Spreading infection
An infection spreading in the soft tissues from one of the foci may take the form of the
following:
1. A suppurative infection
2. A cellulitis
3. Gangrene
A suppurative infection
A suppurative infection are characteristic of staphylococci often with anaerobes such as
bacteroids and may produce large accumulations of pus which will require immediate
drainage.
cellulitis
Cellulits is is a common infection of the lower layers of skin (dermis) and the subcutaneous
caused by a spreading bacterial infection of the skin and tissues beneath the skin.
Facial cellulitis is a bacterial skin infection that occurs on the face.
Causes
Cellulitis is usually caused by a bacterial infection. The infection may come from bacteria that
normally lives on the mouth and skin.
The main bacteria involved in most common cellulitis cause in adults with no medical
conditions is group A streptococcus Another common cause in adults is Staphylococcus
aureus, which is at is commonly found on human skin and mucosa (lining of mouth and nose).
Other Cellulitis Causes
In rare cases, other bacteria can cause cellulitis. When this does occur, it is usually the result
of a medical condition such as diabetes, HIV, or AIDS, or because the cellulitis is in a very
specific place.
Other bacteria that can lead to cellulitis include:



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

Methicillin-resistant S. aureus (MRSA)
P. aeruginosa
Vibrio vulnificus
Clostridium septicum
Pasteurella multocida
Erysipelothrix
E. coli
I

Group B streptococcus.
Cellulitis usually begins as a small area of pain and redness and tenderness , swelling, and
redness. This area spreads to surrounding tissues, resulting in the typical signs of
inflammation – redness, swelling, warmth, and pain. A person with cellulitis can also develop
fever and sometimes with chills and sweats and/or swollen lymph nodes in the area of the
infection..
The signs of cellulitis include redness, warmth, swelling, and pain in the involved tissues.
Symptoms
Symptoms may begin within hours or days and can include:
 Skin inflammation that begins in a small area and spreads. This includes:
o Redness
o Pain or tenderness
o Swelling
o Warmth
o A red streak (possibly)
 Swollen lymph nodes
 Fever or chills
 Fatigue
 Headache
Gangrene
In pre-antibiotic days the pressure within tissue compartments produced by massive oedema
and suppuration in response to fulminating infections could lead to necrosis of involves
muscles in case of subtemporalis muscle infection and Ludwig's angina. Swelling of this
degree is rarely seen but occasionally infection by gas-forming organisms and anaerobes
occurs which results in muscle necrosis.
Soft tissue infections and their spread
Infection of the soft tissues around the jaws usually originate from odontogenic infection.
Occasionally the infecting organisms enter the soft tissue from the penetrating wound,
especially with retained foreign body, following an injection with a contaminated needle. In
children a staphylococcal, facial or submandibular cellulitis may arise from tonsillar or nasal
infection or during eruption of a tooth or following loss of the deciduous predecessor.
The routes by which the infection can spread are as follows:
1. By direct continuity
2. By the lymphatic to the regional lymph nodes, secondary abscesses may develop
3. By bloodstream local thrombophlebitis entering the cranial cavity via emissary veins
to produce cavernous sinus thrombophlebitis. The infected emboli may lead to
bacteraemia, septcaemia and pyaemia with development of embolic abscesses.
II
The factors affect the ability of the infection to spread as follows:
1. The type and virulence of the organism or organisms.
2. A failure to drain accumulations of pus.
3. The general condition of the patient.
4. The effectiveness of the patient's immune mechanism.
The anatomical factors influencing the direction of spread within the tissues:
1. The site of the source of the infection
2. The point at which the pus escapes from the bone and discharges into the soft tissue
3. The natural barriers to the spread of pus in the tissue
The most important muscles play a part in containing infections around the jaws are
myohyoid, buccinator, masseter, the medial and lateral pterygoid muscles, the temporalis
and superior constrictor of the pharynx.
The fascial layers probably play a slightly less important role than the muscle in influencing
the spread of infection through the soft tissues of the face and neck. From a surgical point of
view, the investing layer of cervical fascia, the prevertebral fascia, the carotid sheath and
parotid fascia.
The investing layer of deep cervical fascia
The prevertebral fascia
The pretrachial fascia
The carotid sheath
Sites at which pus accumulates
Pus tends to accumulate in specific tissue space, non of which are actually space until pus
has been formed.
The muscle is attached to bone by sharpey's fibers by strong attachment and tendinous.
The narrow interval between muscle also contains a layer of loose connective tissue.
The important potential spaceses in the vicinity of the jaws are:
In relation to the lower jaw
1. Submental space
2. Submandibular space
3. Sublingual space
4. Buccal space
5. Submassetric interval
6. parotid compartment
7. Pterygomandibular space
8. lateral pharyngeal space
9. peritonsilas fossa
In relation to the upper jaw
1. Within the lip
2. Within the canine fossa
3. Palatal subperiosteal interval
4. Maxillary antrum
5. Infratemporal fossa space
6. Subtemporalis muscle interval
III
IV
Submental space infection
Surgical anatomy
The submental space bounded superiorly by mylohyoid muscle, inferiorly investing layer of
the deep fascia, platysma muscle, superficial fascia, and skin, laterally by the lower border of
the mandible and the anterior bellies of the digastric muscles over which the more lateral
submental lymph nodes lies with in these space and are embedded in adipose tissue so that
the submental abscesses tend to be well circumscribed.
The infection of this space usually spread from the lower incisors, the lower lip, the skin
overlying the chin, or from the tip of the tongue and the anterior part of the floor of the
mouth and sublingual tissues.
Signs and symptoms
The submental abscess forms firm swelling beneath the chin, pain and discomfort on
swallowing.
Treatment
Satisfactory drainage of a submental abscess can be effected by a transverse incision through
the skin behind the chin and opened with sinus forceps and a drain inserted.
Submandibular space infection
Surgical anatomy
The Submandibular space bounded by the anterior and posterior bellies of the digastric
muscles, anteriorly above and medially by the mylohyoid muscle, which covered by loose
alveolar tissue and fat, the lower part deep to the platysma muscle, investing layer of deep
cervical fascia, and skin and the upper border beneath the inferior border of the mandible.
More posterioly the Submandibular space projects upwards under cover of the medial aspect
of the mandible as high as the mylohyoid ridge. Medially the wall of the space is formed by
the hypoglossus muscle. The space contains the submandibular lymph nodes and
Submandibular salivary gland as C shaped which provides a route of communication with
the sublingual space around the posterior border of mylohyoid muscle. Wher thwe facial
artery hooks around the lower border of the mandible the deep fascia is attached to the bone
sufficiently above the lower border to permit the submandibular lymph nides to overlap the
mandible .
Spread of infection from the teeth by direct continuity is influenced by the origin of the
mylohyoid muscle in relation to the level of the apices of the lower teeth. Apical infection
from the lower molar teeth, particularly the 2 nd and 3rd molar, which penetrate the thin
lingual plate can pass directly into the submandibular space. Beside to the teeth the infection
spread from the middle third of the tongue, posterior part of the floor of the mouth, upper
teeth, the cheek, maxillary sinus and palate.
It is possible for infection to extend backwards from the submental space or from the
submental lymph nodes via lymphatics. Similarly infection may pass from the back of the
sublingual space around the deep part of the submandibular salivary gland.
Signs and symptoms
A firm swelling in the submandibular area over the lower border of the mandible at the point
where the facial artery crosses. There is invariably limitation of mouth opining and the usual
systemic signs and symptoms associated with a substantial infection. It is worth, fluctuant,
redness of the skin, degree of tenderness.
V
The secondary deposits of a malignant neoplasm or lymphoma in lymph nodes of the upper
neck may undergo necrosis and present as a fluctuant swelling. Infiltration the surrounding
tissues by neoplasm will produce swelling and induration resembling cellulitis. A biopsy
will establish the diagnosis.
Treatment
Drainage of a submandibular abscess through an incision made parallel with but 2-3 cm
below the lower border of the mandible at a skin crease, after that sinus forceps are pushed
through the length investing deep fascia towards the lingual side of the mandible to release
the pus from the space and a drain inserted.
Sublingual space infections
Surgical anatomy
The sublingual is a V-shaped trough lying lateral to the muscle of the tongue, including the
hypoglossus and the genioglossus and the geeniohyoid, and bounded laterally and inferiorly
by the mylohyoid muscles and the lingual side of the mandible. It is covered superiorly by
the mucous membrane of the floor of the mouth.
Spread of infection on the lingual side of the mandible above the origin of the mylohyoid
muscle and below the level of the mucous membrane of the floor of the mouth into the
sublingual space. These infection usually arise from premolar periapical or periodontal
diseases of the lower anterior teeth but the abscess of these teeth usually discharge labially.
Signs and symptoms
Clinically, a firm painful swelling is produced on the affected side in the anterior part of the
floor of the mouth which raises the tongue. The oedematous tissues have a shiny, gelatinous
appearance. The patient complains pain and discomfort on swallowing with little or without
external swelling.
The infection may discharge into the mouth or pass anteromedially over the hump of the
genial muscles to the sublingual space of other side. From the poster-inferior part of the
space, infection can pass around the submandibular gland to enter the submandibular space,
or spread posteriorly via the tunnel under the superior constrictor muscle for the styloglossus
muscle into the parapharyngeal and pterygoid spaces. As discharged spread to the submental
space occurs most often through lymphatic spread.
Treatment
The moderate infection treated by antibiotic therapy combined with extraction of the
responsible tooth and mouth wash, will promote satisfactory resolution of the condition, but
in gross swelling an incision to drain the floor of the mouth should be made lateral to the
sublingual plica. When both the submental and sublingual spaces contain pus they can be
drained via a skin incision in the submental region, pushing closed sinus forceps through the
mylohyoid muscle and similar to the submandibular space.
Ludwig's angina
Ludwig's angina is a massive firm cellulitis affecting simultaneously the submental and
submandibular and sublingual spaces bilaterally.
Aetiology
Ludwig's angina usually follows a submandibular space infection caused by a periapical or
pericoronitis around lower 3rd molar. The infection then spread to the sublingual space on the
same side, around the deep part of the submandibular gland. From there it passes to the
VI
opposite sublingual space and then to the contralateral submandibular space. The submental
space is involved by lymphatic spread, or visa versa.
From the sublingual spaces the infection may spread backwards in the substance of the
tongue in the cleft between the hypoglossus muscle and the genioglossus muscle and along
the course of the sublingual artery, so that the infection reaches the region of the epiglottis
and so produces swelling around the laryngeal inlet.
From the submandibular space the spread may rarely extend downwards beneath the
investing layer of the deep cervical fascia.
Signs and symptoms
The external clinical appearance is of a massive firm, bilateral submandibular swelling
which soon extends down the anterior part of the neck to the clavicle. Intraorally a swelling
developed rapidly which involves the sublingual space, distends the floor of the mouth and
forces the tongue up against the palate, and in extreme condition the tongue may actually
protrude from the mouth.
The patient is very ill with a marked pyrexia, difficult deglutition and speech and
progressive dyspnoes is caused by the backward spread of the infection, oedema of the
glottis causes a complete respiratory obstruction and the death within 12-24 hours.
Treatment
Treatment by a combination of intensive antibiotic therapy and early intubation to control
the airway, coupled with surgical drainage of the fascial spaces when pus is present. The
immediate IV infusion of 500 mg of metronidazole and 500 mg of amoxycillin usually
brings about a rapid improvement and repeated 8 hourly. If allergic to penicillin use
erythromycin 600 mg given slowly intravenously every 8 hours or 80 mg gentamicin
intramuscularly.
If a general anaesthetic is administered the voluntary control over the airway is lost, and the
becomes unconscious there a massive increase in the oedema and the airway becomes
occluded. If a laryngoscope is used at this stage the pharynx billows inwards like a bolster
and it becomes quite impossible to pass an endotracheal tube, so that the tube should be
passed with the aid of a fiberoptic laryngoscope, while the patient is conscious.
Established cases of Ludwig's angina can operated upon under a combination of local
anaesthesia and intravenous analgesia. It is usually possible to drain the pus after local
infiltration of the skin and subcutaneous tissues overlying both submandibular spaces with
an anaesthetic solution such as 2% lignocaine, with adrenaline.
A nasopharyngeal airway and a laryngotomy set should be kept ready, and the a tracheotomy
set should also be immediately available. Immediate evaluation of the blood gases will give
an additional indication of the degree of respiratory obstruction and may indicate the need
for tracheotomy even if the patient is not obviously in distress.
The oedema reaches the clavicles and the tissues are brawny and inflexible, so that the
trachea is a long way from the surface of the wound and its identification is made difficult
by amount of haemorrhage from the inflamed tissue. Aspirating air with a wide needle and
syringe from the tracheas is indicated. If the operation is delayed until venous congestion
and cyanosis appears, so that cricothriodotomy is indicated.
VII
Abscess formation in relation to the buccinator muscle
Surgical anatomy
The buccinator muscle is a wide, fairly thin muscle which forms a muscular sheet in the
cheek. The attachment of the buccinator muscle is above the level of apices of the lower
molars and below those of the upper molars. The buccinator muscle acts as an effective
barrier to the spread of pus and this is especially true during the early stages of an abscess in
the cheek. Pus which spread buccally from any of the upper or lower molar teeth to perforate
the outer cortex of the alveolar process can discharge into the mouth on the oral side of the
origin of the buccinator muscle.
Signs and symptoms
The swelling in the buccal sulcus beneath the mucosa and opposite the tooth of origin, while
externally the facial swelling is relatively small, soft, and puffy. Sometime the swelling the
occlusal plain and become traumatized, but eventually it will discharge spontaneously.
Treatment
Drain the pus by an incision through the overlying mucosa.
The buccal space
Surgical anatomy
This potential space is bounded anteromedially the buccinator muscle, posteromedially by
the masseter muscle overlying the anterior border of the ramus of the mandible, and it is
covered laterally by a forward extension of the deep fascia from the capsule of the parotid
gland and by the platysma muscle. It is limited below by the attachment of the deep fascia to
the mandible, and by the depressor anguli oris and above by the zygomatic process of the
maxilla and the zygomaticus minor and major.
The buccal space contains the buccal pad of fat and is therefore continuous posteriomedially
around the fat with the pterygoid space through the interval between the buccinator and the
anterior border of the coronoid process.
Signs and symptoms
The infection produces a haematoma in the buccal space.
Treatment
Drainage is affected by a horizontal incision low down inside the cheek through which sinus
forceps either extraorally or intraorally below the parotid papilla, a soft corrugated rubber or
polypropylene grain is essential.
The submasseteric abscess
Surgical anatomy
The masseteric muscle of 3 heads with insertions into the ramus which are separated from
each other by bare areas of bone with a space between the middle and the deep heads, and
called submasseteric space, which provide a pathway for infection to pass upwards and
backwards from the retromolar fossa region.
Aetiology
A submasseteric abscess is not common and usually arises from infextion in the lower 3rd
molar region. Pericoronitis related to vertical and disto-angular lower 3rd molars. Pus can
also reach the submasseteric area if a periapical abscess from a mandibular molar soreads
subperiosteally in a distal direction.
VIII
Signs and symptoms
In the established submasseteric abscess the external facial swelling is moderate in size and
is confined to outline of the masseter muscle. The swelling does not usually extend beyond
the posterior margin of the ramus or encroach on the postauricular tissue like an acute
parotitis, although occasionally the postmandibular sulcus may be obscured by inflammatory
oedema. Extension of the abscess inferiorly is also limited by the firm attachment of the
master muscle to the lower border of the ramus. Forward spread of the swelling beyond the
anterior border of the ramus restricted by the anterior tail of the tendon of temporalis which
is inserted into the anterior border of the ramus. Although the swelling of a submasseteric
abscess is only moderate in extent it usually acutely tender and gives rise to an almost
complete limitation of mouth opening.
The overlying skin is only reddened in advanced cases and fluctuation cannot be elicited
because the muscle lies between the pus and surface. The symptoms are minimal, but at the
acute stage the systemic reaction includes pyrexia and malaise.
If the infection is particularly sever pus may discharge forwards at the anterior border of the
ramus, or backwards immediately behind the angle of the mandible. A chronic submasseteric
infection can persist for years punctuated by recurrent flare-ups. If incomplete resolution of
acute infection spread of the infection into the masseter muscle itself gives rise to a large
multilocular abscess.
The ramus of the mandible is more dependent upon a blood supply from the overlying
muscle than the body which is to a greater extent supplied by the mandibular artery. As a
result, ischaemic changes may take place in that part of the bone denuded of periosteum by a
submasseteric abscess so that a low grade osteomyelitis of the lateral cortical plate occurs
with sequestrum formation. Other submasseteric infection leads to subperiosteal new bone
deposition beneath the periosteum, layers of new bone produce a hard swelling over the
ramus, which is extreme cases may be misdiagnosed as a sarcoma. Some so-called cases of
Garre's osteomyelitis affecting the ramus.
Radiological examination
The early acute submasseteric abscess gives rise to no radiological abnormalities. The new
bone formation is best demonstrated by a tangential postro-anterior radiograph. The new
bone has an opaque linear or irregular fuzzy appearance.
Differential diagnosis
The swelling affecting 4 anatomical compartments have to be distinguished:
1. The masseteric compartment
a. Masseteric hypertrophy
b. Intramuscular haemangioma
c. Thrombophlebitis of an intramuscular haemangioma
2. The buccal space
a. Infection
b. Haematoma
c. Haemangioma
d. Lipoma
3. The parotid compartment
a. Obstruction of the parotid duct
b. Suppurative infection of the gland
c. Infection parotid lymph nodes
d. Mumps
IX
e. Cytomegalovirus
f. Sjogren's syndrome
g. Neoplasm
4. The ramus of the mandible: cystic or neoplastic enlargement.
Treatment
In the early stage of submasseteric infection by the removal of the causative tooth and
administration of antibiotic as benzyl penicillin and metronidazole is usually sufficient.
The established condition must be decompressed by incision and drainage. The incision is
made over the lower part of the anterior border of the ramus and deepened to bone by sinus
forceps along the lateral surface of the ramus downwards and backwards.The corrugated
drain should be sewn in to keep the incision open.
When the mouth can not open the skin incision is made behind the angle of the mandible and
to open the abscess by Hilton's method. The drain is left in position for one days at least and
may need to remain 3-4 days if a recurrent abscess is to avoided.
Pterygomandibular space infection
Surgical anatomy
The pterygomandibular space situated between the medial surface of the ramus of the
mandible and the medial pterygoid muscle. Between the ramus and the medial pterygoid
muscle run the inferior alveolar blood vessel and nerve, lingual nerve, mylohyoid nerve, and
maxillary artery. Posteriorly the lateral pterygoid muscle forms the roof to the space. The
Pterygomandibular space potentially communicates with the parapharyngeal space, So the
infection is more likely to extend into the parapharyngeal space by passing medially around
the anterior border of the medial pterygoid muscle.
Aetiology
Infection may introduced by:
1) Contaminated needle used for an inferior alveolar nerve block injection.
2) Spread of infection from the lower 3rd molar region.
3) Infection originated from the upper 3rd molar.
4) Follows a posterior superior alveolar nerve block injection.
Signs and symptoms
In early infection of the space does not cause much swelling of the face and the swelling
visible involves the submandibular region and buccal space. In severe degree of limitation of
mouth opening and dysphagia and on palpation tenderness can be elicited in the swollen soft
tissue medial to the anterior border of the ramus of the mandible.
The infection may spread upwards along the medial surface of the ramus to produce abscess
in the infratemporal fossa and beneath the temporalis fascia. It can also pass anteriorly
between the front of the ramus and the buccinator muscle into the buccal space, and anteroinferiorly below the lower border of the superior constrictor muscle along the styloglossus
muscle into the submandibular space.
Treatment
Usually the abscess tends to point at the anterior border of the ramus and drainage can be
effected easily by an incision down anterior border, after which a pair of sinus forceps can
be directed into the plane between the ramus and medial pterygoid muscle. If there is
difficulty to drain by incision in a skin crease in the submandibular region and the sinus
forceps can be passed upwards and backwards deep to the mandible.
X
Lateral pharyngeal (parapharyngeal) space infection
Surgical anatomy
The lateral pharyngeal (pharyngomaxilllar) space is a potential cone shaped space or cleft
with its base upper most at the base of the skull and its apex at the greater horn of the hyoid
bone. Its medial wall is the superior constrictor muscle with its covering sheet of
buccopharyngeal fascia, together with styloglossus, stylopharyngeus, and middle constrictor
muscles and the lateral wall from above downwards consists of fascia covering the medial
pterygoid muscle, the angle of the mandible and submandibular salivary gland. More
posteriorly it is closed laterally by parotid gland and the posterior belly of the digastric
muscle. The posterior border is the prevertebral fascia and the upper part of the carotid
sheath.
The infection passes most easily between the lateral pharyngeal space and the submandibular
space by tracking along the styloglossus muscle. There is also a weak zone in the posterior
part of the fascia around the submandibular gland, medial to the stylomandibular ligament
and rupture of the submandibular abscess through into the parapharyngeal space at this point
results in the rapid onset of respiratory embarrassment.
Aetiology
The space may become infected from an abscess extending backwards from the lower 3 rd
molar area or more commonly one passing laterally from a tonsillar abscess. Infection can
also spread backwards into it from a sublingual or submandibular space.
A rare case infection is the surgical displacement of a lower 3 rd molar or the root of the
lower 3rd molar distally at the lingual flap and backwards to the lateral pharyngeal space.
Signs and symptoms
The pyrexia and malaise, pain on swallowing is extreme and there is limitation of opening,
but not severe. The tonsil and the lateral pharyngeal wall are pushed towards the midline.
Usually there is little swelling of the side of the face, but there may be some at the lower
border of the parotid gland and this is probably due to enlargement of the nodes.
Infection of the lateral pharyngeal space is extremely serious owing to thrombophlebitis of
the internal jugular vein may occur and if the pus is not drain the common carotid artery may
become eroded with fatal consequence. Inequality of the pupils due to involvement of the
cervical sympathetic.
Treatment
Early intensive therapy is given with IV metranidazole and benzyl pencillin Or
erythromycin, gentamicin or cefuroxime followed by drainage. If the patient mouth can
opened wide an intraoral incision medial to the anterior border of the ramus and push sinus
forceps. If this is not possible a skin incision is made 1 cm below and behind the angle of the
mandible and then sinus forceps followed by a finger are inserted into the space between the
submandibular and parotid glands and passed medial to the mandible and upwards along the
inner aspect of the medial pterygoid muscle a drain is inserted.
Peritonsillar abscess or Quinsy
Surgical anatomy
A peritonsillar abscess is localized infection in the connective tissue bed of the faucial tonsil
between it and the superior constrictor muscle. Acute infection penetrates from the depth of
a tonsil crypt or the supratonsillar fossa, but may be a complication of acute pericoronitis
associated with a lower 3rd molar.
XI
Signs and symptoms
There is acute pain on one side of the throat radiating to the ear, dysphagia, and difficult to
open the mouth, speech becomes awkward, especially in bilateral cases as hot potato. Pain
on attempting to swallow, saliva may run out the moth. The patient looks and feels ill, is
anorexic and becomes rapidly dehydrated.
The fully developed abscess causes a tense swelling of the anterior pillar of fauces, and a
bulge of the soft palate on the affected side which in extreme cases reaches the midline and
push the uvula downwards and forwards until it impinges against the opposite tonsil. The
tongue is coated and there is foetor oris, oedema may eventually affect the base of the
tongue, epiglottis and aryepiglottic fold. In 3-5 days the mass often becomes fluctuant and if
allowed to pursue its natural course, finally ruptures by pointing usually through the anterior
tonsillar pillar.
Treatment
This involves antibiotics and incision. The abscess is incised using guarded knife and sinus
forceps which are inserted into the most prominent part of the soft palate where fluctuation
is maximal.
Differential diagnosis
Pterygomandibular
Lateral pharyngeal Peritonsillar
Space
Anatomy
Between mandible
Between medial
Between Superior
and medial pterygoid Pterygoid and
Constrictor and
Superior constrictor mucous membrane
Limitation of opening Extreme
Moderate
Some
External swelling
Little
None
None
Swelling in mouth
Some over medial
A good deal of
Pillars of fauces and
and throuat
Aspect of anterior
Pillars of fauces
most of soft palate
Border of ramus
but little of soft
palate
The upper lip
Surgical anatomy
Infections occur as a result of an abscess of the upper anterior teeth, the pus forms on the
oral side of the orbicularis oris muscle and tend to point in the vestibule due to the origin
beneath the anterior nasal spine. Rarely they will point in the floor of the nose and be
mistaken for a boil of the nose. Infection from out side usually occur as a result of a skin
infection such as a furuncle.
Signs and symptoms
Swelling of the upper lip may rarely give rise to an orbital cellulites or a cavernous sinus
thromphlebitis by passing from the superior labial venus plexus to the anterior facial vein
and then retrograde direction via the ophthalmic veins to the Cavernous. This pathway is
facilitated by the fact that these veins have no valve. Cavernous sinus thromphlebitis used to
be a fatal condition before antibiotic therapy.
Treatment
All abscesses in the upper lip should be treated by antibiotic therapy and drainage. Incision
can usually be made in the vestibule and the offending tooth either opened and drained or
extracted.
Differential diagnosis
XII
1. Trauma: Post-traumatic oedema will start to subside after 48 hours where as the
physical signs will worsen if infection is present.
2. Hypersensitivity reaction: Allergic swelling result from contact with a substance as a
lipstick or toothpaste or arise as a feature of angioedema. The enlarged lip is soft and
non-tender and will reduce in size with antihistamines.
3. Oedematous swelling: There are uncommon causes of oedematous swelling as
Merkerson-Rosenthal syndrome which include a swollen lip, fissure tongue, and facial
palsy. Biopsy of the lip will reveal non-caseating Langhan's giant cell granuloms, if
associated with neuropathy are likely to be sarcoid, but if associated with
granulomaous bowel disease is Crohn's disease.
4. Cysts: As odontogenic cysts or nasopalatine cyst, and nasolabial cyst.
5. Neoplasms: Pleomormphic adenoma, muco-epidermoid carcinoma.
The canine fossa
Surgical anatomy
In short root of the upper canine, the periapical abscess will spread to the bone below the
origin of the levator anguli oris and will tend to point in the upper buccal sulcus.
If the pus does not point in the buccal sulcus it tends to travel up the medial border of the
levator anguli oris, deep to the levator labii superioris which it can not penetrate, so then
emerge between the levator labii superioris and the levator labii superioris alaeque naris to
point below the medial corner of the eye.
If the root of the canine is long or the origin of the levator anguli oris relatively low, pus
from a periapical abscess may emerge above the origin of the levator anguli oris, so that the
pus can only escape to the surface between the levator labii superioris alaeque nasi and the
levator labii superioris.
Signs and symptoms
There is oedema of the cheek and upper lip even if the abscess point the buccal slcus, the
nasolabial fold is often obliterated and the swelling of the upper lip produces a drooping of
the angle of the mouth. Oedema of the lower eyelid .
Treatment
The is risk of cavernous sinus thrombosis as complication of these infection so the early
drainage is important with antibiotic should be prescribed.
Differential diagnosis
1. Carbuncle of the skin
2. Acute maxillary sinusitis: the oedema in the infraorbital margin and lower eyelid.
3. Acute ethmoidal sinusitis swelling to the upper and lower eyelids and may extend to
orbital cellulites.
4. Acute frontal sinusitis swelling only upper eyelid.
5. Acute nasolcarimal dacryocsititis can produce swelling below the medial canthus of the
eye.
Abscess involving the upper molar teeth
Abscess in buccal roots usually point in the buccal sulcus if the discharge below the
attachment buccinator muscle, but if pus discharge above the attachment buccinator muscle
reach the buccal space. The palatal root or infection in the bifurcation may point on the
palatal side. More rarely pus may discharge into maxillary sinus lead to acute or subacute
sinusitis.
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Subperiosteal abscess in the palate
Surgical anatomy
The mucoperiosteum is made of mucosal and periosteal layers are bounded together so
strongly that they can not be separated. The periosteum is attached to the underlying bone by
Sharpey's fibres and small blood vessels. No actual space present but the pus can striped up
when it accumulates between the bone and the periodteum.
The pus may sep through the gingival cervice along side a tooth. Pus rarely across the
midline of the palate. The lateral incisor most common source of a palatal abscess.
Signs and symptoms
A circumscribed fluctuant swelling which is usually confined to one side of the palate. There
may be little tendency for discharge spontaneously.
Differential diagnosis
1. Infected dental cysts
2. Cystic pleomorphic adenoma or muco-epidermoid carcinoma
3. Carcinoma from maxillary sinus
4. Malignant lymphoma
Treatment
Incision should be carried out in anteroposterior direction to avoid dividing the greater
palatine vessels and nerve.
Periapical abscesses in relation to the maxillary sinus
Surgical anatomy
The apices of the root of the most upper teeth in close relationship to the floor of maxillary
sinus, which depending upon the size of the maxillary sinus and the length of the roots. The
most related are the apices of the 2 nd and 1st molars followed by the 3rd molar, 2nd and 1st
premolar and canine.
An infected pulpless tooth or a minute oroantral fistula following an extraction may give rise
to a chronic sinusitis with recurrent subepisodes which may give rise to chronic sinusitis.
Radiology
Earliest change is the thickening of the overlying antral mucosa or polypssen on a film.
Treatment
Most of cases extraction of the infected tooth will lead to drainage and the remainder which
has accumulated below the level of the osteum. If the defect is small an the infection
controlled with antibiotics. Even a larger fistula will often close spontaneously with
antibiotic and frequent irrigation with warm saline and protective acrylic plate. If this fail
antrostomy through Calwell-Luc approach, and intranasal antrostomy and closure of the
fistula with a flap will be required.
The infratemporal fossa
Surgical anatomy
The infratemporal fossa forms the upper extremity of the pterygomandibular space. It is
bounded laterally by the ramus of the mandible, the temporalis muscle and its tendon,
medially by the lateral pterygoid plate of the sphenoid bone and superiorly by the
infrattemporal surface of the greater wing of the sphenoid bone. It contains the origin of the
medial and lateral pterygoid muscles , and the maxillary artery and the pterygoid venous
plexus. Pus can extend upward with the origin of temporalis muscle and around the muscle
under temporal fascia.
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This space actually continuous in its anterior part with the upper part of the
pterygomandibular space and separated by the lateral pterygoid muscle poseteriorly.
Signs and symptoms
Subacute infection due to contaminated needles follow injections in the tuberosity area and
the signs apart from trismus which must be distinguished from limitation of opining due to a
T.M.J. disturbance.
Acute infections tend to follow infections of upper 3rd molars, mainly in partially erupted,
and contaminated needle. The infection spreads upwards deep to and lateral to temporalis
muscle. Limitation of opining is marked with bulging of the temporalis muscle. The swelling
may be detected as a filling out of the hollow behind the zygomatic process of the frontal
bone.
Pus may spread upwards beneath the origin of the temporalis muscle to form a subtemporalis
abscess. If drainage was delayed the temporalis muscle and surface of the skull would be
found to be necrotic. In acute infection the patient is very ill and has a high temperature.
Infection are always serious owing to the presence of the pterygoid venous plexus,
sphenoidal emissary vein connect the plexus with cavernous sinus, the foramen lacerum,
foramen spinosum and the foramen ovale which spread to the middle cranial fossawhich
lead to headach, irritability, photophobia, vomiting and drowsiness will indicate intracranial
infection.
Treatment
Antibiotic must be given, Benzylpencillin 60 mg, 8 hourly, with metranidazol 500 mg, 8
hourly IV, followed by phenoxymethyl pencilin 500 mg , 6 hourly, and metranidazol 500
mg, 8 hourly by mouth.Drainage of the infratemporal fossa can be effected through an
incision buccal to the upper 3 rd molar following the medial surface of the coronoid process
and temporalis muscle upwards and backwards with closed sinus forceps, then put soft drain
must sutured. In sever case drainage through an incision at the upper and posterior edge of
the temporalis muscle within the hairline, the sinus forceps are pssed downwards and
forwards and medially to the pus and put soft drain.
Prolonged limitation of opening treated by active exercise, or by temoporalise myotomy or
excision of the coronoid process.
Cavernous sinus thrombophlebitis
Signs and symptoms
The serious becomes marked oedemaand congestion of the eyelids, and injection and
oedema of the conjunctiva due to impaired venous return, a pulsating exophthalmos where
the carotid pulse is transmited through the retrobulbar oedema. At this stage
ophthalmoplagia is detectable and if the retina can be visualized, papilloedema with multiple
retinal haemorrhages will be seen. Untreated thrombophlebitis will spread to the opposite
side giving rise to bilateral signs.
Treatment
Cavernous sinus thrombophlebitis will require energetic antibiotic therapy and
heparinization to prevent extension of the thrombosis with a neurosurgical consultation.
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The use of heat in the treatment
Poultices were applied to extensive infections of the soft tissues in order to induce local
vasodilatation due to increase blood supply. In case of suppurative infections they appeared
to hasten suppuration and encourage the pus to point under the poultice where it could
readily drained.
Poultice probably increase the spread of a cellulites which they induce could worsen the
patient's condition mainly in the floor of mouth and the neck. Hot salt water mouth wash
may comfort and to degree improve oral hygiene with small therapeutic effect.
The surgical drainage of abscesses
Immediate incision an drainage are required:
1. Where are the sign of pus beneath the deep fascia:
a) A localized dusky redness appearing in the general redness of firm swelling.
b) A localized area of tenderness over the center of the swelling.
c) Pitting oedema in the middle of a previously firm swelling.
d) A sharp rise in the temperature, particularly if the patient is having antibiotic.
2. Where the involved compartment is inaccessible, such as the pterygomandibular,
lateral pharyngeal spaces, submesseteric and infratemporal fossa infections where it
may be impossible to elicit the classic signs of suppuration, so that a lack of local
improvement with adequate doses of antibiotics, a recurrence of pyrexia or a sudden
increase in temperature and severe limitation of mouth opining .
3. With Ludwig's angina.
With prolong antibiotic treatment some middle sized abscesses may be virtually sterilized
but this dose not lead to a satisfactory outcome which lead to antibioma. Where an abscess
points beneath the skin as a red shiny swelling in a conspicuous aspiration may be tried to
avoiding the scar of an incision, but such abscess often heals with puckering and
subcutaneous scar. Treatment any scar should be delayed for at least 6 months because a
slow improvement will occur.
Success in the treatment of a cellulites becomes apparent with a fall in the patient's
temperature, a reduction in malaise and toxaemia, the relief of pain and a decrease in the
swelling. The 1st sign is the appearance of fine wrinkles in the overlying skin where
previously it was tense, red and shiny.
Technique of incision and drainage
In general incisions are placed over the point of maximum fluctuation, or over the most
direct route to the pus.
The sitting of the incision is guided by the direction of Langer's lines and the skin creases.
Closed forceps are pushed through the deep fascia and advanced to pus in a direction away
from important structures. The hinges of the sinus forceps must be external to the incision.
A soft (yeast) or corrugated drain is than inserted using the sinus forceps to carry the end
into the depths of the cavity and the part external to the wound is sutured to one end of the
incision. The drain is left until little pus accumulates in a dressing left for 24 hours, long
drains should be shortened for a further 24 hours, may be the drain left for 3-4 days.
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Sinus formation
When the abscess discharges through the skin for not only may the sinus appear in a location
unfavorable for drainage, but the resulting scar is always puckered, thickened, and depressed
and more obvious than in elective surgical incision and drainage has been carried out. The
sinus will become chronic unless the original source of infection is removed. When the
sinuses are sited on the face or neck their appearance is quite characteristic and a focus of
infection such as a buried tooth or root must be sought and eliminated.
The clinical appearance of sinuses on the face varies according to the place of the infection.
During an active phase are open and discharging small quantities of pus, but during a
quiescent phase they heal over. In an active phase the tissue immediately surrounding the
sinus exhibits signs of inflammation and may be tender, but after pus has been drained the
sinus tends to heal over until another exacerbation of infection. If the buccal sulcus between
the sinus and the jaw is palpated a firm, fibrous cord representing the sinus track may be left.
The position of its attachment to the jaw may indicate the site from which the pus is
drainage.
Sinus excision
An elliptical incision is made round the external orifice so that on closure the scar lies in
Langer\s lines without puckered ends. Some deep soluble catgut or polyglycolate sutures are
inserted to eliminate the dead space and the skin wound is closed with careful eversion of the
edges using interrupted 4/0 black silk or praline or other monofilament sutures. The oral
defect is closed with the black silk sutures.
Summary of the management of patients with spreading infections
1. An acute abscess with collateral oedema
a. Extraction of the tooth alone is normally adequate treatment.
b. If root-canal therapy is to be undertaken.
c. Established local antibiotic or antiseptic treatment in the root canal as soon as
possible.
2. Cellulites or tissue space abscess: Administer antibiotics to help eliminate local
infection and prevent its spread elsewhere, extract the tooth of origin or establish
effective root canal treatment. Incise and drain where there is:
a. Fluctuation as in the case of a local abscess.
b. When there is localized pitting oedema with tenderness.
c. When localized dusky redness and a sharp rise in temperature suggests a tissue
space is involved.
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