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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
anterior, maxillary
Canine
teeth, premolar
Maxillary 2nd / 3rd
Buccal molar Oral anaerobes
Mandibular 3rd molar
Mandibular anterior
Mental
teeth
SPACES INVOLVING ENTIRE NECK
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
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.
• 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.
• Communications-
ANTERIORLY- with submental space
POSTERIORLY - lateral pharyngeal 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
• 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.
sarcomas
Dental tumours
Cysts & abscesses
Osteomyelitis
MASTICATOR SPACE- APPLIED
ASPECTS.
Hemangiomas
Lipomas
Rhabdomyosarcomas
Metastasis from oral mucosa & salivary
glands.
MASTICATOR SPACE- APPLIED
ASPECTS.
• 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
• 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
• complications
• Jugular vein thrombosis
• carotid artery rupture and mediastinitis
Retropharyngeal Space
• Entire length of neck.
• 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
• 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
• 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
• Treatment:
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
• Plain films
– Widened mediastinum
(superiorly)
– Mediastinal emphysema
– Pleural effusions
– Changes appear late in the
disease.