Parotid abscess, Ludwig’s angina
and masticator space abscess
Presented by: Kasaram Muktheshwara Naga Sai
Roll Number : 36
Parotid abscess - Introduction
●It is the suppuration of the parotid space.
●Parotid space is the space that lies deep to the superficial
layer of the deep cervical fascia. Deep cervical fascia splits
into two layers, superficial and deep, to enclose the parotid
gland and its associated structures.
●Contents of parotid space:
– parotid gland
– associated parotid lymph nodes
– facial nerve
– external carotid artery
– retromandibular
• Fascial vein
layer is thick superficially but
thin on the deep side of the parotid
gland where parotid abscess can burst
to form a parapharyngeal abscess and
then spread to the mediastinum.
Parotid abscess - Etiology
●Dehydration, particularly in postsurgical cases and debilitated
patients, with stasis of salivary flow is the predisposing cause.
●Infection from the oral cavity travels via the Stenson’s duct
to invade the parotid gland. Multiple small abscesses may form in
the parenchyma and may then coalesce to form a single abscess.
Bacteriology:
●Most common organism is Staphylococcus aureus
●Streptococci, anaerobic organisms and rarely Gram-negative
organisms have been cultured.
Parotid abscess – Clinical features
●Usually follows 5–7 days after operation.
●Swelling, redness, indurations and tenderness in the
parotid area and at the angle of mandible is seen.
●Parotid abscess is usually unilateral, but bilateral abscesses may
occur.
●Fluctuation is difficult to elicit due to thick capsule.
●Opening of the Stenson’s duct becomes congested and may
exude pus on pressure over the parotid.
●Patient is toxic, running high fever and dehydrated.
Parotid abscess - Diagnosis
Diagnosis is made by:
●Ultrasound
●Computed tomography scan (CT)
More than one loculi of pus may be seen.
●Aspiration of abscess can be done for culture and sensitivity
of the causative organisms
Parotid abscess - Treatment
●Correct the dehydration, improve oral hygiene and promote
salivary flow.
●Intravenous antibiotics are instituted.
●Surgical drainage under local or general anaesthesia is carried
out by a preauricular incision as employed for parotidectomy.
– Skin flap is raised to expose surface of the gland
– the abscess(es) are bluntly opened working parallel to the branches of the VIIth
nerve.
– Skin incision is loosely approximated over a drain and allowed to heal by
secondary intention.
Ludwig’s angina – Introduction
●Ludwig’s angina is infection of submandibular space.
●Submandibular space lies between mucous membrane of the
floor of mouth and tongue on one side and superficial layer
of deep cervical fascia extending between the hyoid bone
and mandible on the other.
• It is divided into two compartments by
the mylohyoid muscle:
1. Sublingual compartment
(above the mylohyoid).
2. Submaxillary and submental
compartment (below the mylohyoid).
• The two compartments are continuous
around the posterior border of
mylohyoid muscle.
Ludwig’s angina – Etiology
1. Dental Infections (80%)
2. Submandibular sialadenitis, injuries of oral mucosa and
fractures of the mandible
Bacteriology:
●Mixed infections involving both aerobes and anaerobes are
common.
●Alpha-haemolytic Streptococci, Staphylococci and
bacteroides groups are common.
●Rarely Haemophilus influenzae, Escherichia coli and
Pseudomonas are seen.
Ludwig’s angina – Clinical features
●Odynophagia (difficulty in swallowing) with
varying degrees of trismus.
●When infection is localized to the sublingual
space, structures in the floor of mouth
are swollen and tongue seems to be
pushed up and back.
●When infection spreads to submaxillary
space, the submental and submandibular
regions become swollen, tender and
impart woody-hard feel.
Ludwig’s angina – Clinical features
●Usually, there is cellulitis of the tissues rather than frank
abscess.
●Tongue is progressively pushed upwards and backwards
threatening the airway.
●Laryngeal oedema may appear.
Ludwig’s angina – Treatment
1. Systemic antibiotics.
2. Incision and drainage of abscess.
a) Intraoral—if infection is still localized to sublingual space.
b) External—if infection involves submaxillary space. A transverse incision
extending from one angle of mandible to the other is made with vertical
opening of midline musculature of tongue with a blunt haemostat. Very often
it is serous fluid rather than frank pus that is encountered.
3. Tracheostomy, if airway is endangered.
Ludwig’s angina – Complications
1. Spread of infection to parapharyngeal and retropharyngeal
spaces and then to the mediastinum.
2. Airway obstruction due to laryngeal oedema, or swelling and
pushing back of the tongue.
3. Septicaemia.
4. Aspiration pneumonia.
Masticator space abscess
●Masticator space: It lies between
two layers of deep cervical fascia.
●The superficial (lateral) layer covers
the masseter and temporal muscles
while deep layer covers the medial
and lateral pterygoids muscles
medially.
●It consists of three spaces:
i. masseteric space
ii. temporal space
iii. pterygomandibular space
●It communicates with the parotid and
parapharyngeal spaces.
Masticator space abscess
Etiology: Dental infections, particularly of the second and third
molar teeth, are the most common source of abscess formation.
Treatment:
●To drain the abscess, this space can be approached through an
incision just lateral to the retromolar trigone and bluntly reaching
the masseteric space and pterygomandibular spaces.
●Temporal space(s) can be drained by a horizontal incision above
the zygomatic arch.
Thank you
