotic therapy.
 Infections are cured by the patient’s defenses,
not antibiotics.
 Risks of allergy, toxicity, side effects,
resistance and superinfection causing serious
or potentially fatal consequences must be
considered.

Principles of antibiotic use
 – Necessity
 – Empirical therapy
 – Narrow spectrum
 – Low toxicity
 – Bacteriocidal
 – Administer properly
 – Cost

Antibiotic therapy, con’t.
 Oral infections are typically polymicrobial.
 Antibiotic effectiveness dependent upon
adequate tissue (not serum) concentration for an
appropriate amount of time.
 Antibiotics should be prescribed for at least one
week – adequate tissue concentration achieved
in 24-48 hours, with bacteriocidal activity
occurring over the next 3-5 days.

EMPIRIC ANTIBIOTIC TREATMENT
 Early infection (first 3 days of symptoms or
mildly immunocompromised)
Penicillin
Clindamycin
Cephalexin (or other first-generation
cephalosporin)
Flynn TR. The swollen face. Severe odontogenic infections.Emerg Med Clin N
Am 2000;18:

 Late infection (after 3 days of symptoms or
moderately to severely
immunocompromised)
Clindamycin (maximum dose)
Penicillin and metronidazole
Ampicillin and sulbactam
Cephalosporin (first or second generation)
Mild, moderate, and severe compromise is
based on CD4/viral loads, glycemic control,
and the degree of alcoholic related disease.

 Penicillin (bacteriocidal) drug of choice for
treatment of odontogenic infections (5%
incident of allergy).
 Clindamycin (bactericiodal) 1st line after
penicillin; effective against anaerobes;
 Cephalosporin (slightly broader spectrum and
bacteriocidal); cautious use in penicillin-
allergic patients → cross-sensitivity; if history
of anaphylaxis to penicillin, do not use.

 Erythromycin (bacteriostatic) good 2nd line
drug after penicillin; use enteric-coated to
reduce GI upset.
 Metronidazole (bacteriocidal) excellent
against anaerobes only.
 Augmentin (amoxicillin + clavulanic acid)
kills penicillinase-producing bacteria that
interferes with amoxicillin; expensive.

Selection of antibiotic therapy
1.Penicillin
2.Metronidazole in combination with
penicillin can be used in severe infections
3.Clindamycin for penicillin-allergic
patients
Causes for clinical failure include
inadequate drainage or antibiotic
resistance

COMPLICATIONS OF SPACE INFECTIONS
 Brain Abscess :
Etiology – bacteremia accompanying any
odontogenic infection
C/F – headache, nausea, vomiting,
Other symptoms : hemiplegia, pappiloedema,
aphasia, convulsions, hemisensory deficit

Drug Therapy – antibiotics & steroids
Mannitol to reduce to edema
Chloramphenicol ; antibiotic of choice
Surgery to provide drainage

 MENINGITIS
Most common neurological complication
C/F : headache, fever, stiffness of neck &
vomiting
Kernig’s sign – passive resistance to extend the
knee from flexed thigh position
Brudzinski’s sign – abrupt neck flexion in
supine resulting in involuntary flexion of
knees
Diagnosis : lumbar puncture

 Rx : chloramphinicol + penicillin G
 Hydration
 Electrolyte balance
 Control of cerebral edema
 Avoidance of vascular collapse and shock

 MEDIASTINITIS
Late complication due to delayed diagnosis &
inadequate surgical drainage
It is a descending cervical cellulitis that arises
from submandibular space infection,
parapharyngeal space, pterygomandibular
space or buccal space

S/S : unremitting high fever, tachycardia,
tachypnoea & hypotension
Brawny edema, induration of neck n chest and
crepitus may be palpable
Rx :early recognition , airway control, agg
surgical intervention (transthoracic or
cervicomediastinal approach), app antibiotic
therapy, supportive systemic care &
hyperbaric oxygen therapy

 CAVERNOUS SINUS
THROMBOPHLEBITIS :
External route – danger area of face
Internal route – odontogenic infection from
post maxillary region through pterygoid
plexus
C/F : Initial – swelling of face with
involvement of eyelids
Pulsating exopthalmos

Cranial nerve involvement (oculomotor,
trochlear, abducens, opthalmic & carotid
sympathetic plexus)
Late – thrombophlebitis
Advanced – toxaemia , meningitis, + Kernig’s
sign and brudzinski’s sign
Septicimia

Rx : antibiotic therapy
 Heparinization – heparin 20,000 units in
1500ml off 5% dextrose or Dicumarol
200mg
 Neurosurgical consultation
 Mannitol
 Anticoagulants
 Surgical drainage

Early recognition of orofacial infection and
prompt , appropriate therapy is absolutely
necessary
A thorough knowledge of anatomy of the face
and neck is necessary to predict pathways
of spread and to drain these spaces
adequately

 REFERENCES:
 Topazian , Oral & maxillofacial infections ,
Vol 4
 Daniel M Laskin , text book of oral &
maxillofacial surgery vol II
 Peterson ,text book of oral & maxillofacial
surgery
 Neelima malik, text book of oral &
maxillofacial surgery

Head and Neck Infections

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