Anatomy of oral and

maxillofacial infections
 contents
• 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 & 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 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 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
 Posterior layer

• Arises from spinous

processes and ligamentum
nuchae.
• Splits into two layers at the
transverse processes:
– Alar layer
• Superior border – skull
base
• Inferior border – upper
mediastinum at T1-T2
– Prevertebral layer
• Superior border – skull
base
• Inferior border – coccyx
• Envelopes vertebral
bodies and deep muscles
of the neck.
• Extends laterally as the
axillary sheath.
 Carotid Sheath
• Formed by all three layers of deep fascia
• Anatomically separate from all layers.
• Contains carotid artery, internal jugular vein, and vagus nerve
• “Lincoln’s Highway”(IJV thrombophlebitis & carotid artery erosion)
• Travels through pharyngomaxillary space.
• Extends from skull base to thorax.
•
 Classification 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)
• 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 classified
by 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
sublingual
SECONDARY FACIAL SPACES massetric
pterygomandibular
superficial and deep
temporal
lateral pharyngeal
retropharyngeal
prevertebral
Grodinsky & holoyoke(1938)
Potential pathways of extension of deep fascial space infections of the
head and neck
 Background
• 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
 Anticipated
Space Common portal entry
Bacteria
Spaces of the face
   

anterior, maxillary
Canine
teeth, premolar
Maxillary 2nd / 3rd
Buccal molar Oral anaerobes
Mandibular 3rd molar
Mandibular anterior
Mental
teeth
 SPACES INVOLVING ENTIRE NECK

Superficial Skin Staph. aureus

Oral anaerobes
Retropharyngeal Pharynx Strepto pyogenes
Staph aureus
Oral anerobes
from retropharyngeal,
Streptoc
Danger space prevertebral or lateral
pyogenes
pharyngeal infections
Staph aureus
Oral anaerobes
Prevertebral Pharynx Streptoc
pyogenes
from deep neck infection, Oral anaerobes
Visceral vascular especially post Streptoc
pharyngomaxillary pyogenes
 SUPRAHYOID SPACES
Mandibular 1st or 2nd
Submandibular
molar
Submental Anterior mandib teeth

Sublingual Mandib premolars

Oral anaerobes
Space of the body of Mandib premolars/
the mandible mandib 1st or 2nd molar
3rd molars, Secondary
Masticator
spread from adj spaces
Pharynx: Mastoditis
Lateral pharyngeal mandib molar extN , Strept pyogenes
spaceS
Oral anaerobes
Peritonsillar Pharynx
Strept pyogenes
Parotid Stensen’s duct Staph aureus
 INFRAHYOID SPACES.

Pharynx, trauma to
Pretracheal Oral anaerobes
esophagus / larynx
Vestibular space
 Canine space
SURGICAL 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.

• .

24
CANINE SPACE - APPLIED 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.
CANINE SPACE - APPLIED ASPECTS.
CANINE SPACE - APPLIED ASPECTS.

• 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 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 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
mandibular odontogenic infections
• Space of body of mandible:
• Originate in mandibular molar and
premolar teeth
• Borders- periosteal envelope and cortical
surface of bone.
 Sublingual 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.
 Clinical features
• 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 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 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 treatment
• Incision along lateral and parallel to
submandibular duct
• Avoids injury to lingual, hypoglossal n.
sublingual artery, submandibular duct,
sublingual gland.
 Submandibular 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 SPACE

• Present posterolateral to sublingual space

• Separated from it by fibers of mylohyoid
muscle.
SUBMANDIBULAR SPACE APPLIED
ASPECTS

• 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.
 Clinical features
• 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.
 Surgical treatment
• 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 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 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.
 Surgical treatment
• Incision in midline of neck parallel or within
neck crease inferior to abscess.
 Masticator 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
Spaces
• Formed by superficial layer of deep
cervical fascia

• Masticator space
– Antero-lateral to pharyngomaxillary
space.
– Contains
• Masseter
• Pterygoids
• Body and ramus of the mandible
• Inferior alveolar nerves and vessels
• Tendon of the temporalis muscle

• Temporal space
– Continuous with masticator space.
– Lateral border – temporalis fascia
– Medial border – periosteum of
temporal bone
– Superficial and deep spaces divided
by 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
ASPECTS.
MASTICATOR SPACE- APPLIED
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
MASTICATOR SPACE- APPLIED
ASPECTS.
• Lesions which could present in
this space-
Nerve sheath tumours
Mandibular & soft tissue

sarcomas
Dental tumours
Cysts & abscesses
Osteomyelitis
MASTICATOR SPACE- APPLIED
ASPECTS.
Hemangiomas
Lipomas
Rhabdomyosarcomas
Metastasis from oral mucosa & salivary
glands.
 MASTICATOR SPACE- APPLIED
ASPECTS.

• 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 SPACE
SURGICAL 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 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 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 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
 CLINICAL FEATURES
• 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.
 Spread

• 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
 Surgical treatment

• Submandibular,
suprazygomatic,
transoral approach
• Vertical incision-
lateral & parallel to
pterygomandibular
raphe
 Temporal 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 space
• Lies between
temporal fascia
• Origin- zygomatic
arch
• Termination-
superficial temporal
crest
 Boundaries
• 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 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)
 Surgical treatment
• 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 Space
Splitting of investing layer of
deep cervical fascia
• Superficial layer of deep
fascia
– Dense septa forms capsule
into gland
– Direct communication to
parapharyngeal space

• Contains
– External carotid artery
– Posterior facial vein
– Facial nerve
– Lymph nodes
 PAROTID 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 spaces
• Lateral pharyngeal space
• Retropharyngeal spaces
 Lateral 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 space

• Prestyloid
– Muscular compartment
– Medial—tonsillar fossa
– Lateral—medial pterygoid
– Contains fat, connective
tissue, nodes
• Poststyloid
– Neurovascular
compartment
– Carotid sheath
– Cranial nerves IX, X, XI, XII
– Sympathetic chain
 PARAPHARYNGEAL 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.
 Clinical features
• 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
ASPECTS

• 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 SPACE

• complications
• Jugular vein thrombosis
• carotid artery rupture and mediastinitis
 Retropharyngeal Space
• Entire length of neck.

• Anterior border - pharynx and

esophagus (buccopharyngeal
fascia)
• Posterior border - alar layer of
deep fascia
• Superior border - skull base
• Inferior border – superior
mediastinum
– Combines with buccopharyngeal
fascia at level of T1-T2

• Midline raphe connects superior

constrictor to the deep layer of
deep cervical fascia.

• Contains retropharyngeal nodes.

 Retropharyngeal space
c/f: acute throat infection, difficulty in
deglutition, obstructive symptoms like
snoring, choking, dyspnoea
 Retropharyngeal space
infections
• 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
 Surgical treatment
• Lateral pharyngeal
space:
• Vertical incision
parallel to
pterygomandibular
raphe
• Blunt dissection
carried out along
lateral to superior
constrictor & medial
to medial pterygoid
 Retropharyngeal 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 Space
• Suprahyoid

• Medial—capsule of
palatine tonsil
• Lateral—superior
pharyngeal constrictor
• Superior—anterior tonsil
pillar
• Inferior—posterior tonsil
pillar
 Presentation/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 Space
• Infrahyoid • Superior border - thyroid
cartilage
• aka – pretracheal space • Inferior border - anterior
superior mediastinum down to
• Enclosed by visceral division of the arch of the aorta.
middle layer of deep fascia
•
• Posterior border – anterior wall
Contains thyroid
•
of esophagus
Surrounds trachea
• Communicates laterally with
the retropharyngeal space
below the thyroid gland.
 Primary Maxillary Spaces
• Infratemporal Space
1. 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 sinus
3. Veins of the face and orbit valve less so retrograde flow can
occur
 Clinical features

• 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.
palatal abcess
 cellulitis
• 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 abscess

Characteristic Cellulitis Abscess

Duration 3-7days Over 5 days
Pain severe and generalised Moderate and localised
Size large Small
Localization diffuse Circumscribed
Palpation hard exquisitely tender Fluctuant and tender
Appearance reddened Peripherally reddened
Skin quality thickened Centrally undermined
Surface temp. Hot Moderately heated
Loss of function severe Moderately severe
Tissue fluid serosanguineous Pus
0 of seriousness severe Moderate
Bacteria mixed Anaerobic
 Ludwig’s angina

• ‘’Ludwigs angina’’ • Ludwig’s angina is a

• ‘’Angina maligna’’
• ‘’Morbus strangulatorius’’
• ‘’Garotillo’’
firm, acute, toxic
cellulitis of the
submandibular and
sublingual spaces
bilaterally and of the
submental space.
 LUDWIG’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 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 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
 CLINICAL FEATURES

• 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.
 INTRAORALLY

• 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 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 abscess
3. Penrose drains inserted into cavity to allow for postoperative
drainage of the abscess
• Cavernous sinus thrombosis
• Brain abscess
• Meningitis
• Necrotizing fasciatis
• mediastinitis
Cavernous sinus thrombosis
 Cavernous 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 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 Thrombosis

• Treatment:

• Tooth extraction root canal

• Drainage deep spaces
• High dose IV antibiotics
• Anticoagulation(heparinization)
 Brain Abscess
Risk Factors & Pathophysiology
 Definition
• 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 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
 microbiology
• 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 FACTORS

• IV Drug Abuse (2.5%)

• Congenital heart disease (6.1%)
• HIV infection (1.2%)
• Immunosuppression (3.7%)
• Diabetes mellitus (3.1%)
 Stages
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 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
Possible Risk Factor of Brain
Abscess
~Neurosurgery. 2001 Jul;49(1):204-6

 may be a predisposing factor of brain abscess caused by

hematogenous 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 Excision
indications
• 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: Obana & Rosenblum (Neurosurg
• • increase in size at any time Clin 3(2): 359, 1992)
• • no change after 4 weeks of antibiotics
• • continue abx for at least 6-8weeks
• 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
 meningitis
• 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
 diagnosis
• Lumbar puncture to examine csf
• Fluid is opalescent or cloudy
• Contains polymorphonuclear cells, protein
is increased, glucose is reduced
 treatment
• Penicillin G+Chloramphenicol
 Necrotizing 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
 cause
• Immunocompromise status
• Odontogenic, peritonsillar infection, burns,
superficial cuts & abrasions, contusions,
pyogenic skin lesions
 microbiology
• Gram +ve hemolytic streptococci
• Peptostreptococcus, staph.pyogenes,
bacteroides fragilis, clostridium
perfringens, pseudomonas, enterobacter,
prevotella, porphyrymonas sp.
 Clinical features
• 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
 cause
• Deep anterior neck infection(via carotid
sheath)
• Retropharyngeal, pretracheal space
infection
• Esophageal, tracheobronchial perforation,
extension of infection in pulmonary
parenchyma, chest wall, vertebrae
 Clinical Presentation
• Symptoms
– Respiratory difficulty
– Tachycardia
– Erythema/edema
– Skin necrosis
– Crepitus
– Chest pain
– Back pain
– Shock
 Mediastinitis Imaging

• Plain films
– Widened mediastinum
(superiorly)
– Mediastinal emphysema
– Pleural effusions
– Changes appear late in the
disease.

• CT neck and thorax.

– Esophageal thickening
– Obliterated normal fat planes
– Air fluid levels
– Pleural effusions
– CT helps establish dx and
surgical plan
 Treatment
– IV antibiotics
– Cervical drainage
• Cervical abscesses
• Superior mediastinal
abscesses above T4 (tracheal
bifurcation)
– Transthoracic drainage
• Abscesses below T4
– Subxyphoid approach
• Anterior mediastinal drainage
– Thoracostomy tubes