Anatomy of Oral and Maxillofacial Infections

Anatomy of oral and Anatomy of oral and maxillofacial infectionsmaxillofacial infections

contentscontents

• Fasciae of head and neck

• Clinical anatomy of fascial infections

• Fascia of head and neck consists of:

• Superficial fascia

• Deep cervical fascia

• Fasciae- broad sheath of dense connective tissue whose function

is to separate structures that must pass over each other during movement like muscles & glands(topazian)

• The fascial spaces in head and neck are the potential spaces between the various layers of fascia normally filled with loose connective tissue (Shapiro, 1950) and bounded by anatomical barriers, usually of bone, muscle or fascial layers (Moore).

• Space- clefts or compartments containing connective tissue &

various anatomic structures

Fasciae of head & neckFasciae of head & neck

• Superficial fascia• Deep fascia:-• Anterior layer:• investing fascia• Parotideomesseteric• Temporal• Middle layer:• sternohyoid-omohyoid division• Sternothyroid-thyrohyoid division• Visceral division• buccopharyngeal• pretracheal• retropharyngeal• Posterior:• alar• prevertebral

Investing fasciaInvesting fascia

• Covers the posterior as well as the anterior triangle of the neck

• Superiorly it attaches to – Superior nuchal line of occipital

bone (a) – Spinous processes of cervical

vertebrae and nuchal ligament(b)

– Mastoid processes of temporal bones(c)

– Zygomatic arches(d) – Inferior border of mandible(e) – Hyoid bone(f)

• Inferiorly it attaches to – Manubrium(g) – Clavicles(h) – Acromion(i)

Cervical FasciaCervical Fascia

• Superficial Layer of the Deep Cervical Fascia– Muscles

• Sternocleidomastoid

• Trapezius

– Glands• Submandibular

• Parotid

– Spaces• Posterior Triangle

• Suprasternal space of Burns

• Middle Layer of the Deep Cervical Fascia– Muscular Division

• Infrahyoid Strap Muscles

– Visceral Division• Pharynx, Larynx,

Esophagus, Trachea, Thyroid

• Buccopharyngeal Fascia

• Arises from spinous Arises from spinous processes and ligamentum processes and ligamentum nuchae.nuchae.

• Splits into two layers at the Splits into two layers at the transverse processes:transverse processes:– Alar layerAlar layer

• Superior border – skull Superior border – skull basebase

• Inferior border – upper Inferior border – upper mediastinum at T1-T2mediastinum at T1-T2

– Prevertebral layerPrevertebral layer• Superior border – skull Superior border – skull

basebase• Inferior border – coccyxInferior border – coccyx• Envelopes vertebral Envelopes vertebral

bodies and deep muscles bodies and deep muscles of the neck.of the neck.

• Extends laterally as the Extends laterally as the axillary sheath.axillary sheath.

Posterior layer

Carotid SheathCarotid Sheath

• Formed by all three layers of deep fasciaFormed by all three layers of deep fascia• Anatomically separate from all layers.Anatomically separate from all layers.• Contains carotid artery, internal jugular vein, and vagus nerveContains carotid artery, internal jugular vein, and vagus nerve• ““Lincoln’s Highway”(IJV thrombophlebitis & carotid artery erosion)Lincoln’s Highway”(IJV thrombophlebitis & carotid artery erosion)• Travels through pharyngomaxillary space.Travels through pharyngomaxillary space.• Extends from skull base to thorax.Extends from skull base to thorax.

Classification of fascial spacesClassification of fascial spaces• Based on mode of involvment:• direct: primary spaces: maxillary, mandibular spaces.• indirect involvment:• secondary spaces

• Spaces involved in odontogenic infection:

• Primary maxillary space-canine, buccal,infratemporal• Primary mandibular spaces-submental, buccal, submandibular, sublingual• Secondary spaces- messeteric, pterygomandibular,superficial & deep temporal, lateral

pharyngeal, retropharyngeal, prevertebral, parotid.

• Based on clinical significance:

• face- buccal, canine, masticatory, parotid• Suprahyoid: sublingual, submandibular, pharyngomaxillary, peritonsillar• Infrahyoid- pretracheal• Spaces of total neck: • retropharyngeal, space of carotid sheath

Scott (1952)Scott (1952)

• A) Suprahyoid spaces:• 1. Superficial facial compartment• 2. Floor of the mouth

(a) Sublingual space(b) Submandibular space(c) Submental space

• 3. Masticator space• (a) Temporal space : Superficial• Deep• (b) Submasseteric space

(c) Superficial Pterygoid space• 4. Parapharyngeal space including deep pterygoid space• 5. Parotid compartment• 6. Paratonsillar space

• 7. Space of the body of mandible.(Described by Coller & Yglesias, 1935)

• (B) Infrahyoid spaces are classifiedby Hollinshead(1958) as follows.

• 1. Visceral compartment• (a) Pretracheal space / Previsceral space• (b) Retrovisceral space• 2. Visceral space• 3. Other spaces• (a) Cavity within carotid sheath• (b) Space between 2 layers of

prevertebral fascia

CLASSIFICATION BY PETERSON

PRIMARY MAXILLARY SPACES canine buccal infratemporal

PRIMARY MANDIBULAR SPACES submental buccal submandibular sublingualSECONDARY FACIAL SPACES massetric pterygomandibular superficial and deep

temporal lateral pharyngeal retropharyngeal prevertebral

Grodinsky & holoyoke(1938)Grodinsky & holoyoke(1938)

Potential pathways of extension of deep fascial space infections of the Potential pathways of extension of deep fascial space infections of the head and neckhead and neck

BackgroundBackground

• Among most frequently encountered infections in human body

• Plagued our species for as long as we have existed• Pre-Columbian Indians, unearthed in the American

Midwest• Early Egypt revealed bony crypts of dental

abscesses, sinus tracts, and the ravages of osteomyelitis of the mandible

• Treatment of localized dental infection was probably the first primitive surgical procedure performed, using a sharp stone or pointed stick to establish drainage

Space Common portal entryAnticipated

Bacteria

Spaces of the face

Canineanterior, maxillary

teeth, premolar

Oral anaerobesBuccalMaxillary 2nd / 3rd

molarMandibular 3rd molar

Mental Mandibular anterior

teeth

SPACES INVOLVING ENTIRE NECKSPACES INVOLVING ENTIRE NECK

Superficial Skin Staph. aureus

Retropharyngeal PharynxOral anaerobes

Strepto pyogenesStaph aureus

Danger spacefrom retropharyngeal, prevertebral or lateral pharyngeal infections

Oral anerobesStreptoc pyogenes

Staph aureus

Prevertebral PharynxOral anaerobes

Streptoc pyogenes

Visceral vascularfrom deep neck infection,

especially post pharyngomaxillary

Oral anaerobesStreptoc pyogenes

SUPRAHYOID SPACESSUPRAHYOID SPACES

SubmandibularMandibular 1st or 2nd molar

Oral anaerobes

Submental Anterior mandib teeth

Sublingual Mandib premolars

Space of the body of the mandible

Mandib premolars/ mandib 1st or 2nd molar

Masticator3rd molars, Secondary spread from adj spaces

Lateral pharyngealPharynx: Mastoditis mandib molar extN , spaceS

Strept pyogenes

Peritonsillar PharynxOral anaerobesStrept pyogenes

Parotid Stensen’s duct Staph aureus

INFRAHYOID SPACES.INFRAHYOID SPACES.

PretrachealPharynx, trauma to esophagus / larynx

Oral anaerobes

Vestibular spaceVestibular space

2424

Canine spaceCanine space

SURGICAL BOUNDARIESSURGICAL BOUNDARIES • superiorly- levator labii

superioris alaeque nasi, levator labii superioris,zygomatic minor muscles.

• inferiorly- levator anguli • oris muscle• anteriorly-orbicularis oris• posteriorly-buccinator• medially-anterolateral surface

of maxilla.

• .

CANINE SPACE - APPLIED CANINE SPACE - APPLIED ASPECTS.ASPECTS.

• Infection of the canine is mostly on the labial side than on the palatal side.

• If canine infection perforates lateral cortex of max. bone SUPERIOR to the origin of muscle this space is affected.

• infection Involving this space is less common

b cos of odontogenic cause,• Involvement is even less in case of nasal

infections.


• Involvement may cause marked cellulitis of eyelids.

• Infection may burrow toward skin on either side of quadratis labii superioris , & may point thru’ medial or Lateral aspect of lower eyelid.

Buccal SpaceBuccal Space

• anteromedially-buccinator muscle.• posteromedially-masseter overlying the anterior border of ramus of

mandible.• laterally-by forward extension of deep fascia from the capsule of parotid

gland and by platysma.• inferiorly-limited by attachment of the deep fascia to the mandible and by

depressor anguli oris.• superiorly-zygomatic process of major & minor muscles.

CONTENTS – buccal fat pad parotid duct facial artery SPREAD OF INFECTION – through maxillary and mandibular molars

Clinical featuresClinical features

• Pus accumulated in the oral side of muscle

• When pus accumulates lateral to the muscle, prominent extra oral swelling is seen extending from lower border of mandible to the infraorbital margin & from the anterior margin of masseter muscle to the corner of the mouth. Sometimes edema of lower eyelid is seen..

Deep space associated with Deep space associated with mandibular odontogenic infectionsmandibular odontogenic infections

• Space of body of mandible:

• Originate in mandibular molar and premolar teeth

• Borders- periosteal envelope and cortical surface of bone.

Sublingual spaceSublingual space

• Boundaries:• superior: mucosa of floor of

mouth • Inferior: mylohyoid muscle• Anteriorly and laterally- lingual

surface of mandible• medial: intrinsic muscles of

tongue & genioglossus divides into rt & lt sublingual spaces

• Contents: lingual n, sublingual gl. Submand.duct, sublingual a.& v.


• Extra orally Little or no swelling• Lymph nodes may be enlarged

and tender• Difficulty in swallowing • Speech slurred• Intra orally firm, painful

swelling seen in the floor of the mouth on the affected side

• Tongue pushed to one side • Difficulty in protruding the

tongue

SUBLINGUAL SPACE- APPLIED SUBLINGUAL SPACE- APPLIED ASPECTS. ASPECTS.

• Root apices of 1molar & premolar are usually are sup to the attachment

• As a result the lingual perforation of infection penetrate into more sup compartment – sublingual space.

• Infection of this space clinically seen as brawny, erythematous, tender swelling of floor of mouth.

SUBLINGUAL SPACE- APPLIED SUBLINGUAL SPACE- APPLIED ASPECTS.ASPECTS.

• Communications-

ANTERIORLY- with submental space

POSTERIORLY - lateral pharyngeal space.

• Usually beginning close to the mandible & spreading towards the midline or beyond.

• Elevation of tongue is the clinical hallmark.

Surgical treatmentSurgical treatment

• Incision along lateral and parallel to submandibular duct

• Avoids injury to lingual, hypoglossal n. sublingual artery, submandibular duct, sublingual gland.

Submandibular spaceSubmandibular space

• anteromedially-mylohyoid muscle• posteromedially-hyoglossus muscle• superomedially-medial surface of

mandible• anterosuperiorly-ant. belly of

diagastric• posterosuperiorly-post. belly of

diagastric,stylohyoid & stylopharyngeus muscle.

SUBMANDIBULAR SPACESUBMANDIBULAR SPACE

• Present posterolateral to sublingual space • Separated from it by fibers of mylohyoid

muscle.

SUBMANDIBULAR SPACE APPLIED SUBMANDIBULAR SPACE APPLIED ASPECTSASPECTS

• Odontogenic infections of this space commonly are caused due to infections of 2nd & 3rd molar infections.

• Diagnosis made by typical swelling either brawny or soft.


• Frequently involved mandibular molars

• Generalised constitutional symptoms

• extraoral-firm swelling in submandibular region

• tenderness&redness of overlying skin.

• intraoral-teeth sensitive to percussion

• mobility of teeth• dysphagia• moderate trismus.


• Incision along digastric muscles at submandibular, submental sublingual loation and dissection pass superiorly & medially until lingual plate of mandible is contacted

• Dependent drainage• Incision In inferior

demarcation of abscess parallel to inferior border of mandible

Submental spaceSubmental space

• Boundaries:• Laterally: anterior belly of

digastric• Superficial border:

anterior layer of deep cervical fascia between hyoid bone & inferior border of mandible

• Contents: areolar CT, submental lymph nodes, anterior jugular vein

SUBMENTAL SPACESUBMENTAL SPACE

• Contents - areolar tissue lymph nodes ant. Jugular veins• infections begin in mandib ant teeth.• Or from submandib spaces from either side.• Infected skin wounds or ant mandibular fractures may also cause

infection of this space.


• Incision in midline of neck parallel or within neck crease inferior to abscess.

Masticator spacesMasticator spaces

Masticator spaces comprise of the following spaces:

(i) pterygomandibular,

(ii) submasseteric,

(iii) temporal-superficial temporal, and

(iv) deep temporal or subtemporal spaces.

All these spaces are well differentiated, and communicate with other fascial spaces; such as buccal, submandibular, and parapharyngeal spaces. Infection from one compartment, may spread to any of the other compartments.

• Masticatory spaces are divided into two by the ramus of mandible:-

• i. Lateral compartment

• ii. Medial compartment.

• Masticatory space is formed by splitting of investing fascia into superficial and deep layers around the masticatory muscles which define the lateral and medial extent of space

Masticator and Temporal Masticator and Temporal SpacesSpaces

• Formed by superficial layer of deep Formed by superficial layer of deep cervical fasciacervical fascia

• Masticator spaceMasticator space– Antero-lateral to pharyngomaxillary Antero-lateral to pharyngomaxillary

space.space.– ContainsContains

• MasseterMasseter• Pterygoids Pterygoids • Body and ramus of the mandibleBody and ramus of the mandible• Inferior alveolar nerves and vesselsInferior alveolar nerves and vessels• Tendon of the temporalis muscleTendon of the temporalis muscle

• Temporal spaceTemporal space– Continuous with masticator space.Continuous with masticator space.– Lateral border – temporalis fasciaLateral border – temporalis fascia– Medial border – periosteum of Medial border – periosteum of

temporal bonetemporal bone– Superficial and deep spaces divided Superficial and deep spaces divided

by temporalis muscleby temporalis muscle

• When the pus accumulates between the ramus of the mandible and the masseter muscle, it produces a submasseteric space abscess.

• Involvement :Infection usually originates from the lower third molars; either resulting from

(i) pericoronitis related to vertical and distoangular third molars, or

(ii) if a periapical abscess spreads subperiosteally in a distal direction

• The extension of abscess inferiorly is limited by the firm attachment of masseter to lower border of ramus of mandible. The forward spread beyond the anterior border of ramus is restricted by the anterior tail of the tendon of temporalis, which is inserted into the anterior border of the ramus.

MASTICATOR SPACE- APPLIED MASTICATOR SPACE- APPLIED ASPECTS. ASPECTS.

MASTICATOR SPACE- APPLIED MASTICATOR SPACE- APPLIED ASPECTS ASPECTS..

• Thrombophlebitis may ascend into the cavernous sinus.( post. Pathway of cavernous sinus thrombosis.)

• Pterygoid venous plexus in the region receives tributaries from trans facial vein which passes thru buccal space , so buccal space infections that erode into this vein, ascending thrombophlebitis of pterygoid plexus occurs


• Lesions which could present in this space-

Nerve sheath tumours

Mandibular & soft tissue

sarcomas

Dental tumours

Cysts & abscesses

Osteomyelitis

MASTICATOR SPACE- APPLIED MASTICATOR SPACE- APPLIED ASPECTS ASPECTS..

Hemangiomas

Lipomas

Rhabdomyosarcomas

Metastasis from oral mucosa & salivary

glands.


• Mandibular br. Of trigeminal N. exits the skull thru’ Foramen ovale which is located above the masticator space & has been termed as THE CHIMNEY OF MASTICATOR SPACE.

• Lesions can invade the middle cranial fossa by this route ,or intracranial lesion such as meningiomas can descend into masticator space & become extracranial.

SUBMASSETRIC SPACESUBMASSETRIC SPACE SURGICAL BOUNDARIESSURGICAL BOUNDARIES

• anterior- anterior border of masseter & buccinator

• posterior-parotid gland & post part of masseter

• Superior- attachment of parotidomesseteric fascia with lateral border of zygomatic arch.

• inferior-attachment of masseter to lower border of mandible, pterygomesseteric sling

• medial-lateral surface of ramus of mandible

• lateral-medial surface of masseter

• contents: masseteric nerve, superficial temporal artery, and transverse facial artery

CLINICAL FEATURESCLINICAL FEATURES

• External fascial swelling extending from the lower border of the mandible to the zygomatic arch; and anteriorly to the anterior border of masseter; and posteriorly to the posterior border of the mandible.

• Tenderness over the angle of mandible.

• LIMITATION OF MOUTH OPENING trismus is characteristic feature with minimal swelling.

• Pyrexia and malaise.

PTERYGOMANDIBULAR SPACEPTERYGOMANDIBULAR SPACE

• laterally-medial surface of ramus of mandible

• medially-lateral surface of medial pterygoid muscle

• posterior-parotid gland• anterior-pterygomandibular

raphae• superior-lateral pterygoid muscle.

Contents: Lingual nerve, mandibular nerve, inferior alveolar or mandibular artery. Mylohyoid nerve and vessels. Loose areolar connective tissue

Pterygomandibular spacePterygomandibular space

• Involvement • (i) The situation most frequently responsible

for involvement of this space, is the pericoronitis related to the mandibular third molar.

• (ii) Infection can also be produced by a contaminated needle used for an inferior alveolar nerve block.

• (iii) Infection, at times can originate from a maxillary third molar, following a posterior superior alveolar nerve block injection


• no much swelling of face• Trismus • tenderness over the area• dysphagia may be present• medial displacement of lateral wall of pharynx• redness & edema over 3rd molar area• midline of palate displaced to affected side,uvula swollen

& difficulty in breathing.

SpreadSpread

• Occasionally, infection may spread superiorly along the medial surface of ramus to involve the infra temporal fossa and beneath the temporal fascia.

• The infection can spread posteriorly to lateral pharyngeal space and then to retropharyngeal space.

• It can also spread around the front of the ramus of the mandible to involve the buccal space.

• It can also spread around the front of the ramus of the mandible extending anteroinferiorly below the lower border and under the superior constrictor to involve the submandibular space


• Submandibular, suprazygomatic, transoral approach

• Vertical incision- lateral & parallel to pterygomandibular raphe

Temporal space infectionTemporal space infection

• Is secondary to initial involvement of pterygopalatine and infratemporal space

• Surgical anatomy: two in number

• Superficial temporal space- lies between temporal fascia and temporalis muscle

• Deep temporal pouch is between the temporalis and skull

Superficial temporal spaceSuperficial temporal space

• Lies between temporal fascia

• Origin- zygomatic arch

• Termination- superficial temporal crest

BoundariesBoundaries

• Anterior- posterior surface of lateral orbital rim

• Posterior- fusion of temporal fascia with pericranium at posterior edge of temporalis

• Inferior- zygomatic arch

Clinical features• Pain and swelling in temporal region

• Trismus

Deep temporal spaceDeep temporal space

• Boundaries:• Lateral: temporalis muscle• Medial: squamous temporal bone

and skull base• Inferior: superior surface of lateral

pterygoid m.• Superior & posterior: attachment

of temporalis to cranium• Anterior: posterior wall of maxillary

sinus, pterygomaxillary fissure, posterior part of orbit, infraorbital fissure

• Contents: internal maxilary artery, trigeminal nerve(mandibular division)


• Incision- superior to zygomatic arch

• Blunt dissection through superficial and deep temporal fascia

• Intraoral- incision in superior aspect of posterior max. buccal vestibule

• Proceeds in supraperiosteal plane

Parotid SpaceParotid Space

Splitting of investing layer of Splitting of investing layer of deep cervical fasciadeep cervical fascia

• Superficial layer of deep Superficial layer of deep fasciafascia– Dense septa forms capsule Dense septa forms capsule

into glandinto gland– Direct communication to Direct communication to

parapharyngeal spaceparapharyngeal space

• ContainsContains– External carotid arteryExternal carotid artery– Posterior facial veinPosterior facial vein– Facial nerveFacial nerve– Lymph nodesLymph nodes

PAROTID SPACEPAROTID SPACE

• Capsule is thick on lateral surface , but is less well defined medially where the gland abuts the styloid process , carotid sheath in lateral pharyngeal space.

• Symptoms of the infection of parotid space - marked swelling of the angle of the jaw without associated trismus or pharyngeal swelling.

• symptoms of parotitis - pain and induration over the involved gland.

• Purulent secretions may sometimes be expressed after massage from the parotid depth.

Parapharyngeal spacesParapharyngeal spaces

• Lateral pharyngeal space

• Retropharyngeal spaces

Lateral pharyngeal spaceLateral pharyngeal space

• Boundaries:• Superiorly:base of skull, petrous

temporal bone• Inferiorly: hyoid, submandibular

gland, posterior belly of digastric• Anteriorly: pterygomandibular

raphe• Laterally: ascending ramus of

mandible, insertion of medial pterygoid, medial surface of deep parotid lobe

• Medially: pharyngeal constrictors• Posteriorly: stylohyoid muscle,

upper part of carotid sheath, prevertebral fascia

Lateral pharyngeal spaceLateral pharyngeal space

• Prestyloid Prestyloid – Muscular compartmentMuscular compartment– Medial—tonsillar fossaMedial—tonsillar fossa– Lateral—medial pterygoidLateral—medial pterygoid– Contains fat, connective Contains fat, connective

tissue, nodestissue, nodes

• Poststyloid Poststyloid – Neurovascular Neurovascular

compartmentcompartment– Carotid sheathCarotid sheath– Cranial nerves IX, X, XI, XIICranial nerves IX, X, XI, XII– Sympathetic chainSympathetic chain

PARAPHARYNGEAL SPACEPARAPHARYNGEAL SPACE

• A short layer of fascia runs from the ant layer of deep cervical fascia overlying the medial pterygoid across the styloid process & stylohyoid muscles to the buccopharyngeal fascia.

• This fascial condensation is called THE APONEUROSIS OF ZUCKERKANDL & TESTUT.


• Brawny induration of face above mandibular angle. It may extends to submandibular or parotid region

• Anterior part of lateral pharyngeal space may be swollen.it pushes soft palate & palatine tonsil towards midline

• Trismus, severe pain, dysphagia

PARAPHARYNGEAL SPACE -APPLIED PARAPHARYNGEAL SPACE -APPLIED ASPECTSASPECTS

• Infections can also spread from , pharyngitis, tonsillitis, parotitis, otitis , mastoiditis.

• Herpetic gingivostomatitis of pericoronal tissue can also cause abscess of this space.

• Ant . Comp. involvement –pain ,fever ,chills, medial bulging of lat pharyng walls . With deviation of uvula., dysphagia ,swelling below the angle of mandible. With trismus.

PARAPHARYNGEAL SPACEPARAPHARYNGEAL SPACE

• complications• Jugular vein thrombosis• carotid artery rupture and mediastinitis

Retropharyngeal SpaceRetropharyngeal Space

• Entire length of neck.Entire length of neck.

• Anterior border - pharynx and Anterior border - pharynx and esophagus (buccopharyngeal esophagus (buccopharyngeal fascia)fascia)

• Posterior border - alar layer of Posterior border - alar layer of deep fasciadeep fascia

• Superior border - skull baseSuperior border - skull base• Inferior border – superior Inferior border – superior

mediastinummediastinum– Combines with buccopharyngeal Combines with buccopharyngeal

fascia at level of T1-T2fascia at level of T1-T2

• Midline raphe connects superior Midline raphe connects superior constrictor to the deep layer of constrictor to the deep layer of deep cervical fascia.deep cervical fascia.

• Contains retropharyngeal nodes.Contains retropharyngeal nodes.

Retropharyngeal spaceRetropharyngeal space

c/f: acute throat infection, difficulty in deglutition, obstructive symptoms like snoring, choking, dyspnoea

Retropharyngeal space Retropharyngeal space infectionsinfections

• Retropharyngeal Abscess– 50% occur in patients 6-12

months of age– 96% occur before 6 years

of age– Children--fever, irritability,

lymphadenopathy, poor oral intake, sore throat

– Adults--pain, dysphagia, anorexia, snoring, nasal obstruction, nasal regurgitation

– Dyspnea and respiratory distress

– Lateral posterior oropharyngeal wall bulge


• Lateral pharyngeal space:

• Vertical incision parallel to pterygomandibular raphe

• Blunt dissection carried out along lateral to superior constrictor & medial to medial pterygoid

Retropharyngeal spaceRetropharyngeal space

• Horizontal incision in carotid triangle

• Dissection is directed to lateral aspect of thyroid cartilage medial to carotid sheath

• On entering the space, dissection carried almost to base of skull posterior to thoracic inlet.

Peritonsillar SpacePeritonsillar Space

• SuprahyoidSuprahyoid

• Medial—capsule of Medial—capsule of palatine tonsilpalatine tonsil

• Lateral—superior Lateral—superior pharyngeal constrictorpharyngeal constrictor

• Superior—anterior tonsil Superior—anterior tonsil pillarpillar

• Inferior—posterior tonsil Inferior—posterior tonsil pillarpillar

Presentation/OriginPresentation/Origin

• Peritonsillar Space– Fever, malaise

– Dysphagia, odynophagia

– “Hot-potato” voice, trismus, bulging of superior tonsil pole and soft palate, deviation of uvula

– Cause—extension from tonsillitis

Anterior Visceral SpaceAnterior Visceral Space

• Infrahyoid Infrahyoid

• aka – pretracheal spaceaka – pretracheal space

• Enclosed by visceral division of Enclosed by visceral division of middle layer of deep fasciamiddle layer of deep fascia

• Contains thyroidContains thyroid• Surrounds tracheaSurrounds trachea

• Superior border - thyroid Superior border - thyroid cartilagecartilage

• Inferior border - anterior Inferior border - anterior superior mediastinum down to superior mediastinum down to the arch of the aorta.the arch of the aorta.

• Posterior border – anterior wall Posterior border – anterior wall of esophagusof esophagus

• Communicates laterally with Communicates laterally with the retropharyngeal space the retropharyngeal space below the thyroid gland.below the thyroid gland.

Primary Maxillary SpacesPrimary Maxillary Spaces

• Infratemporal Space1.Location: posterior to the maxilla 2.Boundaries:

1. Medial: lateral plate of the pterygoid process of the sphenoid bone

2. Superior: skull base 3. Lateral: infratemporal space is continuous with the

deep temporal space

3.Rare involvement with odontogenic infections, but when occurs related to 3rd maxillary molar infections

• Primary maxillary space (canine, buccal, and infratemporal space) involvement can ascend to cause orbital cellulitis (preseptal or postseptal) or cavernous sinus thrombosis

1. Ocular findings include erythema and swelling of the eyelids, and ophthalmoplegia

2. Cavernous sinus thrombosis 1. Can result from hematogenous spread of odontogenic

infections 2. Bacterial routes of spread:

1. Posterior: via pterygoid plexus or emissary veins 2. Anterior: via angular vein and inferior or superior ophthalmic

veins to the cavernous sinus3. Veins of the face and orbit valve less so retrograde flow can

occur

• swelling of cheek,upper lip(vestibular abscess).

• obliteration of nasolabial fold.(pus accumulation in canine fossa).

• drooping of angle of mouth.• edema of lower eyelid;it indicates

pointing of abscess below medial corner

• a.extraoral early phase• usually on the first or second day,there

is an inflammatory enlargement of upper lip,and angle of the mouth is seen to drop. periorbital edema.

• late phase on 2nd or 3rd day• marked periorbital edema,forcing

eyelids to close.• redness and marked tenderness of the

facial tissues.• b.intraoral the offending tooth is

mobile or is tender to percussion.

Clinical features

palatal abcesspalatal abcess

cellulitiscellulitis

• Diffuse inflammation of connective tissue

• Diffuse, reddened, soft or hard swelling that is tender to palpation.

• Inflammatory response not yet forming a true abscess.

• Microorganisms have just begun to overcome host defenses and spread beyond tissue planes.

Difference bet’n cellulitis and abscessDifference bet’n cellulitis and abscess

Characteristic CellulitisDuration 3-7daysPain severe and generalisedSize largeLocalization diffusePalpation hard exquisitely tenderAppearance reddenedSkin quality thickenedSurface temp. HotLoss of function severeTissue fluid serosanguineous0 of seriousness severeBacteria mixed

AbscessOver 5 daysModerate and localisedSmallCircumscribedFluctuant and tender Peripherally reddenedCentrally underminedModerately heatedModerately severe PusModerateAnaerobic

Ludwig’s anginaLudwig’s angina

• ‘’Ludwigs angina’’

• ‘’Angina maligna’’

• ‘’Morbus strangulatorius’’

• ‘’Garotillo’’

• Ludwig’s angina is a firm, acute, toxic cellulitis of the submandibular and sublingual spaces bilaterally and of the submental space.

LUDWIG’S ANGINALUDWIG’S ANGINA

• Three ‘fs’ of Ludwig’s Angina became evident • feared• rarely fluctuant • often fatal

• The original description of the disease was given by Wilhelm Friedrich von Ludwig who was a court physician.

LUDWIG’S ANGINALUDWIG’S ANGINA

• Ludwig’s original description he emphasized that the angina

1. Is characterized by rapidly spreading gangrenous cellulitis.

2. Originates in the region of submandibular gland but never involves one single space and

3. Arises from extension by continuity and not by lymphatics and

4. Produces gangrene with serosanguinous, putrid infiltration but very little or no frank pus.

Ludwig’s anginaLudwig’s angina

• Ludwig’s angina– 1. Cellulitis, not abscess– 2. Foul serosanguinous fluid,

no frank purulence– 3. Fascia, muscle, connective

tissue involvement, sparing glands

– 4. Direct spread rather than lymphatic spread

• Tender, firm anterior neck edema without fluctuance

• “Hot potato” voice, drooling• Tachypnea, dyspnea, stridor


• pyrexia,dysphagia,impaired speech &hoarseness of voice.

• firm hard brawny swelling in bilateral submandibular & submental region.

• severe muscle spasm may lead to trismus with restricted mouth opening & jaw movements.

• airway obstruction• respiratory rate may be increased• dilation of alae nasi,raising of thoracic

inlet by scaleness & sternocliedomastoid muscle & indrawing of tissues above clavicle.

• cyanosis may occur due to hypoxia.• fatal death in untreated cases within

10 – 24 hours due to hypoxia.

INTRAORALLYINTRAORALLY

• swelling develops rapidly• distends or raises floor of

mouth.,woody edeme of floor of mouth & tongue.

• tongue raised against the palate• inc. salivation,stiffness of tongue• backward spread of infection leads to

edema of glottis,resulting in respiratory obstruction.

• oral opening &jaw movement limited.• progressive dyspnoea due to

backward spread of infection.

NECROTISING FASCITISNECROTISING FASCITIS

• More common in

chronic debilitated pts.

diabetes mellitus.

• Canine, sublingual and vestibular abscesses are drained intraorally

• Masseteric, pterygomandibular, and lateral pharyngeal space abscesses can be drained with combination intraoral and extraoral drainage

• Temporal, submandibular, submental, retropharyngeal, and buccal space abscesses may mandate extraoral incision and drainage

• Technique:1. Small incision are made in a dependent area 2. Placement of a hemostat in the abscess cavity with entry into

all loculations of the abscess3. Penrose drains inserted into cavity to allow for postoperative

drainage of the abscess

• Cavernous sinus thrombosis

• Brain abscess

• Meningitis

• Necrotizing fasciatis

• mediastinitis

Cavernous sinus thrombosisCavernous sinus thrombosis

Cavernous sinus thrombosisCavernous sinus thrombosis

• Ascending septic thrombophlebitis from anterior & posterior maxilla

• Sphenoidal or ethmoidal sinusitis

• Anterior route – angular vein (infraorbital space)

• Posterior route – facial vein (buccal space)

• Otitis media & mastoiditis through petrosal sinus

• Congestion retinal veins

• CN 6 paresis → ophthalmoplegia / blindness

Clinical findingsClinical findings

• Severe orbital / periorbital / infraorbital swelling

• Ptosis, proptosis, chemosis, occulomotor palsy

• Headache in frontal & retro-orbital areas

• Photophobia, eye pain, dysesthesia, generalized sepsis

Cavernous Sinus ThrombosisCavernous Sinus Thrombosis

• Treatment:

• Tooth extraction root canal• Drainage deep spaces• High dose IV antibiotics• Anticoagulation(heparinization)

Brain AbscessBrain Abscess

Risk Factors & PathophysiologyRisk Factors & Pathophysiology

DefinitionDefinition

• A focal, intracerebral infection that begins as a localized area of cerebritis

->a collection of pus surrounded by a well-vascularized capsule

~Clin Infect Dis. 1997 Oct;25(4):763-79

• The brain is remarkably resistant to bacterial and fungal infection:

-> abundant blood supply -> blood-brain barrier

Common Sources of Brain AbscessCommon Sources of Brain Abscess

1. Direct or indirect infection from paranasal sinuses, middle ear, and teeth (via valveless emissary veins to cavernous sinus)

2. Orbital infection, congenital heart disease, septic thrombi from SABE

3. Penetrating brain injury (low incidence)4. Metastatic seeding from distant

extracranial sources

microbiologymicrobiology

• Microbiology (Mampalam& Rosenblum, 1970-1986)• • 75% Aerobic (streptococcus viridans, s.hemolyticus

staph aureus,)• • 20% Anaerobes• • Immunosuppressed (Neurology 50(1): 1-17, 1997 – • HIV practice guidelines)• • toxoplasmosis (*most common CNS mass lesion)• • fungal• • mycobacterium• • Neonates:• • proteus

PREDISPOSING FACTORSPREDISPOSING FACTORS

• IV Drug Abuse (2.5%)

• Congenital heart disease (6.1%)

• HIV infection (1.2%)

• Immunosuppression (3.7%)

• Diabetes mellitus (3.1%)

StagesStages

1. Early cerebritis stage (D1-3):focal area of inflammation and edema

2. Late cerebritis stage (D4-9):development of a necrotic central focus

3. Early capsule stage (D10-14):ring-enhancing capsule of well-vascularized tissue with early appearance of peripheral fibrosis

4. Late capsule stage (>D14):host defenses lead to a well-formed capsule

~Clin Infect Dis. 1997 Oct;25(4):763-79

IMAGING STUDIESIMAGING STUDIES

1. Contrasted CT focal hypodensity-

>enhances after iv contrast->ring-enhanced lesion

Frequently located in watershed areas, regular thin-walled capsule with peripheral enhancement

Brain tumor: irregular border & diffuse enhancement

2. MRI

hyperintense central area of pus surrounded by a well-defined hypointense capsule

Patent Foramen Ovale as a Patent Foramen Ovale as a Possible Risk Factor of Brain Possible Risk Factor of Brain

AbscessAbscess ~Neurosurgery. 2001 Jul;49(1):204-6~Neurosurgery. 2001 Jul;49(1):204-6

may be a predisposing factor of brain abscess caused by may be a predisposing factor of brain abscess caused by hematogenous spread from a distant infectious focushematogenous spread from a distant infectious focus

• 1876: Sir William Macewen• Pyogenic Infectious Diseases of the Brain and Spinal

Cord, 1893.• First to propose operative management for brain abscess• Advocated abscess drainage• 1926: Walter Dandy (JAMA 87: 1477-1478, 1926)• First to advocate aspiration as primary treatment• • 1936: C. Vincent (Gaz. Med. Fr., 43: 93-96, 1936)• First to advocate complete excision as primary treatment• • 1971: Heinemann and Baude (JAMA 218: 1542-1547,

1971)• First to suggest medical management alone (cerebritis)• • 1975: Chow (West. J. Med., 122: 167-171, 1975)• First non-surgical cure of encapsulated abscess (Listeria)• • 1976-1980: publications advocate CT-guided stereotactic

aspiration

Surgical Excisionindications

• single abscess• • superficial location• • well-formed (capsule stage)• • especially for:• • traumatic, retained foreign body (J Neurosurg 28: 166- 168, 1968)• • recurrent infection• • fungal (J Neurol. Neurosurg. Psychiatr., 36: 758-768, 1973)• • risk of recurrence (within capsule wall).• Pressure in the brain continues or gets worse • The brain abscess does not get smaller after medication • The brain abscess might break open (rupture) • Surgery: aspiration & excision

Medical Therapy Indications

• known source/organism• • cerebritis > capsule stage• • good neurological status• • multiple abscesses• small size (1.5-3.0cm)• severe medical morbidities• Recommended Protocol• • weekly CT first 4 weeks• Then monthly until:• • lack of contrast enhancement• • off antibiotics for 2 weeks• • rescan in any clinical deterioration• • surgery if:• • increase in size at any time• • no change after 4 weeks of antibiotics• • continue abx for at least 6-8weeks

Obana & Rosenblum (Neurosurg Clin 3(2): 359, 1992)

• antibiotics like metronidazole, chloramphenicol, ceftriaxone

Steroids

• Useful for reduction of symptomatic mass effect caused by edema

• Rosenblum et al. (J Neurosurg 49: 658-668, 1978)• – NO relationship between presence or duration of

steroids and mortality (36 patients, retrospective, non-randomized review)

• • Mampalam & Rosenblum (Neurosurgery 23(4): 451-458, 1988)

• – Review of 102 cases (1970-1986)• – Steroids correlated with poorer neurological outcome• (worse initial neurological grade also)• • Rosenblum (Neurosurgery 36(1): 76-86, 1995)• – Review of 16 cases with multiple abscess• – Steroids did not correlate with outcome• • Takehsita et al. (Japan) Acta Neurochir 140: 1263-

1270, 1998)• – Review of 113 cases (1976-1995)• – 24 treated with steroids (all with impaired

consciousness and edema)• – Steroids did not correlate with outcome

meningitismeningitis

• Headache, fever, stiffness of neck. Vomiting, confusion, coma

• Kernig’s sign: strong passive resistance when attempt made to extend knees from flexed position

• Brudzinski’s sign: neck flexion in supine position resulting in involuntary flexion of knees

diagnosisdiagnosis

• Lumbar puncture to examine csf

• Fluid is opalescent or cloudy

• Contains polymorphonuclear cells, protein is increased, glucose is reduced

treatmenttreatment

• Penicillin G+Chloramphenicol

Necrotizing fascitisNecrotizing fascitis

• Necrotizing fasciitis is a soft tissue infection that causes necrosis of fascia and subcutaneous tissue, but spares skin and muscle initially.

• In 1952, Wilson first used the term

causecause

• Immunocompromise status

• Odontogenic, peritonsillar infection, burns, superficial cuts & abrasions, contusions, pyogenic skin lesions

microbiologymicrobiology

• Gram +ve hemolytic streptococci

• Peptostreptococcus, staph.pyogenes, bacteroides fragilis, clostridium perfringens, pseudomonas, enterobacter, prevotella, porphyrymonas sp.


• onset of symptoms- 2 to 4 days after the insult. The skin is smooth, tense and shiny with no sharp demarcation, and develops a dusky discoloration with poorly defined borders.

• localized necrosis of skin which is secondary to thrombosis of nutrient vessels as they pass through the zone of involved fascia.

• If untreated, this will progress to frank cutaneous gangrene. Clinically there is sudden pain and swelling and the skin becomes warm, erythematous, and edematous and can be mistaken for cellulitis.

• Three zones of skin are recognized.1)a wide peripheral zone of erythema surrounding a tender dusky zone,

• 2)central zone of necrosis that eventually ulcerates. There can be anesthesia of the skin from involvement of the cutaneous nerves as they pass through necrotic subcutaneous tissue. Soft tissue crepitance.

• low-grade fever . Massive amounts of fluid can be sequestered with resultant hyponatremia, hypoproteinemia, and dehydration.

• Hypocalcemia can develop from necrosis of subcutaneous fat.

• Mediastinitis: infection of the region within the thorax between the pleural sacs that is bounded by the diaphragm (inferiorly), the sternum and costal cartilages (anteriorly), and the thoracic vertebrae (posteriorly

causecause

• Deep anterior neck infection(via carotid sheath)

• Retropharyngeal, pretracheal space infection

• Esophageal, tracheobronchial perforation, extension of infection in pulmonary parenchyma, chest wall, vertebrae

Clinical PresentationClinical Presentation

• SymptomsSymptoms– Respiratory difficultyRespiratory difficulty– TachycardiaTachycardia– Erythema/edemaErythema/edema– Skin necrosisSkin necrosis– CrepitusCrepitus– Chest painChest pain– Back painBack pain– ShockShock

Mediastinitis ImagingMediastinitis Imaging

• Plain filmsPlain films– Widened mediastinum Widened mediastinum

(superiorly)(superiorly)– Mediastinal emphysemaMediastinal emphysema– Pleural effusionsPleural effusions– Changes appear late in the Changes appear late in the

disease.disease.

• CT neck and thorax.CT neck and thorax.– Esophageal thickeningEsophageal thickening– Obliterated normal fat planesObliterated normal fat planes– Air fluid levelsAir fluid levels– Pleural effusionsPleural effusions– CT helps establish dx and CT helps establish dx and

surgical plansurgical plan

TreatmentTreatment

– IV antibioticsIV antibiotics– Cervical drainageCervical drainage

• Cervical abscessesCervical abscesses• Superior mediastinal Superior mediastinal

abscesses above T4 (tracheal abscesses above T4 (tracheal bifurcation)bifurcation)

– Transthoracic drainageTransthoracic drainage• Abscesses below T4Abscesses below T4

– Subxyphoid approachSubxyphoid approach• Anterior mediastinal drainageAnterior mediastinal drainage

– Thoracostomy tubesThoracostomy tubes

Anatomy of Oral and Maxillofacial Infections

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