The document discusses head and neck space infections, including their etiology, microbiology, classification of facial spaces, and principles of management. It provides details on specific spaces like the canine, buccal, infratemporal, and submental spaces. Guidelines are presented on determining the severity of infection, evaluating the patient, surgical and antibiotic treatment, and monitoring for treatment response.

1. Head and neck space
infections
Dr. Nigusu G. ( DMD)

2. Outline
Introduction
 Etiology
 Microbiology
Principle of management
 Classification of fascial spaces
Possible untoward or life-threatening complications of
orofacial infection
12/19/2023 2

3. Introduction
Maxillofacial space infections particularly those of odontogenic
origin are the most common
It arises from periapical abscess to superficial and deep neck
infections
The infections generally spread by following the path of least
resistance through connective tissue and along fascial planes
Finally they spread to such an extent, distant from the site of
origin, causing considerable morbidity and occasional death
12/19/2023 3

4. Cont.
The palatine tonsils and peritonsilar area in children
and odontogenic structures in adults are the most
prevalent initial anatomic origins of deep neck space
infections
Almost all odontogenic infections are caused by
multiple bacteria with anaerobic-aerobic characteristic
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5. 1-Odontogenic origin
Pulp disease, Periodontal disease, Secondarily infected
cyst & odontomes, Remaining root fragment, Pericoronal
infection
2-Trauma
3-Implant Surgery
4-Reconstructive Surgery
5-Contaminated Needle Puncture
6-Infections Of Maxillary Antrum
7-Infections of salivary glands
8-Secondary to oral malignancies
5
Etiology
12/19/2023

6. Invasion of dental pulp by bacteria after
decay of a tooth

Inflammation, edema & lack of collateral
blood supply

Venous congestion or avascular necrosis
(pulpal tissue death)

Reservoir of bacterial growth(anaerobic)

Periodic egress of bacteria into surrounding
alveolar bone 6
Pathways of odontogenic infections
12/19/2023

7. • Aerobic gram positive cocci bacteria(α-hemolytic
streptococci) or streptococci viridans that includes strept
milleri, strep. Sanguis, strep. Salivarius, strep. Mutans
• Anaerobic Cocci-peptostreptococcus
• Bacteriodes-porphyromonas, prevotella
Most odontogenic infections are caused by anaerobic and
aerobic bacteria
Aerobic bacteria-5%
Anaerobic bacteria-35%
Mixed infection-60% 7
Microbiology
12/19/2023

8.  Acute
Chronic
Acute stage:- 3 forms
Cellulitis
Abscess
Fulminating infection
8
Types of head and neck infection
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9. Cellulitis
It is spreading infection of loose connective tissues
It is a diffuse, erythematous, mucosal or cutaneous
infection
It is the result of streptococcal infection
Streptococcus produces streptokinase, hyaluronidase &
streptodornase which break down fibrin, connective
tissue ground substance & lyse cellular debris, which
facilitate rapid spread of bacteria
9
Cont.
12/19/2023

10. Abscess
It is a circumscribed collection of pus in a pathologic tissue space
 Infections are characterised by staphylococci and bacteroides
They produce coagulase, an enzyme, that may cause fibrin
deposition in citrated or oxalated blood
Fulminating Infections
In this the infection involves secondary spaces involving vital
structures along the pathway of least resistance
10
Cont.
12/19/2023

11. Chronic fistulous tract or sinus formation
• Abscesses neglected for a long time may discharge
intraorally or extra orally
Chronic osteomyelitis of Jaws
 Cervicofacial actinomycosis
11
Chronic stage
12/19/2023

12. Steps in odontogenic infections management
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
12/19/2023 12

13. Step1: Determine Severity of Infection
Three major factors must be considered in
determining the severity of an infection of the
head and neck
Anatomic location
Rate of progression
Airway compromise
12/19/2023 13

14. Cont.
Anatomic location
Low severity:- Little threat to the airway or vital structures
Vestibular, buccal, subperiosteal, infraorbital
Moderate severity:- Hindered access to the airway b/c of
swelling and trismus
Perimandibular spaces, masticatory spaces
High severity:- Direct threat to the airway or vital structures
Lateral pharyngeal, Retropharyngeal, danger space,
Mediastinum, Intracranial infections, Cavernous sinus
thrombosis, Brain abscess, Necrotizing fasciitis
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15. Cont.
Rate of Progression
Comparing onset of swelling and pain with current signs
and symptoms of swelling, pain, trismus, and airway
compromise
Four stages of odontogenic infections:-
Innoculation, Cellulitis, Abscess, Resolution
12/19/2023 15

16. Cont.
Airway Compromise
The most frequent cause of death in odontogenic
infection is airway obstruction
Complete airway obstruction is a surgical emergency
Infection in the region of surgical airway access is not a
contraindication to an emergency cricothyroidotomy or
tracheotomy
12/19/2023 16

17. Step 2: Evaluate Host Defenses
12/19/2023 17
Factors associated with immune system compromise
DM, Steroid therapy, Organ transplants, Malignancy,
Chemotherapy, CKD, Malnutrition, Alcoholism, End-
stage AIDS

18. Step 3: Decide on Setting of Care
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Indications for Hospital Admission
Temperature > 101°F (38.3°C)
Dehydration
Threat to the airway or vital structures
Infection in moderate or high severity anatomic spaces
Need for general anesthesia
Need for inpatient control of systemic disease
Multiple space involvement

19. Step 4: Treat Surgically
Immediate establishment of airway security and early
aggressive surgical therapy
When to go to the operating room
To establish airway security
Moderate to high anatomic severity
Multiple space involvement
Rapidly progressing infection
Need for general anesthesia
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20. Cont.
 General Principles of Surgical Infection Mgt
 Incisions should be placed within non‐involved skin and mucosa
 Incisions should be placed within aesthetic areas
 Incisions should be placed to allow for gravity dependent drainage
 Sharp dissection for superficial layers only & blunt dissection for
deeper layers to minimize damage to vital structures
 Explored spaces require drain placement except peritonsillar space
 Drains should be removed when they become nonproductive
12/19/2023 20

21. Cont.
Culture and Sensitivity Testing
Moderate or greater severity
Immunocompromised patients
Eg. (Klebsiella pneumoniae in DM, MRSA in IV drug abusers,
and intracellular pathogens, such as mycobacteria in HIV/AIDS)
Prior courses of antibiotic therapy
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22. Step 5: Support Medically
Is composed of mainly
Fluid & electrolyte resuscitation
Nutrition
Control of fever
Control of systemic diseases
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23. Step 6: Choose And Prescribe Antibiotic Therapy
12/19/2023 23
Empirical antibiotics of choice for odontogenic infections

24. Step 7: Administer Antibiotic Properly
The tissue level of antibiotics determines their
effectiveness
PO antibiotics achieve much lower serum levels at a
slower rate than IV antibiotics
Some antibiotics are equally well absorbed intravenously
and orally
Eg. The fluoroquinolones( ciprofloxacin and
moxifloxacin)
12/19/2023 24

25. Step 8: Evaluate The Patient Frequently
In outpatient infections that have been treated by tooth
extraction and intraoral incision and drainage, the
appointment is usually at 2 days postoperatively
For odontogenic deep fascial space infections that are
serious enough for hospitalization, daily clinical
evaluation and wound care are recommended
12/19/2023 25

26. Cont.
By 2 to 3 postoperative days, the clinical signs of
improvement should be apparent like
Decreasing swelling
Defervescence
Cessation of wound drainage
Declining white blood cell count
Decreased malaise
Improvement in mouth opening
12/19/2023 26

27. Cont.
If the previous signs of clinical improvement are not
apparent, then it may be necessary to begin an
investigation for possible Rx failure
Causes of Treatment Failure
Inadequate surgery, Depressed host defenses, Foreign
body, Patient noncompliance, Drug not reaching site, Drug
dosage too low, Wrong bacterial diagnosis, Wrong
antibiotic
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28. Criteria for Changing Antibiotics
Allergy, toxic reaction, or intolerance
Culture and/or sensitivity test indicating resistance
Failure of clinical improvement
Removal of odontogenic cause
Adequate surgical drainage (suggest postoperative
imaging)
48–72 hr of the same antibiotic therapy
12/19/2023 28

29. Primary maxillary spaces
Canine
Buccal
Infratemporal
Primary mandibular spaces
Submental
Buccal
Submandibular
Sublingual
29
Classification of facial spaces
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30. Secondary facial spaces
Parotid space
Masseteric
Pterigomandibular
Superficial & deep temporal
Lateral pharyngeal
Retropharyngeal
Danger space
30
Cont.
12/19/2023

31.  Located between the levator anguli oris and the
levator labii superioris muscles
Etiology
 Infection of maxillary canine, premolars &
mesiobuccal root of 1st molar
31
Canine space infection
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32. Clinical features
• Swelling of cheek & upper lip
• Obliteration of nasolabial fold
• Drooping of angle of mouth
• Edema of lower eyelids
• Redness & marked tenderness of facial tissues
32
Cont.
12/19/2023

33. Treatment
Incision & drainage
• Through the mucosa of labial vestibule in the region of
lateral incisor & canine
• A curved mosquito artery forceps is inserted, pus is
evacuated & a drain is inserted & is secured with suture
33
Cont.
12/19/2023

34. Etiology
Infection of maxillary(mostly) & mandibular premolars &
molars
Pericoronitis of lower 3rd molar
Boundaries
• Anteromedially-buccinator muscle
• Posteromedially-masseter muscle
• Laterally-deep fascia from parotid capsule & platysma muscle
34
Buccal space infection
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35. • Inferiorly-deep fascia & depressor anguli oris
• Superiorly-zygomatic process of maxilla & zygomaticus
major & minor muscles
Contents
Buccal pad of fat
Buccal branch of CN Ⅶ
Stenson`s duct
Facial artery
35
Cont.
12/19/2023

36. Clinical features
Gum boil in vestibule
Swelling extending from lower border of mandible to
infraorbital margin
Edema of lower eyelid
36
Cont.
12/19/2023

37. Spread
To pterigomandibular space
Infratemporal space
Submasseteric space
Treatment
• Incision & drainage through mucosa of cheek in premolar
molar region
37
Cont.
12/19/2023

38. Also called retrozygomatic space because it is
situated behind the zygomatic bone
Regarded as a serious event
Etiology
Infection of buccal roots of maxillary 2nd & 3rd
molars
LA injection with contaminated needles in the area
of tuberosity
Spread from other spaces
38
Infratemporal space infection
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39. Boundaries
• Laterally - by ramus of mandible, temporalis muscle
• Medially - medial pterygoid plate, lateral pterygoid
muscle, medial pterygoid muscle, lower part of temporal
fossa of the skull & lateral wall of pharynx
• Superiorly - greater wing of sphenoid & by zygomatic
arch
39
Cont.
12/19/2023

40. • Inferiorly - lateral pterygoid muscle
• Anteriorly - infra temporal surface of maxilla
• Posteriorly- parotid gland
Contents
 Medial & lateral pterigoid muscle
Pterigoid venous plexus
Maxillary artery
Mandibular nerve and middle meningeal artery
40
Cont.
12/19/2023

41. Clinical features
Limitation of mouth opening
Swelling in front of ear on the affected side
Proptosis of eye
Swelling in the area of tuberosity
Fever
41
Cont.
12/19/2023

42. Incision & drainage
• Incision is given in buccal vestibule opposite the 2nd &
3rd molars
• In severe infection incision is made at the upper
posterior edge of temporalis muscle
• Sinus forceps is directed upwards & medially
42
Cont.
12/19/2023

43. Etiology
• Periodontal abscess from palatal pockets
• Apical abscess from palatal roots of posterior teeth
usually from the lateral incisor + 1st molar
43
Palatal abscess
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44. Clinical features
• Fluctuant swelling in palate near the offending tooth
• Offending tooth is tender to percussion
Incision & drainage
• Anterioposterior incision is made through the mucosa
down to bone
44
Cont.
12/19/2023

45. Etiology
• Infection from 6 mandibular anterior teeth
• Infection of submental lymph nodes
Boundaries
• Laterally-lower border of mandible, anterior belly of
digastric muscle
• Superiorly-mylohoid muscle
45
Submental space infection
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46. • Inferiorly-deep cervical fascia, platysma, superficial fascia, skin
Contents
Submental lymph nodes
Anterior jugular vein
Clinical features
Distinct, firm swelling in midline, beneath the chin
Skin overlying the swelling is board like & taut
Fluctuation of swelling
Nonvital, fractured or carious lower anterior teeth
Offending tooth is tender on percussion & sometimes
mobile
46
Cont.
12/19/2023

47. Incision & drainage
• Transverse incision in skin below symphysis of mandible
Spread
Submandibular space
47
Cont.
12/19/2023

48. Etiology
• Infection from mandibular molars
• Infection of submandibular salivary gland
• Infection from middle 1/3 of tongue, posterior part of
floor of mouth, maxillary teeth, cheek, maxillary sinus &
palate
48
Submandibular space infection
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49. Contents
• Submandibular salivary gland
• Submandibular lymph nodes
• Facial artery & vein
Clinical features
Firm swelling in submandibular region
Constitutional symptoms
49
Cont.
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50. Tenderness of swelling
Redness of overlying skin
Teeth are sensitive to percussion & mobile
Dysphagia
Moderate trismus
50
Cont.
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51. Incision & drainage
• Incision of 1.5 to 2cm length is made 2cm below the
lower border of mandible in the skin creases
• Skin & subcutaneous tissues are incised
51
Cont.
12/19/2023

52. Etiology
• Infection from mandibular incisors, canines, premolars & 1st
molars
Boundaries
• Inferiorly-mylohyoid muscle
• Laterally-medial side of mandible
• Medially-hyoglossus, genioglossus, geniohyoid muscles
• Posteriorly-hyoid bone
52
Sublingual space infection
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53. Contents
Geniohyoid, genioglossus, mylohyoid muscle
Deep part of submandibular salivary gland
Sublingual salivary gland
Lingual nerve
Hypoglossal nerve
53
Cont.
12/19/2023

54. Clinical features
Enlarged tender lymph nodes
Pain & discomfort on deglutition
Speech is affected
Painful swelling in floor of mouth
Tongue may be pushed superiorly
Incision & drainage
• Incision made close to lingual cortical plate
54
Cont.
12/19/2023

55. Spread
• Sublingual space of opposite side
• Submandibular space
• Pterigomandibular space
• Parapharyngeal space
• Submental & submandibular lymph nodes
55
Cont.
12/19/2023

56. Etiology
• Infection through stenson`s duct
• Blood borne infection
• Infection from submasseteric, pterigomandibular & lateral
pharyngeal space
Boundaries
• Inferiorly-stylomandibular ligament
• Anteriorly-masseteric space
56
Parotid space
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57.  Space formed by splitting deep cervical fascia
around the parotid gland
Contents
 Facial nerve
 Retromandibular vein
 External carotid artery
57
Cont.
12/19/2023

58. Clinical features
Severe pain referring to ear accentuated by eating
Swelling extending from zygomatic arch to lower
border of mandible
Ear lobe may be lifted up
Pus escapes from stenson`s duct when gland is milked
58
Cont.
12/19/2023

59. Incision & drainage
• Incision is made on skin behind the posterior border of
mandible extending from inferior aspect of lobule of ear to
just above mandible
Spread
• Submasseteric space
• Pterigomandibular space
• Lateral pharyngeal space
59
Cont.
12/19/2023

60. The masticatory space
60
12/19/2023
 Submasseteric space
 Pterygomandibular space
 Superficial temporal space
 Deep temporal space
 A maximum interincisal distance ≤
20 mm in a patient with acute pain

61. Etiology
• Spreading from buccal space
• Infection of lower 3rd Molar
Boundaries
• Anterior-anterior border of masseter & buccinator
muscle
• Posterior-parotid gland, posterior part of masseter
• Inferior- attachment of masseter to lower border of
mandible
• Medial-lateral surface of ramus of mandible
61
Submasseteric space infection
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62. • Lateral-medial surface of masseter muscle
Contents
• Masseteric nerve
• Superficial temporal artery
• Transverse facial artery
62
Cont.
12/19/2023

63. Clinical Features
• Moderate swelling extending from lower border of
mandible to zygomatic arch, anteriorly to anterior border
of masseter, posteriorly to posterior border of mandible
• Tenderness over angle of mandible
• Complete limitation of mouth opening
• Pyrexia & Malaise
63
Cont.
12/19/2023

64. Incision & drainage
• Intraoral-incision is made vertically over the lower
part of anterior border of ramus of mandible, deep
to bone
• Extraoral-incision is placed in skin behind the angle
of mandible
64
Cont.
12/19/2023

65. Etiology
• Pericoronitis related to the mandibular third molar
• Inferior alveolar nerve block using contaminated needle
• Infection form maxillary third molar
Boundaries
• Posterior - parotid gland
• Medial - lateral surface of medial pterygoid muscle
65
Pterigo-mandibular space infection
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66. • Lateral - medial surface of ramus of mandible
• Anterior -pterygomandibular raphae
• Superior - lateral pterygoid muscle
Contents
Lingual nerve
Mandibular nerve
Inferior alveolar artery
Mylohyoid muscle
66
Cont.
12/19/2023

67. Clinical features
Trismus
Tenderness & swelling medial to anterior border of
ramus of the mandible
Dysphagia
Difficulty in breathing
67
Cont.
12/19/2023

68. Incision & drainage .
• Intraoral – a vertical incision; approximately 1.5 cm in
length, is made on the anterior & medial aspect of the
ramus of mandible
• Extraoral - an incision is taken in the skin below the angle
of the mandible
Spread
Infra temporal space
Lateral pharyngeal space
Retropharygeal space
Submandibular space
68
Cont.
12/19/2023

69. Rarely becomes infected
Etiology
• Secondary to the involvement of infratemporal space
Boundaries
• Superficial temporal space-b/w temporal fascia &
temporalis muscle
• Deep temporal space-b/w temporalis muscle & skull
69
Temporal space
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70. Clinical features
Pain
Trismus
Swelling over temporal region
Incision & drainage
• Incision in temporal region in hairline 45 to
zygomatic arch
70
Cont.
12/19/2023

71. Deep cervical fascial space infection
Is uncommon occurrence
When it does happen may have serious life threating
sequele
They can compress, deviate or completely obstruct the
air way
Invade vital structure such as the major vessel and can
extend to mediastinum
71
12/19/2023

72. Etiology
Mandibular third molar area
Sublingual, submandibular & ptergomandibular space
infection
Boundaries
• Inferiorly - hyoid bone
• Anteriorly - pterygomandibular raphe
• Laterally - ascending ramus of mandibular
• Medially - pharyngeal wall
• Posteriorly - styloid muscle, upper part of carotid sheath,
prevertebral fascia
72
Lateral Pharyngeal Space
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73. Contents
• Anterior compartment - lymph nodes, facial artery,
loose areolar connective tissue
• Posterior compartment - carotid sheath, cranial
nerves IX, X and XII, cervical sympathetic trunk
73
Cont.
12/19/2023

74. Clinical signs
Truisms as a result of inflammation of medial pterygoid muscle
Lateral swelling of the neck between angle of mandible &
SCM
Swelling of lateral pharyngeal wall causing bulge to ward
midline
Difficulty swallowing
High temperature
74
Cont.
12/19/2023

75. Incision & drainage
• Extraoral - an incision is made along the anterior border
of sternocleidomastoid muscle, extending from below the
angle of the mandible, to the middle third of
submandibular gland
• Intraoral - a vertical incision is placed over the
pterygomandibular raphe
75
Cont.
12/19/2023

76. • Bounded anteriorly by the pharyngeal constrictor muscles
and retropharyngeal fascia and posteriorly by alar fascia
• It begins at the base of the skull and end inferiorly at
T4 vertebrae, where the alar fascia fuses anteriorly
with retropharyngeal fascia
• Contains only loose connective tissue and lymph nodes
• The major concern is that the infection can rupture the
alar fascia posteriorly to enter danger space
76
Retropharyngeal space
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77. Cont.
Etiology
• Infection from the lateral pharyngeal space
Clinical features
Painful deglutition, Snoring, Choking, Stertorous
breathing
Incision & drainage
• Same as lateral pharyngeal space
12/19/2023 77

78. Danger Space
• It lies between the alar fascia anteriorly and
prevertebral fascia posteriorly
• It extends from base of skull to the diaphragm
and it is continuous with posterior mediastinum
78
12/19/2023

79. Possible life threatening complications of orofacial
infection
1. Those related to the lower jaw
Ludwig‘s angina
Descending deep cellulitis of the neck, resulting in
mediastinitis
Carotid sheath invasion
2. Those related to the upper jaw
Intracranial complications, with possibilities of
cavernous sinus thrombosis, brain abscess, durral
meningitis and osteomyelitis of the skull
Retrobulbar cellulitis with possibility of blindness
12/19/2023 79

80. Ludwig`s angina
A massive, firm, brawny, cellulitis or induration & acute
toxic stage involving simultaneously submandibular,
sublingual & submental spaces bilaterally
Etiology
Odontogenic(90%)
Tonsillitis, Foreign bodies like fish bone, Oral soft tissue
lacerations, LA using contaminated needles, Trauma in orofacial
region, Osteomyelitis, Submandibular & sublingual sialadenitis,
Secondary infections of oral malignancies
80
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81. Cont.
Clinical features
Pyrexia, Anorexia, Chills, Malaise, Dysphagia
Hoarseness of voice
Firm, non pitting, non fluctuant,tender with ill defined
border of swelling in bilateral submandibular & submental
regions extending to the clavicles
Air way obstruction, ↑RR, Cyanosis
Trismus
Mouth remains open due to edema of sublingual tissues
Tongue is raised against palate
Drooling of saliva
81
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82. Cont.
82
12/19/2023
Ludwig’s angina, if untreated, can be fatal within 12– 24
hours; death due to asphyxia

83. Cont.
83
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Principles of Treatment of Ludwig’s Angina
Early diagnosis
Early aerobic and anaerobic antibiotics cover at aggressive
dosages
Urgent, skillful management of a patent, safe airway
Elimination of original focus (Exo of the offending teeth)
Incision and surgical drainage of fascial spaces involved to
decompress the involved areas and treat the cause
Stringent control of fluid management & adequate nutritional

84. Necrotizing fasciitis
Is an infection that spreads along the fascial planes,
causing subcutaneous tissue death with relative sparing of
skin and underlying muscles, characterized by rapid
progression, systemic toxicity, and even death
Diagnostic features of NF are high fever, hypotension,
prostration, and multiple organ failure. The condition is
known as streptococcal toxic shock syndrome
Gas in the tissues is considered a hallmark of NF
84
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85. Cont.
85
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86. Cont.
When necrotizing fasciitis is suspected
1. Emergency surgery
2. High dose broad-spectrum antibiotic
3. Treatment of underlying medical condition
4. Correction of fluid and electrolyte imbalances
86
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87. Osteomyelitis
It is defined as an inflammation of the bone
marrow with a tendency to progression
It involves adjacent cortical plates and often
periosteal tissues
The incidence of osteomyelitis is much higher
in the mandible
87
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88. Cont.
It has been associated
Systemic diseases including DM, autoimmune states,
malignancies, malnutrition, and AIDS
Medications (steroids, chemotherapeutic agents, and
bisphosphonates)
In the maxillofacial region, osteomyelitis primarily occurs
as a result of contiguous spread of odontogenic infections
or as a result of trauma
Primary hematogenous osteomyelitis is rare in the
maxillofacial region, generally occurring in the very
young
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89. Cont.
It is divided into acute or chronic forms based on the
presence of the disease for a 1-month duration
Clinical Presentation
Pain (deep and boring )
Swelling and erythema of overlying tissues
Adenopathy, Fever
Paresthesia of the inferior alveolar nerve (pressure on
the inferior alveolar nerve from the inflammatory
process within the medullary bone of the mandible )
Trismus, Malaise
Fistulas
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90. Cont.
Investigations
Laboratory work-up(leukocytosis, ESR, CRP)
Plain X-ray shows “moth-eaten” bone or sequestrum of
bone, which is the classic appearance of chronic
osteomyelitis
CT scanning, like plain films, requires 30 to 50%
demineralization of bone before changes can be seen
MRI may benefit in identifying the earlier stages of
osteomyelitis
Biopsy
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91. Cont.
Treatment
Medical
Complete bed rest, Supportive therapy, Control of pain,
Antimicrobial agents
Surgical
I&D, Exo offending teeth, Debridement, Decortication,
Sequestrectomy, Saucerization, Resection of jaw
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92. Actinomycosis
Usually caused by actinomyces israeli ( normal flora)
Uncommon disease because the bacteria has low degree
of virulence
If infection erodes through a cutaneous surface, which is
common with orofacial actinomycosis, multiple sinus
tract typically develop
92
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93. Cont.
Clinical presentation
Soft or firm tissue masses on the skin; which have
purplish, dark-red, oily areas with occasional small zones of
fluctuation
Spontaneous drainage of serous fluid containing granular
material. These granules are yellowish substances called
sulfur granules, and represent colonies of bacteria
93
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94. Cont.
Management
 I&D and excision of all sinus tracts
The antibiotics of choices in the non allergic patient is IV penicillin's,
followed by long term oral therapy
Alternative antibiotics:- doxycycline or clindamycin
94
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