This presentation depicts the space infection occuring in dental practice, their symptoms and management.

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SPACE INFECTION
Presentedby :
Dr. Mayank Nahta
Rungta college of dental sciences and
research, Bhilai

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Lateral Pharyngeal Space
 It’s potential cone shaped or cleft with its base uppermost at base of skull and apex at the greater horn of hyoid
bone.
The space is divided into by styloid process , as anterior and posterior
Involvement:-
 It may be infected from absecss extending from mandibular third molar area .
Infection can also spread from backwards from sub-lingual , sub-mandibular, & pterygomandibular space infection.
 lateral spred from the tonsillar abscess.
The boundary wall of space do not permit easy communicaion with adajcent space.
Infection passes most easliy b/w lateral pharyngeal space, sub-mandibular space by tracking along the stloglossus
muscle.

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Boundaries-
 inferiorly: hyoidbone,( sub-mandibulargland& posteriorbellyof digastric)
 Shapeof aninvertedconeor pyramid,thebaseis at sphenoidboneandthe apexat hyoidbone.
 Anteriorly: boundedby pterygomandibularraphe.
 Posteriorly: boundedby styloidmuscle,andupperpartof carotidsheath,preveertebralfasciawithjugular
vein.
 Laterally: ascendingramusof mandible, insertionof medialpterygoidmuscleandmedialsurfaceof deep
lobeof parotidgland.
 Medially: boundedby pharyngealwall( palatalmuscleat levelof nasopharnyxandpharyngeal
constrictor(superiorandmiddle)& stylopharyngeus;coveredby buccopharyngealfascia
.

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Styloid process divides the space into anterior and posterior compartment
Contents-
 Anteriorcompartment: fat, muscle, lymph nodes and connective tissue.
 Posteriorcompartment:carotid sheath(carotid artery, internal jugular vein,vagus nerve), cranial nerves
IX through XII.
Etiology-
 Infected mandibular 3rd molars.
 Tonsillar infections.
 Pharyngitis.
 Parotitis.
Spreadof Infection-
 To retropharyngeal space.
 To peritonsillar space.

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ClinicalFeatures-
• Its grave because of generalized septicaemia & respiratory embarrsassment due to oedema of larynx.
•General constitutional symptoms in form of malaise and pyrexia are present
Anteriorcompartment:
a) extraoral:-
• induration of face above angle of mandible
• it may extend downward to sub-mandibular region as well as upward to parotid region.
b) Intraoral:-
• Anterior part of lateral pharyngeal wall may be swollen that pushes soft palate and palatine tonsil
towards midline.
• Trismus may be present.

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• Severe pain arising from collection of pus
• Dysphagia is present
Posteriorcompartment:
• its clinical feature is dominated by septicaemia.
• Usually little or no trismus
•Slight pain is present.
• Posterior tonsillar pillar deviation.
•Neurological involvement.
• Thrombosis of internal jugular vein.
• Erosion of carotid vessels may occur.

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Treatment :-
•There are multiple approach to lateral pharyngeal space that is intra& extra oral.
Intra oral incision can be either transpharyngeal or lateral.
•the transpharyngeal approach is made through tonsillar fossa but this approach is not recommended since
adequate drainage Is difficult.
Intraoralapproachis moreeasilyperformedin making.
• An incision b/w ramus and medial pterygoid.
• dissecting bluntly with haemostat medial and posterior to medial and posterior to medial pterygoid muscle into
pharyngeal space.
Allper-oral incision are contraindicatedwhentherehas beenpriorhaemorrhage no matterhowminimal.
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Extraoralsubmandibularincisionis safest approach and shouldbe used:-
• An incision is made anterior and inferior to angle of mandible.
• Blunt dissection is carried out with haemostat superficially and medially along medial pterygoid muscle into
pharyngeal space.
In the combinedapproach :-
•The lateral mucosal incision is made and a large curved haemostat is passes lateral to superior constrictor and
medial to medial pterygoid muscle.
•A blunt dissection is carries out posterioinferiorly below the angle of mandible.
•The tip of instrument is palpalted extraorally anterior to sternocleidomastoid and a cutaneous incision is made over
the tip.
•This technique offers direct access into lateral pharyngeal space and aids in correct placement of incision in swollen
face.
•A drain is inserted & sutured to wound margin to allow drinage.

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Retropharyngeal Space
It’s a potential midline space b/w pharyngobasilar fascia, which attaches pharyngeal constrictor to
base of skull and pre-vertebral fascia.
Involvement:-
Its involvement by extension of infection from lateral pharyngeal space.
Boundaries-
 Anterior: posterior pharyngeal wall.
 Posterior: prevertebral fascia.
 Superior: skull base.
 Inferior: mediastinum.
 Laterally: lateral pharyngeal space.
 Medially: common space no wall

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ClinicalFeatures-
•it include pain,fever, stiffness of neck, dyspnoea, drooling and dysphagia.
•Bulging of posterior pharyngeal wall is often more prominent on one side because of adherence of
median raphe of prevertebral fascia but this is difficult to approach
•Retropharyngeal space abscess should be considered the most dangerous space deep.
•neck space abscess because complication include supraglottic oedema with air way obstruction,
aspiration,pneumonia due to rupture of abscess and acute mediastinitis.
•It represent main avenue for spread of infection into mediastinum.
.

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Likelysourceof infection:-
•Suppurative adenitis.
•Dental infection diffusing through contiguous space
•Nasal and pharyngeal space infection
Complications-
 Airway obstruction.
 Aspiration pneumonia.
 Acute mediastinitis.
 Can spread to Danger space

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Treatment :-
in most cases it result from an extension of lateral pharyngeal space infection there fore will not drained
independently
In condition where independently drainage is necessary .
intraoralapproachis made:-
•A vertical incision is made on pharyngeal wall lateral to midline.
•Using a blunt dissection while the patent is trendelenblurg position to avoid aspiration of pus.
In case of concernabout rupture of abscess extraoralincisionis used.
•An incision is made along anterior border of strenocleidomastoid inferior to hyoid bone and muscle and carotid
sheath retracted laterally.
•Dissection b/w carotid sheath and inferior constrictor helps in drainage of retropharyngeal space.

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Masticatory Space
It comprise of following space:-
a) Pterygomandibular space.
b) Submasseteric space.
c) Temporal or sub temporal space.
 All the space are well differentiated & communicate with other fascial spaces such as;- buccal, sub-mandibular and
parapharyngeal spaces.
 Infection from one compartement can spread to any of thr other compartment.
its divided into two by ramus of mandible:-
I. Lateral compartment
II. Medial compartment.
 Masticatory space formed by splitting of investing fascia into superficial and deep lavers; which defines lateral and
medial extent of space.
 The superficial layer lies along the lateral surfacce of masseter and lower half of temporalis muscle.

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Superiorly, the superficial layer fuses with periosteum of zygoma and temporalis fascia.
 The deep layer passes along the medial surface of pterygoid muscle before attaching to base of skull superiorly
The masticatory space borders the number of other space which include:
i. Parotid space posteriorly
ii. Parapharyngeal space medially
iii. Sub-mandibular and sub-lingual space inferiorly

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Sub- masseteric space
It consist of three layers which are fused anteriorly but can be separated posteriorly.
There is potential space in substance of the muscle b/w middle and deep heads, while the bony insertion is firm above
and below, the intermediate fibers have only loose attachment.
Its possible for these fiber to be separated from bony relatively easily by accumulation of pus.
Whenthe pusaccumulatesbetweentheramusof mandible and masstericspace it producessub-massetericspace.
Boundaries;-
Anteriorly – Anterior borderof masseter muscle and buccinator
Posteriorly – Partoid gland and posterior part of masseter
Superiorly– Zygomaticarch
Inferiorly – Attachment of masseter to lowerborderof mandible
Medially– Lateralsurface of ramus of mandible
Laterally– Medialsurface of masseter muscle

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Involvement: -
 Infection usually orginates from third molar either resulting from:-
i. Pericoronitis related to vertical and distoangular third molar
ii. If a periapical abscess spreads subperiosteally in distal direction
 The presence of buccinator attachment probably discourage backward extension of pericornal infection, where
third molar crown is anterior to this muscle barrier.
 The extension of abscess inferiorly is limited by firm attachment of masster to lower border of ramus of mandbile
.
 The forward spread beyond the anterior border of ramus is restricted by anterior tail of tendon of temporalis ,
which is inserted into anterior border of the ramus.

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Clinicalfeature: -
 External swelling is moderate confined to outline of masseter muscle that is the swelling is seen extending from the
lower border of mandible to zygomatic arch.
Anteriorly to anterior border of masseter and posteriorly to posterior border of mandible.
There is tenderness over the angle of mandible.
 Limited mouth opening.
Fluctutaion may be absent if it’s present cannot be elicited because the muscle lies between the pus and the surface.
There is pyrexia and malasie.

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Treatment : -
Intraoralapproach:-
An incision is made vertically over lower part of anterior border of ramus of mandible deep into bone.
 A sinus forcep are passed along the lateral surfacce of the ramus downwards and backwards and the pus is
drained.
The drain is inserted and sutured
The abscess is usually situated below the level of incision, and not at the point of dependent drainage and hence the
drainage is inefficient.
Extraoralapproach:-
When the mouth cannot be opened.
An incision is placed in skin behind the angle of mandible to open the abscess by hilton’s method
A rubber drain is inserted and secured in position with suture.

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