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
12/19/2023 4
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
12/19/2023
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
12/19/2023 14
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
12/19/2023 18
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
12/19/2023 19
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
12/19/2023 21
22. Step 5: Support Medically
Is composed of mainly
Fluid & electrolyte resuscitation
Nutrition
Control of fever
Control of systemic diseases
12/19/2023 22
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
12/19/2023 27
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
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
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
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
12/19/2023
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.
12/19/2023
50. Tenderness of swelling
Redness of overlying skin
Teeth are sensitive to percussion & mobile
Dysphagia
Moderate trismus
50
Cont.
12/19/2023
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
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
12/19/2023
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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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
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
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
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
12/19/2023
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
12/19/2023
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
12/19/2023
83. Cont.
83
12/19/2023
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
12/19/2023
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
12/19/2023
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
12/19/2023
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
12/19/2023 88
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
12/19/2023 89
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
12/19/2023 90
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
12/19/2023 91
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
12/19/2023
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
12/19/2023
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
12/19/2023
The most common causative organisms are streptococci, which comprise about 90% of the aerobic bacterial species that cause odontogenic infections. Staphylococci account for about 5% of the aerobic bacteria, and many miscellaneous bacteria contribute 1% or less. Rarely found bacteria include group D Streptococcus organisms, Neisseria spp., Corynebacterium spp., and Haemophilus spp
The bacteria that cause odontogenic infections are part of the normal oral flora: those that comprise the bacteria of plaque, those found on mucosal surfaces, and those found in the gingival sulcus
They are causing- dental caries, gingivitis and periodontitis through which they will get access to deeper underlying tissues odontogenic infection
The anaerobic gram positive cocci and gram negative anaerobic rods play a more important pathogenic role
The aerobic bacteria found in odontogenic infection are primarily gram-positive cocci, most are viridans streptococci species(80% ), include Streptococcus milleri, S. sanguis, S. salivarius, S. mutans
Staphylococci found are about 6%
Almost all odontogenic infections are caused multiple bacteria ( lab test can identify average of five species)
The anatomic spaces of the head and neck can be graded in severity by the level to which they threaten the airway or vital structures
Ultrasound offers the advantages of portability and avoiding radiation; however, ultrasound for deep neck structures is a sensitive technique, requiring a level of expertise that is not as widely available as that for CECT.
The dentoalveolar complex is composed of the teeth and surrounding gingival and bony tissues
The mandibular incisors and canines often show labial extension in the vestibule. Lingual extension involving the incisors can occur.
The mandibular premolars and molars often show buccal extension
The maxillary incisors, canines, and buccal root of the first premolars often show labial extension.
Infections of the premolar palatal root more often spread to the palate
The maxillary second premolar and molars frequently show a buccal extension with the exception of infections involving the palatal root of the molars.
In highly skilled hands, one brief attempt at endotracheal intubation may be made, but a direct surgical approach to the airway by cricothyroidotomy or tracheotomy is more predictably successful
In partial airway obstruction, abnormal breath sounds will be evident, consisting of stridor or coarse airway sounds suggestive of fluid in the upper airways
Diabetes is listed first because it is the most common immune-compromising disease
such as Klebsiella pneumoniae in diabetes, intracellular pathogens in HIV infection, methicillin-resistant Staphylococcus aureus (MRSA) with drug abuse, and fungi in iatrogenic or oncologic immunodeficiency.
Diabetics have the combination of a white blood cell migration defect, which inhibits successful chemotaxis of white blood cells to the infected site from the blood stream
A vascular defect that impairs blood flow to small vessel tissue beds, especially in end organs such as the foot.
Orally, diabetics have an increased susceptibility to periodontal infections.
Dehydration can be assessed in the presence of normal serum creatinine by an elevated urine specific gravity (>1.030) or an elevated blood urea nitrogen (BUN) with a normal serum creatinine, which indicates prerenal azotemia.
Evaluation of the anatomic extent and source of the infection, medical compromise, and possibly C-reactive protein are important in determining the severity of infection as well as in estimating the length of hospital stay
The host response to severe infection can place a damaging
physiologic load on the body
The statistically significant predictors of the length of stay, based on multivariate analysis, were indicators of the severity of infection, such as number of infected anatomic spaces, time in the operating room, and complications, such as therapeutic antibiotic failure, and the need for reoperation.
In other studies,number of involved spaces,diabetes,Neck swelling, lower facial swelling, C-reactive protein greater than 100, and trismus also have been associated with an increased hospital stay.
Fever can increase sensible and insensible fluid losses and caloric requirements shifting the body metabolism to a catabolic state
A prolonged fever may cause dehydration, which can, therefore, decrease cardiovascular reserves and deplete glycogen stores
Clinical signs of dry skin, chapped lips, loss of skin turgor,and dry mucous membranes
The inpatient setting affords the patient with continual professional monitoring, supportive medical care, the availability of radiologic and medical consultative services, and, most important, a team that can rapidly secure the airway should it become compromised
The involvement of moderate- or high severity anatomic spaces generally necessitates a definitive airway management procedure, as well as surgical intervention in anatomic locations that are not amenable to profound local anesthesia
Guide line of surgical drainage
By using appropriate anatomic landmarks to use small incisions and blunt dissection without direct exposure and visualization of the entire infected anatomic space
It is crucial to insert the instrument closed, then open it at the depth of penetration, and then withdraw the instrument in the open position
Incisions placed within necrotic or inflamed tissues result in delayed healing and unaesthetic scars
Sharp dissection for superficial layers only (skin, subcutaneous tissues, and mucosa) & blunt dissection for deeper layers to minimize damage to vital structures
Pus usually stops flowing from surgically drained abscesses in 24 to 72 hours, but this process may take somewhat longer when only cellulitis has been encountered
Identification of an abscess is not required before surgical intervention
Early incision and drainage aborts the spread of infection into deeper and more critical anatomic spaces, even when it is in the cellulites stage
Daily sensible fluid loss, consisting primarily of sweat, is increased by 250 mL per degree of fever. Insensible fluid loss, consisting mainly of evaporation from lungs and skin, is increased by 50 to 75 mL per degree of fever per day. Therefore, a 70-kg patient with a fever of 102.2°F would have a daily fluid requirement of about 3100 mL. This would translate to a required intravenous infusion rate of approximately 130 mL/hr, assuming no oral intake and no other extraordinary fluid losses
Therefore, it may be necessary to supplement the infected patient’s oral intake, which is likely to be significantly inhibited by the local effects of the infection and surgery, by using supplementary feedings or even enteral nutrition via a feeding tube
Ampicillin-sulbactam is now the antibiotic of choice in odontogenic infections that are serious enough to warrant hospital admission. And also penicillin + metronidazole
Erythromycin and clarithromycin, for example, are metabolized in the liver by the cytochrome P-450 CYP3A4, which is responsible for 50% of drug interactions. While azithromycin is metabolized in different way although in vitro antibiotic sensitivity testing has recently shown that the macrolide antibiotics are generally ineffective against oral anaerobes and even streptococci the fact that azithromycin is concentrated in phagocytic macrophages by 10 to 15 times the serum concentration may explain its clinical effectiveness for oral infections when combined with appropriate surgical therapy
Clindamycin, conversely, does not cross the blood-brain barrier. Therefore, it is appropriate to use penicillin plus metronidazole or ampicillin-sulbactam when there is a risk of an odontogenic infection entering the cranial cavity.
Metronidazole has a disulfiram-like reaction with alcohol; it should be avoided in patients that may have difficulty abstaining from alcohol.
Because ceftriaxone can cause pseudocholelithiasis owing to sludging of bile salts, it should be used with caution or avoided in patients with hepatobiliary disease
One of the best methods of reevaluation is the postoperative CT.
that have been treated by tooth extraction and intraoral incision and drainage
1.
Shapiro defined fascial spaces as potential spaces between the layers of fascia. These spaces are normally filled with loose connective tissues and various anatomical structures like veins, arteries, glands, lymph nodes
Problem that should be considered
When this space is involved, the OI is severe and may be progressing at rapid rate.
Direct effect on the contents that include thrombosis of internal jugular vein, erosion of carotid artery or its branch and interference with function of cranial nerves.
Can progress to retropharyngeal space or beyond.
Referred to by laypersons as “flesh eating bacteria”
Necrosis of the overlying platysma, subcutaneous tissue and skin occurs because of thrombosis and occlusion of the arterioles that pass through the muscle to provide blood supply to overlying tissue
The distinguishing features are fast progression, pain, systemic toxicity, and presence of subdermal gas
necrosis and liquefaction of the fat and fascia lead to arterial thrombosis, wet gangrene, and finally ischemic death of the skin
The incidence of osteomyelitis is much higher in the mandible
due to the dense poorly vascularized cortical plates and
the blood supply primarily from the inferior alveolar artery. It is much less common in the maxilla due to the excellent blood supply from multiple nutrient feeder vessels. In addition the maxillary bone is much less dense than the mandible.
The clinician must be aware that malignancies can mimic the presentation of osteomyelitis and must be kept in the differential diagnosis until ruled out by tissue histopathology