1. Inflammatory processes SCHLD soft tissues in children (abscesses, cellulitis, lymphadenitis, boils, carbuncles).Patterns of clinical course, diagnosis, differential diagnosis and comprehensive treatment. Specific inflammatory disease.

2. Introduction
Penicillin 1940’s
Odontogenic infections
Deep anatomic fascial space
Threaten vital structures

4. Clinical examination underestimate extent in 70%
Introduction
Most important:
Submandibular
Lateral Pharyngeal
Retropharyngeal / Danger / Prevertebral
Clinical examination underestimate extent in 70%

5. Potential pathways of extension of deep fascial space infections of the head and neck

7. Fascial spaces around the mouth and face

8. Figure 69-4 Natural progression of dental infection
Figure 69-4 Natural progression of dental infection. The pathways by which such infections may travel are: 1, postzygomatic (from canine fossa in cuspid and bicuspid region; pterygomaxillary fossa communicates from rear); 2, vestibular; 3, facial; 4, submandibular; 5, sublingual; 6, palatal; 7, antral; 8, pterygomandibular; 9, parapharyngeal; 10, masseteric. (Redrawn from Rose LF, Hendler BH, Amsterdam JT: Temporomandibular disorders and odontic infections. Consultant 22:125, 1982.)
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9. Clinical examination of odontogenic infections

10. Stages of infection
4 stages
Inoculation
Cellulitis
Abscess
Rupture
Spreading odontogenic infection

11. Trismus
Inability to open mouth widely
Inflammation muscles of mastication
Masticator space / Pterygomandibular space
Difficult intubation

12. Airway / Physical evaluation
Pharyngeal swelling – difficulty swallowing
Difficulty sleeping supine
Sniffing position – Retropharyngeal space
Head deviated to opposite side – Lateral pharyngeal space
Muffled voice – Epiglottitis
Distant quality to voice – Retropharyngeal / Lateral Pharyngeal
Elevated tongue – Sublingual space

14. Intraoral examination
Caries
Swellings of oral vestibule
Periodontal disease
Tooth mobility
Pericoronitis
Swellings
Position of uvula

17. Radiographic evaluation
Rapid CT scanners
Contrast enhanced CT
Postero-anterior / lateral soft tissue x-rays of neck
Dental panoramic view (Orthopantomogram)

18. Lateral radiograph of the neck

20. Figure 69-5 Periapical abscesses (arrows) as seen on Panorex film.
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21. Culture and sensitivity testing
Penicillin resistance 30 – 50%

23. 1. Submandibular Space

24. Introduction
‘’Ludwigs angina’’
‘’Angina maligna’’
‘’Morbus strangulatorius’’
‘’Garotillo’’

25. Early appearance of patient who has Ludwig’s angina with characteristic submandibular ‘’woody’’ swelling

27. Anatomy and pathogenesis
Sublingual and submylohyoid spaces
Odontogenic ( periapical abscesses of mandibular molars – 2nd / 3rd)
Communicate freely:
Entire submandibular space
Buccopharyngeal gap – lateral pharyngeal space – retropharyngeal space

28. Anatomic relationships in submandibular infections

29. Routes of spread of odontogenic orofacial infections along planes of least resistance

30. Clinical manifestations
Mouth pain / stiff neck / drooling / dysphagia
No trismus
Woody inflammation
No lymph node involvement
Protruding tongue

31. Ludwig's Angina
Involvement submandibular spaces bilaterally and submental space in midline
Rapid spread to lateral pharyngeal / retropharyngeal space
Rapidly obstruct upper airway

32. Early Ludwig's angina

33. Early Ludwig's angina

34. Submandibular space abscess and Cellulitis

35. Potential complications
Airway compromise
Spread into the lateral pharyngeal space and beyond

36. Figure 69-6 Extensive spread of infection of odontogenic origin involving masseteric, sublingual, submental, and submandibular spaces with extension to mediastinum. A, Preoperative. B, Postoperative. Note drainage from mediastinum. (From Guernsey LH: Practical problem solving in oral surgery. In Cohen DW [ed]: Continuing Dental Education, vol 2, suppl 10. Philadelphia, University of Pennsylvania School of Dental Medicine, 1979.)
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37. Figure 69-6 Extensive spread of infection of odontogenic origin involving masseteric, sublingual, submental, and submandibular spaces with extension to mediastinum. A, Preoperative. B, Postoperative. Note drainage from mediastinum. (From Guernsey LH: Practical problem solving in oral surgery. In Cohen DW [ed]: Continuing Dental Education, vol 2, suppl 10. Philadelphia, University of Pennsylvania School of Dental Medicine, 1979.)
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38. Therapeutic considerations
Mixed infection – synergistic interaction
Immunocompromised
MRSA
Candida / Aspergillus

39. 2. Lateral Pharyngeal Space

40. Potential pathways of extension of deep fascial space infections of the head and neck

42. Anatomy and pathogenesis
Anterior / muscular compartment
Posterior / neurovascular compartment
Carotid sheath
9 to 12 cranial nerves
Sympathetic trunk
Peritonsillar abscesses

43. Clinical manifestations
Anterior compartment
Dysphagia
Trismus
pain
Posterior compartment
No trismus
Neurologic / vascular
Edema epiglottis / larynx

45. Abscess of lateral Pharyngeal space

47. Potential complications
NB: Posterior compartment
Laryngeal edema
Vagal nerve
Horner's syndrome
Cranial nerve palsies
Suppurative jugular thrombophlebitis (lemierre syndrome)
Carotid artery erosion

48. Lemierre’s Syndrome
Septic thrombophlebitis of internal jugular vein
Septic emboli – lung / liver abscesses / septic arthritis
Fusobacterium necrophorum

49. Jugular venous thrombosis

50. Therapeutic considerations
Suppurative
Posterior more conservative
Anterior more aggressive treatment

51. 3. Retropharyngeal / Prevertebral / Danger Space

52. Introduction
Caudal extension of infection
Considered together

53. Anatomy and pathogenesis
Between pharynx-esophagus and spine
Delineated by fascial planes: 3 layers of deep cervical fascia

55. Retropharyngeal space
Base skull to C7 / T1
Mediastinal spread
Pleural / pericardial spread
Deep cervical chain of nodes in children
Other causes eg: oesophageal instrumentation, foreign bodies….

56. Retropharyngeal abscess

57. Retropharyngeal space

59. Danger space
Base skull to diaphragm
Contiguous spread from adjacent spaces

60. Prevertebral space
Between prevertebral fascia and vertebral bodies
Base skull to coccyx
Contiguous with psoas muscle sheath
Haematogenous spread NB
Local instrumentation
Contiguous spread
Different microbiology

61. Clinical manifestations Retropharyngeal danger space
Sore throat / dysphagia / stiff neck
Upper airways obstruction
Head tilt contralateral side
Pleuritic chest pain
Bulging posterior oropharynx

62. Lateral radiograph of the neck

63. Prevertebral space
Spinal cord compression
Epidural abscess

64. Potential complications
Laryngeal inflammation
Rupture with aspiration
Descending necrotizing mediastinitis
Pyothorax / pericardial involvement
Spinal epidural collections
Psoas muscle infection

65. Therapeutic considerations
Retropharyngeal / danger space:
Adequate anaerobic / oral gram + cover
Surgery if indicated
Prevertebral:
Surgical drainage
NB gram + / MRSA / gram - rods

66. 4. Buccal space Subcutaneous space
Connects to: infraorbital space, periorbital tissues, superficial temporal space
Hemophilus influenzae Cellulitis:
Children
Recent URTI / sinusitis

69. Buccal Cellulitis (Hib)

70. 5. Infraorbital space Lower lid / periorbital swelling
Point medially (inner canthus) or laterally (lateral canthus)
Septic thrombophlebitis angular vein → cavernous sinus

71. 6. Orbital space Preseptal Cellulitis
Subperiosteal abscess (orbital wall)
Orbital Cellulitis / abscess → optic nerve damage / cavernous sinus thrombosis

75. 7. Vestibular space Diffuse facial swelling
Elevation of the oral vestibule
Potential space between oral mucosa and muscles facial expression
Draining sinus

77. 8. Subperiosteal space Dental infection
Perforates cortical layer but not periosteum
Eg: mandibular subperiosteal infection

78. 9. Submental space
Secondary spread from submandibular space

80. 10. Masticator space
Severe trismus
Surrounding muscles of mastication

82. Masticator space infection with trismus

83. Masticator space abscess

84. 11. Temporal space
Trismus (infratemporal fossa – part of masticator space)
Cavernous sinus thrombosis

85. Deep temporal space infection with spread to parotid space

87. Treatment

88. The admission decision
Airway issues
High fever
Dehydration
Need for I+D
Inpatient control systemic disease
Immune compromise

89. Airway security
Protect against aspiration
ETT ruptures abscess
Trismus / Swelling
Maintain airway reflexes during intubation

90. Surgical treatment
Gravity dependent surgical drainage
Antibiotics secondary
Tooth extraction

91. Antibiotic therapy
Predominately anaerobic nature
Initially: aerobic streptococci ( penicillin )
Later: anaerobic bacteria ( penicillin resistant )
Synergistic interaction

94. Complications

95. Mediastinitis
Airway security
Contrast CT
Open thoracotomy
Broad spectrum antibiotics

96. Cavernous sinus thrombosis
Ascending septic thrombophlebitis
Anterior route – angular vein (infraorbital space)
Posterior route – facial vein (buccal space)
Congestion retinal veins
CN 6 paresis → ophthalmoplegia / blindness
Severe orbital / periorbital / infraorbital swelling

97. Cavernous Sinus Thrombosis
Treatment:
Tooth extraction root canal
Drainage deep spaces
High dose IV antibiotics
Anticoagulation

100. Summary
Preventative dental care
Effective antibiotics

101. Lymphadenitis is the inflammation of a lymph node.
Lymph nodes
The glandlike masses of tissue in the lymphatic system that contain lymphocytes. The lymph nodes also filter lymph, which is a clear yellowish tissue fluid that carries lymphocytes and fats throughout the body.

102. Lymphoid system of maxillofacial area: 1 — glandula parotis; 2 — nodi lymphatici occtpitales; 3 — nodi lymphatici auriculares poster. 4 — nodi lymphatici cervicales profundi superiores; 5 — v. jugutaris dextra; 6 — nodi lymphatici : cales superficiales; 7 — nodi lymphatici cervicales profundi inferiores; 8 — nodi lymphatici auricu anteriorea; 9 — nodi lymphatici submaxillares; 10 — nodulus lymphaticus submentalis; 11 — a. ca communis dextra; 12— truncus lymphaticus jugularis dexter.

103. THE MAINS WAYS OF FLOWING LYMPH FROM LOWER AND APPER LIPS

104. Lymphadenitis is often a complication of a bacterial infection of a wound, although it can also be caused by viruses or other disease agents. Lymphadenitis may be either generalized, involving a number of lymph nodes; or limited to a few nodes in the area of a localized infection. Lymphadenitis is sometimes accompanied by lymphangitis, which is the inflammation of the lymphatic vessels that connect the lymph nodes.

105. Causes
Streptococcal and staphylococcal bacteria are the most common causes of lymphadenitis, although viruses, protozoa, rickettsiae, fungi, and the tuberculosis bacillus can also infect the lymph nodes. Diseases or disorders that involve lymph nodes in specific areas of the body include rabbit fever (tularemia), cat-scratch disease, lymphogranuloma venereum, chancroid, genital herpes, infected acne, dental abscesses, and bubonic plague. In children, tonsillitis or bacterial sore throats are the most common causes of lymphadenitis in the neck area. Diseases that involve lymph nodes throughout the body include mononucleosis, cytomegalovirus infection, toxoplasmosis, and brucellosis.

106. Physical examination
The diagnosis of lymphadenitis is usually based on a combination of the patient's history, the external symptoms, and laboratory cultures. The doctor will press (palpate) the affected lymph nodes to see if they are sore or tender. Swollen nodes without soreness are often caused by cat-scratch disease. In children, the doctor will need to rule out mumps, tumors in the neck region, and congenital cysts that resemble swollen lymph nodes.

107. PALPATION OF SUBMANDIBLE LYMPH NODES

108. PALPATION OF SUBMENTAL LYMPH NODES

109. PALPATION OF RETROMANDIBLE LYMPH NODES

110. CLINICAL CLASSIFICATION OF LYMPHADENITIS
-Acute: serous, purulent.
-Chronic: hyperplastic, purulent.

111. Symptoms
Lymphadenitis is marked by swollen lymph nodes that are painful, in most cases, when the doctor touches them. If the lymphadenitis is related to an infected wound, the skin over the nodes may be red and warm to the touch.

112. Acute lymphadenitis

113. Chronic lymhadenitis

114. Operation of removed lymph nodes attached chronical inflammation

115. Operation of removed lymph nodes attached chronical inflammation

116. Removed lymph nodes

117. Treatment
The medications given for lymphadenitis vary according to the bacterium or virus that is causing it. If the patient also has lymphangitis, he or she will be treated with antibiotics, usually penicillin G (Pfizerpen, Pentids), nafcillin (Nafcil, Unipen), or cephalosporins. Erythromycin (Eryc, E-Mycin, Erythrocin) is given to patients who are allergic to penicillin. Supportive care of lymphadenitis includes resting the affected limb and treating the area with hot moist compresses. Cellulitis associated with lymphadenitis should be treated surgically because of the risk of spreading the infection. Pus is drained only if there is an abscess and usually after the patient has been started on antibiotic treatment. In some cases, a biopsy of an inflamed lymph node is necessary if no diagnosis has been made and no response to treatment has occurred.

118. Prognosis
The prognosis for recovery is good if the patient is treated promptly with antibiotics. In most cases, the infection can be brought under control in three or four days. Patients with untreated lymphadenitis may develop blood poisoning (septicemia), which is sometimes fatal.

119. Hair follicle anatomy

120. A furuncle is an infection of a hair follicle.
A carbuncle is a skin infection that often involves a group of hair follicles.

121. Causes
Furuncles are very common. They are caused by staphylococcus bacteria, which are normally found on the skin surface. Damage to the hair follicle allows these bacteria to enter deeper into the tissues of the follicle and the subcutaneous tissue. Furuncles may occur in the hair follicles anywhere on the body, but they are most common on the face, neck, armpit, buttocks, and thighs.Furuncles are generally caused by Staphylococcus aureus, but they may be caused by other bacteria or fungi.

122. Risk factors Although anyone — including otherwise healthy people — can develop boils or carbuncles, the following factors can increase your risk:
Poor general health. Having chronic poor health makes it harder for your immune system to fight infections.
Diabetes. This disease can make it more difficult for your body to fight infection, including bacterial infections of your skin.
Clothing that binds or chafes. The constant irritation from tight clothing can cause breaks in your skin, making it easier for bacteria to enter your body.
Other skin conditions. Because they damage your skin's protective barrier, skin problems, such as acne and dermatitis, make you more susceptible to boils and carbuncles.
Immune-suppressing medications. Long-term use of corticosteroids, such as prednisone or other drugs that suppress your immune system, can increase your risk.

123. FURUNCLE (the first stage of development)

124. FURUNCLE (the second stage of development)

125. Furuncle of face

126. Furuncle of face

127. Furuncle of face

128. Furuncle of face

129. Carbuncle of face

130. Carbuncle of the lower lip

131. Signs and symptoms
A boil usually appears suddenly as a painful pink or red bump that's generally not more than 1 inch in diameter. The surrounding skin also may be red and swollen.
Within a few days, the bump fills with pus. It grows larger and more painful for about five to seven days, sometimes reaching golf ball size before it develops a yellow-white tip that finally ruptures and drains. Boils generally clear completely in about two weeks. Small boils usually heal without scarring, but a large boil may leave a scar.
A carbuncle is a cluster of boils that often occurs on the back of the neck, shoulders or thighs, especially in older men. Carbuncles cause a deeper and more severe infection than single boils do. In addition, carbuncles develop and heal more slowly and are likely to leave a scar. Carbuncles sometimes occur with a fever.
Boils and carbuncles often resemble the inflamed, painful lumps caused by cystic acne. But compared with acne cysts, boils are usually redder or more inflamed around the border and more painful.

132. Treatment
Doctor may drain a large boil or carbuncle by making a small incision in the tip. This relieves pain, speeds recovery and helps lessen scarring. Deep infections that can't be completely cleared may be covered with sterile gauze so that pus can continue to drain. Sometimes doctor may prescribe antibiotics to help heal severe or recurrent infections.

133. Self-care The following measures may help the infection heal more quickly and prevent it from spreading:
Apply a warm washcloth or compress to the affected area. Do this for at least 10 minutes every few hours. If possible, first soak the cloth or compress in warm salt water. This helps the boil rupture and drain more quickly. To make salt water, add 1 teaspoon of salt to 1 quart of boiling water and cool to a comfortable temperature.
Gently wash the boil two to three times a day. After washing, apply an over-the-counter antibiotic and cover with a bandage.
Never squeeze or lance a boil. This can spread the infection.
Wash your hands thoroughly after treating a boil. Also, launder clothing, towels or compresses that have touched the infected area.

134. Prevention Although it's not always possible to prevent boils, especially if you have a compromised immune system, the following measures may help you avoid staph infections:
Thoroughly clean even small cuts and scrapes. Wash well with soap and water and apply an over-the-counter antibiotic ointment.
Avoid constricting clothing. Tight clothes may be stylish, but make sure they don't chafe your skin.

135. Inflammation may spread in three ways:
1. By passing through tissue spaces and planes.
2. By way of the lymphatic system.
3. By way of blood circulation.

136. Most Common Teeth and Associated Periodontium Involved in Clinical Presentations of Abscesses and Fistulae.
Maxillary vestibule
Maxillary central or lateral incisor, all surfaces, and roots.
Maxillary canine, all surfaces, and roots (short roots below levator anguli oris).
Maxillary premolars, buccal surfaces, and roots.
Maxillary molars, buccal surfaces, or buccal roots (short roots below buccinator).
Penetration of nasal floor
Maxillary central incisor, roots.
Maxillary canine, all surfaces, and root (long root above levator anguli oris).
Palate
Maxillary lateral incisor, lingual surfaces, and roots. Maxillary premolars, lingual surfaces, and roots. Maxillary molars, lingual surfaces, or palatal roots.
Perforation Into maxillary sinus
Maxillary molars, buccal surfaces, and buccal roots (long roots). Maxillary molars, buccal surfaces, and buccal roots (long roots above buccinator). Mandibular first and second molars, buccal surfaces, and buccal roots (long roots below buccinator).
Mandibular vestibule
Mandibular incisors, all surfaces, and roots (short roots above mentalis).
Mandibular canine and premolars, all surfaces, and roots (all roots above
depressors).
Mandibular first and second molars, buccal surfaces, and roots (short roots
above buccinator).

137. Most Common Teeth and Associated Periodontium Involved in Clinical Presentations of Abscesses and Fistulae.
Submental skin region
Mandibular incisors, roots (long roots below mentalis).
Sublingual region
Mandibular first molar, lingual surfaces, and roots (all roots above mylohyoid). Mandibular second molar, lingual surfaces, and roots (short roots above mylohyoid).
Submandibular skin region
Mandibular second molar, lingual surfaces, and roots (long roots below mylohyoid). Mandibular third molars, all surfaces, and roots (all roots below mylohyoid).

138. Possible Space. Teeth, and Periodontium Involved With a Clinical Presentation of Phlegmon from the Spread of Dental Infection.

139. SPREAD BY SPACES
The spaces of the head and neck can allow the spread of infection from the teeth and associated oral tissues because the pathogens can travel within the fascial planes, from one space near the infected site to another distant space, by the spread of the related inflammatory exudate. When involved in infections, the space can undergo phlegmon or abscess, which can cause a change in the normal proportions of the face.

140. Frontal section of the head and neck highlighting the submandibular and sublingual spaces.

141. SPREAD BY LYMPHATICS
The lymphatics of the head and neck can allow the spread of infection from the teeth and associated oral tissues. This occurs because the pathogens can travel in the lymph through the lymphatics that connect the series of nodes from the oral cavity to other tissues or organs. Thus, these pathogens can move from a primary node near the infected site to a secondary node at a distant site .

142. Superficial cervical lymph nodes and associated structures.

143. Deep cervical lymph nodes and associated structures.

144. SPREAD BY THE BLOOD SYSTEM
The blood system of the head and neck can allow the spread of infection from the teeth and associated oral tissues, because pathogens can travel in the veins and drain the infected oral site into other tissues or organs. The spread of dental infection by way of the blood system can occur from bacteremia or an infected thrombus.

145. Pathways of the internal jugular vein and facial vein, as well as the location of the cavernous venous sinus.

146. SPREAD TO THE PARANASAL SINUSES
The paranasal sinuses of the skull can become infected through the direct spread of infection from the teeth and associated oral tissues, resulting in a secondary sinusitis. A perforation in the wall of the sinus can also be caused by an infection. Secondary sinusitis of dental origin occurs mainly with the maxillary sinuses, since the maxillary posterior teeth and associated tissues are in close proximity to these sinuses.

147. Lateral view of the skull and the paranasal sinuses.

148. Dental abscess
An abscess is an accumulation of pus. Pus is a thick fluid that usually contains white blood cells, dead tissue and bacteria (germs). The usual cause of an abscess is an infection with bacteria. A dental abscess is an infection in the centre of a tooth which spreads through the tooth to infect supporting bone and other nearby tissues.

149. Dental abscess
Dental abscess is common. It may develop as a complication of tooth decay (caries), or from an infection in the gums.

150. CAUSES The cause of these infections is direct growth of the bacteria from an existing cavity into the soft tissues and bones of the face and neck.
An infected tooth that has not received appropriate dental care can cause a dental abscess to form. Poor oral hygiene, (such as not brushing and flossing properly or often enough) can cause cavities to form in your teeth. The infection then may spread to the gums and adjacent areas and become a painful dental abscess.

151. Classification abscesses and phlegmons of maxillofacial area:
1.Abscesses and phlegmons of the maxilla region.
2.Abscesses and phlegmons of the mandible region.
3.Abscesses and phlegmons of the bottom oral cavity.
4.Abscesses and phlegmons of the tongue and of the neck.

152. Symptoms of a dental abscess include:
Pain (toothache) which can quickly become worse. It can be severe and throbbing.
Swelling of the gum which can be tender.
Swelling of the face. The skin over an abscess may become red and inflamed.
The affected tooth may become tender to touch, and may even become loose.
High temperature and feeling generally unwell.
In severe cases there may be spasm of the jaw muscles with difficulty swallowing and/or breathing.

153. PHYSICIAN DIAGNOSIS
A doctor or dentist can determine by physical examination if you have a drainable abscess. X-rays of the teeth may be necessary to show small abscesses that are at the deepest part of the tooth. Signs observed by the doctor, including nausea, vomiting, fever, chills, or diarrhea, may indicate that the infection has progressed to the point where it is making your whole body sick.

154. PHYSICIAN TREATMENT
The doctor may decide to cut open the abscess and allow the pus to drain. Unless the abscess ruptures on its own, this is the only way that the infection can be cured. People with dental abscesses are typically prescribed pain relievers and, at the discretion of the doctor, antibiotics to fight the infection. An abscess that has extended to the floor of the mouth or to the neck may need to be drained in the operating room under anesthesia.

155. Directions of cuts during treatment of purulent processes in maxillofacial area.

156. Directions of cuts during treatment of purulent processes in maxillofacial area.

157. Prognosis
If treated, the outlook is good. The pus can usually be drained and the tooth can be saved if it is not badly broken down.
If left untreated, complications may develop which can include:
Spread of infection
The abscess may 'burst' onto the skin of the face, or into the mouth. This may leave a sinus tract (a channel) between a persistent focus of infection and the skin or mouth which can discharge pus from time to time.
Cavernous sinus thrombosis - a serious infection and clotting of a blood vessel in the brain.
Sinusitis - spread of infection to the nearby sinus in the face bone.
A dental cyst (fluid filled cavity) may develop.