Detailed description of diagnosis and management of maxillofacial and neck space infections. Discussion of anatomy of the spaces is also done in details. Drainage of such spaces are also discussed. Medical management is also discussed. Complications are also discussed.

1. Presented by: Dr Dibya Falgoon Sarkar

2.  Introduction
Fascial spaces
Fascial layers of Neck
Classification of Maxillofacial spaces
 Stages of infection
Microbiology of maxillofacial infections
Pathways of spread of dental infection
Sequelae of dental infections
Diagnosis of maxillofacial space infection
Imaging of maxillofacial spaces
Antibiotic treatment
Surgical management of space infection
Discussion of individual space infections

3. •The incidence and severity of maxillofacial space
infections have diminished since the advent of
antibiotic therapy.
•However, significant morbidity and mortality of
these infections continue.
•Dentists and physicians must be alert to the
potential seriousness of these infections, which
should never be dismissed as simple dental
abscesses.

4. • Shapiro defined fascial
spaces as potential spaces
between the layers of fascia.
•These spaces are normally
filled with loose connective
tissues and various
structures like veins, arteries,
glands, lymph nodes
•Space is a misnomer. There
are voids in the tissues in
actual reality.
The term fascia is used
to describe broad
sheets of dense
connective tissues
whose function is to
separate structures
that may pass over
each other during
movement and serves
as pathways for
vascular and neural
structures.

5. Fascial plane Common Name Structures within the Plane
Superficial cervical
fascia
SMAS Platysma, muscles of facial
expression
Superficial layer of
Deep Cervical
Fascia (DCF)
Investing layer Trapezius, SCM, Anterior belly of
digastric, masseter, parotid and
submandibular glands
Middle layer of DCF Visceral fascia Strap muscles, buccinator,
pharyngeal constrictors, esophagus,
trachea, thyroid and parathyroid
glands
Deep layer of DCF Prevertebral fascia Paraspinous muscles, cervical
vertebrae, scalene muscles
Carotid sheath Confluence of each
layer of DCF
Common carotid, IJV, Vagus nerve,
ansa cervicalis

7. Space Anatomy
Space 1 Lies superficial to superficial fascia (Subcutaneous space)
Space 2 Group of spaces surrounding strap muscles, lying superficial to middle layer
of deep cervical fascia
Space 3 • Lies superficial to visceral division of middle layer of DCF.
• Contains pretracheal, retropharyngeal and lateral pharyngeal spaces
Space 3A Carotid sheath (Lincoln’s highway)
Space 4 • Potential space between alar and prevertebral division of posterior layer
of DCF
• Also known as Danger space
Space 4A Situated in posterior triangle of neck, posterior to the carotid sheath
Space 5 Prevertebral space
Space 5A Enclosed by prevertebral fascial, posterior to transverse process pf vertebrae,
as it surrounds the scalene and spinal postural muscles

9. 1. Direct involvement (Primary spaces)
• Maxillary spaces: Canine, buccal, infratemporal
• Mandibular spaces: Submental, submandibular,
sublingual, buccal
2. Indirect involvement (Secondary spaces)
• Masseteric
• Superficial and deep temporal
• Pterygomandibular
• Lateral and retropharyngeal
• Prevertebral, parotid, pretracheal, pertonsillar, carotid
sheath and danger spaces

10. I. Face- Buccal, canine, masticator spaces
II. Suprahyoid- Sublingual, submandibular,
submental, peritonsillar, lateral pharyngeal
III. Infrahyoid- Pretracheal
IV.Space of total neck- Retropharyngeal,
Danger space, Space of carotid sheath

11. Characteristic Inoculation Cellulitis Abscess
Duration 0-3 days 3-7 days >5 days
Pain Mild- moderate Severe & generalized Moderate-severe &
localized
Size Small Large Small
Localization Diffuse Diffuse Circumscribed
Palpation Soft, doughy, mild
tender
Hard, exquisitely tender Fluctuant, tender
Appearance & skin
quality
Normal Reddened & thickened Peripherally reddened,
shiny skin texture
Surface temperature Slightly heated Hot Moderately heated
Loss of function Minimal Severe Severe
Tissue fluid Edema Serosanguinous, flecks
of pus
Pus
Percutaneous bacteria Aerobic Mixed Anaerobic

12. 1. Hyperemia and vasodilation
2.Passage of plasma proteins and
leukocyte rich exudate into
surrounding tissues
Precipitation of fibrin network
which walls off the affected region
1. Phagocytosis of bacteria and
dead cells
2. Disposal of macrophages of
necrotic debris
Aerobic bacteria Frequency Anaerobic bacteria Frequency
Gram- positive cocci (85%) Gram- positive cocci (30%)
Streptococcus ( Gr D ,B
haemolytic, Viridans)
Very common Streptococcus Common
Staphylococcus Rare
Gram- negative bacilli Gram –ive bacilli (50%)
H. Influenzae, E. coli Prevotella, Fusobacterium Very common
Eikenella corrodens Porphyromonas Rare

14. Periapical
infection
Bacteremia-
septicaemia
Deep fascial
space
infection
Ascending
cerebral
infection
Osteomyelitis
Intraoral soft
tissue abcess
Cellulitis
Fistula

15. Involved teeth Usual exit
from bone
Relation of muscle
to Root apices
Site of localization of
infection
Upper central
incisor
Labial Oral vestibule
Upper lateral
incisor
Labial
Palatal
Oral vestibule
Palate
Upper canine Labial Above (Levator
muscle)
Below
Oral vestibule
Canine space
Upper
premolars
Buccal
Palatal
Above Oral vestibule
Palate
Upper molars Buccal
Palatal
Above (Buccinator)
Below
Oral vestibule
Buccal space
Palate

16. Involved teeth Usual exit
from bone
Relation of muscle
to Root apices
Site of localization of
infection
Lower incisors Labial Above (Mylohyoid)
Below
Submental space
Oral vestibule
Lower canine Labial Below (Buccinator) Oral vestibule
Lower
premolars
Buccal Below (Buccinator) Oral vestibule
Lower 1st
molars
Buccal
Lingual
Below (Buccinator)
Above
Oral vestibule
Buccal space
Sublingual space
Lower 2nd
molars
Buccal
Lingual
Below (Buccinator)
Above
Below (Mylohyoid)
Above
Oral vestibule
Buccal space
Sublingual space
Submandibular space
Lower 3rd
molars
Lingual Submandibular/
pterygomandibular
space

17. • History:
1. Recent dental/ surgical
procedures in upper
aerodigestive tract
2. Trauma
3. Past medical history: Diabetes,
HIV, etc,
4. Drug history
• Symptoms:
1. Onset and duration of symptoms
2. Pain, fever, redness at the site,
dysphagia
3. Trismus, dyspnoea
• Physical examination:
1. Palpation of neck mass,
tenderness, crepitation, fluctuance
2. Visual inspection of oral, nasal
cavity, oropharynx
3. Upper airway inspection (Flexible
fibreoptic illumination)
• Laboratory tests:
1. Complete blood count
2. Renal function, blood sugar and
hydration status
3. Pus/blood culture and sensitivity

18. • Plain films: OPG, A-P/ Lateral
cervical radiographs for
evaluation of retropharyngeal
abscess
• CECT scan: Most reliable (95%
sensitivity) imaging means for
deep neck space infections.
• MRI: Helpful when intracranial or
neural extension is suspected
• MRI useful in patients with
impaired renal function
• Ultrasonography: Useful for
needle drainage and localization.
MRI- Cavernous sinus thrombosis
CECT scan

19. Principles for choosing appropriate antibiotic
( Topazian 4th edition) :
1. Identification of causative organism- Pus,
blood or tissue culture
2. Start with empirical therapy till antibiotic
sensitivity is obtained
3. Use of a specific, narrow spectrum antibiotic
4. Use the least toxic antibiotic of the sensitivity
list
5. Patient’s drug history and medical history
should be taken
6. Use of bactericidal rather than bacteriostatic
antibiotic
7. Cost of antibiotic
8. Encourage patient compliance
9. Proper dosage and route of administration
10. Combination therapy

20. 1. Incise healthy skin and mucosa
when possible
2. Place incision in an aesthetically
acceptable area
3. Place incision in a dependent
area
4. Dissect bluntly and explore
every part of abscess cavity up
to the infected tooth
5. Place a drain and stabilize it
with sutures
6. Consider use of through and
through drains in bilateral cases
7. Don’t leave the drains for an
extended period of time
8. Clean wound margins daily
under sterile conditions
Goals of surgical
intervention:
1. Providing tissue/ fluids
for culture and
sensitivity
2. Allowing drainage of pus
and irrigation of the
isolated infected spaces

21. • Boundaries
• Anteriorly: Ends at modiolus just
posterior to the oral commissure
• Posteriorly: Masseter and
pterygomandibular raphe
• Superiorly: Infraorbital space and
anterior surface of maxilla
• Inferiorly: Inferior border of
mandible
• Superficial: Skin ; Deep: Buccinator
• Contents: Stensen duct, facial
artery and buccal fat pad
• Buccal cellulitis: Non odontogenic
origin ;Common in children <
3years. Caused by H. influenzae.;
high fever for atleast 24 hrs prior
clinical signs ; otitis media

22. Buccal
space
Superiorly:
Infraorbital
space
Posteriorly:
• Submass-
eteric space
• Lateral
pharyngeal
space
Medial side:
• Pterygo-
mandibular
space
• Infra-
temporal
space
Via buccal fat
pad: Superficial
temporal space

24. • Potential space between oral
vestibular mucosa and nearby
muscles of facial expression.
• Boundaries:
• Posteriorly: Buccinator muscle
• Anteriorly: Intrinsic muscle of
lip like orbicularis oris, etc.
• Medially: Alveolus
• Contents: Areolar tissue, long
buccal and mental nerve
• Communicates: buccal and
subcutaneous spaces
• Drainage: Via buccal vestibule

25. • Incidence: Rare
• Clinical features: Marked swelling
lateral to nose, cellulitis of eyelids and
obliteration of nasolabial fold
• Boundaries:
oSuperiorly: Levator labii superioris &
alaque nasi
oInferiorly: Caninus muscle
oMedially: Anterior surface maxilla,
levator anguli oris
oAnteriorly: Orbicularis oris, nasal
cartilage
oPosteriorly: Buccal space, buccinator
oMay involve infraorbital space
• Drainage: Intraorally high in the
maxillary vestibule

26. • Boundaries:
1. Anterior: Inferior border of mandible
2. Posterior: Hyoid bone
3. Superior: Mylohyoid muscle
4. Inferior: Investing fascia and skin
5. Lateral: Anterior belly of digastric
6. Superficial: Investing fascia
• Likely cause: Lower anteriors, fracture
symphysis
• Contents: Anterior jugular vein, submental
nodes
• Communications: Submandibular spaces
• Drainage: Extra oral horizontal incision in most
inferior portion of chin in a natural skin crease.

27. • Boundaries:
1. Anterior: Anterior belly of digastric
2. Posterior: Posterior belly of digastric
3. Superior: Inferior and medial surface of
mandible
4. Inferior: Digastric tendon
5. Superficial: Platysma, investing fascia
6. Deep: Mylohyoid, hyoglossus
• Likely cause: Lower molars
• Contents: Submandibular gland, facial
artery and vein, level IB nodes
• Communications: Submental, sublingual,
lateral pharyngeal, buccal spaces
• Drainage: Extraorally by submandibular
incision.

28. • Stab incision placed
below the lower
border of mandible
over the dependent
part
• Curved haemostat is
passed and blunt
dissection is made
through subcutaneous
fat
• Avoid facial artery, vein
and marginal
mandibular nerve

29. • Boundaries:
1. Anteriorly: Inferior border of mandible
2. Posterior: Hyoid bone
3. Superior: Oral mucosa (FOM)
4. Inferior: Mylohyoid muscle
5. Medial: Muscles of tongue
6. Lateral: Lingual surface of mandible
• Contents: Sublingual glands, Wharton’s duct, Lingual nerve, sublingual
vessels
• Likely cause: Lower premolars, first and second lower molar, direct
trauma
• Communicates: Submandibular, lateral pharyngeal (via
buccopharyngeal gap between constrictors) , visceral ( trachea &
esophagus)

30. Drainage: Incision is placed over floor of mouth in
the lingual sulcus parallel to the Wharton’s duct.
Lingual nerve and sublingual vessels are preserved.

31. • Definition: Firm, acute, toxic cellulitis of the
submandibular and sublingual spaces
bilaterally and of the submental space.
( Topazian, Goldberg, Hupp ; Oral & Maxillofacial
Infections, 4th edition)
• Wilhelm von Ludwig first described this
condition in 1836
• Cause: Dental infection (90% cases)
• Clinical features:
Brawny edema over bilateral submandibular
region
Elevated tongue
Airway obstruction
Paucity of pus
• May spread to masticator spaces

32. • Early diagnosis and maintenance of airway
• Tracheostomy / fibreoptic laryngoscopy
may be considered
• Fluid resuscitation
• Prolonged, intense, intravenous antibiotic
therapy
• Use of Inj. Dexamethasone to reduce
oedema
• Extraction of affected teeth
• Early surgical drainage
• Incision: Horizontal incision midway
between the chin and hyoid bone along
with bilateral incisions into the
submandibular spaces
• Masticator spaces are also drained if
trismus is present
Signs of airway compromise:
1. Clinical: Dyspnoea,
stridor, inability to
control secretions
2. Radiographic: Deviation
of airway

33. • Masticator space is an anatomical
compartment enclosed by splitting
of the anterior layer of deep cervical
fascia around muscles of
mastication, following those
muscles to their attachments to the
cranium and skull base
( Topazian, Goldberg, Hupp ; Oral &
Maxillofacial Infections, 4th edition)
• Parts:
1. Submasseteric
2. Pterygomandibular
3. Superficial temporal
4. Deep temporal
• Common clinical sign: Trismus

34. • Boundaries:
1. Superior: Dense attachment of
fascia to inferior border of ZM arch
2. Inferior: Pterygomassteric sling
3. Lateral: Masseter
4. Medial: Lateral surface of ramus
5. Anterior: Buccal space
6. Posterior: Parotid gland
• Likely cause: Lower 3rd molars, angle
of mandible fracture
• Contents: Massteric artery and vein
• Communications: Pterygomandibular
( Via sigmoid notch), superficial
temporal, parotid, buccal spaces
• Drainage: Extraorally by
submandibular incision near angle of
mandible avoiding marginal
mandibular nerve

35. Superficial temporal space
• Boundaries:
1. Anterior: Posterior surface of lateral orbital
rim
2. Posterior: Fusion of temporal fascia to cranium
3. Superior: Superficial temporal crest
4. Inferior: ZM arch and submassteric space
5. Lateral: Temporal fascia
6. Medial: Temporalis muscle
• Likely cause: Upper and lower molars
• Contents: Temporal fat, temporal branch of VII nv
• Communications: Deep temporal, buccal spaces
• Drainage:
a. Percutaneously by incision superior and
parallel to ZM arch
b. Intraorally: Sicher’s incision ( Not possible in
trismus)

36. • Boundaries:
1. Anterior: Posterior surface of maxilla,
2. Posterior: Temporalis attachment to crest
3. Superior: Temporal crest
4. Inferior: Superior surface of lateral
pterygoid
5. Lateral: Temporalis muscle
6. Medial: Squamous temporal bone,
sphenoid
• Likely cause: Upper molars
• Contents: Pterygoid plexus, internal maxillary
vessels, mandibular nerve, skull base foramina
• Communications: Superficial temporal,inferior
petrosal sinus, buccal
• Drainage: Intraorally via Sicher’s incision

37. • Boundaries:
1. Anterior: Buccal space
2. Posterior: Parotid gland
3. Superior: Lateral pterygoid, infratemporal
space
4. Inferior: Inferior border of mandible
5. Lateral: Ascending ramus
6. Medial: Medial pterygoid
• Likely cause: Lower 3rd molars, angle of
mandible fracture
• Contents: Inferior alveolar nerve and vessels
• Communications: Deep temporal,
submassteric, lateral pharyngeal, parotid,
buccal spaces
• Drainage: Extraorally by submandibular
incision near angle of mandible avoiding
marginal mandibular nerve

38. • Formed by splitting of the
anterior layer of deep cervical
fascia to form capsule of parotid
gland.
• Parotideomasseteric fascia is
thick laterally and thin medially.
• Content: Parotid gland,
branches of facial nerve,
posterior facial vein
• Clinical features: Very painful
since the overlying fascia is
tenacious.
• Drainage: Preauricular modified
Blair incision

40. • Boundaries:
1. Anterior: Palatal musculature
(sup.),superior and middle constrictor
muscle, stylohyoid (inf.)
2. Posterior: Carotid sheath and scalene
fascia
3. Superior: Skull base
4. Inferior: Hyoid bone
5. Lateral: Medial pterygoid muscle
6. Medial: Pharyngeal constrictor, bucco-
pharyngeal fascia, retropharyngeal
space
• Likely cause: Lower 3rd molars, tonsils,
infections in neighbouring spaces
• Contents: Carotid artery, IJV, vagus nerve,
sympathetic chain
• Communications: Submandibular,
sublingual, peritonsillar, retropharyngeal
spaces

41. Inverted pyramid shaped with apex at hyoid
bone.
Space is divided into 2 compartments :
(by Aponeurosis of Zuckerkandl & Testut)
1. Anterior (prestyloid) - Areolar tissue
2. Posterior (poststyloid) – Cranial nerves IX-
XII, Carotid sheath and its contents
Clinical signs:
• Airway obstruction and dysphagia in severe
cases
• Visible swelling in suprahyoid region
between posterior belly of digastric and
anterior border of SCM
• Intraorally mild trismus, blunted ipsilateral
palatoglossal arch, deviated uvula.
• Imaging : CECT of neck
Church- steeple sign

43. • Therapy consists of antibiotics, surgical
drainage, tracheostomy if indicated.
• Incisions:
1. Oral: Vertical incision on lateral pharyngeal
wall over PTM raphe. Blunt dissection
made lateral to superior constrictor.
2. Extraoral:
• Incision made along anterior border of SCM
extending from below angle of mandible
• Exposure of the carotid sheath near the
lateral tip of hyoid by retracting the SCM
posteriorly.
• Blunt dissection along posterior border of
digastric muscle leads to lateral pharyngeal
space
3. Combined intra and extraoral approach

44. • Boundaries:
1. Anterior: superior and middle
constrictor muscle
2. Posterior: Alar fascia
3. Superior: Skull base
4. Inferior: Fusion of alar with
prevertebral fascia at C6-T4
5. Lateral: Carotid sheath and lateral
pharyngeal space
• Likely cause: Nasal and pharyngeal
infections in children, dental infections,
esophageal trauma/ foreign bodies and
tuberculosis.
• Contents: Retropharyngeal nodes
• Communications: Submandibular,
sublingual, peritonsillar, lateral
pharyngeal spaces

45. • Clinical features:
1. Dysphagia, dyspnoea
2. Fever , nuchal rigidity
3. Oesophageal regurgitation
4. Buldging of posterior pharynx
5. Risk of rupture of pharyngeal wall during intubation
• Radiographs:
1. Lateral soft tissue radiographs: Widening of the space
( Normal width: Adults- 3-6mm, Children- >14mm at C2 level)
2. CT scans: Loss of curvature of cervical spine
• 10-40% infections resolve with medicines
• Drainage:
1. Trans orally - Under local anaesthesia in Trendelenburg position with constant
suctioning. Incision made through posterior wall of pharynx.
2. External approach -
• More dependent drainage, deep drains are placed.
• Incision made along ant. border of SCM and parallel to it, inferior to hyoid bone
• Avoid injuring XII nerve and carotid sheath while blunt dissection
3. Needle aspiration of the abscess under CT guidance

46. • Named due to its communication with
posterior mediastinum
• Relations:
1. Above: Skull base
2. Below: Diaphragm
3. Lateral extent is at fusion of alar and
prevertebral fascia at the transverse
process of cervical and thoracic
vertebrae.
4. Midline structure behind retro-
pharyngeal space.
• According to Pearse et al study on 110
cases of mediastinitis:
a) 71% cases- From danger space
b) 21% cases- From carotid sheath
c) 8% cases- From pretracheal space

47. Complication Notes Symptoms & Signs Diagnosis &
Management
Cavernous sinus
thrombosis
• Often direct spread of
Streptococcus/
Staphylococcus from
paranasal sinuses
• Mortality- 30-40%
Picket fence fever, orbital
pain, proptosis, decreased
ocular motility, sluggish
pupillary reflex, dilated
pupil, loss of consciousness
 MRI with contrast
 ICU care
 Broad spectrum
antibiotics
 Anticoagulation
Mediastinitis  Caused due to
descending infection
via danger space and
carotid sheath
 Mortality- 30-40%
 Diffuse neck edema
 Dyspnea
 Mediastinal widening
 Pleuritic chest pain
 Hypoxia, tachycardia
o CT with contrast
o Broad spectrum
antbiotics
o Transcervical/
transthoracic drainage
Necrotizing fascitis  Often caused due to
odontogenic infection
in immunocomp-
romised patient
 Does not follow fascial
planes
o Rapidly progressive
cellutis
o Pitting edema, painful
o Subcutaneous crepitus
• CT with contrast
demonstrating tissue
gas, necrosis
• ICU care, resuscitation
• Debridements
• Hyperbaric oxygen
• Treatment of
underlying condition
Lemierre
syndrome
• Fusobacterium
necrophorum
• Potentially fatal
 Fever, sore throat
 Trismus
 Lateral neck
tenderness, septic
emboli
 CT with contrast
showing IJV
thrombosis
 Beta lactamase
antibiotics +/- surgery