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Fascial spaces

and
spread of infection
SHASHI KANT CHAUDHARY
JR-I

PERIODONTOLOGY AND ORAL IMPLANTOLOGY

Contents
Introduction
Pathway

of infection

Fascial

spaces

Fascial

space infection

Conclusion
References

Introduction

Fascial space is a misonomer

There are no voids in tissues in actual reality

Shapiro defined Fascial spaces as potential spaces between


the layers of fascia

A fascial space is an area of relatively loose connective tissue,


which naturally forms a padding between & around the various
structures in the head and neck; being more dense where it is
arranged immediately about organs

Pus tends to accumulate in these specific region which are


referred to as tissue spaces; non of which are actual spaces until
pus is formed

Pus destroys the lose connective tissues and separates the


anatomical boundaries of the compartment as it increases in
volume thus creation of an abscess cavity bounded by muscles
tissues and bone

The majority of infections in orofacial and neck region belongs to


odontogenic

These infection range from periapicl abscess to superficial and


deep neck infection

Etiology
Based on origin of the infection

Based on causative organism

Pathways of odontogenic infection

Two major origin

Periapical origin most common

Spread of infection from maxillary teeth


Tooth

Involvement

Incisor

Labial, vestibular or palatal abscess


Sometimes with in lip when above
the muscle attachment

Canine

Below muscle labial or palatal


abscess
Above muscle canine space
infection

Premolars

Mostly on buccal or palatal abscess


Above muscle canine space

molars

Buccal or palatal abscess


If above buccinators muscle buccal
space

Spread of infection from mandibular teeth


Teeth

Involvement

Incisor

Labial abscess
Below muscle submental space infection

Canine

Only labial or vestibular abscess due to all muscles


are below the apex of canine

Premolars

Vestibular abscess
Lingual perfortation may form sublingual space
infection

1st Molar

Vestibular abscess
Submandibular or sublingual if below the muscle

2nd

Vestibular ,buccal, submandibular, sublingual

3rd

Submandibular or pterygomandibular or
submasseteric space infection

Spread of orofascial infection

From the site of the initial lesion, inflammation may spread in


three ways:
1
1
2

3
1

Pathways Of Dental Infection can lead to


Soft
tissue
abscess
Bacteremia

fistula

Septicemia

Acute
chronic
Ascending
facialcerebral
infection

Descending
facial
infection

periapical
infection

celluliti
s

Osteomyelitis

Classification
Based on the mode of involvement

Maxillary
Primary
space

Mandibular
Secondary

Spaces involved in odontogenic infection


Secondary fascial
spaces
Masseteric
Pterygomandibular
Superficial & deep
temporal
Lateral pharyngeal
Retropharyngeal
Prevertebral

Based on clinical significance

Sublingual, submandibular, submental


pharyngomaxillary, peritonsillar

Anterovisceral (pretracheal)

Retropharyngeal, space of carotid


sheath

Based on Relative severity of space infection

Relative Severity of Deep Fascial Space Infection

Stages of odontogenic infection

Resolution
stage

Stages of
Infection

Characteristics

Inocluation

Cellulitis

Abscess

Duration

0-3 days

3-7 days

Over 5 days

Pain

Mild-moderate

Severe and
generalized

Moderate severe and


localizied

Size

small

Location

Diffuse

Diffuse

Circumscribed

Palpation

Soft, doughly, mildly


tender

Hard, exquisitely
tender

Fluctant, tender

Appearance

Normal coloration

Reddened

Peripherally reddened

Skin quality

Normal

Thickened

Centrally undermined

Surface temperature

Slightly heated

Hot

Moderately headted

Loss of function

Minimal or none

Severe

Moderately severe

Tissue fluid

Edema

Serosanguineous,
flecks of pus

Pus

Level of malaise

Mild

Severe

Moderate-severe

Degree of seriousness

Mild

Severe

Moderate-severe

Predominant bacteria

Aerobic

mixed

Anaerobic

large

Small

Principles of therapy of odontogenic


infection

The eight steps in the management of odontogenic infections


are as follows:

Facial Space Of Clinical Significance

Buccal space
Boundaries

Etiology
-may originate from infected root
canals of posterior teeth of the
maxilla and mandible

Clinical presentation
-Swelling of cheek which extends from
the zygomatic arch as far as the inferior
border of the mandible and from the
anterior border of ramus to the corner of
mouth

Treatment:

Access is usually intraoral for three main reason:

I)

Because the abscess fluctuates intraorally in majority of


cases

II)

To avoid injury to facial nerve

III) For

esthetic reason

Intraoral incision is made at the posterior region of the mouth


in the antero posterior direction and very carefully to avoid
injury of parotid duct

Extraoral incision is made approx. 2 cm below and parallel to


the inferior border of mandible

Canine space
Boundaries:-

Etiology:-infected root canals of premolar and


especially those of canines of maxilla

Clinical presentation
- edema localised in the infraorbital region
which spreads towards medial canthus
of eye, lower eyelid and side of nose as
far as the corner of mouth
-obliteration of nasolabial fold and
mucobuccal fold

Stages of canine space infection:-

Stage I - Infection limited to canine space

Stage II spread to medial canthus

Stage III sinus drainage at medial canthus

Complication of canine space infection

Cavernous sinus thrombosis

Treatment:
-incision is placed intra orally at the mucobuccal folds
(parallel to alveolar bone) in the canine region

Infratemporal space
Boundaries

Etiology
-infected root canals of posterior teeth
of maxilla and mandible ,by way of
pterygomandibular space and may also be
the result of posterior superior alveolar
nerve block and inferior alveolar nerve
block

Clinical presentation:-

trismus and pain during opening of


mouth and lateral deviation
towards the affected side

edema at the anterior region


which extends above the
zygomatic arch

edema of the eyelid

Treatment :
-incision is made intraorally at the depth of the
mucobuccal fold
-extraoral drainage is done through an incision at the
angle created by the junction of the frontal and temporal
processes of zygomatic bone

Masticator space

The masticator space is composed of 3 discrete spaces1.


2.
3.

The masseteric space ,


The pterygomandibular space &
The temporal space

Etiology: the pericoronitis & abscess involving 3rd molars


fracture of angle & ramus of mandible
Clinical presentations: trismus - the hallmark
Swelling

Massetric space
Boundaries:-

Surgical Treatment:-

Drainage through submandibular, suprazygomatic or


trans oral approach

Pterygomandibular space
Boundaries:-

Surgical treatment:-

Drainage by

Extraoral submandibular incision

Transoral approach

Temporal space

It is divided into
superficial
deep

&

temporal space

by belly of temporalis

Boundaries:-

Surgical treatment:Drainage by:

Suprazygomatic incision

Trans oral approach

Sublingual space
Boundaries

Etiology
infection

of mandubular anterior teeth ,


premolar and the first molar whose apices
are found above the attachment of mylohyoid
muscle
spread

also from other contiguous space


with it communicates (submandibular , lateral
pharyngeal)

Clinical presentation

Characteristic swelling of the mucosa of the floor of


the mouth resulting in elevation of tongue towards
palate and laterally

Mandibular lingual sulcus is obliterated

Difficulty in speech

Surgical Treatment :
incision for drainage is performed intraorally, laterally and along
Whartons duct and lingual nerve

Submandibular space
Boundaries

Etiology
Usually

from mandibular 2nd or 3rd molar if


the apices are found beneath the attachment of
mylohyoid muscle
Also spread from submental and sublingual
space infection

Clinical presentation:

Indurated swelling at the


submandibular area creating
greater edema

Angle of mandible gets


obliterated

Treatment:
- incision for drainage is performed on the skin approx. 1
cm beneath and parallel to inferior border of mandible

Contd

Submental space
Boundaries

Etiology:usually

originates in the mandibular anterior


teeth or is the result of spread of infection from
other anatomic spaces (sublingual,
submandibular)

Clinical presentation:-indurated and painful edema


-may even spread as far as the hyoid bone

Surgical Treatment:
-incision on the skin beneath the chin,in a horizontal
direction and parallel to the anterior border of chin

Other important spaces

Lateral pharyngeal

Boundaries;-

Medially superior & middle


pharyngeal constrictor muscle

Laterally medial pterygoid & parotid capsule

Superiorly base of skull

Inferiorly hyoid bone

Anteriorly pterygomandibular raphe ,submandibular &


sublingual spaces

Posteriorly retropharyngeal space

Etiology :

Spread from lower 3rd molar


Pharyngotonsilitis
Adenoids
Otitis media
Necrotic lymph nodes
Secondarily infected malignancies
Medial spread of intracapsular parotid infection

Clinical Presentation
Deviation of uvula to contralateral side
Slight swelling at the angle of the mandible
Dysphasia
Dyspnea
Severe trismus
Surgical Treatment
Drainage by extra & intra oral approach

Peritonsillar space
Boundaries:

Medially superior constrictor muscles

Laterally tonsil

Anteriorly anterior tonsillar pillar

Posteriorly posterior tonsillar pillar

1.
2.
3.
4.
5.
6.

Etiology
Secondary to pharyngotonsillitis

Clinical presentation
Deviation of the uvula to the contralateral side
Unilateral peritonsillar swelling
Malaise
Hot potato voice
Trismus
Dehydration or malnutrition

MANAGEMENT

Pretracheal space

It is incased by middle layer of deep cervical


fascia

It is rarely involved in odontogenic infection

Boundaries

Superiorly - thyroid cartilage

Inferiorly anterior superior mediastinum

posteriorly anterior wall of esophagus

Laterally retropharyngeal space

Etiology

Thyroiditis

perforation of anterior cervical oesophagus

Clinical presentation

Mainly dysphagia

Hoarseness

Dyspnea

Airway obstruction

Surgical treatment

Dependent drainage with an incision made along anterior border


of sternocleidomastoid muscle & parallel to it inferior to hyoid
bone

Spaces of Total Neck

Fig.
1.Visceral fascia (surrounding thyroid gland, trachea, and esophagus);
2. posterior visceral space (or retropharyngeal space);
3. carotid sheath;
4. anterior visceral space;
5. danger space.

Retropharyngeal space

Boundaries

Medially & laterally lateral pharyngeal space

Superiorly base of skull

Inferiorly vertebrae C6 to T4 & mediastinum

Anteriorly posterior wall of pharynx

Posteriorly alar ( buccopharyngeal ) fascia &


prevertebral space

Etiology

Direct extension of odontogenic infection

Traumatic intubation

Clinical presentation

Fever & chills

Odynophagia

Dysphasia

Neck pain & stiffness

Neck swelling

Sailorrhea

Surgical Treatment:

Aspiration followed by drainage

Horizontal neck incision follow carotid


sheath into space finger dissect below
submandibular gland, along posterior
belly of digastric deep to mastoid tip
toward styloid process

Danger space

Communicates with mediastinum

Also known as prevertebral space

Boundaries

Anteriorly- retropharyngeal space


Posteriorly - prevertebral space
base of skull
Inferiorly- diaphragm
Laterally - fusion of alar & prevertebral fasciae
(transverse process of cervical & thoracic
vertebrae)

Etiology

Vertebral osteomyelitis

Infection in retropharyngeal space

Clinical presentation

Pain & fever

Leukocytosis

Dysphasia

Odynophagia

Surgical Treatment

same as retropharyngeal space

Carotid sheath

The potential space within carotid sheath extends from


the base of skull at jugular foramen & carotid canal
through the thoracic inlet to the pericardial sac of the
middle mediastinum

Etiology:

Secondary to spread of oropharyngeal


infections
Parenteral drug use via internal jugular vein

Clinical presentation

Pain

Swelling

Trismus

Diagnosis

Gallium 67 scan

White cell labeled indium

Surgical treatment:Drainage by incision in anterior lateral neck with


exploration of carotid sheath
Complications:Spread to chest
Septic venous thrombosis

major complications

Suppurative jugular thrombophlebitis


Vocal cord paralysis
Metastatic abscess
Ipsilateral Horners syndrome

Complications of space infection

Orbital infections

Ludwigs angina

Cavernous sinus thrombosis

Necrotizing fascitis

Brain abscess

Mediastinitis

Peritonsillar abscess

Abdominal abscess

IJV septic thrombophlebitis

Neuropathy Horners, hoarseness, unilateral tongue paresis

Erosion of carotid artery

Ludwigs angina
-

Term Ludwigs angina coined by Camerer


1837

First described by Wilhelm Friedreich Von


Ludwig (1836)

Massive, firm, brawny cellulitis/induration,


and acute toxic stage, involving
simultaneously the submandibular,
sublingual and submental spaces
bilaterally
-

Etiology
1.Dental
-primary dental infection
-post extraction phenomenon
2.Submandibular gland sialadenitis
3.Compound mandibular fracture
4.Oral soft tissue lacerations
5.Puncture wound of the floor of the mouth
6.Secondary infections of oral malignancies

Bacteriology
Aerobic
Streptococcus spp. : S. viridans, B - hemolytic
streptocci
Staphylococcus
Others include: Diptheroid, Klebsiella, Hemophillus
spp.
Anaerobic
Bacteroids: Oralis, Bivus, Fragilis
Peptostreptococcus
Fusobacterium
Lactobacillus

Clinical features

bilateral infection of the sulingual, submandibular and


submental spaces with brawny/indurated edema

trismus

fever

dysphagia/odynophagia

elevation of tongue and glottic edema

airway obstruction

paucity of pus

Management
1.

Immediate hospitalization

Intense and prolonged antibiotic therapy

Penicillin is to be administered IM or IV in high doses


2.

3. Establish

and maintain an adequate airway


tracheostomy is a routine procedure, but is often difficult to
perfrom in the late stage
cricothyroidotomy may be performed as an emergency
procedure in the late stage
4. Surgical

treatment
Incision & drainage for individual spaces

Contd

Cavernous sinus thrombosis

serious condition consisting of formation


of thrombus in the cavernous sinus or
its communicating branches

maxillary odontogenic infection may


also spread superiorly to cause
secondary periorbital or orbital
cellulitis or cavernous sinus thrombosis

bacteria may travel from the maxilla


posteriorly via pterygoid plexus and
emissary veins or anteriorly via angular
vein and inferior or superior opthalmic
veins to cavernous sinus

Etiology
-infection of face can cause a septic thrombosis of the
cavernous sinus
-frunculosis and infected hair follicle in the nose are the
frequent causes
-extraction of maxillary anterior teeth in the presence of
acute infection and especially curettage of the sockets
under such circumstances
-usually staphylococcal infection

Diagnosis
-made in the presence of following six
features according to Eagleton:
1. a known site of infection
2. evidence of blood stream infection
3. early sign of venous obstruction in the retina,
conjnuctiva and eyelid
4. paresis of 3rd,4th and 6th cranial nerves resulting from
inflammatory edema
5. abscess formation in the neighbouring soft tissue
6. evidence of meningeal irritation

Treatment

Antibiotic therapy

Heparinization
-to prevent extension of thrombosis

Neurosurgical consultation
Mannitol
-reduces intracranial edema

Anticoagulants
-prevents venous thrombosis

Surgical drainage

Conclusion

The incidence & severity of odontogenic infections have


diminished since the advent of antibiotic therapy, however
significant morbidity & mortality of these infections continue

Deep space infections must be recognized promptly & treated


as an emergency

Underlying medical problems must be controlled , a patent


airway established , contemporary diagnostic imaging done &
deep drainage performed with elimination of etiology

References

Oral & maxillofacial infections-Topazian

Oral and Maxillofacial Surgery, Fonseca (Surgical pathology),


2nd edition, Marciani and Hendler

Contemporary Oral and Maxillofacial Surgery, 4th edition,


Petersen, Ellis, Hupp, Tucker

Oral and maxillofacial surgery vol.2-Daniel.M.Laskin

Textbook of Oral and Maxillofacial Surgery, 2nd edition,


Neelima Anil Malik

Human anatomy vol. 3,4th edition,B.D. Chaurasiya

Than
ks