Dr. Mohit Bindal

Senior Lecturer

Department Of OMFS

DR.MOHIT BINDAL, Subharti Dental College, SVSU

CONTENTS INTRODUCTION

HOST DEFENSE AND INFECTION

MICROBIOLOGY AND ANTIBIOTIC THERAPY

FASCIAE OF HEAD AND NECK

CLASSIFICATION OF SPACES

MAXILLARY SPACES

MANDIBULAR SPACES

SECONDARY SPACES

COMPLICATIONS

OVERALL MANAGEMENT

STAGES OF INFECTION

CONCLUSION

INTRODUCTION Fascial spaces are potential spaces between the layers of fascia- Shapiro

Represent major pathways for spread of infections

When infections spread deeply into soft tissue- involvement following

path of least resistance

INFECTIONS AND HOST DEFENSE

In establishing presence of an infection, interaction occurs among

three factors:

1. Host

2. Environment

3. Microorganism

Infection occurs when either host

is immunocompromised or

when pathogenecity and number

of microbes invading host is more

SPREAD OF OROFACIAL INFECTION

FACTORS INFLUENCING SPREAD

GENERAL FACTORS:

Host resistance

Virulence of microorganism

Medically compromised

LOCAL FACTORS:

- Intact anatomical barriers

Alveolar bone

Periosteum

Adjacent muscles and fascia.

ANATOMICAL CONSIDERATIONS MUSCLE ATTACHMENTS-

Posteriors- Buccinator- midroot level

Anteriors –Intrinsic lip muscles & risorius- at apex

In maxilla- infection above attachment of muscle enters extra oral space

In mandible- infection below attachment of muscle enters extra oral space

PREDISPOSING FACTORS 1. Dental caries or periodontal infections

2. Lowered body resistance

3. Trauma

Primary signs & symptoms of these infections:

- Redness

- Raised temperature

- Edema overlying tissue

- Tenderness

- Loss of function

- Lymphadenopathy

MICROBIOLOGY –SPACE INFECTION Aerobic bacteria (5%)

Gram positive cocci (85%)–

Streptococcus species( 90% )

• S.Milleri

• S.Sanguis

• S.Salivarius

• S.Mutans

Staphylococcus species (6 %)

Anaerobic bacteria (25%)

Gram positive cocci (30%)-

Peptococcus species 33%

Pepto Streptococcus species 33%

Gram negative bacilli (50%) –

Prevotella species, Porphyromonas

species (75%), Fusobacterium -20%

Mixed bacteria (70%)

70

5

25

MICRO ORGANISMS

MIXED

AEROBIC

ANAEROBIC

Indications for antibiotics:

Toxic signs and symptoms, febrile condition or trismus.

Poorly localized extensive abscesses, diffuse cellulitis

Abscesses in systemically compromised patients

Deep fascial space infections

Pericoronitis, Osteomyelitis, Fractures

Soft tissue wounds

Selection of antibiotics:

Identification of causative organism

Antibiotic sensitivity

Bactericidal drugs preferred

Antibiotics of the narrowest spectrum preferred

The least toxic antibiotic should be selected

Cost of antibiotics

COMMON ANTIBIOTICS

β-lactams- Penicillins, Cephalosporins, Monobactams, Carbapenems

Macrolides- Erythromycin, Clindamycin, Azithromycin,

Clarithromycin, Aminoglycosides

Nitromidazoles- Metronidazole

Quinolones- Ciprofloxacin, Moxifloxacin

STAGES OF INFECTIONS

Stage I – Inoculation- caused by early spread

Stage II – Cellulitis- inflammatory process

Stage III – Abscess- necrosis predominates

Stage IV – Resolution- occurs after spontaneous or therapeutic

drainage

LAYERS OF NECK

SUPERFICIAL FASCIA

Ensheathes-

1. Platysma

2. Muscles of facial expression

Dense connective tissue

SUPERFICIAL LAYER OF DEEP CERVICAL FASCIA Superficial Layer of the Deep Cervical Fascia

Muscles

Sternocleidomastoid

Trapezius

Glands

Submandibular

Parotid

Spaces

Posterior Triangle

Suprasternal space

Of Burns

MIDDLE LAYER OF DEEP CERVICAL FASCIA

Muscular Division

Infrahyoid Strap Muscles

Visceral Division

Pharynx, Larynx, Thyroid

Esophagus, Trachea

Buccopharyngeal Fascia

The deep neck spaces viz. retropharyngeal, lateral pharyngeal &

pretracheal lie superficial side of visceral division

DEEP LAYER OF DEEP CERVICAL FASCIA

Arises from spinous processes and ligamentum nuchae.

Splits into two layers at the transverse processes:

Alar layer

Superior border – skull base

Inferior border – upper mediastinum at T1-T2

Prevertebral layer

Superior border – skull base

Inferior border – coccyx

Envelopes vertebral bodies and deep muscles of the neck.

Extends laterally as the axillary sheath.

CLASSIFICATION OF FASCIAL SPACES BASED ON CLINICAL SIGNIFICANCE - TOPAZIAN

FASCIAL SPACES

FACE SUPRAHYOID INFRAHYOID TOTAL NECK

Buccal

Canine

Masticatory

Parotid

Sublingual

Submandibular

Pharyngomaxillary

Anterovisceral

(Pretracheal)

Retro

pharyngeal

Carotid sheath

space

MAXILLARY MANDIBULAR

DIRECT (Primary spaces) INDIRECT (Secondary spaces)

CLASSIFICATION OF FASCIAL SPACES BASED ON MODE OF INVOLVEMENT

Masseteric

Pterygomandibular

Superficial & Deep

Temporal

Lateral Pharyngeal

Retropharyngeal

Prevertebral & Parotid

Spaces

Canine

Buccal

Infratemporal

Submental

Buccal

Submandibular

Sublingual

FASCIAL SPACES

CLASSIFICATION OF FASCIAL SPACES ACCORDING TO GRODINSKY AND HOLYOKE (1938)

Space 1 – Superficial to superficial fascia

Space 2 – Group of spaces surrounding cervical strap muscle

lying superficial to sternothyroid-thyrohyoid division

of middle layer of deep cervical fascia.

Space 3 – Space lying superficial to visceral division of middle

layer of deep cervical fascia

Space 3A – Carotid sheath space or viscerovascular space

Space 4 – Space lies between alar & prevertebral division of

posterior layer of deep cervical fascia (Danger space)

Space 4A – Posterior triangle space posterior to carotid sheath

Space 5 - Prevertebral space

Space 5A- Space enclosed by Prevertebral fascia

BUCCAL SPACES ANTERIOR POSTERIOR SUPERIOR INFERIOR MEDIAL LATERAL

Modiolus of

Mouth

Pterygomandib

ular Raphe,

Masseter

Maxilla,

infraorbital

space

Lower Border

Of Mandible

Buccinator

Muscle,

Buccopharyng

eal Fascia

Skin Of

Cheek

CONTENTS: Buccal pad of fat, Stenson’s duct , Anterior and transverse facial artery

LIKELY SOURCE OF INFECTION: Maxillary & mandibular premolars and molars

BUCCAL SPACES- COMMUNICATIONS

Submasseteric Space

Pterygomandibular Space

Superficial Temporal Space

Infratemporal space

Lateral Pharyngeal Space

BUCCAL SPACES CLINICAL FEATURES:

Vestibular abscess

Extra oral swelling

TREATMENT:

Antibiotic prophylaxis

Intra oral horizontal vestibular incision through oral mucosa of cheek in the

premolar, molar region.

CANINE SPACE ANTERIOR POSTERIOR SUPERIOR INFERIOR MEDIAL LATERAL

Nasal

cartilages

Buccal space

Quadratis

labii

superioris

Oral mucosa Quadratis

labii

superioris

Levator anguli

oris

CONTENTS : Angular artery and vein, Infraorbital nerve.

LIKELY SOURCE OF INFECTION : Maxillary canine or first premolar

CANINE SPACE CLINICAL FEATURES :

Swelling lateral to the nose

Obliteration of the nasolabial fold,

Swelling of the upper lip,

Edema occurs in the upper and lower lid that may close the eye

TREATMENT:

Antibiotic prophylaxis

Mucosa of buccal vestibule in incisor and canine region

SUB MANDIBULAR SPACE ANTERIOR POSTERIOR SUPERIOR INFERIOR LATERAL MEDIAL

Anterior belly

of digastric

Posterior belly

Of digastric,

Stylohyoid,

Stylopharyngus

Inferior &

medial

surface of

mandible

Digastric

tendon

Platysma,

Investing

fascia

Mylohyoid,

Hypoglossus,

Superior

Constrictor

CONTENTS: Submandibular gland, Facial artery & vein

LIKELY SOURCE OF INFECTION : Mandibular molars

CLINICAL FEATURES : Induration and erythema Obliteration of the mandibular line & extending to the level of hyoid bone No trismus

SUB MANDIBULAR SPACE

SUMBANDIBULAR SPACE I & D through Extra-oral incision.

Incision – 2 stab incisions given

over dependent part below lower

border of mandible

Curved hemostat inserted &

blunt dissection through subcutaneous

fat

Drain is placed & dressing is given

SUBMANDIBULAR SPACE- COMMUNICATION Submental space

Lateral pharyngeal space

Sublingual space

Contralateral spaces

SUB LINGUAL SPACE ANTERIOR POSTERIOR SUPERIOR INFERIOR MEDIAL LATERAL

Lingual

surface of

mandible

Submandibular

space

Oral mucosa Mylohyoid

muscle

Muscles of

tongue

Lingual

Surface

of mandible

CONTENTS : Sublingual glands, Wharton’s duct, Lingual nerve, Sublingual artery &

vein

LIKELY SOURCE OF INFECTION : Mandibular premolars & molars

SUB LINGUAL SPACE CLINICAL FEATURES :

Elevation of tongue

Edema and induration of floor of mouth

Tongue cannot be extended beyond vermilion border of upper lip

COMMUNICATIONS:

Infection through buccopharyngeal gap into lateral pharyngeal space

Infection along posterior border of mylohyoid into submandibular space

SUB LINGUAL SPACE TREATMENT:-

Antibiotic prophylaxis

Incision made Intraorally over

lingual sulcus at the base of

the alveolar process

Haemostat passed beneath

sublingual gland in an antero posterior direction and drain is placed.

SUB MENTAL SPACE ANTERIOR POSTERIOR SUPERIOR INFERIOR SUPERFICIAL DEEP

Inferior

border of

mandible

Fascia between

Hyoid and

inferior border

of mandible

Mylohyoid Investing

fascia

Investing Fascia Anterior

bellies of

digastric

CONTENTS : Anterior Jugular veins, Lymph Nodes

LIKELY SOURCE OF INFECTION : Lower anteriors

SUB MENTAL SPACE CLINICAL FEATURES :

Limited to point of chin & to region immediately below it

Fullness of submental space

Limitation of swelling to hyoid bone

TREATMENT:

Transverse incision in skin below symphysis of the mandible and blunt in upward and backward, Drain & dressings are placed.

MASTICATORY SPACE These are secondary spaces, well differentiated and communicate

with each other

PTERYGOMANDIBULAR SPACE ANTERIOR POSTERIOR SUPERIOR INFERIOR MEDIAL LATERAL

Buccal space Deep lobe

Of Parotid

gland

Lateral

Pterygoid

Inferior

border of

mandible

Medial

pterygoid

muscle

Ascending

Ramus of

mandible

CONTENTS : Mandibular division of trigeminal nerve, inferior alveolar artery & vein

LIKELY SOURCE OF INFECTION : Lower third molars

PTERYGOMANDIBULAR SPACE CLINICAL FEATURES :

No external swelling, trismus

Dysphagia

Medial displacement of lateral wall of pharynx

Uvula displaced to opposite side

INCISION AND DRAINAGE:

Intraorally : Sicher’s incision along the pterygomandibualr raphe

Extraorally : In cases of severe trismus, incision is placed behind the angle of the

mandible

SUBMASSETRIC SPACE ANTERIOR POSTERIOR SUPERIOR INFERIOR MEDIAL LATERAL

Buccal space Parotid gland Zygomatic

arch

Inferior

border of

mandible

Ascending

ramus of

mandible

Masseter

muscle

CONTENTS : Massetric artery & vein

LIKELY SOURCE OF INFECTION: Lower 3rd molar

SUBMASSETRIC SPACE CLINICAL FEATURES:

Mild swelling over angle of mandible

Deep seated severe throbbing pain

Trismus

Tenderness over the mandibular ramus

Ear lobes are obscured

TREATMENT:

Intra oral

Vertical incision along external oblique line

Haemostat is passed

Drain is placed

Extra oral

Incision beneath angle of mandible

Blunt dissection through masseter

muscle fibres

Drainage with plastic or rubber catheter to withstand muscle contraction.

SUBMASSETRIC SPACE

SUPERFICIAL TEMPORAL SPACES ANTERIOR POSTERIOR INFERIOR MEDIAL LATERAL

Posterior

surface of

lateral orbital

rim

Fusion of

temporalis

fascia with

pericranium

Zygomatic arch Lateral surface

of temporalis

muscle

Temporal

Fascia

CONTENTS: Temporal fat pad, temporal branch of facial Nerve

LIKELY SOURCE OF INFECTION: Upper & Lower molars

DEEP TEMPORAL SPACES ANTERIOR SUPERIOR INFERIOR MEDIAL LATERAL

Posterior wall of

maxillary sinus,

Pterygomaxillary

fissure, posterior

surface of orbit

Attachment of

temporalis to

cranium

Lateral

pterygoid

muscle

Temporal bone Temporalis

muscle

CONTENTS: Pterygoid plexus, inferior maxillary artery &

vein, mandibular division of trigeminal nerve

LIKELY SOURCE OF INFECTION: Upper molars

SUPERFICIAL & DEEP TEMPORAL SPACES CLINICAL FEATURES :

Characteristic dumbell shaped swelling (Superficial)

Mild swelling over temporal region (Deep)

TREATMENT:

Intraoral- vertical incision made medial to upper extent of anterior border of the

ramus

Haemostat Passed superiorly along lateral aspect of the coronoid (Superficial)

Passed supero-medially (Deep)

Extra oral incision- slightly superior to zygomatic arch

INFRATEMPORAL SPACE ANTERIOR POSTERIOR SUPERIOR INFERIOR MEDIAL LATERAL

Maxillary

tuberosity

Mandibular

condyle

Infratemporal

crest of

sphenoid

Lateral

pterygoid

muscle

Lateral

pterygoid

plate

Temporalis

Tendon,

Coronoid

process

CONTENTS: Pterygoid plexus, internal maxillary artery and vein , mandibular

division of trigeminal nerve

INFRATEMPORAL SPACE CLINICAL FEATURES:

Marked Trismus

Swelling of face in front of ear, over TMJ, behind zygomatic process

Eye is closed and proptosed

TREATMENT:

INTRAORAL

Incision is made into buccolabial fold lateral to maxillary third molar- Kruger

Curved hemostat is inserted behind maxillary tuberosity

Vertical incision made medial to upper extent of the anterior border of the ramus-

Laskin

Curved hemostat is passed superiorly into infratemporal region, drain is inserted

EXTRAORAL

Horizontal incision above the zygomatic arch

Curved hemostat is directed in inferior and medial direction to enter infratemporal

space

Insertion of drain.

INFRATEMPORAL SPACE

PREVERTEBRAL SPACE Formed by deep cervical fascia

Extends from skull base to coccyx

Fascia attaches to transverse process of cervical vertebra dividing it into anterior and posterior compartments

Anterior compartment :

-Vertebral bodies.

-Spinal cord.

-Vertebral arteries.

-Phrenic nerve.

-Prevertebral and scalene muscles

Posterior compartment :

-Posterior vertebral elements.

-Paraspinous muscles.

PERITONSILLAR SPACE INFECTION (QUINCY) Clinical evaluation:

3-7 days H/o pharyngitis

Severe sore throat, dysphagia,

Odyonophagia and referred otalgia.

The speech is muffled and classically

described as hot potato voice.

Trismus is not present

Needle aspiration instead of open incision and drainage - JOMS,Vol 51,2009

LATERAL PHARYNGEAL SPACE Inverted pyramid shape with base

at base of skull and apex at hyoid

bone

Medial- pharyngeal constrictor

Lateral- medial pterygoid muscle

& deep cervical fascia

Anterior- palatal musculature,

buccinator, superior constrictor,

stylohyoid and posterior belly of

digastric

Posterior- carotid sheath, retropharyngeal space

LATERAL PHARYNGEAL SPACE Infection spreads from peritonsillar infection, sublingual, submandibular &

retropharyngeal space infections

May encircle airway by spreading from one side to another

Patients head may tilt to unaffected side to position upper airway over

deviated trachea and lungs

LATERAL PHARYNGEAL SPACE CLINICAL FEATURES:

Firm swelling with surrounding erythema lateral and anterior to sternocleidomastoid muscle

Difficulty in flexing and turning of neck

Trismus, Dysphagia, Dyspnoea

TREATMENT:

Hospitalization with IV antibiotics

Airway protection

Surgical approach always through neck not through oral cavity

Incision is made at the level of hyoid bone across the SCM muscle

RETROPHARYNGEAL SPACE Extends from base of skull to retropharyngeal fascia (between 4th and

6th thoracic vertebra)

Lateral border- lateral pharyngeal

space and carotid sheath

Separated in midline by septum

Contains areolar tissue,

lymph nodes draining Waldeyer’s

ring

Infections impinge directly on airway,

involve danger space

RETROPHARYNGEAL SPACE

CLINICAL FEATURES:

• Dysphagia

• Cervical lymphadenopathy.

• Slight neck rigidity

• Noisy breathing due to laryngeal edema.

• Neck tilts towards involved side.

• Hyperextended complete inability to flex

the neck.

RETROPHARYNGEAL SPACE- COMMUNICATION Posterior- pre-vertebral space

Lateral- carotid artery (haemorrhage, pseudoaneurysm,

thrombosis) and jugular vein (thrombosis)

Anterior-compression and compromise of the airway

Inferior- mediastinum resulting in mediastinitis

DANGER SPACE

• Entire length of neck

• Anterior border - alar layer of deep fascia

• Posterior border - prevertebral layer

• Extends from skull base to diaphragm

• Contains loose areolar tissue

• Infection may enter mediastinum &

compress major vessels, lower airway and upper digestive tract

• 71% mediastinitis cases- infection from retropharyngel space through danger

space: Mediastinitis following cervical suppuration, Pearse, 1938

CAROTID SPACE

Encloses common & internal carotid arteries, internal jugular vein and vagus nerve

Named “Lincoln’s Highway” by Mosher in 1929

Extends from jugular foramen &

carotid canal to mediastinum

Infection eroding this space may cause-

Expanding hematoma in neck

Bleeding episodes( herald bleeds)

Horner’s syndrome- miosis, ptosis

and anhidrosis

MEDIASTINUM

• Extension of infection from deep neck spaces into the mediastinum is clinically seen as

– chest pain

– severe dyspnea ,Unremitting fever,

– Radiographic demonstration of mediastinal widening.

LUDWIG’S ANGINA

Ludwig’s angina is a firm, acute, rapidly progressing polymicrobial toxic

cellulitis of the submandibular and sublingual spaces bilaterally and of the

submental space resulting in life threatening airway compromise.

• Wilhelm Friedrich von Ludwig

1. Rapidly spreading gangrenous cellulitis.

2. Originates in the region of submandibular gland

but never involves one single space

3. Arises from extension by continuity and

not by lymphatics

4. Produces gangrene with serosanguinous,

putrid infiltration but very little or no frank pus.

Polymicrobial - predominantly oral flora

Organisms isolated - Streptococcus viridans and Staphylococcus

aureus

Anaerobes - bacteroides, peptostreptococci, and peptococci.

Other gram-positive bacteria- Fusobacterium nucleatum, Aerobacter

aeruginosa,spirochetes, and Veillonella, Candida, Eubacteria, and

Clostridium species.

Gram-negative organisms Neisseria species, Escherichia

coli,Pseudomonas species, Haemophilus influenzae, and Klebsiella

species

LUDWIG’S ANGINA- BACTERIOLOGY

Clinical features :

Toxic, ill, dehydrated

Difficulty in deglutition

Firm, brawny swelling

Mouth slightly open, Hot potato voice

Respiratory difficulties, cyanosis,

increased respiratory rate, stridor

Increased salivation, stiffness of tongue,

Elevation of floor of mouth

LUDWIG’S ANGINA

LUDWIG’S ANGINA SPREAD

ACCORDING TO KRUGER,TOPAZIAN,LUDWIG

THIRD MOLARS - SUBMANDIBULAR SPACE - SUBLINGUAL SPACE -

CONTRALATERAL SUBMANDIBULAR AND SUBMENTAL SPACE

INVOLVEMENT

ACCORDING TO LASKIN

SUBLINGUAL SPACE - SPREADS BILATERALLY - SUBMANDIBULAR

AND SUBMENTAL SPACE - BACKWARD SPREAD TO SUBSTANCE

OF TONGUE - INFECTION REACHES EPIGLOTTIS - SWELLING

AROUND LARYNGEAL INLET

PRINCIPLES OF MANAGEMENT OF LUDWIG’S ANGINA

• Hospitalization

• Securing the airway

• Anaesthetic implications

• Early I.V. antibiotics & hydration

• External surgical exploration with division of mylohyoid muscle and

drainage

• Medical supportive therapy

• Review and re-evaluation in the post op period

LUDWIG’S ANGINA MANAGEMENT Early diagnosis and hospitalization

Maintenance of airway:

i} cricothyrotomy/laryngotomy

ii} Nasoendotracheal intubation using fibre optic laryngoscope.

Anaesthesia: LA into superficial tissue of neck or if intubated then G.A.

I.V. analgesics

Removal of cause: Extraction of offending tooth which facilitates

evacuation of pus

LUDWIG’S ANGINA MANAGEMENT

Bilateral incision, Midline incision Blunt dissection

Initially no pus, but later on profuse pus drains out Drain placement

LUDWIG’S ANGINA MANAGEMENT Antibiotic therapy:

Penicillin– 2-4MU i.v. 4hourly, then penicillin V- 500mg orally slowly.

Amoxicillin- 500mg TID orally

Cloxacillin-500mg TID orally

Erythromycin-600mg 6-8hourly

Clindamycin-600mg i.v. 300-400mg orally TID

Cephalosporin

Treatment of dehydration: excess oral fluid intake or i.v. fluid infusion

LUDWIG’S ANGINA RISKS Posteriorly into larynx causing suffocation, death

Spread of infection to mediastinum

Septicaemia and septic shock

Venous and cavernous sinus thrombosis, carotid sheath erosion

Brain abscess and meningitis.

Aspiration pneumonia

Pericarditis.

Death

COMPLICATIONS OF SPACE INFECTION

Scar formation

Sinus tract formation

Cavernous sinus thrombosis

Necrotising fascitis

CAVERNOUS SINUS ANATOMY Large venous space situated in the middle cranial fossa

Interior divided into number of caverns by trabeculae

ANTERIOR POSTERIOR MEDIAL LATERAL SUPERIOR INFERIOR

Medial end of

superior

orbital fissure

Apex of

petrous

temporal bone

Pitutary

above and

sphenoid

below

Temporal lobe

and uncus

Optic chiasma Endosteal

dura mater,

greater wing

of sphenoid

CONTENTS

DANGEROUS AREA OF FACE

The cavernous communicate with dangerous

area of face through 2 routes:

Superior opthalmic vein

Deep facial veins , pterygoid plexus of vein ,

emissary vein.

SPREAD OF INFECTION TO CAVERNOUS SINUS 1. Infection of upper lip, vestibule of nose and eyelids Angular,

supraorbital and supratrochlear veins to ophthalmic veins

2. Intranasal surgeries on septum, turbinates or ethmoid / sphenoid sinus

infection Ethmoidal veins

3. Surgeries on tonsil, peritonsillar abscess, osteomyelitis of maxilla, dental

extraction and deep cervical abscess spread through pterygoid plexus or

by direct extension to the internal jugular vein.

CAVERNOUS SINUS THROMBOSIS- DIAGNOSIS

Eagleton’s criteria for Cavernous Sinus Thrombosis:

1. Sepsis

2. Early obstructive signs

3. Ocular nerve paralysis

4. Surrounding soft tissue abscesses

5. Symptoms of a complicated disease

CAVERNOUS SINUS THROMBOSIS

Characterized by multiple cranial neuropathies

Clinical feature -

General feature of infection

Exopthalmos & tender eye ball

Oedema of eyelid & chemosis of conjuctiva

Oculomotor feature –

External opthalmoplegia ,Ptosis

Slight exophthalmos,Dilated pupil with loss of accomdation reflex

TREATMENT Septic cavernous sinus thrombosis –

Early and aggressive antibiotic administration.

Broad-spectrum coverage for gram-positive, gram-negative,

and anaerobic organisms

Antibiotic therapy should include a penicillinase-resistant penicillin plus a

third generation cephalosporin.

Vancomycin may be added for MRSA.

IV antibiotics are recommended for a minimum of 3-4 weeks

Corticosteroid therapy ( adrenal insufficiency due to cranial nerve

dysfunction or pituitary necrosis)

DIAGNOSTIC IMAGING OF FASCIAL & NECK SPACES

•Plain film- AP & Lateral view

•MRI

•CT

•Ultrasound

PRINCIPLES OF INCISION AND DRAINAGE Incise healthy skin and mucosa when possible

Incision placed at site of maximum fluctuance

Incision in esthetically acceptable area

Incision should be in dependent position

Dissect bluntly with closed surgical clamp or finger, through deeper

tissues

Clean wound margins daily under sterile conditions

Place a drain and stabilize it with sutures

GENERAL MANAGEMENT 1. Determine severity

Assess history of onset and progression perform

physical examination of area:

- Determine character and size of swelling

- Establish presence of trismus

2. Evaluate host defenses :

-Diseases that compromise the host

- Medications that may compromise the host

3. Relieve pressure

- Remove the cause of infection

- Drain pus by performing incision and drainage

GENERAL MANAGEMENT 4. Select antibiotic

Determine:

- Most likely causative organisms based on history

- Host defense status

- Allergy history

- Prescribe drug properly

(route, dose and dosage interval, and duration)

- Culture & sensitivity

5. Administration of steroids to reduce edema

6. Follow up

Monitor frequently

Out-patient follow up in 2-3 days

Decreased swelling, discharge, airway edema, malaise in 2-3 day

STAGES OF INFECTION CHARACTERISTIC INOCULATION CELLULITIS ABSCESS

Duration 0-3 days 3-7 days More than 5 days

Pain Mild- moderate Severe & generalized Moderate – severe and

localized

Size Small Large Small

Localization Diffuse Diffuse Circumscribed

Palpation Soft, doughy, mildly

tender

Hard, exquisitely tender Fluctuant, tender

Appearance Normal color Reddened Peripherally reddened

Skin Quality Normal Thickened Centrally undermined,

shiny

Surface temperature Slightly heated Hot Moderately heated

Loss of function Minimal or none Severe Moderately severe

Tissue fluid Edema Serosanguinous, flecks of

pus

Pus

Levels of malaise Mild Severe Moderate- severe

Severity Mild Severe Moderate- severe

Percutaneous bacteria Aerobic Mixed Anaerobic

CONCLUSION Thorough knowledge of anatomy is necessary to diagnose and manage the

space infections.

To be alert to the potential seriousness of these infections-never to be

dismissed as simple dental abscess

In severe cases the systemic management of the patient is also very important

Incidence and severity have diminished with advent of antibiotic therapy

Deep fascial infections must be recognized promptly and treated as an

emergency

Repeat diagnostic and therapeutic measures may be necessary until the very

end