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CELLULITIS

A.prof. Keam Born.Dental department of Khmer

Soviet Friendship Hospital



CELLULITIS OF MAXILLA

Cellulitis KWCa A painful swelling of the soft tissue of the

mouth and face resultating from a diffuse spreading of purulent

exudate along the facial planes that separate the muscle

bundles.

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ETIOLOGY –

tamkarRsavRCav )anbBa¢ak;;[dwgfa 84 % énGñkCMgW Cellulitis TaMgGs; eRcIn

bNþalmkBI Odontogenic factors .

tamRbPBEdlbgá[man Infections manBIrRbePTKW ³

● local factors

● general factors



● local factors :

- Apical infection

- pericoronitis

- impacted teeth

- Pus in the gingival pocket- Trauma (fracture of the facial bone,tooth extractions)

- Infected needle through infected area

- Infected cysts

- Stomatitis

- infection of the salivary glande or lymph node



Apical infection



Pulp polyp





Extraction #36



Pathways of Odontogenic Infection

Usual cause of odontogenic infection: necrosis of tooth pulp

and bacterial invasion through the pulp chamber into deeper tissues.

Pulp necrosis results from deep decay in tooth,(inflammatory reaction).

The pulpal foramen does not allow drainage of the infectedpulp.

Further progression leads to medullary space infection andosteomyelitis.

More commonly, get fistulous tracts through alveolar bone.

Fistulous tract may penetrate oral mucosa or facial skin .



Subperiosteal abscess



Periodontal abscess

This is an acute or chronic purulent inflammation,

Which develops in existing periodontal pocket



Fistula

Osteitis



Periodontal abscess in the region of

the mandible second molar



Radiographic Appearence

Radiograph will tend to

show a carious tooth with a

periapical lesion.

Need to establish cause –

never assume it isodontogenic.



Fracture of facial bone



Injury to hard & soft tissue



Impacted teeth



Pericoronitis



Stomatitis Gingivitis



● General factors :

Infection of maxilla , zygomatic bone or sinus:

- Osteomyelitis

- radicular cyst

- infection of salivary glands or lymph node

- O R L diseases

Cellulitis manemeraK EdlPaKeRcInCaBBYk Aerobic

bacteria

CaBiessBBYk streptococci .



Infected cysts



Radicular cyst & periodontal cyst



Cyst formation per iodon tal cys t



Sialolitiasis submandibule



Wharton`s duct



The Stensen’s duct



sialadenitis



Lymph node



MICROBIOLOGY OF ODONTOGENIC INFECTIONS

Usually caused by endogenous bacteria Aerobic bacteria alone rarely causative agents

Streptococcus species are usually the etiologic organisms if

aerobic bacteria present

Half odontogenic infections: anaerobes Most odontogenic infections due to mixed flora

Mixed infections may have 5-10 organisms present

Bacterial composition :

1. 5%-aerobic bacteria

2. 60%-anaerobic bacteria

3. 35% mixed aerobic and anaerobic bacteria



Local symptoms

Pain.The severity of the pain depends on the stage of development of the inflammation.In the initial phase thepain is dull and continous and worsens duringpercussion of the responsible tooth and when it comesinto contact with antagonist teeth

Edema.Edema appears intraorally or extraorally and itusually has a buccal localization and more rarely palatalor lingual.

Usually the edema is soft with redness of the skin.

Other symptoms.There is a sense elongation of theresponsible tooth,slight mobility and difficulty inswollowing.





Systemic symptoms

fever ( to 39 –40 °C )

chill

malaise with pain in muscles and joints

anorexia, insomnia, nausea, and vomiting

Complications :

trismus, lymphadenitis at the respective lymph nodes

osteomyelitis

bacteremia,

septicemia.



Spread of pus inside tissues

From the site of the initial lesion, inflammation may

spread in three ways :

- by continuity through tissue spaces and planes

- by way of the lymphatic system- by way of blood circulation



The facial planes

1- surface of gingiva

2- palatal abscess

3- maxillary sinus

4- maxilla and mandible5- floor of the mouth



Fascial Spaces

Fascial planes offer anatomic highways for infection tospread superficial to deep planes

Antibiotic availability in fascial spaces is limited due topoor vascularity

Treatment of fascial space infections depends on I and D

Fascial spaces are contiguous and infection readilyspreads from one space to another (open primary and

secondary spaces)

Despite I and D the etiologic agent (tooth) must beremoved



Infections from teeth are related

to specific tissue spaces.



Spread of pus depending on the length of root and

attachment of buccinator muscle.

Buccal space

Buccinator muscle

Maxillary sinus

Vestibule



Buccal root :

Buccal direction

Palatal root :

Palatal direction



Determine the severity

Anatomic Location

Graded in severity in relation

to threat to airway or vital

structures.

Low – Medium – High severity

Low Severity

subperiosteal, vestibular, Buccal,infraorbital.

Medium Severity

Submandibular,submental,sublingual, Pterygomandibular,

submasseteric, infratemporal

High Severity

Ludwig’s Angina,

Lateralpharyngeal,

retropharyngeal, pretracheal,

mediastinum, intracranial.



I- Low Severity

Abscess of base of upper lip


Vestibular abscess

Intraalveolar abscess of maxilla& mandible Infraorbital ascess

Buccal abscess



a-Abscess of base of upper lip

This abscess develops the loose connective tissue of thebase of the upper lip at the anterior region of the maxilla,

beneath the pearshaped aperture.

Etiology :It is usually caused by infected root canals of maxillary

anterior teeth.

Clinical :- the swelling and protrusion of the upper lip

- obliteration of the depth of the mucolabial fold



Abscess of base of upper lipEdema in half of the upper lip



The tooth responsible for the

development of infection



Incision for the drainage of

an abscess



Insertion of a hemostat into the abscess cavity for drainage

of pus.

Placement and stabilization of the rubber drain at the

drainage site.



b-vestibular abscess

- Infections from maxillary premolars tend to form buccal

abscesses



Subperiosteal

Central incisors labialaspect

Commonly spontaneousdischarge.







The subperiosteal abscess involves limitedaccumulation of pus that is semi-fluctuant.

It is located between bone and the periosteum,at

the buccal,palatal,or lingual region,relative to the

tooth responsible for the infection.

Clinical :

- Mild edema

- severe pain due to tension of the periosteum- sensitivity during palpation



Subperiosteal abscess with lingual localization




Subperiosteal abscess with buccal localization



Incision



c- Intraalveolar abscess of maxilla& mandible

This is an acute purulente infection,which develops

at the apical region of the tooth in cancellous bone.



Clinical :

Severe pulsating pain

Tooth mobility

Sense of elongation causative tooth



TreatmentTrephination of buccal bone for drainage of an abscess.



Chronic Dentoalveolar Abscess

Many of the acute odontogenic infections, if not treated in

time, develop into chronic infections, resulting in spontaneous

drainage intraorally or on the skin.



Chronic dentoalveolar abscess with drainage, through a

fistula, at the buccal mucosa of the mandible and at the

mucosa of the palate



Cutaneous fistula at the mental region as a result

of a chronic dentoalveolar abscess originating from a

mandibular central incisor



Treatment

Treatment consists of eliminating the infection from the

responsible tooth with endodontic therapy or in conjunctionWith surgical treatment (apicoectomy),when endodontic therapy

alone does not produce the desired results.

Usually in intraoral fistulas, the fistulous tract disappears a fewdays after endodontic therapy begins,without requiring

intervention for excision of the opening.

In extraoral fistulas, though, after treating the infected site, thefistulous tract must be excised as far as the bone cavity and,

after debridement,must be sutured tightly.



d-Submucosal abscess

Submucosal abscess is located exactly underneath the

buccal and labial vestibular mucosa of the maxilla or

mandible,as well as the palatal or lingual region,respective to

the tooth responsible for the infection.

Clinical :

- sweeling of the mucosa with obvious fluctuation

- the mucosa appears reddish

- obliteration of the mucobuccal fold in the area of infection

- sensitivity during palpation



Submucosal abscess with buccal localization

Submucosal abscess

b l b f h ill i h



submucosal abscess of the maxilla with

buccal localization

Submucosal abscess



Incision and drainage of submucosal abscess



Placement of a hemostat in the cavity of an

abscess to facilitate the drainage of pus.

R bb d i t bili d ith t li



Rubber drain stabilized with suture on one lip

of the incision



e-Submucosal abscess with palatal localization

Lateral incisor teeth Abscess towards the palate.



Palatal abscess

Palatal abscess



Submucosal abscess with palatal localization

Palatal abscess



Incision and drainage of an abscess



Insertion of a hemostat into the abscess cavity for drainage

of pus.

Stabilization of the rubber drain with a suture on one lip of

the incision.



f- Subcutaneous abscess

This abscess is localized in various areas of the face

underneath the skin,with characteristic swelling that usually

fluctuates.

Clinical :

- edema

- the skin appears reddish

Subcutaneous abscess originating from



Subcutaneous abscess originating from

a mandibular tooth

Subcutaneous abscessSkin



Subcutaneous abscess



Peripheral infiltration anesthesia of healthy tissues

surrounding inflammation



Incision & drainage



g- Buccal space abscess



Buccal Space

1. Boundaries:

1. Lateral-Skin of the face

2. Medial-Buccinator muscle

2. Both a primary mandibular and maxillary space

3. Most infections caused by posterior maxillary teeth

Buccal Space Abscess





Buccinator muscle

Platysma muscle

Mylohyoid muscle








h- Canine fossa abscess

Untreated canine infections may sperad to canine space,then via various channels to cavernus sinus

Canine fossa abscess




The canine fossa,which is where this type of abcess

develops, is a small space between the levator labiisuperioris and the levator anguli oris muscle.

Etiology : Infected root canals of premolars and canine of

the maxilla are considered to be responsible for thedevelopment of abscesses of the canina fossa.

Clinical :

- edema,localized in the infraorbital region,medial canthusof the eye,lower eyelid and nose.

- painful during palpation.









Incision of the vestibular fold for drainage of

an abscess of the canine fossa



Insertion of a hemostat and exploration of the abscess

cavity as far as the bone surface,to faciliate the drainage of

pus



Rubber drain stabilized in position with suture.



Secondary Canine fossa abscess

P i ill



Primary maxillary space

(canine, buccal, and infratemporal space) involvement can

ascend to cause orbital cellulitis (preseptal or postseptal)or cavernous sinus thrombosis

1. Ocular findings include erythema and swelling of theeyelids, and ophthalmoplegia

2. Cavernous sinus thrombosis1. Can result from hematogenous spread of

odontogenic infections

2. Bacterial routes of spread:1. Posterior: via pterygoid plexus or emissary veins

2. Anterior: via angular vein and inferior or superior ophthalmicveins to the cavernous sinus

3. Veins of the face and orbit valve less so retrograde flow canoccur

O bit l Ab



Orbital Abscess



II-Moderate Severity

Submental

Submandibular

Sublingual

Submasseteric space,Pterygomandibular

Superficial and deep temporal

spaces

Why are these moderate?

Because they can hinder

access to airway due to

trismus or swelling.



Moderate Severity

Submental

Submandibular

Sublingual

Masseteric

Pterygomandibular

Superficial temporal

Deep temporal



Infections from Mandibular Posterior Teeth

Infection Spread

Lower moler teeth infection spread

posteriorly

Trismus (difficulty in mouth opening),

pain, swelling, respiratory distress

may result.

Moderate Severity



Moderate Severity

a-Mental abscessThe accumulation of pus in this space is located at the

anterior region of the mandible,near the bone,and,more

specifically,underneath the mentalis muscle,with spreat

of the infection towards the symphysis menti.

Clinical :

- firm and painful swelling in the area of the chin

- the skin becomes shiny and red



Mylohyoid muscle

Mental abscess

Mentalis muscle

b- Submental space



b Submental space

1- Infection can result directly due to infected mandibular

incisor or indirectly from the submandibular space

2- Space located between the anterior bellies of the

digastric muscle laterally, deeply by the mylohyoid muscle,

and superiorly by the deep cervical fascia, the platysmamuscle, the superficial cervical fascia, and the skin.

3- Dependent drainage of this space is performed by

placing a horizontal incision in the most dependent area

of the swelling extraorally with a cosmetic scar being the

result



Submental Space Infections from mandibular incisors tend to spread to

the labial sulcus or may spread extra-orally.



Submental abscess

Submental abscess



Incision and drainage





d Submandibular abscess



d- Submandibular abscess

Submandibular abscess






Mylohyoid muscleBuccinator muscle

Submandibular space



p

The submandibular space is bounded laterally by the inferior

border of the body of the mandible.

Boundaries:



Boundaries:

medially by the anterior belly of the digastric muscle

posteriorly by the stylohyoid ligament and the posterior

belly of the digastric muscle

superiorly by the mylohyoid and hyoglossus muscles

inferiorly by the superficial layer of the deep cervical fascia

Submandibular Space Abscess



Submandibular Space Abscess

Infected mandibular 2nd and 3rd molars cause

submandibular space involvement since root apices lay

below mylohyoid muscle

Ponction





Clinical :



- moderate swelling at the submandibular area

- edema that is indurated

- redness of the overlying skin

- pain during palpation

- moderate trismus due to involvement of the medial

pterygoid muscle.

Treatment :

The incision for drainage is performed on the skin,

approximately 1 cm beneath and parallel to the inferior

border of the mandible.



Incision & drainage



Insertion of a hemostat and exploration of the cavity of an

abscess for drainage of pus



TECHNIQUE OF INCISION



Secondary Mandibular Spaces




Referred to as secondary spaces since they are infected after involvement of primary mandibular spaces

Failure to treat a primary space infection or a compromisedhost results in secondary space involvement

Connective tissue fascia has poor blood supply hencetreatment usually surgical to drain purulent exudates

The secondary mandibular spaces include the masseteric,pterygomandibular, and temporal spaces





e- Sublingual Space



Tongue will be raised.

Floor of mouth tenderness and swelling.

May be in respiratory distress.

Sublingual Space



1-Submandibular and sublingual spaces surgically distinct,

but should be considered as surgical unit due to

proximity and frequent dual involvement inodontogenic infections.

2-Boundaries:

a-Superior-oral mucosa

b-Inferior-mylohyoid muscle

3-Infected premolar and 1st molar teeth frequently drain into

this space due to their root apices existing superior to the

mylohyoid muscle

Sublingual abscess



g

Sublingual abscessSublingual abscess

Incision for the drainage of an abscess .



insertion of a hemostat and exploration of the

abscessed space

Stabilization of the rubber drain with a suture at the



Stabilization of the rubber drain with a suture at the

cavity of the abscess

f- Submasseteric abscessis located between the masseter muscle and the lateral



is located between the masseter muscle and the lateral

surface of the rumus of the mandible.

Masseter muscle

Submasseteric abscess

Third molar

Masseteric Space



Masseteric Space

1-Located between lateral aspect of the mandible and

the masseter muscle

2-Involvement of this space generally occurs frombuccal space primary involvement

3-Signs of involvement of the masseteric space include

trismus and posterior-inferior face swelling

g- Pterygomandibulary abscess



g yg y

Location :between medial aspect of the mandible and the medial

pterygoid muscle (communicates with infratemporal spaces)

Etiology :

- infection of mandibular third molars (pericoronitis)

- the result of an inferior alveolar nerve block

Pterygomandibulary space B d i



Boundaries:

- medially by medial pterygoid muscle- laterally by the medial surface of the

ramus of the mandible.

- superiorly by the lateral pterygoid

muscle- anteriorly by pterygomandibular

raphe

- posteriorly by the parotid gland

P tid l d



Parotid gland

Retropharyngeal space

Medial pterygoid muscle

Pterygomandibular space

Masseter muscle

Ramus of mandible

Lateral pharyngeal space

Submandibular space

Buccinator muscle

Clinical :

t i d li ht t l d b th th



- severe trismus and slight extraoral edema beneath the

angle of the mandible

- edema of the soft palate

- displacement of the uvula and lateral pharyngeal wall

- difficulty in swollowing

Treatment :

The incision for drainage is performed on the mucosa of the

oral cavity and,more specifically,along the mesial temporal

crest.The incision must be 1,5 cm long and 3-4 mm deep.

Incision for drainage of a

pterygomandibular abscess



pterygomandibular abscess

2ndary infection results from spread from the sublingual and

submandibular spaces

h- Parotid space abscess



h Parotid space abscessis located in the area of the ramus of the mandible.

Mylohyoid muscle

Parotid space abscess

Incision for sufficient drainage of



a parotid space abscess

Insertion of a hemostat and exploration of the




abscess cavity.

Rubber drain placed at the site of incision

Temporal Space



1-Location: posterior and superior to the masseteric and

pterygomandibular spaces

2-Bounded laterally by the temporalis fascia and

medially by the temporal bone

3-Two components :

1. Superficial temporal space: located between temporal

fascia and temporalis muscle

2. Deep temporal space: located between the temporalis

muscle and the temporal bone

1. Continuous with the infratemporal space

e- Infratemporal abscessTh i hi h thi b d l i th i



The space in which this abscess develops is the superior

extension of the pterygomandibular space.

Infratemporal

abscess

Buccinator muscle

Infratemporal Space

1 Location: posterior to the maxilla



1-Location: posterior to the maxilla

2-Boundaries:

1. Medial : lateral plate of the pterygoid process of the sphenoid

bone

2. Superior : skull base

3. Lateral : infratemporal space is continuous with the deeptemporal space

3-Rare involvement with odontogenic infections, but when

occurs related to 3rd

maxillary molar infections

The incision at the depth of the mucobuccal

fold for drainage of the abscess



fold for drainage of the abscess

Clinical :- trismus and pain during

opening of the mouth

- edema at the region anterior

to the ear

- edema of the eyelid

III- High Severity



Cellulitis (Phlegmon) Ludwig’s angina

Lateral Pharyngeal Space Abscess

Retropharyngeal Abscess

Cellulitis (Phlegmon)



Anatomic Location. This condition is an acute, diffuse inflammatory infiltration

of the loose connective tissue found underneath the skin.

It is believed today that cellulitis and phlegmon areinterchangeable terms.

The term cellulitis has prevailed and so the term phlegmon

has just about been abandoned.

Etiology.



It may be the result of any infected tooth and is usuallydue to a mixed infection.

The microorganisms thought to be responsible are

aerobic and anaerobic streptococci and staphylococci.

Cellulitis originating from a mandibular

t i t th



posterior tooth

Accumulation of pus in deep tissue

Buccinator muscle

Clinical :



extensive swelling of the right side, resulting in severe

disfigurement of the face Edema.The edema may present in various areas of the

face and its localization depends on the infected tooth

responsible.

headache reddish skin.

In the initial stage, cellulitis feels soft or doughy during

palpation, without pus present, while in more advanced

stages, a board-like induration appears,whichmay leadto suppuration.

At this stage, the pus is localized in small focal sites in

th d ti



the deep tissue.

Treatment :

large doses of antibiotics are administered (penicillin or

ampicillin parenterally).

Drainage may be performed in one or more sites tofacilitate evacuation of the exudate.

In grave cases admission of the patient to a hospital is

recommended.

Cellulitis

Diff ll liti



Diffuse cellulitis

Pre- and Postoperative clinical



Pre-and Postoperative clinical



Ludwig’s angina



Ludwig’s Angina is a grave acute cellular infection and ischaracterized by bilateral involvement of the submandibular

and sublingual spaces as well as the submental space.

Abstract Ludwig’s Angina is a rapid progressive cellulitisof the submandibular , sublingual and submental spaces,with potential for significant upper airway obstruction.

First described by Wilhelm Fredrick Von Ludwig in 1836,

then by Camerer in 1837.

Ludwig’s angina



Submandibular space

Sublingual space

Submental space

Ludwig’s angina



Tongue

Mylohyoid muscle Sublingual salivary gland

Sublingual Space Infection



Ludwig’s angina



These infections may spread to

submandibular, lingual or buccalspaces.

“ludwigs angina”

Bilateral sublingual,

submandibular and submental

spreading cellulitis.

Etiology.

The most frequent cause of the disease is



The most frequent cause of the disease is

periapical or periodontal infection of mandibular

teeth, especially of those whose apices are found beneath

the mylohyoid muscle.

Clinical. Severe pain

severe difficulty in swallowing, speaking and breathing,

drooling of saliva

elevated temperature

Treatment.

This is treated surgically with surgical decompression



This is treated surgically with surgical decompression

(drainage) of the spaces of infection and concurrent

administration of a double regimen of antibiotics.

The incisions must be bilateral, extraoral, parallel,and

medial to the inferior border of the mandible, at the

premolar and molar region and intraoral, parallel to the

ducts of the submandibular glands.

Immediate intubation,surgical decompression

and antibiotic therapy successfully resolved the



Intubation done before the drainage

a d a t b ot c t e apy success u y eso ed t e

episode.

Incision for sufficient drainage




Pre-and Postoperative clinical



Pre and Postoperative clinical

after drainage of the purulent accumulation



after drainage of the purulent accumulation

Masseteric, pterygomandibular, and temporal spaces



p yg p p

referred to as masticator space due to delineation by

the muscles of mastication

1. Communicate freely with one another and are

simultaneously involved

Primary Maxillary Spaces

C i S



Canine Space

1. Location: between the levator anguli oris and thelevator labii superioris muscles

2. Involvement primarily due to maxillary canine toothinfection

3. Long root allows erosion through the alveolar bone of

the maxilla4. Signs:

1. Obliteration of the nasolabial fold

2. Superior extension can involve lower eyelid

Buccal Space1. Posterior maxillary teeth are source of most buccal

space infections

2. Results when infection erodes through bone superior to attachment of buccinator muscle

Deep Neck Spaces



Extension of odontogenic infections beyond the primary

spaces of maxilla and mandible is uncommon.

When occurs upper airway compromise and descending

mediastinitis are possible adverse sequelae.

Posterior spread of ptyerygomandibular space infection is

to lateral pharyngeal space.

Lateral Pharyngeal space



Shape of an inverted cone with its base at the skullbase and its apex at the hyoid bone.

Location: medial to the medial pterygoid muscle and

lateral to the superior pharyngeal constrictor muscle.

Anterior: pterygomandibular raphe.

Posterior: prevertebral fascia.

Lateral pharyngeal space communicates with

t h l



retropharyngeal space.

The styloid process separates posterior compartment of

the lateral pharyngeal space that contains the great

vessels from the anterior space.

Clinical presentation



1. Severe trismus

2. Lateral swelling of the neck3. Bulging of the lateral pharyngeal wall

4. Rapid progression of infection in this space is common

5. Posterior compartment involvement can result in

thrombosis of the internal jugular vein, erosion of thecarotid artery or its branches, and interference with

cranial nerves IX to XII

Lateral Pharyngeal Space Abscess



Retropharyngeal Space

1. Posteromedial to lateral pharyngeal space and anterior



p y g p

to the prevertebral space

2. Anterior: superior pharyngeal constrictor muscle

3. Posterior: alar layer of prevertebral fascia

4. Extends from skull base superiorly to C7 to T1 inferiorly

5. Retropharyngeal space infections can spread to

mediastinum

6. Other complications of retropharyngeal space

involvement:

1. Airway obstruction

2. Aspiration of pus in the event of spontaneous rupture

3. Rupture can occur during endotracheal intubation

Retropharyngeal Abscess



Prevertebral Space



Prevertebral Space

1. Potential space between two layers of prevertebralfascia (alar and prevertebral layers)

2. Extends from skull base superiorly to the diaphragm

inferiorly

3. Mediastinitis is concern with prevertebral spaceinfections similarly to retropharyngeal space infections

Anatomic Planes





Management of Odontogenic Infections



Goals of management of odontogenic infection:

1. Airway protection

2. Surgical drainage

3. Medical support of the patient4. Identification of etiologic bacteria

5. Selection of appropriate antibiotic therapy

Technique:

1 Small incision are made in a dependent area



1. Small incision are made in a dependent area

2. Placement of a hemostat in the abscess cavity with entryinto all loculations of the abscess

3. Penrose drains inserted into cavity to allow for

postoperative drainage of the abscess

Lines of incision





Lines of incision





Superficial incisions on the skin and on the

mucosa of the oral cavity



mucosa of the oral cavity

TECHNIQUE OF INCISION

Peripheral infiltration anesthesia of healthy tissues

di i fl ti



surrounding inflammation





abscessed space



abscessed space

Exploration of the cavity of an abscess for

drainage of pus



g p

Rubber drain stabilized in position with suture.













Selection of antibiotic therapy

1. Parenteral penicillin

2 M t id l i bi ti ith i illi b



2. Metronidazole in combination with penicillin can be

used in severe infections3. Clindamycin for penicillin-allergic patients

4. Cephalosporins (first-generation cephalosporins)

5. Antibiotics do not substitute for incision and drainage

in cases of significant odontogenic infections

6. Causes for clinical failure include inadequate

drainage or antibiotic resistance

7. Mediastinal involvement should prompt CT scan of

the chest and cardiothoracic surgery consultation



Th k !