Deep space infections of the
neck and floor of mouth
Dr David Maritz
Introduction
• Penicillin 1940’s
• Odontogenic infections
• Deep anatomic fascial space
• Threaten vital structures
Introduction
• Most important:
• Submandibular
• Lateral Pharyngeal
• Retropharyngeal / Danger / Prevertebral
• Clinical examination underestimate extent in 70%
Potential pathways of extension of deep fascial space infections of the
head and neck
Fascial spaces around the mouth and face
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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Clinical examination of odontogenic infections
Stages of infection
• 4 stages
• Inoculation
Cellulitis
Abscess
Rupture
• Spreading odontogenic infection
Trismus
• Inability to open mouth widely
• Inflammation muscles of mastication
• Masticator space / Pterygomandibular space
• Difficult intubation
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
Intraoral examination
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Caries
Swellings of oral vestibule
Periodontal disease
Tooth mobility
Pericoronitis
Swellings
Position of uvula
Radiographic evaluation
• Rapid CT scanners
• Contrast enhanced CT
• Postero-anterior / lateral soft tissue x-rays of neck
• Dental panoramic view (Orthopantomogram)
Lateral radiograph of the neck
Figure 69-5 Periapical abscesses (arrows) as seen on Panorex film.
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Culture and sensitivity testing
• Penicillin resistance 30 – 50%
1. Submandibular Space
Introduction
• ‘’Ludwigs angina’’
• ‘’Angina maligna’’
• ‘’Morbus strangulatorius’’
• ‘’Garotillo’’
Early appearance of patient who has Ludwig’s angina with characteristic
submandibular ‘’woody’’ swelling
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
Anatomic relationships in submandibular infections
Routes of spread of odontogenic orofacial infections along planes of
least resistance
Clinical manifestations
• Mouth pain / stiff neck / drooling / dysphagia
• No trismus
• Woody inflammation
• No lymph node involvement
• Protruding tongue
Ludwig's Angina
• Involvement submandibular spaces bilaterally and submental space
in midline
• Rapid spread to lateral pharyngeal / retropharyngeal space
• Rapidly obstruct upper airway
Early Ludwig's angina
Early Ludwig's angina
Submandibular space abscess and Cellulitis
Potential complications
• Airway compromise
• Spread into the lateral pharyngeal space and beyond
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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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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© 2007 Elsevier
Therapeutic considerations
• Mixed infection – synergistic interaction
• Immunocompromised
• MRSA
• Candida / Aspergillus
2. Lateral Pharyngeal Space
Potential pathways of extension of deep fascial space infections of the
head and neck
Anatomy and pathogenesis
• Anterior / muscular compartment
• Posterior / neurovascular compartment
• Carotid sheath
• 9 to 12 cranial nerves
• Sympathetic trunk
• Peritonsillar abscesses
Clinical manifestations
• Anterior compartment
• Dysphagia
• Trismus
• pain
• Posterior compartment
• No trismus
• Neurologic / vascular
• Edema epiglottis / larynx
Abscess of lateral Pharyngeal space
Potential complications
• NB: Posterior compartment
• Laryngeal edema
• Vagal nerve
• Horner's syndrome
• Cranial nerve palsies
• Suppurative jugular thrombophlebitis (lemierre syndrome)
• Carotid artery erosion
Lemierre’s Syndrome
• Septic thrombophlebitis of internal jugular vein
• Septic emboli – lung / liver abscesses / septic arthritis
• Fusobacterium necrophorum
Jugular venous thrombosis
Therapeutic considerations
• Suppurative
• Posterior more conservative
• Anterior more aggressive treatment
3. Retropharyngeal / Prevertebral / Danger Space
Introduction
• Caudal extension of infection
• Considered together
Anatomy and pathogenesis
• Between pharynx-esophagus and spine
• Delineated by fascial planes: 3 layers of deep cervical fascia
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….
Retropharyngeal abscess
Retropharyngeal space
Danger space
• Base skull to diaphragm
• Contiguous spread from adjacent spaces
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
Clinical manifestations
Retropharyngeal danger space
• Sore throat / dysphagia / stiff neck
• Upper airways obstruction
• Head tilt contralateral side
• Pleuritic chest pain
• Bulging posterior oropharynx
Lateral radiograph of the neck
Prevertebral space
• Spinal cord compression
• Epidural abscess
Potential complications
• Laryngeal inflammation
• Rupture with aspiration
• Descending necrotizing mediastinitis
• Pyothorax / pericardial involvement
• Spinal epidural collections
• Psoas muscle infection
Therapeutic considerations
• Retropharyngeal / danger space:
• Adequate anaerobic / oral gram + cover
• Surgery if indicated
• Prevertebral:
• Surgical drainage
• NB gram + / MRSA / gram - rods
4. Buccal space
• Subcutaneous space
• Connects to: infraorbital space, periorbital tissues, superficial
temporal space
• Hemophilus influenzae Cellulitis:
• Children
• Recent URTI / sinusitis
Buccal Cellulitis (Hib)
5. Infraorbital space
• Lower lid / periorbital swelling
• Point medially (inner canthus) or laterally (lateral canthus)
• Septic thrombophlebitis angular vein → cavernous sinus
6. Orbital space
• Preseptal Cellulitis
• Subperiosteal abscess (orbital wall)
• Orbital Cellulitis / abscess → optic nerve damage / cavernous sinus
thrombosis
7. Vestibular space
• Diffuse facial swelling
• Elevation of the oral vestibule
• Potential space between oral mucosa and muscles facial expression
• Draining sinus
8. Subperiosteal space
• Dental infection
• Perforates cortical layer but not periosteum
• Eg: mandibular subperiosteal infection
9. Submental space
• Secondary spread from submandibular space
10. Masticator space
• Severe trismus
• Surrounding muscles of mastication
Masticator space infection with trismus
Masticator space abscess
11. Temporal space
• Trismus (infratemporal fossa – part of masticator space)
• Cavernous sinus thrombosis
Deep temporal space infection with spread to parotid space
Treatment
The admission decision
• Airway issues
• High fever
• Dehydration
• Need for I+D
• Inpatient control systemic disease
• Immune compromise
Airway security
• Protect against aspiration
• ETT ruptures abscess
• Trismus / Swelling
• Maintain airway reflexes during intubation
Surgical treatment
• Gravity dependent surgical drainage
• Antibiotics secondary
• Tooth extraction
Antibiotic therapy
• Predominately anaerobic nature
• Initially: aerobic streptococci ( penicillin )
• Later: anaerobic bacteria ( penicillin resistant )
• Synergistic interaction
Complications
Mediastinitis
• Airway security
• Contrast CT
• Open thoracotomy
• Broad spectrum antibiotics
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
Cavernous Sinus Thrombosis
• Treatment:
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Tooth extraction root canal
Drainage deep spaces
High dose IV antibiotics
Anticoagulation
Summary
• Preventative dental care
• Effective antibiotics