1. Deep space infections of the neck and floor of mouth
Dr David Maritz

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