Fatal Complications of

Odontogenic Infections
Fatal complications
of head and neck
infections
Related to Related to
Maxilla Mandible
 Orbital Infection
Cavernous Sinus Thrombosis
Brain Abscess

Odontogenic infections

Ludwigs Angina Septicemia

Airway compromise Shock

Mediastinitis

Necrotizing Fasciitis
Why FATAL?
• Rapid progression
• Requires early diagnosis
• Prompt aggressive treatment
• Hospitalization ICU admission
• Consultation & Cooperation with other
medical specialties is a MUST
 Ludwig's Angina

Acute Septic Cellulitis •

Involving: (5 spaces).

• Bilateral Submandibular
spaces

• Bilateral Sublingual Spaces

• Submental space
 LUDWIG'S ANGINA
It is the name given
to a massive, firm, brawny
cellulitis/induration, and acute,
toxic stage, involving
simultaneously, the
submandibular,
sublingual and submental
spaces bilaterally
 1. to be feared of

3 F’s 2. Rarely fluctuant

3. often fatal (75%)

Ludwigs Angina = Air way

 LUDWIG'S ANGINA
Etiology
Lower molars infection (2nd/3rd molars) •

• Penetrating injuries to floor of mouth

• Compound Angle fracture

• Osteomyelitis of mandibular angle

• Submandibular salivary gland infection

• Immuno-compromised patient
 LUDWIG'S ANGINA
Signs & Symptoms
• Hard (Board like) diffuse swelling

• Painful

• Rapid onset

• Dyspnea ( loss of patent Airway)

• Severe constitutional symptoms

• Late Suppuration
 LUDWIG'S ANGINA
Signs & Symptoms:
Systemic: Intraoral:
• High Fever
- Edema & congestion in floor
• Lymphadenopathy of mouth
• Malaise - Glottic Edema
- Elevated protruded tongue
• Toxic appearance
(Wooden)
• Elevated white blood cell count - Decreased mouth opening
• Altered blood gases - Excessive salivation
- Difficult swallowing

Septicemia & Shock

 Airway obstruction

Elevation and protrusion of tongue

 LUDWIG'S ANGINA
• Treatment:

- Based on:
I. Early Diagnosis
II. Maintenance of patent airway
III. Intense and prolonged antibiotic therapy
IV.Surgical drainage and decompression
V. Removal of the cause
 LUDWIG'S ANGINA
Treatment
• Rapid Hospitalization

• Secure Airway……..How?

• Supportive measures

• Massive prolonged IV
Antibiotics

• Early I & D

• Removal of the cause

 LUDWIG'S ANGINA
Incision & Drainage
• Submandibular
• Submental
• Sublingual
• Through & Through Drains
• Dressing
• Post operative care”
Daily irrigation
 LUDWIG'S ANGINA
Incision & Drainage
• Submandibular
• Submental
• Sublingual
• Through & Through Drains
• Dressing
• Post operative care”
Daily irrigation
▪ Ludwig’s angina is a life-threatening infection

▪ Early diagnosis and immediate treatment is the key for

successful management

▪ Antibiotic therapy should be administered empirically

and tailored to culture and sensitivity results

▪ Prompt an early surgical intervention is required to provide

a higher control of the patient’s health.

 Cavernous sinus Thrombosis

• Two Cavernous sinuses

(2x1 cm )

• Each side of sella Turcica

(Sphenoid Bone)
 Cavernous sinus Thrombosis

Relations:

Superior: ICA
Inferior: Sphenoid bone (Body)
Medially: Pituitary gland
Sphenoid air sinus
Laterally: Temporal lobe brain
Trigeminal ganglion
Contents
• Internal Carotid Artery

• Nerves:

Cranial nerves (3-6)

III (Occulomotor)
IV ( Trochlear)
V (Trigeminal…..d1, d2)
VI ( Abducent)
Communications & source of Infection
(Via external or internal routes)

External route and Internal Route

1. Dangerous Area of Face & Anterior Maxilla

2. From Eyes ( Sup & Inf Opth. Veins)

3. Pterygoid venous plexus ( Emissary veins) Infra

Temporal & Pterygomandibular Spaces

4. Otitis Media (Petrosal sinuses)

5. Ethmoid , Sphenoid sinuses (Max Sinus)

 Rapid complications….. Why?

• No valves in facial vessels

• Short distance from facial region

• Direct communication due to frequent and

complicated anastomosis
 CAVERNOUS SINUS THROMBOSIS
1. Early symptoms:
- Venous Obstruction
- Cranial Nerves Affection
2. Late symptoms:
Bilateral affection
3. Advanced symptoms:

- Toxemia
- Meningitis
 CAVERNOUS SINUS THROMBOSIS

Signs & Symptoms

Venous obstruction:
- Pulsating Exophthalmos

- Edema of orbit, eye lids, nasal

bridge

- Ptosis

- Epistaxis
 CAVERNOUS SINUS THROMBOSIS
Signs & Symptoms
Cranial nerves involvement: III-VI
- Diplopia (EARLY SIGN)

- Fixed dilated pupil, ptosis

- Impairment or loss of vision

- Ophthalmoplegia

- Absence of corneal reflexes

- Pain or paresthesia over the area innervated by

Ophthalmic & Maxillary nerves

 CAVERNOUS SINUS THROMBOSIS
Signs & Symptoms
Meningitis & Meningeal irritation:
- Pyrexia ( Fever)

- Headache
As a
- Neck stiffness
- Vomiting consequence
- Convulsions of CST
- Confusion
or DE novo
- Rapid pulse
- Chills & Sweating
- Leukocytosis
 CAVERNOUS SINUS THROMBOSIS
Treatment of CST
• hospitalization/ ICU

• Neurosurgical consultation

• Early massive IV Antibiotics: chloramphenicol

• Mannitol

• Heparinization

• Cavernous sinus Exploration & Drainage(Rare)

 Orbital Cellulitis
• Routes of spread:
- Paranasal sinuses

- Ant maxilla…Angular vein…ophthalmic

vein

- Post Maxilla…Infra Temporal

- Pterygoid venous plexus → Inferior

Ophthalmic vein
 Orbital Cellulitis
•Orbital infections are classified by a 5-tier
system (Chandler classification):
Group I :Preseptal cellulitis
Group II : Orbital cellulitis
Group III : Subperiosteal abscess
Group IV : Orbital abscess
Group V : Cavernous sinus thrombosis
• Classification not necessarily imply order of disease
progression
• It helps explain physical signs and symptoms of
various infections and helps organize treatment plans.
 ORBITAL CELLULITIS
Signs & Symptoms
• Edema & Inflammation of eye
lid
• Proptosis
• Painful eye movement
• Chemosis
• Ophthalmoplegia
• Loss of visual acuity
 ORBITAL CELLULITIS
Signs & Symptoms
• Edema & Inflammation of eye
lid
• Proptosis
• Painful eye movement
• Chemosis
• Ophthalmoplegia
• Loss of visual acuity
Imaging
 ORBITAL CELLULITIS
Treatment

• Hospitalization

• Broad spectrum Antibiotics

• Culture & Sensitivity

• Remove the cause

• I &D if pus is identified in CT

 Brain Abscess

• Routes of spread:

- Para nasal sinuses ( Sphenoid , Frontal)

- Ear infection

- Orbital infection

- Odontogenic infections

Inflammation, Septic thrombosis,

Localized edema
 BRAIN ABSCESS
Signs & Symptoms (depends on site)
• Headache ( Intracranial pressure)

• Low grade fever

• Nausea & Vomiting

• Nuchal rigidity

• Mental state change

• Meningitis ( High fever, Seizures)

• Convulsions
 BRAIN ABSCESS
Diagnosis
• Clinical

• Lumbar puncture ( CSF)

• CT scan

• MRI
 BRAIN ABSCESS
Treatment
• Hospitalization

• Massive Antibiotics ( Cross BBB )

IV chloramphenicol

• Steroids & Mannitol

• Remove the cause

• Drainage (Trephination)
 Mediastinitis

• Potential space
• Contains a lot of vital
structures:
- Heart
- Aortic arch
- Pulmonary artery
-Esophagus , Trachea
- Carotid artery
Route of spread:
Ant neck…..Carotid sheath
Post neck….Retropharyngeal
MEDIASTINITIS
 MEDIASTINITIS

Routes of spread:
Ant neck…..

-Carotid sheath

Post neck….

- Peritonsillar

- Retropharyngeal

- Prevertebral
 MEDIASTINITIS
Signs & Symptoms
• Exacerbation of Fever

• Substernal pain

• Tachycardia Septicemia & Shock

• Dyspnea 40% mortality rate
• Hypotension

• Profound Leukocytosis
 MEDIASTINITIS
Treatment
(early diagnosis, airway control, aggressive treatment)

• Hospitalization/ ICU

• Massive Antibiotics

• Supportive measures

• Remove the cause

• Incision & Drainage

 Necrotizing Fasciitis
Rapidly spreading infection
along the superficial fascia
causing subcutaneous necrosis
due to:
• thrombosis of vessels
• Compromised blood supply
Predisposing factor:
Immuno-compromised Patients
 Necrotizing Fasciitis
Clinically:
Dusky purple discoloration
Purulent discharge
Vesicles
Necrosis
Bad odor
 NECROTIZING FASCIITIS
Causes of death
• Necrotizing Mediastinitis

• Disseminated intra vascular coagulopathy

(DIC)

• Fluid , Electrolyte disturbance

• Acidosis

• Shock
 NECROTIZING FASCIITIS
Treatment
• Hospitalization

• Massive Antibiotics

• Supportive measures

( Fluids, Calcium)

• Surgical drainage

• Repeated debridement

• Antiseptic dressings

• Hyperbaric Oxygen
 Orbital Infection
Cavernous Sinus Thrombosis
Brain Abscess
Meningitis

Odontogenic infections

Ludwigs Angina Septicemia

Airway compromise Shock

Mediastinitis

Carotid sheath invasion

Necrotizing Fasciitis