Space infection 2 /certified fixed orthodontic courses by Indian dental academy

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COMPARTMENTS OF THE HEAD
AND NECK – SURGICAL
ANATOMY & APPLIED ASPECTS
Presenter :
Dr. Kiran H.Y.
Department of Oral & Maxillofacial Surgery,

Under the guidance of
Dr. David Tauro M.D.S.
Department of Oral & Maxillofacial Surgery,
S.D.M. College of Dental Sciences & Hospital.

What are Fascial compartments?
“The facial spaces or compartments are regions
of loose C.T. that fill the areas between facial
layers”.
The concept of fascial ‘spaces’ is based on
anatomists knowledge that all ‘spaces’, exist
only potentially, until fasciae are separated
by pus, blood, drains or a surgeon’s finger.

Basic plan of the neck


How did the concept of facial
spaces arise?
“If I have seen further, it is by standing on the
shoulder of Gaints”.
• In the 1930s the classic anatomical studies of
Grodinsky and Holyoke established the modern
understanding of the fascial layers and the
potential anatomical spaces through which
infection can spread in head and neck.

What is fascia and its functions?
• It is a sheet or layer of more / less
condensed connective tissue.
• Fascial layers are like tissue paper
surrounding each item of clothing within a
garment box, which allows them to pass
over each other without their becoming
unfolded.

Functions of the fascia
• Acts as a musculovenous pump• Limits outward expansion of muscles as
they contract.
• Contraction of muscles compress the
intramuscular veins (push the blood
towards the heart).
• Determine the direction of spread of
infection

CLASSIFICATION
FASCIAE IN THE NECK

SUPERFICIAL
(SCF)

DEEP
(DCF)


Superficial fascia

Superficial fascia is not a fascial sheet in the classic sense, but
rather a fatty loose connective tissue in which are embedded the
voluntary muscles of facial expression and the platysma muscle.

Superficial fascia
Skin
+
Superficial fascia
+
Platysma muscle

Complex
morphological
unit

Superficial
musculoaponeurotic
system
(SMAS)

Clinical considerations:
1. Surgeons consider SMAS most important component of
rhytidectomy / face-lift surgery / plastic surgery of the face.
2. Necrotizing fascitis – Infection of this fascia causes necrosis
of the tissues in the subcutaneous space leading to necrotizing
fascitis.

Necrotising fascitis


Deep fascia
Superficial layer
of deep fascia

Middle layer of
deep fascia


Deep layer of
deep fascia

Superficial layer of deep cervical fascia


Middle layer of deep cervical fascia


Buccopharyngeal fascia


Deep layer of deep cervical fascia


Carotid sheath


Schematic diagram showing the arrangement
of deep neck spaces


Anatomical basis for classification
•
•
•

The greatest clinical implication of cervical fascia is that
it divides the neck into potential spaces that function as
a unit but are anatomically separate.
Hyoid bone is considered the most important
structure limiting the spread of infection.
For this reason infection are classified by dividing the
potential spaces into 3 general divisions based on hyoid
bone
1.
2.
3.

Space of entire neck.
Supra hyoid spaces.
Infra hyoid spaces.

Classification of the spaces of Face & Neck
REF:THE NECK- DIAGNOSIS&SURGERY
WILLIAM.W.SHOCKLEY,HAROLD.C.PILLSBURY

I Spaces of the Face
A.

Maxillary spaces
1. Buccal space.
2. Canine space.
B. Mental space.

II Spaces of neck
A.

Spaces involving the entire length of the neck.
1. Superficial space
2. Deep neck spaces (all involve only the posterior side of the
neck)
a)
b)
c)
d)

Retropharyngeal space (Space 3).
Danger space (Space 4)
Prevertebral space (Space 5)
Visceral vascular space (within carotid sheath).

B. Suprahyoid spaces:
1) Mandibular space
•
•
•
•

Submandibular space.
Submental space.
Sublingual space.
Space of the body of the mandible.

2) Masticatory space.
3) Lateral pharyngeal space (Pharyngomaxillary,
peripharyngeal / parapharyngeal).
4) Peritonsillar space.
5) Parotid space.

C. Infrahyoid space (involves anterior side of the
neck only).
1. Pretracheal space. www.indiandentalacademy.com

What are primary spaces?
What are secondary spaces?
Primary spaces:
• Maxillary spaces
• Mandibular spaces
Secondary spaces:
Masseteric,pterygomandibular,superficial &
Deep temporal,lateral pharyngeal,
retropharyngeal,prevertebral,parotid space

Concepts about space infections
• The spaces are not empty they contain various
organs, nerves, blood vessels, salivary glands,
lymph nodes and fat surrounded by loose fibrous
connective tissue.
• The spaces of head and neck are not perfectly
enclosed they are pathways around the muscles
through which infection can spread.

Concepts about space infections
• Infections within each space has its own
diagnostic signs and tends to spread in an
orderly, anatomic fashion from one space to
another by continuous extension.
• If the surgeon understands this process, he
can anticipate the spread of infection into
dangerous spaces and abort the process by
timely incision and drainage.

General pathways of spread of maxillary and mandibular
infection


Pathways of spread of dental infection

Pericoronitis of third molar area

Spread of infection from erupted and
infected third molar area


Anatomical factors influencing the spread of
infection

Infection enters soft tissue through
thinnest bone

In respect

to buccinator muscle

Anatomical factors influencing the spread of
infection


Predisposing factors
1. Dental caries or diseases of the gums.
2. Lowered body resistance
3. Traumatic
Primary signs & symptoms of these infections:
- Localized pain.
- Tenderness.
- Redness.
- Edema of the overlying tissue.
- Loss of function
- lymphadenopathy

Stages of infections
• Stage I – Inoculation
• Stage II –Acute stage-cellulitis,abscess
• Stage III – Chronic stage-fistulous/sinus
tract or osteomyelitis
• Stage IV – Resolution


Differences between cellulitis and abscess
Characteristics.
Cellulitis.
• Acute phase
Duration.
• Severe and
Pain

•
•

Chronic phase
Localised

generalised

Size
Localization
Palpation
Presence of pus
Degree of
seriousness
Bacteria.

Abscess.

•
•

Large.
Diffuse borders

•
•

Small
Well-demarcated

•
•

Doughy/indurated
No

•
•

Fluctuant
Yes

•

Greater

•

Less

•

Aerobic

•

Aerobic/mixed


Surgical anatomy of deep facial
spaces of head and neck


Buccal space

Clinical evaluation: Examination of the patient with the buccal space infection
demonstrate swelling confined to the cheek with abscess forming beneath the
buccal mucosa and bulging into the mouth.

Repated buccal space infection suspect crohn’s disease

Canine space / Infraorbital space

•
•
•
•

Clinical evaluation: Patient exhibits 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 .

Differential diagnosis of upper face
infections

Dacrocystitis with
minimal involvement
of nasolabial fold.

Odontogenic cellulitis.
The nasolabial fold is
effaced.

Suprahyoid spaces
1) Mandibular space
•
•
•
•

Submandibular space.
Submental space.
Sublingual space.
Space of the body of the mandible.


Mandibular spaces
Submandibular space

Clinical Evaluation:
•Infection mostly arises from 2nd or 3rd molar.
•Induration and erythema in the submandibular area obliterating
the mandibular line and extending to the level of hyoid bone.
•No trismus.

Submandibular space

Spread of submandibular.S
infection to Sublingual.S

Sublingual space

Clinical evaluation: Edema and induration of the floor of the mouth on the
affected side displacing tongue medially and superiorly.
Hot potato voice.
Elevation of tongue to palate causing airway compromise.
Prevents patient from extending tongue beyond the vermilion border of upper lip.

Submental space

Clinical evaluation:
Swelling will be limited to the point of the chin & to the region
immediately below it

Ludwig’s Angina

Ludwig’s angina is a firm, acute, toxic cellulitis of the submandibular
and sublingual spaces bilaterally and of the submental space.
Three ‘fs’ of Ludwig’s Angina
-feared
-fatal (often)
-fluctuant (rarely)

Ludwig’s Angina
•

The original description of the disease was given by Wilhelm
Friedrich von Ludwig.

1.

Rapidly spreading gangrenous cellulitis.

2.

Originates in the region of submandibular gland but never
involves one single space and

3.

Arises from extension by continuity and not by lymphatics
and

4.

Produces gangrene with serosanguinous, putrid infiltration
but very little or no frank pus.

Ludwig’s Angina
-

-

It is characteristically
aggressive and rapidly
spreading.
Patient will appear toxic, fever,
chills.
Airway compromise occurring
quickly and with little fore
warning.
Drooling, dysphagia, mouth
pain and neck stiffness are not
uncommon.
Physical examination.
Anteriorly protruding tongue
induration and erythema
Trismus is usually absent.


Principles of Management of
Ludwig’s Angina
•
•
•
•
•

Hospitalization.-criterias(Flynn 2000)
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

Incision for surgical drainage of Ludwig’s Angina

X


Masticator space

The masticatory spaces are called secondary spaces and are combination of
four smaller spaces.
Clinically if one space is involved with infection, this usually implies that all
spaces are involved.
These are known as secondary spaces because they are usually involved with
infection via spread from one of the primary spaces like buccal, sublingual or
submandibular.

Clinical examination
• Difficulty in swallowing.
• Severe pain.
• Swelling extending over the ramus of the
mandible with obliteration of subungular
depression.
• Marked trismus.
• Posterior portion of tongue is impossible to
depress.
• No fluctuance
• Parotid secretions are clear.
• Patient is not acutely illed.

Superficial temporal space

Clinical appearance:

Note the lack of swelling over the zygomatic
arch causing a dumbell shaped configuration

Infratemporal space

• Clinical features :
• Marked Trismus
• swelling of face in front of ear, over TMJ,behind
zygomatic process
• Eye is closed and proptosed

Lateral pharyngeal spaceinfection

.

Lateral pharyngeal space infections
• It lies immediately posterior and lateral to
the pharynx
• Anatomically the lateral pharyngeal space
may be thought of as an inverted pyramid
shape-the base of the pyramid being the
skull base and the apex the hyoid bone.
• In 1929 Mosher called this potential avenue
of infection the “Lincoln highway” of the
body.

Lateral pharyngeal/retropharyngeal
space infection


Clinical evaluation
• Firm induration with surrounding erythema
lateral and anterior to sternocleidomastoid muscle.
• Difficulty of flexing and turning of neck.
• Trismus secondary pterygoid muscle
involvement.
• Dysphagia.
• Dyspnea.
• Extension into mediastinum along the carotid
sheath.
Diagnostic evaluation
• Chest CT scan, www.indiandentalacademy.com radiographs
Gram stain, Chest

Lateral pharyngeal space infections
This space is further divided by the
styloid process
The prestyloid compartment contains
fat, lymph nodes and internal maxillary
artery.
The post styloid compartment contains
the carotid artery, internal jugular vein,
cervical sympathetic chain and cranial
nerves IX, X, XI, XII


Management
•
•
•
•

Hospitalization with I.v. antibiotics.
Airway protection.
Rapid surgical drainage.
Surgical approach always through neck not
through oral cavity.
• Incision is made at the level of hyoid bone
across the sternocleidomastoid muscle.
• If abscess not present that means the infection
material had no time to form an abscess.

Drainage of lateral pharyngeal space


Complications
• Suppurative jugular venous thrombosis.
• Patient will have shaking chills, spiking
fevers, prostration.
• Tenderness at the mandibular angle and
along sternocleidomastoid muscle.
• Carotid artery rupture.
• Internal carotid artery most commonly
involved than external.

Pterygomandibular space

• Clinical features :
•
•
•
•
•

Do not cause external swelling
Limitation of mouth opening
Dysphagia
Medial displacement of lateral wall of pharynx
Uvula displaced to unaffected side

Peritonsillar space infection
• 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
• In recent literature,needle
aspiration instead of open
incision and drainage
(JOMS,Vol 51,1993)

Relationship showing lateral pharyngeal,
peritonsillar and pterygomandibular spaces


Differantial diagnosis of spaces
Pterygomandibular space

Anatomy

• Bet n
mandible
•
&MT

Lateral pharyngeal space Peritonsillar space

• Bet n sup
• Bet n
MT and
const
sup const
&mucous
membrane

Trismus
• Extreme
External
swelling

• Little

• Moderate • Some

• None

• None

Parotid space infection

•

.

•
•
•

The symptoms of parotitis include pain and induration over the involved gland.
Purulent marked swelling of the angle of the jaw without associated trismus or
pharyngeal swelling.
Secretions may sometimes be expressed after massage from the parotid depth.
Very characteristic pitting edema of the gland is pathognomic for parotid gland
abscess.

•
•

Deep neck infections
• All involve only posterior side of neck.
a)Retropharyngeal space (space 3, posterior
visceral space).
b)Danger space (space 4).
c)Prevertebral space (space 5).
d)Visceral vascular space (within the carotid
sheath)

Principles for Rx of the deep neck spaces
Benjamin J. Gans, in his Atlas of oral
1.
2.
3.

4.
5.

surgery, articulated these principles:
Drain all significant deep space infections.
Do not wait for fluctuance. Fluctuance is a late
sign.
Determine incision placement, incisions
designed to avoid important anatomical
structures, provide dependent drainage and leave
cosmetically acceptable scar.
Institute definitive treatment as soon as
possible, Offending tooth to be removed.
Check for systemic disease.

Retropharyngeal space
Retropharyngeal space is the potential space sandwiched between
alar and prevertebral layers of deep layer of the deep investing
fascia.
Extension

Base of the skull
Mediastinum

Most dangerous of all types of deep neck
infections

Two compartments:
Suprahyoid

Sagittal section of retropharyngeal space

Infrahyoid

1. Only fat
1. Lymph nodes and fat.

Oblique section of retropharyngeal space

Clinical Evaluation
• Children less than 4 yrs commonly affected.
• In adults it manifests as cold abscess.
• Sore throat, dysphagia, odynophagia, difficulty handling
secretions.
• Hot potato voice.
Early signs:

Late signs

•Refusal to take food.

•Neck tilts towards involved side.

•Cervical lymphadenopathy.

•Hyperextended complete inability
to flex the neck.

•Slight neck rigidity.
•Noisy breathing due to laryngeal
edema.

•Respiratory embarssment may
occur if abscess not ruptured or
drained.


Diagnosis of the soft tissue radiograph
for retropharyngeal space infection
ref:Diagnosis & treatment of the retropharyngeal abscess in adults
BJOMS(1990)28,34-38

Step I:
• Look at the prevertebral or
retropharyngeal soft tissue
shadow.
• In the area of 2nd and 3rd CV, RP
soft tissue shadow should be less
than 7mm wide.
• In the area of 6 cervical vertebra
soft tissue shadow is behind the
trachea and includes the thickness
of esophagus making it approx.
Children – 14mm wide
adults – 22mm wide www.indiandentalacademy.com

Step II.
The second feature that
should be looked for in
this radiograph is the
presence of gas.
Anaerobic bacteria will
produce gas that can be
seen as emphysema in the
soft tissues of the neck

Areas of Emphysema in the
submandibular and lateral
pharyngeal space region

Step III.
- Finally, the lateral soft tissue radiograph will show the curve of
the cervical spine
- Loss of the lordotic curve is a strong indication of
retropharyngeal space infection.
- Tipping of the head forward in sniffing position to maintain an
open airway.


Management of Retropharyngeal
space infection


Danger space

• Danger space or space for cannot be reliably differentiated
from the retropharyngeal space on imaging and is therefore
combined with retropharyngeal space for discussion.

Prevertebral space
•
•
•

Is formed by the deep cervical fascia.
It extends from skull base to coccyx
Facia attaches to the transverse process of the cervical vertebra
dividing this space into anterior and posterior compartments.

Anterior compartment contains:
-Vertebral bodies.
-Spinal cord.
-Vertebral arteries.
-Phrenic nerve.
-Prevertebral and scalene muscles
Posterior compartment contains:
-Posterior vertebral elements.
-Paraspinous muscles.

Lesions in prevertebral space
• Arise in the vertebral body,
intervertebral disc spaces Or
Prevertebral / paraspinous
muscles. E.g. vertebral
osteomyelitis and metastatic
rare lesions chondroma and
nerve sheath tumors.
Imaging:
• Prevertebral lesions
anteriorly displace the
retropharyngeal space and
Retropharyngeal tuberculous abscess
anterior border of the
prevertebral muscles.
CT demonstrates hypodense fluid
collection involving the
• Posteriorly displace the
retropharyngeal space (Asterisks)
posterior triangle fat.

Carotid space / Visceral vascular space
• The cylindrical space
extends from base of
the skull to the aortic
arch.
• It is invested with all
three layers of the
deep cervical fascia
Thrombosed internal jugular vein
Left IJV fails to fill with contrast.
The lumen is hypodense

Vascular complications:
1. Artery rupture – 20 to 40% mortality

2. Venous thrombosis – Life threatening problem

Complications of space infection
• Scar formation

Sinus tract formation


Complications of space infection
cavernous sinus thrombosis

• Venous congestion of the fundus of the right eye.
• the same patient two weeks later.
Clinically
One eye experiences early involvement than the other.

Cranial nerve most likely to be involved is abducens.

• Venous drainage of the head including the dural
sinuses.


Diagnosis of cavernous sinus thrombosis
•

Eagleton’s six features.
– Known site of infection.
– Evidence of blood stream
infection.
– Early sign of venous
obstruction in retina,
conjunctiva or eyelids.
– Paresis of III, IV, VI cranial
nerves resulting from
inflammatory edema.
– Abscess forms and
neighboring tissues and
– Evidence of meningeal
irritation.

Mediastinitis

• Extension of infection from deep neck spaces into the
mediastinum is heralded by
–
–
–
–

chest pain
severe dyspnea
Unremitting fever,
Radiographic demonstration of mediastinal widening.

Mediastinits, occurring 9 days after drainage of
the retropharyngeal space

CT Scan
A-P view


Whom to consider for
hospitalization?
• Induviduals who show signs of
systemic toxicity
• who have CNS changes and
• Presence of airway compromise

Signs of
toxicity
•
•
•
•
•
•
•
•

CNS symptoms

Paleness
Tachypnea
Tachycardia
Fever
Appearance of illness
Shivering
Lethargy
diaphoresis

level of
consiousness
• Evidence of meningeal
irritation(severehead
ache,stiffneck,vomitin
g)
• Eyelid edema &
abnormal eye signs
•


Principles of incision and drainage
• Incise in healthy skin and mucosa when possible.
• Incision placed at the site of maximum fluctuance
results in a puckered, unesthetic scar.
• Place the incision in an esthetically acceptable
area.
• When possible place the incision in a dependent
position to encourage drainage by gravity.
• Dissect bluntly with closed surgical clamp or
finger, through deeper tissues.
• Place a drain and stabilize it with sutures.

Principles of incision and drainage
• Consider use of through and through drains in
bilateral submandibular space infections.
• Do not leave drains in place for an overly
extended period.
• Remove them when drainage becomes minimal.
• Clean wound margins daily under sterile
conditions to remove clots and debris.
• Another approach to drainage is the use of
computed tomographic (CT) guided catheter.

Computed Tomography – Guided Percutaneous
Drainage of a Head and Neck Infection – JOMS 1992
Left
submandibular
space abscess

Percutaneous
needle being
guided into the
abscess

Radiopaque
markers on the
skin

Aspiration to
evacuate the
abscess

Surgical incisions used to approach deep neck
infections


Drainage of Submandibular space abscess


Drainage of parotid and Masseter space
infection


Diagnostic Imaging of Fascial & Neck
Spaces
Plain film.

CT.

MRI


Ultrasound

Plain Film
• Diagnostic imaging starts with a plain film
study of pharyngeal or cervical airways.
• Views taken

AP view

– AP view
– Lateral view

• Plain film findings:
- In the AP view the normal cervical airway should
appear symmetrical over the middle third of the
cervical spine.
- Lateral view – In the adult the width of the
prevertebral soft tissue should not exceed 7mm at
the C3 level and 20mm at C7 level.

Lateral view

Ultrasound
• Not been used extensively
• cannot
penetrate
osseous
structures.
• Useful
in
differentiating
between solid and cystic
masses
• echomorphological
classification of soft tissue
head and neck swelling,
consisting of edema, infiltrate,
preabscess echo-poor and echofree abscess,.

US of submandibular region
demonstrating a branchial cleft cyst

US of Rt parotid showing an
www.indiandentalacademy.com echogenic shadowing sialolith in
hilus of Rt parotid

MRI


References.
• Oral &maxillofacial infections-Topazian
• Oral & Maxillofacial Surgery-Laskin Vol.I&II
• Killey & kay’s -Outline of oral surgery-Peter
Banks
• Contemporary Oral & maxillofacial surgeryPeterson
• Head & neck Imaging –Peter.M.Som
• The Neck –Diagnosis & SurgeryWilliam.W.Shockley, Harold .C .Pillsbury

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