Fascial spaces

• Fascia: it's continuous .layer of dense C.T. that envelop, support and
separate structures
• Fascial spaces:
• They are Potential spaces between fascial layer.
They become true space with pus accumulation or emphysema
• Cervical fascia consists of:
a- Superficial cervical fascia

b- Deep cervical fascia: that is devided into

1-Superficial layer : envelope neck, masseter ms, parotid gland ,

submandibular gland

2- Middle layer --Sterno- hyoid-omohyoid and visceral e.g. around

pharynx,larynx, trachea and oesophagus.

3-- Deep layer ---- e.g. prevertebral fascia

N.B Carotid sheath is called (Lincoln's highway).

• Importance of Fascia:
• 1- Invest
• 2- Support
• 3- Protect
• 4- Directing the spread of infection
• 5- Surgical orientation
• Pus-forming infections spread from potential space to potential
space by:
• 1- Direct expansion and/or
• 2- Destruction of boundaries
• Barriers that control spread of infection are:
• 1- Bone
• 2- Muscles
• 3- Heavy Fascia
• 4- Large vessels / Nerves
• 5-Skin
• Fascial spaces
Fascial spaces are either

1. Clefts: if they only contain loose alveolar tissue or

2. Compartments: if they contain named neurovascular structures

Primary spaces: are involved directly

Secondary spaces: are involved when infection spreads into them

beyond primary spaces and secondarily.
1ry spaces (Direct spread from ADAA 2ry spaces (Indirect spread)

Masticator spaces:
Vestibular space / Palatal space
Submasseteric
Canine space
 Pterygomandibular
Buccal space
Temporal (Superficial' and
Infratemporal Space
deep)

Submental space Lateral pharyngeal

Submandibular space Retropharygeal
Sublingual space Danger space (Space 4)
Maxillary spaces infection
Abscess of Base of Upper Lip
Anatomic Location. This abscess develops at the loose connective
tissue of the base of the upper lip at the anterior region of the maxilla,
beneath the pearshaped aperture
Etiology. It is usually caused by infected root canals
of maxillary anterior teeth.
Clinical Presentation.
1-swelling and protrusion of the upper lip,
2-diffuse spreading and obliteration of the depth of the mucolabial fold
3-pain and constitutional symptoms
Treatment. The incision for drainage is made at the
mucolabial fold parallel to the alveolar process
• Complication
• Cavernus sinus thrombosis, through angular or ophthalmic vein
• Differential diagnosis
• TRAUMATIC OEDEMA
• ALLERGY
• NEOPLASM
• NORMAL FLESHY LIP
• LYMPHANGIOMA
 Canine Fossa Abscess
• Etiology. Infected root canals of premolars ,canines and occasionaly
from the mesial root of the first molar

• Boundaries

• Anteriorly levator labii superioris and orbicularis oris anteriorly

• Posteriorly buccinators muscle

• Lateraly zygomaticus muscle and levator anguli oris

• Clinically

• 1- obliteration of nasolabial fold

• 2- swelling of the upper lip

• 3- edema of the upper and lower eye lids

• 4- the entire face is painful to touch

• 1. incision and drainage parallel to max. vestibule of affected tooth.
• 2- Extraction or R.C.T.
• 3- Antibiotics to avoid cavernous sinus thrombosis as angular vein
(branch of facial vein) courses through canine space
 Buccal Space Abscess
• Anteriomedialy : buccinators muscle
• Posteromedially : medial ptrygoid, ramus of the mandible and
masseter
• Laterally skin, superficial fascia. platysma. Deep cervical fascia
• Above : zygomatic arch
• Below: lower border of the mandible
• Contents
• 1-buccal pad of fat

• 2-facial artery vein nerve

• 3-Buccal lymph nodes

• 4- stensen duct
• Pathological development of buccal space
• From infected upper 2nd and 3rd molars and lower 1st and 2nd molar
• Clinically
• 1- intraoral bulging
• 2- extraoral swelling confined to the cheek
• 3-sever pain
• The intraoral incision is made at the posterior region
of the mouth, in an anteroposterior direction and very
carefully in order to avoid injury of the parotid duct.
A hemostat is then used to explore the space thoroughly.
An extraoral incision is made when intraoral access
would not ensure adequate drainage, or when the pus
is deep inside the space. The incision is made approximately 2 cm below
and parallel to the inferior border of the mandible
Infratemoraltemporal space infection( post
zygomatic space)
• It is fatal space where infection can be transmitted to
the cavernus sinus through inferior and superior
ophthalmic vein or directly through foramen oval or
lacerum
• Boundaries
• Anteriorly
• Posterior surface of maxilla and that of zygomatic process
• Posteriorly
• Parotid gland
• Laterally
• Inner surface of the zygomatic arch
• Ramus of the mandible . Coronoid process and temporalis muscle
• Medially pterygoid plate , lateral pterygoid muscle, superior constrictor
muscle
• Superiorly : infratemporal surface of sphenoid bone
• Contents of infratemporal fossa
-Lateral pterygoid muscle
-Ptrygoid plexus of vein
-Mandibular nerves and its branches
-Lingual nerve
-
• Long buccal nerve
•-Mylohyoid nerve
•-Maxillary artery and vein
•Otic ganglion and its roots
•Chorda tympani nerve
• Pathological development of infratemporal abcess

• 1- infection from maxillary molars specially 3rd molar

• 2-osteomyelitis of the assending ramus ,condyle or coronoid process

• 3- local anaesthesia of maxillary nerve or posterior superior alveolar

nerve

• 4-ascending infection from ptrygomandibular space

• Signs and symptoms
• 1-sever pain on opening

• 2- trismus

• 3-swelling of the pharynx

• 4-deviation of the mandible to the affected site on opening

• 5- if the cause is the upper molars there is swelling of the upper eye lids

• 6- if untreated the whole side of the face is involved , the eye closed
• Treatment. The incision for drainage of the abscess can be made
intraorally or extraorally by performing a superficial incision followed
by blunt evacuation of pus using hemostat
• Intraoral incision
• 1- Incision is performed medial and parallel to the medial aspect of
the ascending ramus
• 2-or incision is made in the mucobuccal fold lateral to upper 3rd
molar and curved hemostat is introduced and advanced behind the
tuberosity and the directed medially and superiorly into the abcess
cavity then drains inserted
• Extra oral incision
• 3 cm long incision is performed at the angle formed by the fontal and
temporal processes of the zygomatic bone the incisons carried in the
hair line through the skin and superfacial and deep temporal fascia
the blunt dissection completed by curved hemostat into infratempral
space then rubber dam drain is inserted
Temporal space infection
• Superficial temporal space
Superficial to temporalis muscle
• Deep temporal space
Deep to temporalis muscle
Pathogenesis
Infected maxillary molars
Sign and symptoms
Swelling tenderness above temporal region
Trismus
• Incision and drainage
• Hair line of temporal region
palatal Abcess
• Pathogenesis
infected roots lateral incisor or palatal roots of upper posterior teeth
infected cyst
• Signs and symptoms
• Globular tender swelling slightly elevated ,factuation is difficult to
elicit due to thick firmly attached mucoperiostium
• Incision and drainage
Must be in anteroposterior palatal direction and at the alveolar rather
than paltal mucosa to avoid injury to greater palatine artery
Mandibular abcesses
Submandibular space infection
• it lies below mylohyoid muscle and it is located below and medial to
the posteror part of the mandible
• Boundaries
• Medially
Mylohyoid muscle and hyoglossus muscle
superior laterally
Medial aspect of the mandible and mylohyoid ridge
Inferolaterally
Investing layer of deep cervical fascia ,platysma, superfacial facia skin
• Inferiorly

The hyoid bone ,intermediate tendon of digastric muscle

Anterior

Anterior belly of digastric

Posteriorly

Posterior-belly of digastric , stylohyoid muscle , and stylomandibular

ligament that separate submandibular space from parotid space
• Pathological development of submandibular space

• 1- infected mandibular molars with roots below mylohyoid muscle

• 2- mandibular fracture

• 3-osteomyelitis

• Contents

• 1- submandibular gland ,warton,s duct lymph nodes

• 2-Facial artery

• 3- facial vein
• Clinical signs and symptoms

• 1- swelling and obliterating the angle of the mandible

• 2-pain and tenderness on palpation

• 3- dysphagia

• 4- trismus

• 5-severe cases show systemic signs and symptoms as fever malaise

,tachycardia
• Differential diagnosis

• 1- submandibular sialadenitis

• 2- submandibular salivary gland tumor

• 3- branchial cleft cyst

• 4-lymphoma

• 5-leukemia

•
• Treatment

• Incision 15- 2 cm below the lower border of the mandible , through the
skin superfacial facia then followed by blunt dissection using hemostat
then drain is inserted
Submasseteric space infection
• Anatyomy
• Medially
• Lateral surface of the ramus of the mandible
• Lateral
• Masseter muscle
• Posteriorly
• parotid gland
• Pathologucal development
• 1- periapical infection from lower third molar
• 2- pericoronitis
• 3- ramus fracture
• Signs and sympptoms

• 1-deeply seated' severe throbbing pain over the mandibular ramus of

sudden onset

• 2-, swelling of the soft tissues of the face

• 3-trismus.

• 4-The temperature remains high until drainage is established,

• 5-patient becomes toxic-

• Treatment:
• Through an intra-oral incision not less than 3 cm down the anterior
border of the ramus , starting from the coronoid process , till the
buccal sulcus opposite the second molar, a curved hemostat is
inserted and passed backward and upward while keeping in close
contact with the external surface of the bone
• 2-an extraoral incision
• is made beneath the angle of the mandible and the ramus is
exposed . The lower part of the masseter muscle is then detached
which allows pus to drain A rubber drain is inserted next and attached
to the skin of the wound'
Abscess of sublingual spaces:

• The sublingual spaces are separated in the mid-line

by a dense fascia median raphe they are situated
above the mylohyoid muscle.
• Boundaries

• Above: The mucous membrane of the floor of the mouth.

• Below: Mylohyoid muscle.

• Medially: Fascia median raphe.

• Antro-laterally: the lingual surface of the body of the mandible.

Posteriorly: The hyoid bone
• Each space is divided into two spaces:

• 1. Superficial: situated between mylohyoid and geniohyoid muscles'

2.Deep: Beteen geniohyoid and genioglossus muscles.
• contents:

• - Deep part of submandibular gland

• -Submandibular gland duct (Wharton's duct).

• - Sublingual gland.

• - Lingual nerve.
• Hypoglossal nerve

• hyoglossus muscle

• Genioglossus muscle

• Terminal branches lingual artery

• Pathologic development of sublingual abscess

• 1-from an infected tooth, progressing toward the lingual side of the jaw,
the infection emerges above the mylohyoid muscle.

• 2-infection extended from other spaces primarily the submandibular

space.
• Signs and symptoms –

• Firm, painful swelling which raises the floor of the mouth

• . The tongue is displaced medially and backwards.

• - The sublingual glands are prominent

• - Painful difficult swallowing (dysphagia).

• - Systemic signs and symptoms in severe cases. - Little evidence of

swelling of the face unless the submandibular space involved
• Treatment:
• - The incision should be made at the base of the alveolar process of the
mandible in the lingual sulcus so that the sublingual gland, the lingual
nerve, and the submandibular duct will not be injured
 Abscess of sub-mental space
• Boundaries
• Superior:
• Mylohyoid muscle.
• Inferior: Investing layer of deep cervical fascia, platysma, superficial
fascia and skin
• Lateral: Anterior belly of digastric muscle, separating the sub-mental
space from the submandibular space.
• Antro-laterally: lingual surface of the mandible
• Posteriorly hyoid bone
• Contents of sub-mentat space: -

Sub-mental lymph nodes.

- Anterior jugular vein.

- Communications:

- Submental abscess may extend to the sub_mandibular space and

infection may travel from one to the other
• Clinical signs and symptoms : -

• general cellulitis of the sub-mental region first this board like and stiff
until suppuration

• Dysphagia. –

• The infection may extend to the epiglottis and causes difficulty in

breathing.

• - General signs of sepsis as fever, malaise etc

• Treatment
• Sub-mental abscesses incised below the mandible. Generally, a
transverse incision which follows the normal folds of the skin
• Differential diagnosis of submental abscess:
• - Dermoid cyst.
• - Thyroglossal duct cyst
• - Chronic inflammatory lymph nodes
 5. Abscess Pterygomandibular space.

• It is the lowest part of the infra temporal space

• Boundaries .
• Laterally: Medial surface of the ramus
• Medially: Medial pterygoid muscle.
• Above: lateral pterygoid muscle.
• Anteriorly: the pterygomandibular raphe
• Posteriorly: the deep lobe of the parotid gland
• Contents:

• Lingual nerve.

• Inferior dental nerve.

• Inferior dental vessels.

• Internal maxillary artery.

• Posterior temporal artery.

• Pterygoid plexus of veins surrounding the inferior head of the lateral

pterygoid muscle
AN: inferior alveolar nerve, LN: lingual nerve, LPM: lateral pterygoid muscle, MA: maxillary artery,
MPA: medial pterygoid muscle, NM: nerve to mylohyoid
Pathologic development of Pterygomandibular space abscess:

- Septic mandibular nerve block"

- Acute pericoronitis around mandibular

third molar.

- Apical infection of mandibular molar teeth

- Gun shot wounds or compound fracture of

the angle of the mandible.

- Inferior dissection of pus from the infratemporal space

• Signs and symptoms:
- Severe trismus

- Moderate extra-oral swelling over the submandibular region.

- Swelling of the oral mucous membrane overlying the space with medial
displacement of the lateral pharyngeal wall
• Tenderness and pain on palpation over the medial aspect of the ramus.

• - Dysphagia.

• - General constitutional symptoms.

• - Air hunger posture if bilateral infection 0ccurs

• - May be displacement of the edematous uvula to the opposite side.

• Treatment (lncision and drainage): Incision and drainage can be carried
out through intra-oral approach or extra_oral approach.

• lntra-oral approach

• Incision is made just medial to the anterior border of the ramus. The
tissues medial to the ramus is bluntly dissected with curved hemostat.
rubber dam drain is inserted loosely and sutured in place with (000)
black si1k.
• Extra-oral approach Skin
• incision 4 cm long is carried out through skin and sub cutaneous
tissue in a curved fashion below and behind the angle of the
mandible. Blunt dissection with a hemostat. Rubber dam drain is
inserted.
6. Abscess of parapharyngeal space:

• Shape:
• The space is inverted cone; its base is the skull and its apex at ihe
hyoid bone.
• Laterally: Medial pterygoid muscle.
• Medially: superior consgictor muscle.
• Posteriorly: parotid gland, prevertebral and visceral layers of the deep
cervical fascia.
• Superiorly: base of the skull base of the sphenoid
• Inferiorly: the parapharyngeal space is bounded by the attachment of
the capsule of the submandibular gland to the sheath of the stylohyoid
muscle and posterior belly of digastric muscle
• Communications:
• 1-The pterygomandibular space communicates with the parapharyngeal
space around the anterior and posterior borders of the medial pterygoid
muscle.
• 2-infection of this space may disseminate upward through various
foramina at the base of the skull, producing brain abscess, meningitis
or cavernous sinus thrombosis.
• 3- Infection may travel downward along the carotid sheath toward the
mediastinum and may descend to the lungs causing lung abscess
• 4- ThromboPhlebitis‘
• 5 - Arterial erosion'
• Contents: -
• Deep cervical lymPh nodes'
• - Facial artery.
• - Ascending Pharyngeal artery‘
• - Carotid -sheath (internal carotid artery' internal jugular vein and vagus
nerve)'
• - GlossoPharyngeal nerve'
• - Hypoglossal nerve'
• - Acessory nerve‘
• - Cervical sympathetic trunk'
• Pathotogic development: . –
• 1-acute infection around a mandibular third molar

• 2- - Extention from a pterygomandibular abscess.

• 3 - peri-tonsillar suppurailon may erode the superior pharyngeal

constrictor the lateral pharyngeal space
• Clinical signs and symptoms:
• 1- severe pain in the affected side his referred to the ear, face or neck‘

• 2- (dysphagia)'

• 3-- Severe trismus

• 4-Swelling of the lateral wall of the pharynx and medial displacement of the
tonsils' tonsillar Pillar and the uvula‘

• 5- firm, tender and indurated external swelling may be observed beneath

the angle of the mandible

• -6- the constitutional symptoms are generally present such as fever' malaise'
rapid Pulse .. etc
• Treatment:

• The treatrnent consists of antibiotics' surgical drainage and

tracheostomy' Incision and drainage may be carried out extra-or intra-
orally

• lntra-oral lncision: Vertical incision is made in the retromolar ang1e,

lateral and parallel to the pterygomandibular fold, Acurved hemostat
is introduced medial to the medial. pterygoid muscle to evacuate the
pus present in the para pharyngeal space' A drain is then inserted
• Extra-oral incision: Extra-oral incision is considered safer since there is
no danger of aspiration of pus and pulmonary complication' The
extra-oral incision is the same as that used for drainage of the
submandibular space
 7. RetroPharyngeal space:

• The retro pharyngial space , lies between the posterior wall of the
pharynx and the prevertebal fascia. The loose areolar cornective tissue
which exists here not only permits pharyngeal movement, but allows
infection to travel inferiorly to to the posterior mediastinum as far as
the diapohragm 'and superiorly to the base of the skull adequate
drainage of the retro-pharyryngeal spaces are together considered as
parapharyngeal space'
8. Abscess of Parotid space
• Boundaries
• It is surrounded medially and laterally by deep servical fascia that
form parotid capsule
• Etiology:
• a- Retrograde infection through the duct.
• b- Blood born infection.
• c- Posterior spread from submasseteric or pterygomand Spaces
• d- Mastoiditis and otitis media
• E- fracture of assending ramus
• Contents: -
• -superficial and deep portion of the parotid gland.
• - Stenson's duct.
• - Portion of the facial nerve'
• - Posterior facial vein'
• - AuriculotemPoral nerve‘
• - Superficial temporal artery‘
• - External carotid artery
• - Parotid lymph nodes'
• - Internal maxillary artery'
• Signs and symptoms
• Swelling of the parotid region with eversion of ear lobules
• The patient complains of. pain in the parotid region which is referred
to the ear and temporal area'
• -pain on eating or swallowing
• Pus oozing from parotid papilla
• Lymphadenitis
• Fever malaise
• Differential diagnosis
• Mumps.
• sialolithiasis,
• cyst and tumors affecting the Parotid gland' –
• submassetenc space' –
• Fracture of the ascending ramus of the mandible
• Treatment: Abscess of the parotid space requires an extra oral approach
,is best drained by Blair incision, this extends around the angle of the jaw
from behind the posterior border of the and forward 2 cm below the
bone
9. Abscess of carotid sheath:
• Carotid sheath is fascial condensation surrounding IJV, vagus nerve,
ECA, ICA. It lies below the sterno-mastoid muscle, and the part most
commonly affected lies above the posterior belly of the omohyoid
Muscle.

• Source of infection :- from - Submandibular space - Infratemporal

space - Parapharyngeal space ,parotid space
• Clinical features :-
• 1- pain along the course of carotid sheath
• 2- Intermittent bleeding episodes from nose or pharynx due to
erosions of carotid artery or IJV.
• 2- Palsies of cranial nerves X, XI, XII
• 3- Enlarging hematoma in neck
• 4- Pyrexia, chills, malaise.
• treatment

• incision and Drainage through incision along anterior border of

sternocleidomastoid muscle. Extern al jugular vein can be explored. .if .it
shows evidence of being indurated and thrombosed, it should be ligated
below the lowest limit of its involvment to prevent further descent of the
infection
 Ludwig’s angina

• Definition:-
• It is indurated baord like fascial cellulitis that involving
submandibular, submental, and sublingual spaces bilaterally
• Etiology
- infection of the mandibular molars.
- Compound fracture of the mandibular angle or body.
- Penetrating injury ofthe floor of the mouth.
- Osteomyelitis of the mandible
• Types:-
• (1) Non Suppurative:
--Induration broad likes.
-No tendency for localization of pus.
- Poor prognosis.
(2) Suppurative:-
- Have few drops of pus.
- Tendency for localization of pus.
- Better prognosis.
• True Ludwig's Angina:

• There is bilateral involvement of submandibular, sublingual and sub-

mentaL spaces.

• Pseudo-Ludwi g's An gina:

• There is unilateral involvement of submandibulaR sublingual and sub-

mental spaces.
• Bacteriology:

• Ludwig's Angina caused by mixed infection, mainly hemolytic

streptococci and mixture of aerobic gram -ve microorganisms
including fusiform bacilli, Vincent's organisms and various
staphylococci.
• Clinical signs and symptoms
• 1-brawny non-fluctuant, tender swelling which spreads to the sub-
mental region involving either the sub-mental or the sublingual space
or both
• 2-The patient has open mouth appearance due to swelling and
elevation of the floor of the mouth,
3-and wooden raised hard tongue
• 4-- Displace epiglottis posteriorly
• 5 difficult breathing.
• 6- Dysphagia and
• 7-difficult speech. –
8-Difficulty of breathing due to :

- a- elevated tongue

b- laryngeal edema

c- epiglottic edema

9 Lymphadenopathy

10- Fever, malaise

GENERAL THERAPEUTIC PROCEDURES OF PATIENT
WITH ACUTE INFECTION INCLUDING LUDWIG'S
ANGINA:
• - General supportive measures
• - Massive antibiotics'
• - Sedative.
• - Heat therapy
• - Incision and drainage‘
• - Removal of the cause'
• - Post operative care‘
• - Tracheostomy, if there is respiratory embarrassment
• 1-General supportive measures include
- hospitalization.
- Complete bed rest'
- Adequate fluid intake to compensate dehydration. It should be
remembered that the patient may be dehydrated because of the fever
and inability to swallow
- Hydration can be done by oral rout or by intravenous infusion
- 2-Adequate nourishment
- Diet must be rich in carbohydrate ,proteins and vitamins if
- oral rout is difficult drip methods can be used using IV PROTEINS AS
PANAMINES or amigens
• 3-Antibiotics
• 1- empirical dose
• 2- antibiotics after culture sensitivity tests
• 4-Sedatives: Sedatives and analgesics should be administered because the
relieve the pain dfecrease anxiety of the patient and help fast recovery
• 4-Heat therapy
• Heat is applied intra-orally and extraorally
• 5-lncision and drainage
Surgical treatment (I &D) must be instituted without delay
1-to avoid:
- mediastinitis.
- Suffocation due to Iaryngeal compression or glottic edema.
-Considerable tissue loss due to pressure necrosis
• 2-It must be done early for
• a- Release tension and pressure of edema on airway.
• b- Allow for drainage.
• c- To obtain a specimen for culture and sensitivity test to give proper
antibiotic
• Technique:-
• 1- Disinfection of site of incision.
• 2- IV analgesia and field block LA at incision site avoid GA because of laryngeal
edema and elevated tongue cause occlusion of airway. If the patient is debilitated
or comatosed trachaeostomy can be done
• 3- 2 submanidular incisions 2 cm below the inferior border of mandible.
• - 1 submental skin incision at 1 cm below chin. 4- Insert haemestate to evacuate
pus in spaces.
• 5- Insert penrose fenestrated drain from submandibular to submental space
bilaterally (through and through drainage)
• Post-operative treatment:,

• external drainage the wound and drain should be kept covered with an
adequate dressing held in place by a bandage.

• 2- irrigation by means of a syringe with saline solution one or more times

a day

• 3-and the dressing must be large enough to hold the heat because hot
dressing increases the blood supply to the area involved and thus
stimulate phagocytosis and the elimination of toxic material
Periapical infection