SPACE INFECTIONS OF

HEAD AND NECK

By,
Prathusha.U
CRI,B-Batch,
Department of Public Health Dentistry
Chettinad dental college and Research
Institute
 CONTENTS

• Introduction
• Definition -Fascial space infections
• Spread of infection and factors affecting it
• Pathophysiology of odontogenic infections
• Microbiology of Space Infections
• Anatomy of fascial space infections in head and
neck
• Conclusion
• References
• Quiz
 INTRODUCTION

• An oral infection can originate in the dental pulp and extend through the root canals of the tooth into
the periapical tissues or

• It may originate in the superficial periodontal tissues and subsequently disperse through
the bone.

• Later it may perforate the outer cortical bone and spread in various tissue spaces or discharge onto a free
mucous membrane

• Fascial spaces are fascia lined areas that can be eroded or distended by purulent exudate. These areas
are potential spaces that do not exist in healthy people but become filled during infections
 FASCIAL SPACES
Definition –

The fascial spaces in head and neck are the potential spaces
between the various layers of fascia normally filled with loose
connective tissue and bounded by anatomical barriers, usually of
bone, muscle or fascial layers.
( Moore-1975)
 Shapiro defined fascial spaces as potential spaces between layer
of fascia. Its filled with loose connective tissues and various
anatomical structures
 FACTORS AFFECTING SPREAD OF INFECTION

General factors
1. Microbial factors-
• Level of virulence.
• No. of organisms introduced.
2. Host factors-
• General state of health.
• Integrity of surface defence.
• Level of immunity.
• Capacity for inflammatory & immune response.
• Impact of medical intervention.
3. Combination of both factors.
• Local factors
 DIFFERENCES BETWEEN
CELLULITIS AND ABSCESS
Characteristics Cellulitis Abscess

Duration. Acute phase Chronic phase

Pain Severe and generalised Localised

Size Large. Small

Localization Diffuse borders Well-demarcated

Palpation Doughy / indurated Fluctuant

Presence of pus No Yes

Degree of seriousness Greater Less

Bacteria. Aerobic Anaerobic/mixed

 PATHOPHYSIOLOGY OF ODNTOGENIC
INFECTIONS
• Infection from any tooth will spread along the path of
least resistance. It can perforate either the buccal cortical
plate or lingual / palatal cortical plate depending upon which
is thinner
 NATURAL HISTORY OF PROGRESSION OF
ODONTOGENIC INFECTION
• Once bacteria has reached periapical tissue an active lesion is
established
• Infection will spread equally in all directions, but preferentially along
the lines of least resistance
• Spread through cancellous bone until it encounters a cortical plate
• If thin cortical plate, infection erodes through bone and enters soft
tissue
• It appears in predictable locations
Chow AW. Life-threatening infections of the head and neck. Clin Infect Dis 1992;14:991-1004
Path of Contiguous Spread of Infection
 MICROBIOLOGY –SPACE
INFECTION
Aerobic bacteria (25%)
Gram positive cocci (85%)–
Streptococcus species( 90% ) -
• S.Milleri
• S.sanguis
• S.Salivarius
• S.Mutans
Staphylococcus species (6 %)

Anaerobic bacteria (75%)

Gram positive cocci (30%)–
Peptococcus species 33%
Pepto Streptococcus species 33% Gram pasitive bacilli (50%) –
Prevotella species, Porphyromonas species
(75%)
Fusobacterium -20%
Staphylococcus causes –osteomyelitis and abscess
Streptococcus causes- cellulitis

• In an abscess, common causative organisms are anaerobic

(Higher percentage) & Aerobic.

• Fusobacterium + strep. Milleri – cause aggressive infections.

Eg.,.mediastinum.infections.
Cervical Fascia described under :-
a) Superficial fascia
b) Deep fascia

• SUPERFICIAL FASCIA:
• Layer of dense CT that courses deep to the SC tissue throughout the body

• SC space is defined as tissues lying superficial to superficial fascia

• Also known as tela subcutanea or hypodermis
DEEP FASCIA:
• Formed by dense, organized connective tissue
• “Invests” deep structures such as muscles
• Creates compartments that contain / direct spread of infection

• Limits outward expansion of muscles so that veins are compressed moving blood toward heart
(musculovenous pump)
 FASCIA OF HEAD AND NECK
1. Superficial fascia.

2. Deep cervical fascia.

A. Anterior Layer.
◦ Investing Fascia.
◦ Parotidomassetric fascia.
◦ Temporal.
B. Middle Layer.
◦ Sternohyoid- Omohyoid division.
◦ Sternothyroid- thyrohyoid
Division.
◦ Visceral Division
1. Buccopharyngeal.
2. Pretracheal
3. Retropharyngeal
C. Posterior Layer.
◦ Alar division.
◦ Prevertebral Division

Topazian R, Goldberg M, Hupp Oral and Maxillofacial Infections. 4th Edition. Saunders, Pennsylvania 11
2009
 CAROTID
SHEATH
• Formed by all three layers of deep
fascia
• Contains carotid artery, internal
jugular vein and the vagus
nerve.
• Extends from superior
mediastinum (beginning of
carotid artery) till jugular
foramen and carotid canal at
skull base.
 DANGER SPACE
Potential space between the alar and prevertebral divisions of
the deep layer of the deep cervical fascia

 Boundaries -
• Superiorly:-base of the skull.
• Inferiorly:- upper border of diaphgram.
• Laterally:- fusion of alar and prevertebral fascia at transverse
process of cervical and thoracic vertebrae.
• Anteriorly:- alar fascia.
• Posteriorly:- prevertebral fascia.
 WHY DANGER SPACE???
At the inferior border it continous with the posterior mediastinum containing vena cava
,arch of aorta, thoracic duct, trachea and oesophagus.

Erosion of major blood vessels, lower airway and upper digestive tract

Death of patient.

• Spread within the danger space tends to occur rapidly because of the loose areolar tissue that occupies this
region. This spread can lead to mediastinitis, empyema, and sepsis

107
CLASSIFICATION OF FASCIAL
SPACES
SPACES OF HEAD AND NECK
GRODINSKY AND HOLYOKE IN 1938
DESCRIBED
 Space 1: superficial to the platysma as well as between the
latter and the deep fascia.
 Space 2: lies in the anterior triangle between the superficial
layer of deep fascia and the deep surface of the sternothyroid
sheath, thus including the sternohyoid-omohyoid fascia with its
contents and the sternothyroidthyrohyoid muscles with the
anterior portion of their sheaths.
 Space 3: between the visceral fascia and the sternothyroid-
thyrohyoid layer anteriorly, the carotid sheath laterally, and the alar
fascia posteriorly.

 Space 3a: Lincoln’s highway

• Space 4: also known as danger space, lies between alar &

prevertebral fascia.
• Space 4: also known as
danger space, lies between
alar & prevertebral fascia.

• Space 4a: posterior triangle

of neck

• Space 5: prevertebral
space.

• Space 5a: fascia enclosed

by prevertebral fascia
 BASED ON MODE OF INVOLVEMENT
1. Direct Involvement. (Primary Spaces)
• Maxillary Spaces – Canine, buccal infratemporal
• Mandibular Spaces – Submental, Submandibular,
Sublingual, Buccal
2. Indirect involvement (Secondary Spaces)
• Masseteric
• Pterygomandibular
• Superficial and deep temporal
• Lateral and retro pharyngeal
• Prevertebral, parotid, carotid sheath,peritonsillar and danger
spaces.
• Based on clinical significance- (TOPAZIAN)
Face- Buccal, canine, parotid, masticatory.

Suprahyoid- Sublingual, submental, submandibular,

lateral pharyngeal, peritonsillar.

Infrahyoid- Pretracheal.

Spaces of total neck- Retropharyngeal, space of carotid

sheath.
 BASED ON
AETIOLOGY
General classification
• Odontogenic
• Traumatic
• Implant surgery
• Reconstructive surgery
• Infection arising from contaminated needle puncture
• Others (including from factors such as infected antrum,
salivary gland afflictions)
• Secondary to oral malignancies
 ON THE BASIS OF CAUSATIVE
ORGANISMS
• Bacterial infection
• Odontogenic
• Non odontogenic
• Tonsillar infection
• Nasal infection
• Furuncle overlying skin
 BUCCAL SPACE
THE BUCCAL SPACE OCCUPIES THE PORTION OF SUBCUTANEOUS
SPACE BETWEEN THE FASCIAL SKIN AND BUCCINATOR MUSCLE.

BOUNDARIES:-

• ANTERIORLY-Corner of mouth
• POSTERIORLY-Masseter muscle, Pterygomandibular space
• SUPERFICIAL- skin and Subcutaneous tissue

• DEEP- Buccinator muscle

• SUPERIORILY- Maxilla, Infraorbital space
• INFERIORLY- Lower border of mandible.
• CONTENTS OF BUCCAL SPACE:-
• Buccal pad of fat
• Stensons (Parotid duct)
• Anterior and transverse facial artery and vein.

MUSCLE RELATED – Buccinator muscle

Neighboring spaces-
Infraorbital, pterygomandibular,
infratemporal space
 CANINE SPACE /
INFRAORBITAL SPACE
Boundaries –
Anteriorly –Oribicularis oris
Posteriorly- Buccal space
Superficially – Quadratus labi superioris
Deep- Lavator anguli oris, anterior
surface of maxilla
Medially – Levator labi superioris
alaque
nasi
Laterally – Zygomaticus major,
Superiorly – Quadratus labi superioris
Inferiorly - Oral mucosa
• Contents – Angular artery and vein,
Infraorbital nerve
• Neighboring spaces – Buccal space
 PALATAL ABSCESS
Involvement: palatal roots of posterior teeth, abscesses
from palatal pocket - cause infection.
Boundaries:
inferiorly:- bounded by cortical plates of hard palate
superiorly: overlying periosteium.
laterally: alveolar process of maxilla & teeth
 INFRATEMPORAL
SPACE
Boundaries-
• Superiorly: infratemporal surface of
greater wing of sphenoid.
• Inferiorly: lateral pterygoid muscle.
• Laterally: temporalis tendon ,ramus of
mandible
• Medially: lateral pterygoid plate,muscle
& medial pterygoid plate
• Posteriorly: parotid gland
• Anteriorly: infratemporal surface of
maxilla & posterior surface of zygomatic
bone.
Contents-
• Pterygoid plexus of veins.
• Internal maxillary artery.
•Mandibular nerve & its branches.

Infratemporal
space
 SUBMANDIBULAR
Boundaries- SPACE
• Superiorly: mylohyoid muscle, inferior border of mandible.
• Inferior: anterior & posterior belly of digastric.
• Laterally: deep cervical fascia, platysma, superficial fascia & skin.
• Medially: hypoglossus,styloglossus,mylohyoid muscle.
• Posteriorly:posterior belly of digastric,stylohyoid muscle,stylopharnygeus
muscle.
•Anterior:Anterior belly ofDigastric
• Contents-
• Submandibular salivary gland.
• Proximal portion of Wharton’s
duct.
• Lingual & hypoglossal nerves.
•
 SUBMENTAL
Boundaries- SPACE
 Roof: mylohyoid muscle.
 Inferior: deep cervical fascia, platysma, superficial fascia & skin.
 Laterally: anterior belly of digastric.
 Posteriorly: submandibular space.

• MUSCLE RELATED – mentalis muscle

• CONTENTS – submental lymph nodes and

anterior jugular vein.
 SUBLINGUAL
Boundaries- SPACE
• Superiorly: mucosa of floor of mouth.
• Inferior: mylohyoid muscle.
• Posteriorly: body of hyoid bone.
• Anteriorly & laterally: inner aspect of mandibular body.
• Medially: geniohyoid,styloglossus,genioglossus muscle.
Contents-
• Deep part of Submandibular gland.
• Wharton’s duct.
• Sublingual gland.
• Lingual & hypoglossal nerves.
• Terminal branches of lingual artery.
 MASTICATORY
SPACE
There are 5 masticatory spaces .
1. Superficial temporal space
2. Infratemporal space
3. Deep temporal space
4. Submassetric space
5. Pterygomandibular space
 SUBMASSETERIC
SPACE
Boundaries-
 Superiorly: zygomatic arch.
Inferiorly: inferior border of
mandible.
Laterally: medial surface of
masseter muscle.
Medially: lateral surface of
ramus of mandible.
Posteriorly: parotid gland & its
fascia.
Anteriorly: buccal space &
buccopharyngeal fascia.
CONTENTS -
• Masseteric artery and vein

Neighboring spaces-
• Buccal, pterygomandibular,
superficial temporal, parotid space
 PTERYGOMANDIBULAR
Boundaries- SPACE
• Superiorly: lower head of lateral pterygoid
muscle.
• Laterally: medial surface of ramus.
• Medially: medial pterygoid muscle.
• Posteriorly: deep part of parotid.
• Anteriorly: pterygomandibular raphe.
Contents-
• Inferior alveolar neurovascular bundle.
• Lingual & auriculotemporal nerves.
• Mylohyoid nerve & vessels.
 TEMPORAL SPACES
• Superficial temporal-
Laterally: temporalis fascia.
Medially: temporalis muscle.
• Deep temporal-
Laterally: temporalis
muscle.
Medially: temporal bone &
greater wing of sphenoid.
 LATERAL
PHARYNGEAL SPACE
Boundaries-
Shape of an inverted cone or pyramid, the
base is at sphenoid bone and the apex at
hyoid bone.
 Anteriorly: pterygomandibular raphe.
 Posteriorly: extends to prevertebral
fascia.
Laterally: fascia covering medial pterygoid
muscle, parotid & mandible.
Medially: buccopharyngeal fascia on lateral
surface of superior constrictor muscle.
Styloid process divides the space into
anterior muscular and posterior vascular
Contents-

Anterior compartment: loose areolar connective

tissue, lymph nodes and facial artery

Posterior compartment: carotid sheath(carotid

artery,internal jugular vein,vagus nerve), cranial nerves
IX through XII.
 RETROPHARYNGEAL SPACE
POSTEROMEDIAL TO LATERAL PHARYNGEAL SPACE
AND ANTERIOR TO THE PREVERTEBRAL SPACE .
Boundaries-
 Anterior: posterior pharyngeal wall.
 Posterior: prevertebral fascia.
 Superior: skull base.
 Inferior: mediastinum.
 Laterally: lateral pharyngeal space.

.
 PAROTID
SPACE
BOUNDARIES:-
• superiorly zygomatic arch
• Inferiorly lower border of mandible
• Anteriorly  posterior border of the mandible
• Posteriorly  Retromandibular region

• Space formed by splitting of the superficial layer

surrounding the parotid gland and lies posterior to the
masticator space.
• CONTENTS:
• Parotid gland
• Parotid lymph nodes
• Facial nerve.
• Retromandibular vein
• External carotid artery
CONCLUSION
• Facial and cervical infections are potentially lethal
complications. However, with good knowledge of the anatomic
pathways of the infection, early diagnosis, attention to airway
maintenance, aggressive intravenous antibiotic therapy, surgical
intervention and careful postoperative management, the
infectious process should have a satisfactory outcome. 
REFERENCES

• Textbook of oral & maxillofacial surgery : Neelima Malik.

• Topazian R, Goldberg M, Hupp Oral and Maxillofacial Infections.
4th Edition. Saunders, Pennsylvania
2009Textbook of oral & maxillofacial surgery : Laskin
• Manuel Grodixsky And Edward A. Holyoke:THE FASCIA AND FASCIAL
SPACES OF THE HEAD, NECK AND ADJACENT REGIONS
• Flaviana Soares Rocha, Jonas Dantas Batista, Cláudia Jordão Silva, Roberto Bernardino Júnior
and Luis Henrique Araújo Raposo (April 22nd 2015). Considerations for the Spread of
Odontogenic Infections — Diagnosis and Treatment, A Textbook of Advanced Oral and
Maxillofacial Surgery Volume 2, Mohammad Hosein Kalantar Motamedi, IntechOpen, DOI:
10.5772/59161.
 • Pathway is based on the relationship between point of erosion through alveolar
bone and surrounding muscle attachment
A.Primary anatomic spaces involved in odontogenic infections: Principle
B.Retropharyngeal space: Adjacent space communications
C.Primary anatomic spaces involved in odontogenic infections: Mandibular teeth
D.Primary anatomic spaces involved in odontogenic infections: Maxillary teeth
 • Pathway is based on the relationship between point of erosion through alveolar
bone and surrounding muscle attachment
A.Primary anatomic spaces involved in odontogenic infections: Principle
B.Retropharyngeal space: Adjacent space communications
C.Primary anatomic spaces involved in odontogenic infections: Mandibular teeth
D.Primary anatomic spaces involved in odontogenic infections: Maxillary teeth
•  In a 19 year old patient with a swelling over the left angle of the mandible,
temperature of 38 degrees centigrade and negative history of trauma, one
should suspect:
 A. spontaneous fracture of the mandible
 B. pericoronal infection
 C. Mumps
 D. Sjogren's syndrome
•  In a 19 year old patient with a swelling over the left angle of the mandible,
temperature of 38 degrees centigrade and negative history of trauma, one
should suspect:
 A. spontaneous fracture of the mandible
 B. pericoronal infection
 C. Mumps
 D. Sjogren's syndrome
• A periapical abscess of a mandibular second molar space spreads most
commonly to the:
 A. Submandibular space
 B. Temporal space
 C. Sublingual space
 D. Infratemporal space
• A periapical abscess of a mandibular second molar space spreads most
commonly to the:
 A. Submandibular space
 B. Temporal space
 C. Sublingual space
 D. Infratemporal space
• The most dangerous type of spread of infection from apical abscess is to:
 A. Infratemporal fossa
 B. Pterygoid
 C. Parapharyngeal space
 D. Submandibular space
• The most dangerous type of spread of infection from apical abscess is to:
 A. Infratemporal fossa
 B. Pterygoid
 C. Parapharyngeal space
 D. Submandibular space
• The roof of pterygomandibular space is formed by:
 A. Temporalis muscle
 B. Medial pterygoid muscle
 C. Cranial base
 D. lateral pterygoid
• The roof of pterygomandibular space is formed by:
 A. Temporalis muscle
 B. Medial pterygoid muscle
 C. Cranial base
 D. lateral pterygoid
• The fascia consists of layers of epithelial tissue. The fascia lies underneath the
skin and also surrounds the muscles, bones, vessels, nerves, organs, and other
structures of the body.

A.Both statements are true.

B.Both statements are false.

C.The first statement is true; the second is false.

D.The first statement is false; the second is true.

• The fascia consists of layers of epithelial tissue. The fascia lies underneath the
skin and also surrounds the muscles, bones, vessels, nerves, organs, and other
structures of the body.

A.Both statements are true.

B.Both statements are false.

C.The first statement is true; the second is false.

D.The first statement is false; the second is true.

 • You are presented with a patient having a diffuse swelling in the neck bilaterally
below the chin region. Intra orally the Lower molar is infected on left side.
What is the probable source of infection?
A. Sub maxillary space infection
B. Sub mandibular space infection
C. Sub lingual space infection
D. Sub mental space infection
 • You are presented with a patient having a diffuse swelling in the neck bilaterally
below the chin region. Intra orally the Lower molar is infected on left side.
What is the probable source of infection?
A. Sub maxillary space infection
B. Sub mandibular space infection
C. Sub lingual space infection
D. Sub mental space infection
 • A 36 year old male patient has report to you with swelling in the Submandibular
region. His tongue is elevated and he complains of dysphagia. He has high fever.
Intra orally examination reveals grossly destructed lower first molar. What
would be your initial diagnosis?
A. Sub mandibular space infection
B. Sub mental space infection
C. Both Sub mandibular and submental infection
D. Para pharyngeal infection
 • A 36 year old male patient has report to you with swelling in the Submandibular
region. His tongue is elevated and he complains of dysphagia. He has high fever.
Intra orally examination reveals grossly destructed lower first molar. What
would be your initial diagnosis?
A. Sub mandibular space infection
B. Sub mental space infection
C. Both Sub mandibular and submental infection
D. Para pharyngeal infection
(A) Submandibular and sublingual region. (B) Submandibular region. (C) Cervical region. (D) Palate. (E) Orbital region. (F)
Submandibular and buccal region.