SPACE INFECTIONS OF HEAD &

NECK
SPACE INFECTIONS
OF HEAD & NECK
 Fascia

• Fascia is a term used to describe broad sheets

of dense connective tissue whose function is
to separate structures that must pass over
each other during movement, such as muscles
and glands, and serve as pathways for the
course of vascular and neural structures
• Tissue paper in a shirt box comparison
• Loose areolar tissue, less vascular, pathway of
least resistance to infection
• The fascial “spaces” exist only potentially,
until fasciae are separated by pus, blood,
drains or a surgeon’s finger
• Bacterial infections spread by hydrostatic
pressure, following the path of least resistance
• It is the loose areolar tissue, surrounding the
muscles, enclosed by fascial layers
• This loose areolar tissue is destroyed by
hyaluronidase and collagenase produced by the
bacterial pathogens
• E.g., submandibular space infection pathogenesis
 Fasciae of head and neck
• Superficial fascia
• Deep cervical fascia
a) Anterior layer
b) Middle layer
c) Posterior layer
 Stages of Infection
• Inoculation
• Cellulitis
• Abscess
• Resolution
 Inoculation
• Early spread, 0-3 days
• Streptococci, probably (aerobic)
• Soft, doughy, mildly tender soft tissue swelling
with little redness
• Diffuse swelling
• Minimal or no loss of function
 Cellulitis
• 3-7 days
• Deeply reddened, hard, exquisitely painful
swelling, Diffuse in nature
• Trismus, or inability to protrude the tongue
(severe loss of function)
• Serosanguinous discharge with flecks of pus
• Mixed flora
 Abscess
• Third stage, >5 days
• Necrosis predominates
• Fluctuant – central softening of cellulitic
region
• Circumscribed, tender, peripherally reddened,
centrally undermined and shiny
• Presence pus in tissue fluid
• Anaerobic bacterial flora
 Resolution
• Final stage
• After spontaneous or therapeutic drainage
Pathophysiology of Odontogenic
infection
 Pathophysiology of Odontogenic
infection
• Localised osteomyelitis after infection crosses
apex
• Transudation, exudation, decreased
vascularity
• Chemotaxis, circulating macrophages,
histiocytes. Osteoclast formation
• Bone necrosis, resorption, roughly spherical
pattern until it reaches bony cortex
 Pathophysiology of Odontogenic
infection
• Breach of bony cortex, infection reaching soft
tissue
• The process of bacterial inoculation,
inflammation, necrosis begins anew in soft
tissues
• Invading bacterial pathogens triggering the
autolytic inflammatory process persist thro’
out
 Pathophysiology of Odontogenic
infection
• Early stage, Streptococci, aerobic, produce
hyaluronidase, break down of extracellular
glycoproteins of connective tissue
• Streptococci, exponential growth phase, make
environment conducive for anaerobic,
metabolize nutrients, more acidic environment
• Anaerobes, Prevotella, Porphyromonas spp.
• Anaerobes produce collagenases, destroying
collagen
 Classification of Fascial spaces of
Head and Neck
Based on Mode of Involvement
• Direct involvement – Primary spaces
1) Maxillary 2) Mandibular spaces
• Indirect involvement – Secondary spaces
Based on Clinical significance
i) Face – buccal, canine, masticatory, parotid
ii) Suprahyoid – sublingual, submaxillary
(submandibular & submental), peritonsillar
Pharyngomaxillary(lateral pharyngeal)
 Classification of Fascial spaces of
Head and Neck
Based on Clinical significance
iii) Infrahyoid – Anterovisceral (pretracheal)
iv) Spaces of total neck – retropharyngeal,
spaces of carotid sheath
 Primary Maxillary spaces
• Canine or Infra orbital
• Buccal
• Infratemporal
 Primary Mandibular spaces
• Submental
• Buccal
• Submandibular
• Sublingual
 Secondary fascial spaces
• Massetric
• Pterygomandibular
• Superficial and deep temporal
• Lateral pharyngeal
• Retropharyngeal
• Prevertebral
• Parotid
 Masticator spaces
• Pterygomandibular
• Submassetric
• Superficial temporal
• Deep temporal

Masticator space is divided into two

compartments, lateral and medial by ramus of
mandible
 Vestibular space
• Potential space between the oral vestibular mucosa
and the muscles of facial expression
• Dentoalveolar abscess – infection between the
alveolar process and alveolar mucosa on the facial
wall of the alveolar process
• Boundaries: Anteriorly intrinsic muscles of upper lip
Posteriorly buccinator muscle
Medially by alveolar process
Laterally by oral mucous membrane
 Vestibular space
• Contents: submucosal and areolar connective
tissue, long buccal and mental nerves
• Clinical features: vestibular swelling elevates
the overlying facial structures, distorting the
externally visible features
 Subcutaneous space
• Potential space between superficial fascia, along
with muscles of facial expression, and the skin
• Clinical significance:
Infections from deep fascial spaces may point
thro’ the subcutaneous space to skin
Necrotizing fasciitis, a rapidly spreading infection,
causes necrosis of the tissues in the
subcutaneous space by thrombosis of vessels
supplying superficial muscle and skin
 Space of Body of Mandible
• Cause of Infection: When dental infections
perforate the bony cortical plate, but not the
overlying periosteum
• Borders: Periosteal envelope and cortical surface
of bone
• Mostly from mandibular premolar and molar
teeth
• Extremely painful, mandible itself appears
enlarged
 Buccal space
• It occupies the portion of the subcutaneous space
between the facial skin and the buccinator muscle
• Boundaries:
Anteromedially: buccinator
Posteromedially: Masseter overlying the anterior
border of ramus of mandible
Laterally: By forward extension of deep fascia from
the capsule of parotid and platysma
 Buccal space: Boundaries
• Inferiorly: limited by attachment of deep
fascia to the mandible and by depressor anguli
oris
• Superiorly: Zygomatic process of the maxilla
and zygomaticus major and minor muscle
 Buccal space
• Contents: Buccal pad of fat, Stenson’s duct,
Anterior facial artery and vein, Transverse facial
artery and vein
• Communications of Buccal space:
Superficially with submassetric space
On the medial side of mandible with
Pterygomandibular space
Thro’ the extension of buccal pad of fat into
superficial temporal space
 Buccal space
• Communications of Buccal space:
By extensions along buccal pad of fat, transverse
Facial vein and pterygoid venous plexus, it
enters into Infratemporal space
Cause of Infection:
Upper premolars, Upper molars, Lower premolars
The location of root tips to the level of origin of
buccinator muscle determines the spread of
infection
 Buccal space
• Clinical significance:
Buccal space infections when it erodes the
transverse facial vein or pterygoid plexus reach
cavernous sinus lead to cavernous sinus
thrombosis
Infection may spread thro’ subcutaneous space into
periorbital space
Inferiorly the infection my pass beyond inferior
border of mandible superficial to submandibular
space obscuring diagnosis
 Sublingual Space
• Boundaries: Superiorly by mucosa of floor of
mouth
Inferiorly by Mylohyoid muscle
Anteriorly and laterally by lingual surface of
mandible
Medially the intrinsic muscles of tongue and the
genioglossus muscle divide the space into right and
left
Posteriorly with superior, posterior, and medial
portion of submandibular space
 Sublingual space
• Cause of infection: Mandibular anteriors,
Lower premolars, Lower molars, Direct trauma
• Contents: Sublingual glands, Wharton’s duct,
Lingual nerve, sublingual artery and vein, Deep
part of submandibular salivary gland,
Hypoglossal nerve, geniohyoid and
genioglossus muscles, hyoglossus muscle
complex
 Sublingual space
• Clinical significance: Infections from sublingual
space can directly spread to lateral pharyngeal
space thro’ buccopharyngeal gap created by
styloglossus muscle
Communicates with submandibular space at the
posterior end around mylohyoid muscle
Elevation of tongue is the clinical hallmark of
sublingual space infection
When tongue protrudes beyond vermilion border of
upper lip rules out sublingual space infection
 Sublingual space
• Clinical features: Infections of sublingual space
cause raise in floor of mouth, painful, affects
speech, deglutition, obstruction in airway due
to pushing of tongue superiorly
 Submandibular space
• Boundaries: Anteriorly by anterior belly of digastric
Posteriorly by posterior belly of digastric,
stylohyoid muscle, middle and superior pharyngeal
constrictor
Superiorly by the lingual surface and inferior border
of mandible, inferior to the attachment of
mylohyoid muscle at the mylohyoid line
Medially the mylohyoid muscle from mylohyoid line
to hyoid bone
Submandibular space
 Submandibular space
• Cause of infection: Lower molars
• Contents: Submandibular gland, Facial artery and
its branches, facial vein, submandibular
lymphnodes
• Clinical significance:
The mylohyoid line slopes inferiorly as it passes
anteriorly
Hence infections from mandibular molars perforate
thin lingual cortical plate and enters
submandibular space directly
 Submandibular space
• Clinical significance:
Infections from mandibular premolars perforate
lingual cortex above mylohyoid line to enter
sublingual space
Infections from submandibular space pass around
posterior belly of digastric, or stylohyoid muscle,
or along lateral surface of pharyngeal constrictor
to enter lateral pharyngeal space
Anteriorly pass beyond anterior belly of digastric to
enter submental space
 Submental space
• Boundaries: Laterally by anterior bellies of
digastric and lower border of mandible
Superiorly by mylohyoid muscle
Superficially or inferiorly by suprahyoid portion of
investing layer of deep cervical fascia, platysma,
skin
Cause of infection: lower anterior teeth,
symphyseal fractures, skin infections, from
submandibular space infections
Submental space
 Submental space
• Contents: loose areolar connective tissue,
submental lymphnodes, anterior jugular veins
in the lower portion
• Clinical features: Distinct, firm midline
swelling, beneath chin, board like
Infraorbital space
 Infraorbital space
• Superiorly: Levator labii superioris alaeque
nasi, Levator labii superioris, Zygomaticus
minor
• Inferiorly: Levator anguli oris
• Anteriorly: Orbicularis oris
• Posteriorly: Buccinator
• Medially: anterolateral surface of maxilla
Infraorbital space: Boundaries
 Infraorbital space
• Cause of infection: from maxillary anteriors
(mainly canines – due to long root), maxillary
premolars
• Swelling of upper lip, obliteration of nasolabial
fold, drooping of angle of mouth, edema of
lower eyelid
• Significance of location of root apice
Infraorbital space infection
Thank you

to be continued….
Title
• Lorem ipsum dolor sit amet,
consectetuer adipiscing elit.
Vivamus et magna. Fusce sed sem
sed magna suscipit egestas.
• Lorem ipsum dolor sit amet,
consectetuer adipiscing elit.
Vivamus et magna. Fusce sed sem
sed magna suscipit egestas.
Title
• Lorem ipsum dolor sit amet,
consectetuer adipiscing elit.
Vivamus et magna. Fusce sed sem
sed magna suscipit egestas.
• Lorem ipsum dolor sit amet,
consectetuer adipiscing elit.
Vivamus et magna. Fusce sed sem
sed magna suscipit egestas.
 Title

• Lorem ipsum dolor sit amet, consectetuer

adipiscing elit. Vivamus et magna. Fusce sed
sem sed magna suscipit egestas.
• Lorem ipsum dolor sit amet, consectetuer
adipiscing elit. Vivamus et magna. Fusce sed
sem sed magna suscipit egestas.