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Mandibular space infecton


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BDS Seminar

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Mandibular space infecton

  2. 2. 2 INTRODUCTION various anatomic studies established the modern understanding of the fascial layers and the potential anatomical spaces through which infection can spread in the head and neck. Tissue spaces, or fascial spaces are potential spaces situated between planes of fascia that form natural pathways along which infection may become localized with actual abscess formation. Shapiro defined “ the fascial space as potential tissue space, since none are actually spaces until pus has been formed.” These potential spaces are compartments that contain structures such as salivary glands, fat or lymph nodes. Normally, these structures are surrounded by loose connective tissues, which can be easily stripped back by finger pressure, either during surgery in the patient, or by dissection in the cadaver to produce a cavity. Odontogenic infections are the most common of all infections of the head and neck. These infections range from periapical abscess to superficial & deep neck infections. The infections generally spread by following the path of least resistance through connective tissue and along fascial planes. In 1930 grodinsky & holyoke hypothesized that “the infections spread primarily by hydrostatic pressure.”These hypothesis do explain the usual progress of abscess forming infections in this region. The flow of infected fluids guided by the resistance of certain tissue such as fasciae, muscle and bone. The attachment of muscles may determine the route that an infection will take, channeling the infection into certain tissue spaces. The distribution and the interrelations of the many potential tissue spaces in the facial and cervical regions must be appreciated to understand the ease with which infection may spread throughout this area and even into distant areas. However current theory explains the mechanisms by which suppurative infections of the head & neck can dissect from one anatomical space to another. Although most of these infections can be managed successfully with minimal complications, with the use of antibiotics. General factor including the spread of infection A) patient resistance B) bacterial quality and virulence C) diabetic patient, rapid bacterial multiplication and spread of infection. d) patient resistance depends on both humoral & cellular factors.
  3. 3. 3 humoral cellular factors include polymorphonuclear immunoglobulins derived from leukocytes, monocytes sensitized b-lymphocytes or lymphocytes and tissue plasma cells. macrophages Local factors influencing the spread of infection 1. The alveolar bone represents the first locally limiting barrier to the spread of periapical infection. 2. Further progress in infection extends through cortical plates. 3. The next local barrier is the periosteum. 4. Development of a subperiosteal abscess. 5. The next possible site of localization is the anatomic arrangement of the adjacent muscles & fascia. alveolar bone periosteum development of subperiosteal abscess muscles & fascia Spaces communicate with each other
  4. 4. 4 DEFINITION Infections spread through natural pathways into potential tissue spaces situated between different planes of fascia. Infections into the various tissue spaces are known as the space infections, such infections in the mandibular jaw region through natural pathways into potential mandibular tissue spaces are called mandibular space infection.” The infection in orofacial region doesnot spread haphazardly through the loose connective tissue, but tends to accumulates in these potential spaces around the head and neck. Once the odontogenic infections reach the bone or mucosa or lymphnodes etc, they may either resolve spontaneously or spread to the local or the distant sites. Various factors determing the spread of oral infections to distant sites, i.e virulence of the microorganisms, immunity of the host, anatomical site of the initial infection. The infection from the tooth spreads to various fascial spaces adjacent to the jaw. Commonly the infections from the mandibular molars spread to sublingual or submandibular space. While as the infection to the buccal, submassetric spaces, pterygomadibular space or the lateral pharyngeal space are from the mandibular anteriors either produce the gingival abscess or a submental space abscess.
  5. 5. 5 FASCIA OF THE HEAD AND NECK A. Superficial fascia B. Deep cervical fascia i) superficial fascia ii) deep cervical fascia a) Anterior layer i) Investing fascia cover the neck ii) Parotideomassetric iii) Temporal b) Middle layer i) Sternhyoid-omohyoid division ii) Sternthyroid-thyrohyoid division a. Buccopharyngeal b. Pretracheal c. Retropharyngeal c) Posterior layer i) Alar division ii) Prevertebral division
  6. 6. 6 PATHOPHYSIOLOGY OF INFECTION: THE INFLAMMATORY RESPONSE Hyperemia caused by vasodilation of arteries & capillaries & increased permeability of vesicles Passage of exudates rich in plasma proteins, antibodies & nutrients, & the escape of leucocytes into surrounding tissues Release of a permeability factors, leukotoxin which allows migration of polymorph nuclear leukocytes precipitation of a network of fibrin from exudates tending to wall off phagocytosis of bacteria, dead cells Disposal by macrophages of necrotic debris
  7. 7. 7 PATHWAYS OF DENTAL INFECTION fistula bacteremia septicemia cellulitis acute-chronic deep fascial space periapical infection infection Intra oral soft osteomyelitis ascending facial- Tissue abscess cerebral infection Serious dental infections, spreading beyond the tooth socket, is more common due to the pulpal infection than the periodontal infecteria after detion. invasion of the dental pulp by bacteria after decay of a tooth inflammation, oedema & lack of collateral blood supply venous congestion or avascular necrosis (pulpal tissue death) reservoir for bacterial growth (anaerobic) Periodic egress of bacteria into surrounding alveolar bone The periapical infection progress can vary according to the – 1.the number & virulence of the organism 2. Host resistance 3. Anatomy of the involved area  Types of infections are:- a)acute & b)chronic a) Acute stage – the infection spreading in the clinical situation i.e abscess, cellulitis, fulminating infections. b) Chronic stage – different forms of chronic stages are:- - chronic fistulous tract or sinus formation - chronic osteomyelitis - cervicofacial actinomycosis
  8. 8. 8 FOCI OF INFECTION (FOCAL INFECTION)  It has been observed since long time that infections from oral cavity can spread to distant parts of the body & produce fresh lesions over there. orofacial tissues escepially the teeth & the periodontium normally harbor numerous microorganisms, which are otherwise non pathogenic as long as they are within the oral cavity. However ,once these organisms spread to the distant organs of the body, they behave as strickly pathogenic organisms and produce diseases. Moreover, oral tissues are vulnerable to infections caused by various microorganisms (eg,bacteria,virus&fungus), which produce a wide variety of lesions in the oral cavity. Infections from these primary lesions may spread to the distinct organs to initate secondary diseases. Definition Metastates of microorganisms or their toxins from a localized site of infection to any distant part of the body with subsequent injury are called focal infections. Mechanism of focal infection Focal infections mostly occur by the following mechanisms.  Spread of pathogenic microorganisms from their primary site of infection to the distant part of body via the blood vessels or lymphatics.  Spread of toxins liberated by the pathogenic microbes to distant organs either via blood vessels to distant organs either via blood vessels or lymphatics(erythrogenic toxins) liberated by beta hemolytic streptococci produce diffuse, bright skin rashes in scarlet fever. Various examples of oral foci of infections  Periapical abscess (acute or chronic)  Pericoronitis  Infected periapical granuloma or cyst  Periodontal abscess  Infected dental pulp or root canals  Infected root fragments of teeth  Osteomylitis  Syphilic chancre  Infections in the maxillary sinus, nasal sinus, throat & tonsils etc.
  9. 9. 9 Classification of fascial spaces Based on the mode of involvement involvement primary space:- (a) maxillary spaces (b) mandibular spaces Ii.indirect involvement secondary spaces:- Spaces involved in odontogenic infections: A) primary maxillary spaces: canine, buccal & infratemporal spaces B) primary mandibular spaces: submental, buccal, sub mandibular & sublingual spaces. C) secondary fascial spaces: massetric, pterygmandibular, superficial & deep temporal, lateral pharyngeal, retropharyngeal and prevertebral spaces, parotid space. Based on clinical significance (i) face- buccal, canine, masticatory, parotid (ii) suprahyoid- sublingual, submandibular (sub-maxillary, submental), pharyngomaxillary (lateral pharyngeal), pretonsillar. (iii) infrahyoid- pretracheal (iv) spaces of total neck- retropharyngeal, space of carotid sheath. Fascial spaces of clinical significance Face - buccal,canine,masticatory,parotid Suprahyoid - sublingual - submandibular(submaxillary, submental) - pharyngomaxillary(lateral pharyngeal) - peritonsillar Infrahyoid - anterovisceral (pretracheal) Spaces of total neck - retropharyngeal - space of carotidsheath
  10. 10. 10 SURGICAL ANATOMY OF MANDIBULAR TEETH IN RELATION TO SPACE Mandibular central & lateral incisors- Periapical infections from the lower central & lateral incisors will reach the surface on the labial aspect of the alveolar this region the relationship of the mentalis muscles to the root apices determines the further cause of the infection. If the infection breaks through the bone above attachment of the mentalis msucle, it will be limited to the oral vestibule. If on, the other hand, penetration occurs below this muscle, the infection is then located extraorally. It remains localized in the subcutaneous tissue of the chin or spread beneath the chin into the submental spaces. The latter space is bounded laterally by the anterior bellies of the digastric muscles, superiorly by the mylohyoid muscle & inferiorly by skin, platysma, superficial fascia & deep cervical fascia. Clinically the swelling will be located limited to the point of the chin & the region immediately below it. Mandibular canine Because the muscle attachments (depress or labil inferioris, depressor angulioris & platysma) in the region of the mandibular canine are located wellbelow the root apex, periapical infections from this tooth will localize in the oral vestibule after extending through the labial cortical plate. Mandibular premolar Infection from mandibular premolars usually penetrate the buccal cortex. Further extension then is governed by the same muscles that confine infections from the canine tooth. This results in a vestibular abscess. Occasionally, however alingual cortical perforation may occur & result in a sublingual abscess. Mandibular first molar Infections from the lower first molar also can give rise to a buccal space abscess if the infection exists from the buccal aspect of the bone below the attachment of the buccinator muscle. The oblique line of buccinator attachment on the mandible, however a lingual cortical perforation may occur & result in a sublingual abscess.
  11. 11. 11 Mandibular first molar Infections from the lower 1st molar also can rise to a buccalspace abscess if the infection exits from the buccal aspect of the bone below the attachment of the buccinator muscle. The oblique line of buccinator attachment on the mandible, however generally results in the root apices being above origin of this muscles thereby causing localization of the infection within the oral vestibule. On the lingual aspect of the mandible the attachment of the mylohyoid muscle roughly parallels the oblique downwards and forward courses of the buccinator muscle. The apices of the premolars & the first molar are almost always above attachment of this muscle should lingual perforation of a dental infection arise in such instances, swelling will occur in the sublingual space. This space is bounded inferiorly by the mylohyoid muscles laterally & anteriorly by the lingual aspect of the mandible, superiorly by the mucosa of the oral cavity, posteriorly at the midline by the body of the hyoid bone & medially by the geniohyoid, genioglossus & styloglossus muscles. Because there is loose connective tissue interspersed between the latter muscles, as well as between the intrinsic muscles of the tongue, infections of the sublingual space usually spread across the midline to the opposite side, as well as into the body of the tongue. Such sublingual infections have been erroneously called ludwing's angina because they generally are associated with swelling & elevation of the tongue & with varying degrees of respiration difficulty. It is possible, however for a sublingual space abscess to develop into the ludwing's angina since this space communications with the parapharyngeal space at the posterior border of the mylohyoid muscle lateral to the hyoid bone. Mandibular second molar Because of the position of the mandibular second molar in the alveolar process, there is a 50% possibility of either buccal or lingual perforation from a periapical infection. Likewise there is anequal chance for the root apices to be either above or below the attachment of the buccinator or mylohyoid. Thus there are 4 possible sites of localization for infections arising from this tooth. On the buccal aspect the abscess will form either in the vestibule in buccal space, depending on the relationship of the buccinator muscle on the lingual surface, exit of infection above mylohyoid muscle will result in a sublingual abscess. Perforation below the mylohyoid muscle produces an infection of the submandibular space. With the rare exception of the mandibular 1st molar only the second & third molars. Can give rise to a submandibular space infections. Such infections enter the neck directly because they are
  12. 12. 12 located below mylohyoid muscle, which forms floor of the oral cavity. Deep neck infections arising from all other teeth are secondary to spread from communicating spaces in the faces and oral cavity. The sub mandibular space is bounded laterally by the skin, superficial fascia, platysma & superficial layer of deep cervical fascia. Medially the mylohyoid, hyoglossus & styloglossus muscles bound the space. Inferiorly, the space is bordered by anterior and posterior bellies of the digastric muscle, superiorly the space is limited by medial aspect of the mandible & attachment of the mylohyoid muscle. Clinically there should be no difficulty in differentiating submandibular space infections from those in the buccal space. Whereas the buccal space abscess is a relatively ovoid swelling beginning at lower border of mandible & extending upto level of zygomatic arch. Abscess is triangular begins at lower border of mandible & extends to level of hyoid bone. Mandibular third molar The mandibular 3rd molar generally positioned medial to vertical plane of ramus, apex is much closer to lingual than to buccal cortical plate. In this region the attachment of mylohyoid muscles near the alveolar margin & its posterior border is behind the tooth. Because of this relationship, infections from vertically positioned 3rd molars will extend below mylohyoid muscle & localize in submandibular space with mesio angularly or horizontally positioned teeth. However, the infection will tend to spread beyond the posterior extent of the mylohyoid muscle, localizing in pterygo mandibular space. This region as the name implies, is bounded laterally by the medial ramus of mandible & medially by lateral assessment of medial pterygoid muscle. It is space into which needle is passed in performing an inferior alveolar nerve block injection. Posteriorly, this space communicates with lateral pharyngeal space. An infection of 3 molar also can pass directly into parapahryngeal space by extension medial to medial pterygoid muscle. A patient with a submandibular space abscesses will show no external evidence of swelling. Intra oral examination, however reveals an anterior bulging of half the soft palate & anterior tonsillar pillar with deviation of uvula to unaffected side. The patient will have severe trismus & difficulty in swallowing. Despite the limitation in opening, deep ression of tongue with a tongue blade usually permits inspection of soft palate and pharyngeal wall otherwise an anaesthetic may be needed to permit the mouth to be opened for an adequate examination. The pterygo mandibular space absceses most be distinguished from peritonsillar abscess.
  13. 13. 13 With the latter thereis less trismus & no dental involvement. Occasionally an infection from a third molar can involve the submassetric space, usually this is the result of pericoronitis, but it can arise from a periapical infection when lingvo version of the tooth or extreme curvature of the roof brings apex closer to buccal surface. The submassetric space is banded laterally by masseter muscle & medially by lateral surface of mandibular ramus. The anterior boundary is facial extension of parotid ectomassetric fascia & posterior boundary is parotid fascia & retro mandibular portion of parotidgland. Superiorly the space extends to level of zygomatic arch & communicates with the infratemporal space. Clinically, a submassetric space infection is characterized by deep-seated severe throbbing pain & tenderness over the mandibular ramus associated with severe trismus. The swelling is mainly over angle of mandible, but may extend to level of zygomatic arch. A submassetric space infection can be distingted from a buccal. Space infection by the fact that its anterior bandary ends at nterior border of masseter muscle, whereas the posterior border of buccal space swelling ends at that point.
  14. 14. 14 VESTIBULAR SPACE INFECTION The vestibular space is the potential space between the oral vestibular mucosa & the nearby muscles of facial expression. The term dentoalveolar abscess describes an infection between the alveolar process and the alveolar mucosa on the facial wall of the alveolar process. Boundaries : posteriorly : the local muscle of facial expression is the buccinator. Anteriorly : the instrinsic muscles of either lip, such as the orbicularis oris, quadratus labii superioris, mentalis or risorius, limit the vestibular space. The vestibular space is filled with submucosal and areolar connective tissue is crossed by the long buccal and mental nerves. It communicates, between gaps in the muscle of facial expression, with the buccal and subcutaneous spaces. Clinical features A) vestibular swellings may elevate the overlying facial structures, distorting the externally visible features. Spontaneous drainage often occurs through the oral mucosa. B) the swelling over the alveolar process extends into the labial vestibular with pointing of the infection of the oral mucosa.
  15. 15. 15 SUBCUTANEOUS SPACE INFECTION In the head & neck the sub cutaneous space occupies the potential space between the superficial fascia, along with the muscles of facial expression & the skin. Infection in almost any deep fascial space may point through the subcutaneous space to the skin. Necrotizing fascitis, a rapidly spreading infection, causes necrosis of the tissues in the subcutaneous space by thrombosis of vessels that supply the superficial muscles & skin. Boundaries - in neck necrotizing fascitis may follow the platysma muscle inferiorly, to its terminus on the anterior chest wall. Necrotizing fascitis may also affect the deeper fascial spaces, resulting in a particularly aggressive spread through these spaces to deeper structures, as in descending necrotizing media stinitis.
  16. 16. 16 BUCCAL SPACE INFECTION The buccal space occupies the portion of the sub cutanaeous space between the facial skin and the buccinator muscle. Boundaries of buccal space infection Anteriorly : corner of mouth Posterior : masseter space pterygomandibular space Superior : infraorbital space Inferior : mandible Superficial or medial : subcutaneous tissue & skin Deep or lateral : buccinator muscle Contents of buccal space infection A) parotid's duct B) anterior facial artery & vein C) transverse facial artery & vein D) buccal fat pad Teeth commonly involved Upper premolar, upper molars, lower premolars.
  17. 17. 17 Clinical features 1) pus accumalates an oral side of muscle 'gum-boil' is seen in the vestibule. 2) buccal abscess originating from periapical infection. 3) swelling may be intra oral & extra oral, it depend on the muscle attachment of root apices above & below. 4) massive swelling, erythema, early skin necrosis. 5) marked cheek swelling, which helps in diagnosis. Differential diagnosis 1) cellulitis - caused by h influenzae seen in infants & children under 3 years of age. usually, there is high fever, for at least 24 hours. 2) erysipelas - there is rapid onset, dark red swelling & associated otitis media frequently present. 3) crohn's disease (recurrent buccal space abscess) - it is a segmental transmural intestinal disease. the granulomatous lesions & ulcerations can progress to the buccal space abscess. Communications of buccal space infection Direct - communication with maxillary & mandibular space. Indirect A) submassetric space - if infection tracks backwards & penetrates the parotid omassetric fascia. B) in continuation with pterygo mandibular space. C) superficial temporal space. D) to infratemporal space along the fascia accompanying the stenson's duct. E) superficial temporal space. F) lateral pharyngeal space. G) carotid sinus. Management of buccal space infection 1) incision & drainage 2) supportive care
  18. 18. 18 1) Incision & drainage - Incision is made vertically rather than horizontally. If the intra oral route is used, the horizontal incision should be placed just above the depth of the vestibule. the incision for extra oral drainage of a buccal space abscess are placed below the lower border of the mandible using no.1 scalpel blade. if pus is lateral to the muscle then the muscle is penetrated with curved mosquito forceps to enter the buccal space. Drain is placed and secured with suture. 2) Supportive care includes : Those modalities which aid the patient's own body defenses in combating the infection. It consists of the administration of antibiotics, hydration of the patient, an analgesic for pain, bedrest, the application of heat in the form of moist packs/mouth rinses, & opening the tooth for drainage.
  19. 19. 19 SUBLINGUAL SPACE INFECTION This space is a v shaped trough lying lateral to muscles of tongue, including hyoglossus, genioglossus, geniohyoid. Boundaries of sublingual space infection Anteriorly : lingual surface of mandible Posteriorly : submandibular space Superior : oral mucosa Inferior : mylohyoid muscle Superficial or medial : muscles of tongue Deep or lateral : lingual surface of mandible Contents  Sublingual glands  Wharton's ducts  Lingual nerve  Sublingual artery & vein Teeth commonly involved :  Lower premolars  Lower molars  Direct trauma Clinical features  It appears as browny, firm erythematous, tender swelling on the floor of mouth.  Swelling may be intra oral & extra oral. Extra oral : pain & discomfort on deglutition. Intra oral : the floor of the mouth raised. Tongue may be pushed superiorly. Communication of sublingual space infection I) infection always crosses the midlines & can affect the space on the opposite side. Ii) infection from the postero inferior part of the space can spread around the submandibular space & again can be spread posteriorly.
  20. 20. 20 Iii) the sublingual space is separated from the submental space by mylohyoid muscle, which forms a complete diaphragn in the floor of mouth. Iv) the infection can spread to lateral pharyngeal & visceral (trachea & oesophagus) spaces. Treatment of sublingual space infection These spaces are incised intraorally at the base of the alveolar process in the lingual sulcus, so that sublingual gland, lingual nerve & submandibular duct are not injured. A haemostat is inserted through the incision in an anterior & posterior direction & beneath the sublingual gland to evacuate the pus. A rubber drain is placed & sutured to the alveolar mucosa to avoid displacement by movement of the tongue. Frequently the sublingual spaces swollen bilaterally because of extension of the infection across the midline.
  21. 21. 21 SUBMANDIBULAR SPACE INFECTION The space lies between the anterior and posterior bellies of the digastric muscles. The upper part lies beneath the inferior border of mandible & the lower part lies deep to the investing layer of deep cervical fascia. The submandibular spaces are considered to be the anterior extensions of parapharyngeal space. Boundaries or borders of sub mandibular space infection Anteriorly : anterior belly of digastric muscles Posteriorly : posterior belly of digastric muscles Superior : inferior & medial surfaces of mandible Inferior : digastric tendon Superficial or medial : platysma muscle, investing fascia Deep or lateral : my lohyoid, hypoglossus, superior Constricting muscles Contents  Submandibular glands  Facial artery & vein  Lymph nodes Teeth commonly involved : lower molars Clinical features : swelling appears extra oral swelling will be fever along with constitutional symptoms like fever, tenderness, redness. Intra oral swelling : tender on percussion will be positive, teeth are mobile, dysphagia, moderate trismus. Communication or spread : A) there are no major anatomic barriers between the 2 submandibular & submental spaces. B) hence infection can extend into the submental space. C) the sub mandibulr space communicates with sublingual space. D) the infection can spread to lateral pharyngeal & buccal spaces. E) the infection can spread extend easily across the midline & involve the submandibular space on the contra lateral side.
  22. 22. 22 Diagnosis - of submandibular space infection is made by finding the intra oral swelling. 1) tender on percussion positive. 2) anterior teeth - non vital fractured, carious tooth, mobile teeth. Spread - to sub mandibular space (on either side). Treatment - it is performed by making transverse incision in the skin below the symphysis of the mandible. The incisions for draining a submental space abscess are made bilaterally through skin, subcutaneous tissue & platysma muscle at the inferior aspect of the swelling. A haemostat is inserted through one incision into the abscess cavity & then excised through the second incision. A rubber drain is placed and a dressing applied.
  23. 23. 23 SUBMENTAL SPACE INFECTION A potential fascial space exists in the chin and occasionally becomes infected, either directly from a mandibular incisor or indirectly from the submandibular space. Boundaries anterior : inferior border of mandible Posterior : hyoid bone Superior : mylohyoid bone Inferior : investing fascia Superficial : investing fascia Deep : anterior bellies of digastric muscles Contents : anterior jugular vein, lymph nodes Teeth commonly involved : lower anteriors, fracture of symphysis Clinical features 1. Chin appears grossly swollen & quite firm & erythematous. 2. Extra oral swelling : firm swelling in midline below the chin typical swelling of the spaces either brawny or softy & correlating it with the presence of a diseased mandibular molar. Differential diagnosis : include acute sialadenitis, sublingual trauma or foreign body & submandibular lymphadenitis. Management - of submandibular space infection includes surgical drainage, antibiotics & definitive care of the primary dental infection. Incision is preformed through the skin below & parallel to the mandible. Deep abscess loculations should be entered with a small closed clamp, probing in all directions while attempting to avoid damage to sub mandibular gland, facial artery & lingual nerve. Ludwig's angina It is the infection of submandibular space which lies between the mucous membrane & floor of mouth & tongue & superficial layer of deep cervical fascia. It is divided into 2 compartments.
  24. 24. 24 - sublingual i.e. above the myolhyid. - submandibular & submental below the mylohyoid muscle. 2 compartments are continuous around the posterior border of mylohyoid muscle. Etiology:- 1. 80% cases (dental infection) roots of premolar often lies above attachment of mylohyoid & causes sublingual space infection. Molar tooth extends the mylohyoid line & causes submandibular space. 2. Submandibular sialadenitis 3. Injury to oral mucosa Clinical features: A) it is characterized by swelling combined with inflammatory oedema. B) there will be puttred halitosis. C) there will be marked difficulty in swallowing. When infection is localized to sublingual space structures in floor of mouth & tongue seems to be pushed up. D) infection spreads to submandibular & submental infection E) consistency will be woody hard along with widespread cellulites. F) tongue apparently protrudes upwards & backward & causing obstructino to airways & laryngeal edema occurs. Treatment Systemic antibiotics, incision and drainage may be done intraorally (sublin gual space) extraorally in case of submental & submandibular space involved. - transverse incision if extends from angle of mandible. - tracheostomy may be required. Complications Spread of infection to parapharyngeal & retropharyngeal space. There will be airway obstruction. Peritonsillar abscess (quinsy) It is a localized infection in the connective tissue bed between the tonsil & the Superior constrictor muscle, between the anterior & posterior pillars of fauces. Involvement (i) infection from the depth of the tonsillar crypt or supra tonsillar fossa.
  25. 25. 25 (ii) as a complication of acute pericoronal abscess in which case the abscess points near the lower pole of the tonsil. A) patient looks ill anoxic & dehydrated. B) pain on one side of the throat radiating to the ear. C) dysphasia D) limitation of mouth may not be pronounced. E) speech is difficult, especially in bilateral cases & a peculiar muffled ‘hot potato in mouth voice’ is characteristic. (vi) drooling of saliva (vii) when the abscess is fully developed, a large tense swelling of anterior pillar of fauces, & a bulge in the soft plates n the affected side, which in extreme cases reaches the midline & pushes uvula downwards & forwards, until is impinges against the opposite tonsil. (viii) coated tongue with marked foetor oris.
  26. 26. 26 Incision & drainage Can be achieved by using a guarded knife & sinus forceps which are inserted into most prominent part of the soft palate where the fluctuation is the maximal. Spread Oedema may eventually affect the base of the tongue, epiglottis & aryepiglottic fold. In 3-5 days durations the mass becomes fluctuant & ruptures by pointing usually through anterior faucial pillar.
  27. 27. 27 SUBMASSETRIC SPACE INFECTION Masseter consists of 3 layers, which are fused anteriorly but can be easily separated posteriorly. There is potential space in the substance of the muscle between the middle & the deep heads, while the bony insertion is firm above & below, the intermediate fibers have only a loose attachment. When the pus accumalates between the ramus of the mandible & masseter muscle, it produces a submassetric space abscess. Boundaries anterior : buccal space Posterior : parotid gland Superior : zygomatic arch Inferior : inferior border of mandible Superficial : ascending ramus of mandible Deep : masseter muscle Contents : masseteric artery & vein Teeth or area involved : lower 3rd molars, fracture of angle of mandible Clinical features Infections in this space typically cause inflammation & edema of the overlying masseter muscle. The inflammatory process results in significant trismus the hallmark of this condition. External facial swelling is moderate in size. Tenderness over angle of mandible. Pyrexia & malaise. Differential diagnosis : these swellings must be differentiated from parotid swellings because submassetric swellings. Obscure the ear lobe, while parotid swellings elevate it. Communication or spread : 1) buccal 2) pterygo mandibular 3) superficial temporal 4) parotid
  28. 28. 28 Management of submassetric space abscess A) intraoral approach : an incision is made vertically over the lower part of the anterior border of the ramus of the mandible deep to the bone. a sinus forceps are passed along the lateral surface of ramus downwards & backwards & pus is drained. the drain is inserted & secured with a suture. the abscess is usually situated below level of incision. B) extra oral approach : when the mouth cannot be opened an incisions placed in the skin behind the angle of mandible to open abscess by hilton's method. A rubber drain is inserted & secured in position with a suture. Dressing is applied.
  29. 29. 29 PTERYGO MANDIBULAR SPACE INFECTION In a recent prospective study of severe odontogenic infection the pterygomandibular space was the most frequently affected anatomical compartment; abscess or cellulites was present in the pterygomandibular space. Infection of the pterygomandibular space correlated highly with pericoronitis of the mandibular 3rd molar. Boundaries anterior : buccal space Posterior : parotid gland Superior : lateral pterygoid muscle Inferior : inferior border of mandible Superficial : medial pterygoid muscle Deep : ascending ramus of mandible Contents : mandibular division of trigeminal nerve. inferior alveolar artery & vein. Teeth commonly involved : lower 3rd molars. Fracture of angle of mandible. Clinical features 1) it do not cause much swelling of face over the submandibular region. 2) tenderness may be elicited over the area of soft tissues. 3) dysphagia present. 4) redness & oedema around the 3rd molar area. 5) trismus, caused by edema and inflammation of the medial pterygoid muscle, hinders the view of the swollen anterior tonsillar pillar and deviation of the uvula to the opposite side that are characteristics of infection in this space.
  30. 30. 30 Spread : 1) buccal 2) lateral pharyngeal 3) submassetric 4) deep temporal 5) parotid Management The abscess usually tends to point at the anterior border of the ramus of mandible & drainage can be easily done by intraoral route. A) intra oral : a vertical incision, approximately 1.5 cm in length, is made on the ramus of mandible. A sinus forceps is inserted in the abscess cavity, opened & closed & withdrawn. The pus is evacuated, a rubber drain is introduced & is secured in position with a suture. B) extra oral : an incision is taken in the skin below the angle of the mandible. A sinus forceps is inserted towards the medial side of the ramus in an upward & backward direction. Pus is evacuated & the drain is inserted from an intra oral approach & sutured in position.
  31. 31. 31 SUPERFICIAL TEMPORAL SPACE INFECTION The superficial temporal space lies below the temporal fascia, which is the continuation of parotideomassetric fascia & the temporalis muscle. The temporal fascia arises from the zygomatic arch to terminate at the superficial temporal crest of the temporal bone. Boundaries : Anterior : posterior surface of the lateral orbital rim. Posterior : is fusion of temporal fascia with the percranium at the posterior edge of the temporalis muscle. Inferior : zygomatic arch & areolar connective tissue. Contents : temporal fat pad, temporal branch of facial nerve. Teeth or areas commonly involved : Upper molars Lower molars Spaces or communication : buccal deep temporal. Management Temporal space abscess can be drained intraorally through the same incision used for entrance. The temporal space can be drained extra orally through same incision used for infra temporal space abscesses. As the hemostat is passed medially, it first enters the superficial temporal space.
  32. 32. 32 DEEP TEMPORAL SPACE INFECTION Boundaries : lateral : border of the deep temporal space is the temporalis muscle. Medial border is the squamous temporal bone & skull base, formed mainly by sphenoid bone. The infratemporal space is the portion of the deep temporal space that lies inferior to infratemporal crest of the sphenoid bone. Inferior border - superior surface of the lateral pterygoid muscle. Superior : posterior border is formed by the attachment of the temporalis muscle to the cranium at the temporal crest. Anterior : border of the temporal space is composed of the posterior wall of the maxillary sinus, the pterygomaxillary fissure & the posterior surface of the orbit including the inferior orbital fissure. Contents : pterygoid plexus Interior maxillary artery & vein Mandibular division of trigeminal nerve Skull base foramina Teeth or areas involved : upper molars Management of deep temporal space infection An abscess of the infratemporal fossa is usually incised intra orally. A vertical incision is made just medial to the upper extent of the anterior border of the mandibular ramus & the hemostat is passed superiorly along the medial aspect of coronoid process into the infratemporal region. By using blunt dissection, damage to lingual nerve is avoided. When patient has severe trismus, it may not be possible to approach the infra temporal region intra orally. In such situations a small horizontal incision, parallel to zygomatic branch of facial nerve, is made posterior to junction of frontal & temporal process of zygoma. The extra oral approach has the disadvantage of not producing dependent drainage & should be used when intra oral access is not possible.
  33. 33. 33 PAROTID SPACE INFECTION Boundaries : the parotid space is formed by spliting of anterior (investing) layer of the deep cervical fascia to form the capsule of the parotid gland. In the region the fascia is called the parotideo massetric fascia. Inferiorly : stylomandibular ligaments which separates parotid space from the mandibular space. Contents : A) parotid gland B) facial nerve C) external carotid artery D) posterior facial lymphatic's & E) posterior facial vein (retro mandibular) vein. Clinical features 1) severe pain which may be referred to the ear & is accentuated by eating. Because of the pain associated with eating, these patients do not consume adequate fluids & hence, these patients may get dehydrated. 2) presence of swelling over the masseter muscle, extending from the level of zygomatic arch to lower border of mandible. Anteriorly, it ends at the anterior border of ramus of mandible & posteriorly, it extends into retro mandibular region. Earlobe seems to be exerted. 3) there is escape of pus from the stenson's duct when the gland is milked. Spread or communication Communication between parotid space & submandibular space exist via anterior branches of posterior facial vein. Infection can spread to sub massetric, pterygo mandibular & lateral pharyngeal spaces. Management of parotid space infection The drainage requires an external approach. A retro mandibular incision is used, because the pus is usually not in a single pool, but is located in numerous loculations within glandular parenchyma & exploration of a wider area is often necessary to evaluate all the sites involved. An incision is placed in skin behind posterior border of mandible extending from the level of inferior aspect of the lobule of ear to just above mandible. A sinus forcep is inserted & with blunt dissection the parotid fascia is reached. A rubber drain is inserted & secured to skin with a suture.
  34. 34. 34 LATERAL PHARYNGEAL SPACE INFECTION It is a potential cone shaped space or cleft with its base upper most at the base of skull & its apex at the greater horn of the hyoid bone. The space is divided into 2 by the styloid process, as anterior & posterior compartments. Infection of this space is extremely serious owing to the intimate relationship with the carotid sheath. Boundaries anterior : superior & middle pharyngeal constrictor muscles. Posterior : carotid sheath & scalene fascia Superior : skull base Inferior : hyoid bone Superficial : pharyngeal constrictors, retropharyngeal space Deep : medial pterygoid muscle Contents : carotid artery Internal jugular vein Vagus nerve Cervical symphathetic vein Teeth or areas involved : lower 3rd molars, tonsils, infection in neighbouring spaces. Clinical features of lateral pharyngeal space infection A) infections of the lateral pharyngeal space may result from pharyngitis, tonsillitis, parotitis, otitis, mastoiditis, & dental infection. B) if the anterior compartment becomes infected, the patient exhibits, pain, fever, chills, medial bulging of the lateral pharyngeal wall with deviation of the palatal uvula, from midline, dysphagla, swelling below the angle of the mandible & usually trismus. C) infection of the posterior compartment is noted for absence of trismus & visible swelling, but respiratory obstruction, septic thromboses of the internal jugular vein, & carotidartery hemorrhage may occur in patients at a late stage of infection. Diagnosis of these infection can be done by ct scan & may reveal confluence with other deep space infections. Spread or communications : A) pterygo mandibular space B) submandibular space
  35. 35. 35 C) sublingual space D) peritonsillar E) retro pharyngeal
  36. 36. 36 Management of lateral pharyngeal infection The lateral pharyngeal space can be approached by an intra oral vertical incision similar to that used for enter into the pterygo mandibular space. However instead of passing the haemostat directly posteriorly between the medial aspect of the ramus & the lateral surface of the medial pterygoid muscle, it is passed in a postero medial direction along the deep surface of the muscle into the lateral pharyngeal space. When it is difficult for the patient to open the mouth because of trismus, even when general anesthetic is used, or when there is concern about the possible aspiration of pus, an extra oral incision & drainage can be performed. The incision is made anterior & inferior to the angle of mandible & the hemostat is passed superiorly & medially along the deep surface of medial pterygoid muscle into the lateral pharyngeal space.
  37. 37. 37 RETROPHARYNGEAL SPACE INFECTIONS The esophagus & trachea are enclosed by the middle layer of deep cervical fascia. A thick strand of connective tissue extends laterally from the oesophagus to the carotid sheath thus creating an anterior neck compartment known as the pretracheal (previsceral space) & a posterior or (retro pharyngeal) or (retro visceral space). Boundaries of retropharyngeal space infection Anteriorly : superior & middle pharyngeal constrictor muscle Posterior : alar fascia Superior : skull base Inferior : fascia of alar & prevertebral fasciae at c6-t4 Deep : carotid sheath & lateral pharyngeal space Clinical presentation A) it may result from nasal & pharyngeal infections in children, dental infection through contagious spaces, eosophageal trauma or foreign bodies & tuberculosis. B) infection also may reach this space through the lymphatics to involve the retropharyngeal lymph nodes. C) dysphagia, dyspnoea, nuchal rigidity, esophageal regurgitation & fever characteristics infections of the retropharyngeal space. D) if the pharynx can be visualized, a bulging of the posterior wall may be observed & is usually more prominent unilaterally because of the adherence of the medium raphe of the prevertebral fascia. Involvement : the space involved by an extension of infection from the lateral pharyngeal space. Diagnosis : can be made by lateral soft tissue radiographs of the neck & by widening of the retropharyngeal space, well beyond the 3-6 mm width in normal adults at the second vertebra (>14 mm) in children ct scan can also be used. Management of retropharyngeal space infection It may not need to be drain independently when independent drainage is necessary, it can be done intraorally through vertical incision in the mucosa of the pharyngeal wall lateral to the
  38. 38. 38 midline. The abscess is opened by blunt dissection with a hemostat. The patient should be in a trendelenburg position to avoid aspiration of the pus. When there is rupture of abscess, during placement of an endotracheal tuber a tracheotomy should be done prophylactically & the abscess drained extra orally. An incision is made along the anterior border of the sternocleidomastoid muscle inferior to the hyoid bone, & the muscle & carotid sheath are retracted laterally. Deep dissection between the carotid sheath & the inferior constrictor muscle of the hypopharynx opens the retropharyngeal space for drainage.
  39. 39. 39 DANGER SPACE The deep fascial space known as the danger space is aptly named because of its communication with the mediastinum. The danger space extends from the base of skull. Superiorly, to the diaphragm, inferiorly, its lateral extent is at the fusion of the alar & prevertebral fasciae at the transverse processes of the cervical & thoracic vertebrae. The only content of the danger space in the cervical region is areolar connective tissue. However, in the chest the danger space is continuous with the posterior mediastinum, which contains the vena cava, aorta, thoracic duct, trachea & oesophagus. Clinically : therefore infections that pass through the danger space into the mediastinum can erode into or compress major vessels, lower airway & upper digestive tract.
  40. 40. 40 CAROTID SHEATH Carotid sheath is a fascial condensation surrounding the internal jugular vein, the vagus nerve, the common & internal carotid arteries. It extends from the jugular foramen & carotid canal in the occipital bone to the mediastinum, where it divides to surround the major vessels that contribute to its contents. The cervical symphathetic chain attaches to the posterior surface of the carotid sheath. Clinically : A) infections that have eroded into the carotid sheath may cause disruption of any of the structure associated with it, including a) expanding hematoma in the neck b) bleeding episodes 'herald bleeds'. c) variations in heart rate or speech function, or septic emboli. B) involvement of the cervical symphathetic chain may cause "horner's syndrome on the affected side, which is characterized by miosis (pupillary constrictions), ptosis (dropping of the lid caused by inactivation of miller's muscle) & anhidrosis (decreased sweating of the affected side of head neck & upper extremity). C) chills, septicaemia, fever is present. Management of carotid sheath space abscess An abscess of the carotid sheath is approached through an incision made along the middle third of the anterior border of the sternocleidomastoid muscle. The muscle is retracted posteriorly, exposing the carotid sheath, which is carefully opened through a vertical incision. If thrombosis of the internal jugular vein is noted, the vessel should be ligated above & below the limits of involvement to prevent further spread of the infection.
  41. 41. 41 CONCLUSION The incidence and severity of odontogenic infections have diminished since the advent of antibiotic therapy. However, significant morbidity & mortality of these infections continue. Dentists & physicians constantly must be alert the potential seriousness of these infections, which should never be dismissed as simple dental abscesses. Odontogenic infection therapy- dental, medical, or surgical, outpatient or inpatient- is based on the severity & anatomical location of the infection, the patient’s general health status his or her response to therapy, & the assumed or laboratory- determined pathogenic micro flora of the infection. Small superficial odontogenic infections differ greatly from deep space infection despite their common origins. Deep space infections must be recognized promptly & treated as an emergency. Underlying medical problems must be controlled, a patent airway established, contemporary diagnostic imaging done & deep drainage performed. Repeat diagnostic & therapeutic measures may be necessary until the end point- absence of clinical, radiographic & laboratory signs of infection have been reached.
  42. 42. 42 REFERENCES  Oral and maxillofacial surgery  Danial m. Laskin (volume two)  Oral and maxillo facial infections  Topazian  Goldberg  Hupp  Textbook of oral and maxillofacial surgery  Neelima anil malik   General principles of oral surgery  S.m. balaji  text book of oral pathology  Shafer (7th edition)