Space-infection ih

2. Space Infection
Presenter – Dr. Itrat Hussain
Moderator – Dr. Sukumar Singh

3.  History
 Anatomy of fascia
 Host defense and infection
 Microbiology and antibiotic therapy
 Stages of infection
 Definition of fascial spaces
 Classification of fascial spaces
 Anatomy of fascial spaces
 Diagnosis of Space infection
 Complications
 Controversies
 Recent advances
 Conclusion
 Reference

4. Burns (1811) first described fascial space as an
anatomical entity and gave their clinical significance.
In 1836 Wilhelm Frederick von Ludwig described his
observations concerning repeated occurrences of
inflammation of throat. Hence most severe orofacial
Infection at that time was named as Ludwigs angina.
Greek author Parker(1879) gave vivid descriptions of
infections which produced inflammation oral cavity,
tonsil and larynx.

5. The term “ Quinsy “ was given by Muckleston in
1928.
In 1929 Mosher called Viscerovascular space as
“Lincoln highway”
Space of the body of mandible is described
by Coller & Iglesias. (1935)

8.  Acts as a musculovenous pump-
 Limits outward expansion of muscles as they
contract.
 Contraction of muscles compresses the
intramuscular veins (push the blood towards the
heart).
 Determine the direction of spread of infection

9.  In establishing presence of an infection, interaction
occurs among three factors.
1. Host
2. Environment
3. Microorganism
In state of Homeostasis , balance exists among
these three and disease occurs when imbalance
exists.

10. Characteristic Inoculation Cellulitis Abscess
Duration 0–3 days 3–7 days Over 5 days
Pain Mild–moderate Severe and Moderate–severe
generalized and localized
Size Small Large Small
Localization Diffuse Diffuse Circumscribed
Palpation Soft, doughy Hard, Fluctuant, tender
mildly tender exquisitely tender
Appearance Normal coloration Reddened Peripherally
reddened
Skin quality Normal Thickened Centrally undermined
and
shiny
Surface Slightly heated Hot Moderately heated
temperature
Loss of function Minimal or none Severe Moderately severe
Tissue fluid Edema Serosanguineous, Pus
flecks of pus
Level of malaise Mild Severe Moderate–severe
Degree of seriousness Mild Severe Moderate–severe
Predominant bacteria Aerobic Mixed Anaerobic
Stages of Infection

11. Pathways of Dental Infection

12. Aerobic bacteria (25%)
Gram positive cocci (85%)–
Streptococcus species( 90% ) -
 S.Milleri
 S.sanguis
 S.Salivarius
 S.Mutans
Staphylococcus species (6 %)
Anaerobic bacteria (75%)
Gram positive cocci (30%)–
Peptococcus species 33%
Pepto Streptococcus species 33%
Gram pasitive bacilli (50%) –
Prevotella species, Porphyromonas species (75%)
Fusobacterium -20%
Ref – Micro-organisms and Odontogenic infections 2009
ADJ

13. Staphylococcus causes –osteomyelitis and
abscess
Streptococcus causes- cellulitis
 In an abscess, common causative organisms are
anaerobic (Higher percentage) & Aerobic.
 Fusobacterium + strep. Milleri – cause
aggressive infections.
Eg.,.mediastinum.infections.

14. Definition -
The fascial spaces in head and neck are the
potential spaces between the various layers of
fascia, normally filled with loose connective
tissue and bounded by anatomical barriers,
usually of bone, muscle or fascial layers.
(Ref – Moore-1975)

15. GRODINSKY AND HOLYOKE (1938)
Space 1 – Superficial to superficial fascia
Space 2 – Group of spaces surrounding cervical strap muscles
lying superficial to sternothyroid-thyrohyoid division
of middle layer of deep cervical fascia.
Space 3 – Space lying superficial to visceral division of middle
layer of deep cervical fascia
Space 3A – Carotid sheath space or viscerovascular space
(Lincoln’s High way)
Space 4 – Space lies between alar & prevertebral division of
posterior layer of deep cervical fascia (Danger space)
Space 4A – Posterior triangle space posterior to carotid sheath
Space 5 - Prevertebral space
Space 5A- Space enclosed by Prevertibral fascia, posterior to
transverse processes of vetebrae and surround scalene and spinal
postural muscles.

17.  Hollinshead’s classification(1958)
Infrahyoid spaces -
1.Visceral compartment
A) Pretracheal / previsceral
B) Retrovisceral
2. Visceral space
3. Other space
I. Cavity within carotid sheath
II. Space between 2 layers of prevertebral
fascia

18. 1. Direct Involvement. (Primary Spaces)
 Maxillary Spaces – Canine, buccal
infratemporal
 Mandibular Spaces – Submental,
Submandibular, Sublingual, Buccal
2. Indirect involvement (Secondary Spaces)
 Masseteric
 Pterygomandibular
 Superficial and deep temporal
 Lateral and retro pharyngeal
 Prevertebral, parotid, carotid
sheath,peritonsillar and danger spaces.

20. The buccal space occupies the portion of subcutaneous
space between the fascial skin and buccinator muscle.

21. Infection from maxillary premolars, molars and
mandibular premolars
Relation of root with buccinator muscle

22. Clinical features:
Dome shaped swelling on the
anterior aspect of cheek
extending anteroposteriorly
from corner of mouth to angle of
mandible and superoinferiorly
from level of zygomatic arch to
inferior border of mandible.

23.  CONTENTS OF BUCCAL SPACE:-
 Buccal pad of fat
 Stensons (Parotid duct)
 Anterior and transverse facial artery and vein.
MUSCLE RELATED – Buccinator muscle
Neighboring spaces-
Infraorbital, pterygomandibular, infratemporal space

24.  Antibiotic prophylaxis.
 Intra oral horizontal
vestibular incision.
 Extra oral (2 stab) incisions
below the lower border of
the mandible with No. 11
blade.
 Drainage – Hemostat is
passed from anterior incision
and taken out from the
posterior incision then the
rubber drain is inserted and
secured with pins/suture
and dressing is done.

26.  Maxillary canine, rarely from maxillary first
premolar.
 Rarely from nasal & upper lip infections.

27.  Clinical features:
 Swelling lateral to the
nose over cheek.
 Obliteration of the
nasolabial fold,
 Swelling of the upper
lip
 Oedema occurs in lower
eyelid leading to closure
of eye.

28.  Contents – Angular artery and vein,
Infraorbital nerve
 Neighboring spaces – Buccal space
TREATMENT -
 Antibiotic prophylaxis
 Incision is made intraorally high in the maxillary
labial vestibule.
 Small hemostat is inserted through levator anguli
oris into abcess cavity.
 Drainage with drain secured.

30.  Infection from Mandibular molars.
 From sublingual space
 Infections from middle third of the tongue,
posterior part of floor of the mouth.
 From submental space / submental lymph
nodes
 Infection from the submandibular gland

31. Clinical Evaluation:
Swelling begins at lower
border of mandible
extends to the level of
hyoid bone in a shape of
inverted cone.
No trismus.

32. Contents -
 Superficial lobe of submandibular salivary gland
& submandibular lymph nodes, facial artery &
vein
Neighboring spaces –
Submental, sublingual, lateral pharyngeal, buccal
and submandibular space of other side.

33.  I & D through Extra-oral
incision.
 Incision – 2 stab incisions
are given over the
dependent part below
the lower border of
mandible in the neck
(shadow) of the mandible
 Curved hemostat is
inserted & Blunt
dissection through
subcutaneous fat not to
damage facial A, anterior
facial vein and the facial
nerve
 Drainage – Drain is
placed & dressing is
given
TREATMENT

34. CAUSE - Mandibular premolars and molars, trauma

35. Clinical evaluation:
•Swelling in anterior part
of floor of the mouth on
the affected side displacing
tongue medially and
superiorly.
•Interferes with
swallowing and is
extremely painful.
•Elevation of tongue to
palate causes airway
compromise.

36.  CONTENTS:-
 Sublingual artery and vein
 Lingual nerve.
 Deep part of submandibular salivary gland and
its duct anteriorly.
 Sublingual salivary gland
Neighboring spaces –
Submandibular, Lateral pharyngeal, visceral(trachea,
esophagus)

37. TREATMENT:-
 Antibiotic prophylaxis
 Incision is made intraorally over lingual sulcus at the
base of the alveolar process.
 Haemostat is passed beneath sublingual gland and
anteroposterior dissection is done and drain is placed.
 When infection crosses midline, same incision is made
bilaterally, hemostat is passed through floor of mouth
from one side to other & drain is placed

39. ETIOLOGY:-
 From lower anterior teeth.
 Secondarily due to infection from submental
lymph nodes which drain lower lip, skin
overlying chin, anterior part of floor of the
mouth, tip of the tongue & sublingual tissues.
 Symphysis fracture.

40. Clinical evaluation:
Swelling is limited to
the point of the chin &
to the region
immediately below it

41.  MUSCLE RELATED – mentalis muscle
 CONTENTS – submental lymph nodes and anterior
jugular vein.

42.  TREATMENT:-
Extraoral Incisions are made bilaterally
(two stab incisions) through skin,
subcutaneous tissue and platysma
muscle at most inferior aspect of
swelling.
Drain & dressings are placed.

43. The original description of the disease was given
by Wilhelm Friedrich von Ludwig.
1. Rapidly spreading gangrenous cellulitis.
2. Originates in the region of submandibular
gland but never involves one single space.
3. Arises from extension by continuity and
not by lymphatics.
4. Produces gangrene with serosanguinous,
putrid infiltration but very little or no
frank pus.

44. Ludwig’s angina is acute,
aggressive and rapidly
spreading cellulitis of the
submandibular and
sublingual spaces bilaterally
and of the submental space.
Clinical evaluation:
-Bilateral swelling below chin
extending inferiorly to the
level of hyoid bone.
- Fever, chills.
- Airway compromise occur
quickly and with little fore
warning.

45. - Drooling, dysphagia and neck stiffness are
common.
- Anteriorly protruding tongue is present
- Trismus is usually absent.

46.  Hospitalization.
 Securing the airway.
 Antibiotics & hydration.
 External surgical exploration with bilateral
through and through drainage of the
submandibular spaces with simultaneous
exploration of the submental and sublingual
spaces.
 Medical supportive therapy
 Review and re-evaluation in the post op period

47. Incision for surgical drainage of Ludwig’s
Angina
Classic method – Not used nowadays Bilateral through and through
drainage of spaces
- Ref – Laskin Vol. 2 pg no. 249

48. There are 5 masticatory spaces .
1. Superficial temporal space
2. Infratemporal space
3. Deep temporal space
4. Submassetric space
5. Pterygomandibular space

49. Boundaries –
 Superiorly & Laterally  Temporal fascia
 Inferiorly – Zygomatic arch
 Medially Lateral surface Temporalis muscle
 CAUSE-
 Infection from maxillary and mandibular
molars

50. Clinical evaluation:
•swelling above &
below the zygomatic
arch causing a dumbell
shaped appearance
• Severe pain & trismus

51.  Contents- Temporal fat pad, temporal
branch of the facial nerve.
 Neighboring spaces – Buccal , Deep
temporal.

52. Intraorally vertical incision made medial to the
upper extent of the anterior border of the
mandibular ramus.
 Haemostat  passed superiorily along the
lateral aspect of the coronoid process to enter
superficial temp. space
 Extra-oral incision  horizontal incision
 Haemostat is passed medially to enter
superficial temporal space.
 Drainage  drain is placed, dressing is given.

53. Intraorally vertical incision made medial to the upper extent of the
anterior border of the mandibular ramus for drainage of temporal space.

54. Boundaries -
 Laterally  medial surface of temporalis m.
 Medially  Temporal bone
 Below the level of zygomatic arch both the
spaces communicate with each other and with
the infratemporal space.
Cause -
 Infection from maxillary molars

55. Mild swelling over temporal
region.
Difficult to diagnose.
 Contents – Pterygoid plexus,
Internal maxillary artery and
vein.
 Neighboring Spaces –
Buccal space, superficial
temporal, inferior petrosal sinus

56.  Intraorally vertical incision made medial to the
upper extent of the anterior border of the
mandibular ramus.
 Haemostat  passed supero-medially to enter
deep temporal space.
 Through blunt dissection deep temporal space
is approached through temporalis muscle
 Drainage  drain is placed, dressing is given.

57. Boundaries –
 Anteriorly, -Infratemporal surface of the maxilla
 Posteriorly,- the articular tubercle of the temporal
bone, mandibular condyle
 Superiorly, - Greater wing of the sphenoid below
the infratemporal crest
 Inferiorly, - Medial pterygoid muscle
 Medially - lateral pterygoid plate
 Laterally, - Ramus of mandible

58.  Clinical features :
 Marked Trismus
 Swelling of face in front of ear, over TMJ &
zygomatic arch
 Eye is closed and proptosed

59.  Contents – Pterygoid plexus, Internal
maxillary artery and vein, Mandibular nerve
 Neighboring Spaces – Buccal, superficial
temporal.
Cause -
 Infection from maxillary molars

60.  Intraoral and extraoral approach
 Intraorally, incision is made into
mucobuccal fold lateral to maxillary third
molar. (Kruger)
 Curved hemostat is inserted behind max.
tuberosity superomedially within the cavity
and drain is inserted.
 Intraorally vertical incision made medial to
the upper extent of the anterior border of the
mandibular ramus.(Laskin)
 Curved hemostat is passed superiorly into
infratemporal region and drain is inserted.

61.  Extraoral approach in presence of severe
trismus.
 It consists of horizontal incision above the
zygomatic arch and then curved hemostat is
directed in inferior and medial direction to
enter infratemporal space followed by
insertion of drain.

62.  BOUNDARIES:
Anteriorily Buccal space
Posteriorily  parotid fascia and retromandibular
portion of the parotid gland
Laterally  masseter muscle
Medially  lateral surface of the mandibular ramus
Superiorily  zygomatic arch
Inferiorly – Inferior border of mandible
ETIOLOGY:-
 Periocoronal infection, periapical infection with
mandibular third molars (linguoversion with root
buccally placed)
- Fracture of angle of mandible

63.  Swelling over the angle of mandile
from the level of the zygomatic arch to
inferior border of mandible ,
anteriorily to anterior border of
masseter and posteriorly to posterior
border of mandible.
 Deep seated severe throbbing pain
 Trismus
 Tenderness over the mandibular
ramus,.

64. CONTENTS -
 Masseteric artery and vein
Neighboring spaces-
 Buccal, pterygomandibular, superficial
temporal, parotid space

65.  Incision  Intra oral approach - vertical incision along
the external oblique line of the mandible starting at the
level of the occlusal plane and extending downward and
forward in buccal sulcus opposite 2nd molar.
Haemostat is passed along lateral aspect of ramus
beneath masseter muscle to enter submasseteric space.
drainage is done.
 Incision  Extra oral incision - beneath angle of
mandible.
 Blunt dissection through masseter muscle fibres.
 Drainage with plastic or rubber catheter to withstand muscle
contraction.

67.  CLINICAL FEATURES:
 Trismus, Dysphagia, Dyspnoea
 No external evidence of swelling
 Anterior bulging of half the soft palate and the anterior
tonsillar pillar with deviation of uvula to the
unaffected side.
 ETIOLOGY
Infection from impacted mandibular molars, from
contaminated needle during I.A.N.B

68.  CONTENTS:
 Mandibular division of trigeminal nerve
 Inferior alveolar artery and vein
 Neighboring spaces -
 Deep temporal spaces
 Lateral pharyngeal space
 Buccal space
 Submasseteric space
 Parotid space

69.  If trismus is severe.
-Extraoral mandibular nerve block or G.A. is given
 Incision  intra oral incision in the mucosal area
between medial aspect of ramus and the
pterygomandibular raphae.
 Blunt dissection using hemostat.
 Drainage.
 Extra oral incision is made below the angle of
mandible.

70.  It lies immediately posterior and lateral to the
pharynx
 Anatomically the lateral pharyngeal space
may be thought of as an inverted pyramid
shape-the base of the pyramid being the skull
base and the apex the hyoid bone.

71.  BOUNDARIES:-
 Superiorly  Base of skull
 Inferiorly  Hyoid bone
 Medially  superior pharyngeal
constrictor
 Laterally  medial pterygoid m.,
capsule of parotid gland
 Posteriorly  carotid sheath
,styohyoid, styloglossus, &
stylopharyngeus.
This is a cone – shaped space

72.  ETIOLOGY:-
Spread from
 Sublingual spaces
 Submandibular spaces
 Pterygomandibular spaces
 Lateral spread from tonsillar abscess, pharyngitis,
parotitis, otitis, mastoiditis
 Abcess from the region of 38,48
 Surgical displacement of roots of 38,48 into this
space

73.  CONTENTS:
 Anterior compartment:
 Ascending pharyngeal A.
 Loose areolar connective tissue.
 Posterior compartments:-
 Cervical sympathetic trunk
 Carotid sheath with its contents
 CN IX, X , XI, XII
Neighboring spaces -
Pterygomandibular, submandibular, sublingual,
peritonsillar, retropharyngeal space.

74.  Firm swelling with
surrounding erythema
lateral and anterior to
sternocleidomastoid
muscle.
 Difficulty in flexing and
turning of neck.
 Trismus secondary
pterygoid muscle
involvement.
 Dysphagia.
 Dyspnoea.
Clinical evaluation

75.  Management -
 Hospitalization with i.v antibiotics.
 Airway protection.
 Rapid surgical drainage.
 Surgical approach always through neck or
through oral cavity.
 Incision is made at the level of hyoid bone across
the sternocleidomastoid muscle.
 Complications -
 Suppurative jugular venous thrombosis.
 Patient will have chills, high fever.
 Tenderness at the mandibular angle and along
sternocleidomastoid muscle.

77. Clinical evaluation:
 Pharyngitis .
 Severe sore throat,
dysphagia, and referred
otalgia.
 The speech is muffled and
classically described as hot
potato voice.
 Trismus is not present
 According to recent
literature,needle aspiration
is done instead of incision
and drainage .(JOMS,Vol
51,2009)

78. BOUNDARIES:-
 superiorly zygomatic arch
 Inferiorly lower border of mandible
 Anteriorly  posterior border of the mandible
 Posteriorly  Retromandibular region
 Space formed by splitting of the superficial layer surrounding the
parotid gland and lies posterior to the masticator space.
 CONTENTS:
 Parotid gland
 Parotid lymph nodes
 Facial n.
 Retromandibular vein
 External carotid artery

79. ETIOLOGY:
From extension of infection from
submasseteric,
pterygomandibular, lateral
pharyngeal spaces,
Blood-borne infection,
Retrograde infections through
the stensons duct

80. .
Clinical evaluation:
The symptoms of parotitis
include pain and induration
over the involved gland.
Purulent marked swelling of
the angle of the jaw without
associated trismus or
pharyngeal swelling.
Secretions may sometimes be
expressed after massage from
the parotid depth.
Very characteristic pitting
edema of the gland is
pathognomonic for parotid
gland abscess.

82.  All involve only posterior side of neck.
a) Retropharyngeal space
b) Danger space
c) Prevertebral space
d) Visceral vascular space (within the carotid
sheath)

83. Retropharyngeal space
Retropharyngeal space is the potential space
sandwiched between retropharyngeal facia and the alar
facia.
Extension Base of the skull
Mediastinum
Two compartments:
Suprahyoid
1. Lymph nodes and fat.
Infrahyoid
1. Only fat
Sagittal section of retropharyngeal
space
Most dangerous of all types of
deep neck infections (Danger
space)

84.  Children less than 4 yrs commonly affected.
 Sore throat, dysphagia,
 Hot potato voice.
Early Clinical features
•Refusal to take food.
•Cervical
lymphadenopathy.
•Slight neck rigidity.
•Noisy breathing due to
laryngeal edema.
Late Clinical features -
•Neck tilts towards
involved side.
•Hyperextended complete
inability to flex the neck.
•Respiratory
embarrassment may occur
if abscess is not ruptured or
drained.

85. Step I:
 Look at the prevertebral or
retropharyngeal soft tissue
shadow.
 In the area of 2nd and 3rd CV,
shadow should be less than
7mm in width.
 In the area of 6 cervical vertebra
soft tissue shadow is behind the
trachea and includes the
thickness of esophagus making
it approx.
Children – 14mm wide
adults – 22mm wide

86. Step II
 Second feature that should
be looked for in radiograph is
the presence of gas
 Anaerobic bacteria will
produce gas that can be seen
as emphysema in soft tissue
of neck

87. Step III.
- Finally, the lateral radiograph will show the curve of the cervical
spine
- Loss of the curve is a strong indication of retropharyngeal space
infection.
- Tipping of the head forward in sniffing position to maintain an
open airway.

89.  Is formed by the deep cervical fascia.
 It extends from skull base to coccyx
 Facia attaches to the transverse process of the cervical
vertebra dividing this space into anterior and posterior
compartments.
Anterior compartment contains:
-Vertebral bodies.
-Spinal cord.
-Vertebral arteries.
-Phrenic nerve.
-Prevertebral and scalene muscles
Posterior compartment
contains:
-Posterior vertebral elements.
-Paraspinous muscles.

90. Plain film. CT MRI Ultrasound

91.  Diagnostic imaging starts with a plain film
study of pharyngeal or cervical airways.
 Views taken
 AP view
 Lateral view
 Plain film findings:
- In the AP view the normal cervical airway
should appear symmetrical over the middle
third of the cervical spine.
- Lateral view – In the adult the width of the
prevertebral soft tissue should not exceed
7mm at the C3 level and 20mm at C7 level.
AP view
Lateral view

92. A –Thickening of retropharyngeal soft tissues.
B- Thickning of nasopharyngeal and prevertibral soft tissues.

93.  Osteomyelitis
 Mediastenitis
 Brain abcess
 Meningitis
 Cavernous sinus thrombosis
 Scar formation
 Sinus tract formation

95.  Dyspnoea
 Dysphagia
 Paleness
 Tachypnoea
 Tachycardia
 Fever
 Lethargy
 level of consciousness
 Evidence of meningeal
irritation
(severe headache)
 Eyelid edema & abnormal
eye signs
CNS symptoms
Who should be hospitalized ???

96.  Does the Investing Layer of the Deep Cervical Fascia
Exist?
- Nash, Lance M.Sc November 2005
Journal of American society of anesthesiologists
The placement of the superficial cervical plexus block
has been the subject of controversy. Although the
investing cervical fascia has been considered as an
impenetrable barrier, clinically, authors went on a trial
and found that the placement of the block deep or
superficial to the fascia provides the same effective
anaesthesia.

97.  Conclusion of study:
This study provides anatomical evidence to indicate
that the so-called investing cervical fascia does not
exist in the anterior triangle of the neck. Here the
author’s findings strongly suggest that deep
potential spaces in the neck are directly continuous
with the subcutaneous tissue.

98.  Surgical vs ultrasound-guided drainage of deep neck
space abscesses: a randomized controlled trial: surgical
vs ultrasound drainage
-Vincent L Biron, George Kurien
Journal of Otolaryngology - Head and Neck Surgery 2013,
 Introduction -
Deep neck space abscesses are relatively common head
and neck surgery emergencies and can result in
significant morbidity . Traditionally, surgical incision
and drainage (I&D) with antibiotics has been the
mainstay of treatment. Some reports have suggested
that ultrasound-guided drainage is a less invasive and
effective alternative in selected cases.

99. Results
 Seventeen patients were recruited .They found a
significant difference in mean Length of hospital
stay between patients who underwent USD
(3 days) vs I&D (5 days).They identified significant
cost savings (41%) in comparison to I&D.
 Conclusions
Ultrasound drainage of deep neck space abscesses
in a certain cases is effective, cost saving & safe as
it is less invasive. Still this remains a controversial
topic whether to follow Incision and drainage or
ultrasound drainage.

100. Effective antibiotics for severe infections caused
by resistant bacteria are needed urgently. The
speed with which bacteria develop resistance to
antibiotics, in contrast with the slow development
of new drugs, has led some experts to develop
newer antibiotics.

101. Compound name
(Brand name )
Targeted
Microorganisms
Quinupristin/ dalfopristin (1999)
(Synercid)
methicillin-susceptible S. aureus and
Streptococcus pyogenes
Moxifloxacin (1999 )
(Avelox)
G+ and G-, including multi-drug
resistant Streptococcus pneumoniae
Linezolid (2000)
(Zyvox)
G+; including MRSA
Cefditoren pivoxil (2001)
(Spectracef)
methicillin-susceptible S. aureus and
Streptococcus pyogenes
Daptomycin (2003 )
(Cubicin)
G+, including MRSA
Tigecycline (2005 )
( Tigacil)
G+ and G-
Dalbavancin (2004 ) G+ (including MRSA)

102. Compound name
(Brand name )
Targeted Microorganisms
Faropenem (2005)
(medoxomil )
G+ and G-
Telavancin (2007) G+ (including MRSA)
Ceftobiprole (2007) G+ and G-
Oritavancin (2011) G+ (including MRSA)
Iclaprim (2012) G+ (including MRSA)

103. We being Oral & maxillofacial surgeons must
understand anatomy of fascial spaces, spread of
infection and proper management for the
prevention of further complications and betterment
of health of the patient.

104. Books -
 Oral &maxillofacial Infections-Topazian
 Oral & Maxillofacial Surgery-Laskin Vol. II
Articles –
1. Does the Investing Layer of the Deep Cervical Fascia Exist?
- Nash, Lance M.Sc November 2005 Journal of American
society of anesthetist
2. Surgical vs ultrasound-guided drainage of deep neck
space abscesses: a randomized controlled trial: surgical
vs ultrasound drainage
-Vincent L Biron, George Kurien Journal of Otolaryngology - Head
and Neck Surgery 2013,