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%)–
MICRO ORGANISMS
 Streptococcus species( 90% )
• S.Milleri
• S.Sanguis
• S.Salivarius 25
MIXED
• S.Mutans
5 AEROBIC
 Staphylococcus species (6 %)
70 ANAEROBIC

 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%)
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 Sublingual Anterovisceral Retro

(Pretracheal) pharyngeal
Canine Submandibular
Carotid sheath
Masticatory Pharyngomaxillary space

Parotid
CLASSIFICATION OF FASCIAL SPACES
BASED ON MODE OF INVOLVEMENT

FASCIAL SPACES

DIRECT (Primary spaces) INDIRECT (Secondary spaces)

Masseteric

Pterygomandibular
MAXILLARY MANDIBULAR
Superficial & Deep
Canine Submental Temporal

Buccal Buccal Lateral Pharyngeal

Infratemporal Submandibular Retropharyngeal

Sublingual Prevertebral & Parotid

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 Pterygomandib Maxilla, Lower Border Buccinator Skin Of
Mouth ular Raphe, infraorbital Of Mandible Muscle, Cheek
Masseter space Buccopharyng
eal Fascia

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 Buccal space Quadratis Oral mucosa Quadratis Levator anguli

cartilages labii labii oris
superioris superioris

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 Posterior belly Inferior & Digastric Platysma, Mylohyoid,
of digastric Of digastric, medial tendon Investing Hypoglossus,
Stylohyoid, surface of fascia Superior
Stylopharyngus mandible Constrictor

CONTENTS: Submandibular gland, Facial artery & vein

LIKELY SOURCE OF INFECTION : Mandibular molars
SUB MANDIBULAR SPACE
CLINICAL FEATURES :
Induration and erythema
Obliteration of the mandibular line & extending to the level of hyoid
bone
No trismus
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 Submandibular Oral mucosa Mylohyoid Muscles of Lingual

surface of space muscle tongue Surface
mandible 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 Fascia between Mylohyoid Investing Investing Fascia Anterior

border of Hyoid and fascia bellies of
mandible inferior border digastric
of mandible

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 Lateral Inferior Medial Ascending

Of Parotid Pterygoid border of pterygoid Ramus of
gland mandible muscle 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 Inferior Ascending Masseter

arch border of ramus of muscle
mandible mandible

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

SUBMASSETRIC SPACE
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.

SUPERFICIAL TEMPORAL SPACES
ANTERIOR POSTERIOR INFERIOR MEDIAL LATERAL
Posterior Fusion of Zygomatic arch Lateral surface Temporal
surface of temporalis of temporalis Fascia
lateral orbital fascia with muscle
rim pericranium

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 Attachment of Lateral Temporal bone Temporalis
maxillary sinus, temporalis to pterygoid muscle
Pterygomaxillary cranium muscle
fissure, posterior
surface of orbit

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 Mandibular Infratemporal Lateral Lateral Temporalis
tuberosity condyle crest of pterygoid pterygoid Tendon,
sphenoid muscle plate 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
INFRATEMPORAL SPACE
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.
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.
LUDWIG’S ANGINA- BACTERIOLOGY
 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
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 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 Apex of Pitutary Temporal lobe Optic chiasma Endosteal
superior petrous above and and uncus dura mater,
orbital fissure temporal bone sphenoid greater wing
below 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 Hard, exquisitely tender Fluctuant, tender
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