1. May 2014 CME

2. OUTLINE Background Epidemiology Etiology Pathophysiology
Relevant Anatomy
Fascial planes
Deep neck spaces
Presentation
Management
Overview 2

3. CASE REPORT 1
A 27-year-old female who was referred to us 4/2/2014, on account of a facial and neck swelling occasioned by an impacted lower right mandibular third molar. 3

5. Patient had severe toothache from same tooth for three weeks duration but did not seek Dental treatment for financial reason. On presentation there was a diffuse bilateral submental, sublingual, and submandibular swelling extending to the neck, with associated trismus, pyrexia, and respiratory distress 5

6. A clinical impression of Ludwig’s Angina was made.
Haematological Baseline, blood chemistry, and pus MCS could not be done for financial reasons. 6

7. IV access was promptly secured, and patient was given ;
IV Ceftriaxone 2g stat. (rocephin),
IV Ampicillin/sulbactam1.2g stat.(augmentin),
IV Metronidazole 1g stat,
and IV normal saline 500ml as slow infusion 7

9. The offending tooth was extracted under local anaesthesia, while a bilateral incision with surgical drainage of pus and decompression was done with insertion of a through and through rubber drain. 9

10. Patient was admitted into the ward, and continued on ;
IV Ceftriaxone 1g daily,
IV Ampicillin/sulbactam1.2g bd,
IV Metronidazole 500mg tds, for 1 week
Daily decompression of neck, wound dressing, and jaw opening exercise was done until surgical drain was minimally productive of pus. 10

11. Surgical drain was discontinued, and patient was discharged home on 14/2/2014 to be followed-up on out- patient basis at the Dental clinic. 11

13. CASE REPORT 2 13

14. A 15-year-old female was referred to us 19/4/2014 from Shomolu General Hospital, on account of a painful brawny facial and neck swelling of three days history 14

15. On presentation there was pus discharge distal to the left mandibular second molar tooth, a diffuse bilateral submental, sublingual, and submandibular swelling extending to the neck, with associated trismus, pyrexia, and respiratory distress 15

16. 16

17. A clinical impression of Ludwig’s Angina was made.
Haematological baseline, blood chemistry, and pus MCS could not be done for financial reasons.
Haematological baseline, blood chemistry, and pus MCS could not be done for financial reasons. (. 17

18. IV access was promptly secured, and patient was given;
IV Ceftriaxone 2g stat,
IV Ampicillin/sulbactam1.2g stat,
IV Metronidazole 1g stat,
and IV fluid normal saline 500ml as slow infusion. 18

19. None of the teeth present could be implicated for extraction
however a bilateral incision with surgical drainage of pus and decompression was done with insertion a through and through rubber drain. 19

21. IV Ampicillin/sulbactam1.2g bd , IV Metronidazole 500mg tds
Patient was observed at the casualty over the next five days, and continued on;
IV Ceftriaxone 1g daily,
IV Ampicillin/sulbactam1.2g bd
, IV Metronidazole 500mg tds
. Daily re-exploration and decompression of the swelling, wound dressing, and jaw opening exercise was done until 25/4/2014 when pus drainage from the surgical drain was significantly reduced enough to allow patient to be discharged home and seen on out- patient basis at the Dental clinic 21

22. Surgical drain was removed two days after,
while jaw opening exercises,
and wound dressing continued until extraoral wound healed.
Patient is still being followed up to identify the possible cause of the swelling. 22

23. BACKGROUND

24. Frequency Epidemiology
No accurate estimate of the frequency exists presently worldwide.
complication rate is likely to be greater in areas without wide access to modern medical treatment, including antibiotics, imaging modalities, and intensive care support.

25. Etiology odontogenic origin other causes include the following:
most common in adults, while
tonsillitis
most common in children.
other causes include the following:
Traumatic
Implant surgery
Reconstructive surgery
Infection from contaminated needle punctures
Secondary to oral malignancies
Necrosis and suppuration of a malignant cervical lymph node or mass
Cervical lymphadenitis

26. Etiology 20-50% have no identifiable source. include
immunosuppressed patients
important considerations in etiology
may have
increased frequency of deep neck infections and atypical organisms, and
more frequent complications.

27. Pathophysiology Irrespective of the initiating event,
infection proceeds either
by the lymphatic system
Lymphadenopathy may lead to suppuration and finally focal abscess formation.
by the paths of communication between spaces
or by direct infection
through penetrating trauma.

28. Pathophysiology a deep neck infection can progress to
inflammation or to
fulminant abscess with a purulent fluid collection
signs and symptoms develop either because of
Direct involvement of surrounding structures with the infectious process, or
Mass effect of inflamed tissue or abscess cavity on surrounding structures

29. Pathophysiology
MICROBIOLOGY
mixed aerobic and anaerobic organisms, and both gram-positive and gram-negative organisms may be cultured

30. Pathophysiology They include
Group A beta-hemolytic streptococcal species (Streptococcus pyogenes),
alpha-hemolytic streptococcal species (Streptococcus viridans, Streptococcus pneumoniae), 
Staphylococcus aureus,
Fusobacterium nucleatum,
Bacteroides melaninogenicus,
Bacteroides oralis, and Spirochaeta,
Peptostreptococcus, and Neisseria species and occasionally
Pseudomonas species, 
Escherichia coli,and 
Haemophilus influenzae 

31. Pathophysiology
A study by Asmar of retropharyngeal abscess microbiology demonstrated polymicrobial culture results in almost 90% of patients.[7] 
Aerobes were found in all cultures, and anaerobes were found in more than 50% of patients.
Other studies have shown an average of at least 5 isolates from cultures.

32. RELEVANT ANATOMY

33. Relevant Anatomy
a detailed knowledge of anatomic description of the major facial and deep neck spaces
is beyond the scope of this presentation,
but is necessary for accurate diagnosis and treatment
The deep neck spaces are formed by fascial planes, which divide the neck into
real and
potential spaces.

34. Two main fascial divisions exist, superficial cervical fascia and
Fascial planes
Two main fascial divisions exist,
superficial cervical fascia and
deep cervical fascia.

35. Fascial planes Superficial cervical fascia:
lies just deep to the dermis,
surrounds the muscles of facial expression
includes the superficial musculoaponeurotic system (SMAS)
does not constitute part of the deep neck space system
extends from
epicranium to
axillae and chest.
space deep to it contains
fat,
neurovascular bundles, and
lymphatics.

36. Fascial planes Deep cervical fascia: encloses the deep neck spaces
is further divided into 3 layers, the
superficial,
middle, and
deep layers of the deep cervical fascia.

37. Fascial planes Superficial layer of the Deep cervical fascia
an investing fascia that surrounds the neck
encompasses
the muscles of mastication and
Major salivary glands (submandibular and parotid)
forms the floor of the submandibular space. Laterally, this fascia
helps to define the parotid and masticator spaces.

38. Fascial planes Middle layer of the Deep cervical fascia envelops
larynx,
trachea, and
thyroid gland.
attaches
superiorly to the base of the skull and
inferiorly to the pericardium via the carotid sheath
contribute to the formation of the carotid sheath through its two divisions
muscular and
visceral divisions

39. Fascial planes Deep layer of the Deep cervical fascia
is subdivided into 2 divisions,
prevertebral and
alar.
prevertebral division
adheres to the vertebrae
alar division
defines the posterior border of the retropharyngeal space
surrounds the deep neck muscles
lies between the prevertebral division and the visceral division of the middle layer
contributes to the carotid sheath.

40. Spaces involved in odontogenic infections
Primary maxillary spaces.
Canine
Buccal
Infratemporal

41. Spaces involved in odontogenic infections
Primary mandibular spaces.
Submental
Buccal
Submandibular
Sublingual

42. Spaces involved in odontogenic infections
Secondary fascial spaces
Masseteric
Pterygomandibular
Superficial and deep temporal
Lateral pharyngeal
Retropharyngeal
Prevertebral

44. Potential pathways of extension of deep fascial space infections of the head and neck

45. Potential Complications of Spread of Oral Infections

46. Deep neck spaces deep neck contain 11 spaces,
created by planes between the fascial layers
may be real or potential and
may expand when pus separates layers of fascia
communicate with each other, forming avenues by which infections may spread.
Most important :
Submandibular
Lateral Pharyngeal
Retropharyngeal / Danger / Prevertebral

47. Parapharyngeal space comprise
lateral pharyngeal space,
pterygomaxillary space
pharyngomaxillary space,
pterygopharyngeal space
was the most commonly affected space before the advent of modern antibiotics
provides a central connection for all other deep neck spaces

48. Parapharyngeal Space

50. Parapharyngeal space connects with hallmark of a parapharyngeal space
retropharyngeal space posteromedially
submandibular space inferiorly
with the masticator space laterally
hallmark of a parapharyngeal space
infection is medial displacement of the
lateral pharyngeal wall and
tonsil

51. Retropharyngeal space
Considered as a third medial compartment within the parapharyngeal space
Communicate with parapharyngeal space laterally
primarily contains retropharyngeal lymphatics.
lies between the
visceral division and
alar division of the deep layer of deep cervical fascia

52. Retropharyngeal space
Infection may enter
indirectly, from the parapharyngeal space, or
Directly
from traumatic perforations of the posterior pharyngeal wall or esophagus
infection in this space much more common in children than adults
Because retropharyngeal lymph nodes tend to regress by about age 5 years
Abscess in this space
occlude the airway at the level of the pharynx and
may drain into the chest, causing
mediastinitis and
empyema

54. Retropharyngeal abscess

55. Lateral radiograph of the neck

56. Danger space extends from the
skull base to
posterior mediastinum and diaphragm
Spread of infection within it occur rapidly because of the loose areolar tissue
leading to
mediastinitis,
empyema, and
sepsis.

57. Danger Space

58. Masticator space lies inferiorly to the temporal space and
anterolateral to the parapharyngeal space.
situated
laterally to the medial pterygoid fascia and
medially to the masseter muscle
Infections may result from
dental infections,
removal of suspension wires
may spread to
parapharyngeal,
parotid, or
temporal space.
Trismus
is an initial presentation and
may be a long-term sequela.

59. Masticator Space with Subspaces

61. Submandibular space is bounded inferiorly
by the superficial layer of the deep cervical fascia from the hyoid to the mandible,
laterally
by the body of the mandible, and
superiorly
by the mucosa of the floor of mouth.

62. Submandibular space
is in continuity with sublingual space via the posterior margin of the mylohyoid muscle
Infection may be secondary to
dental abscess of mandibular teeth,
submaxillary or sublingual sialadenitis, or
oral trauma
infections may spread to
parapharyngeal space or
retropharyngeal space.

63. Anatomic relationships in submandibular infections

64. Ludwig angina
Is a term that describes inflammation and cellulitis of the submandibular space, usually starting in the submaxillary space and spreading to the sublingual space via the fascial planes, but not the lymphatics.
typically with bilateral involvement
As the submandibular space is expanded by cellulitis or abscess, the
floor of the mouth becomes indurated, and the
tongue is forced upward and backward, causing airway obstruction.
Ludwig angina does not require the presence of a focal abscess

65. Ludwig’s Angina

66. Ludwig angina
is a life-threatening condition that requires tracheostomy for airway control
mortality rate was 50% before antibiotics,
now less than 5% with modern antimicrobial and surgical therapies
manifests with
drooling,
trismus,
pain,
dysphagia,
submandibular mass, and
dyspnea or airway compromise caused by displacement of the tongue.

67. PRESENTATION AND MANAGEMENT

68. HISTORY Obtain a detailed history Pain Rate of onset
Duration of symptoms
Recent dental procedures
Neck or oral cavity trauma
Breathing difficulties
Dysphagia
Upper respiratory tract infections (URTIs)
Immunosuppression or immunocompromised status

69. EXAMINATION Focus of physical examination is to determine
location of infection
deep neck spaces involved
dentition and tonsils
The most consistent signs are
fever
tenderness
halithosis
elevated WBC count
Asymmetry of the neck, associated neck masses or lymphadenopathy,

70. other signs and symptoms are space specific: Trismus
EXAMINATION
other signs and symptoms are space specific:
Trismus
caused by inflammation of the pterygoid muscles
Medial displacement of the tonsil and lateral pharyngeal wall
caused by parapharyngeal space involvement
Torticollis and decreased range of motion of the neck
caused by inflammation of the paraspinal muscles

71. EXAMINATION Fluctuance not often palpable because of deep location and
extensive overlying soft tissue and muscles
Tachypnea, shortness of breath, use of accessory muscles of respiration,
suggestive of
warn of impending airway obstruction
pulmonary complications
Regularly spiking fevers,
septic embolization
internal jugular vein thrombophlebitis

73. Diagnosis and Workup Laboratory Studies
A high index of suspicion is important for diagnosis
Tests
Abscess cultures with Gram stains
to direct antimicrobial therapy
Complete blood cell count
Clotting profile
Blood cultures
in septic patients

74. Diagnosis and Workup Imaging Studies
Lateral neck radiography
may reveal soft tissue swelling in prevertebral region
retropharyngeal abscess is highly suspected for
Prevertebral soft tissue thickening
greater than 7 mm over C2 or
greater than 14 mm in children and 22 mm in adults over C6
Mandible
Panorex
Chest radiography:
to evaluate the mediastinum for
concurrent pneumonia suggesting aspiration
pneumomediastinum

75. Diagnosis and Workup Imaging Studies
CT scanning with contrast
 gold standard 
indicate location, boundaries, and relation of infection to surrounding neurovascular structures.
abscesses are seen as low-density lesions with rim enhancement, occasional air fluid levels, and loculations
Rim enhancement and partial loculation are well demonstrated

76. Diagnosis and Workup Imaging Studies
Irregularity of the abscess wall on CT is predictive of pus within the cavity

77. Diagnosis and Workup Imaging Studies
MRI:
excellent soft tissue resolution
But not the initial modality of choice because of the increased time and expense involved
Arteriography:
helpful when carotid, jugular, or innominate involvement is suggested.

78. Severity Scores of Facial Space Infections
Severity Score Anatomic Space
Severity Score = 1
Vestibular
(low risk to airway or vital structures)
Subperiosteal
Space of the body of the mandible
Infraorbital
Buccal
Severity Score = 2
Submandibular
(moderate risk to airway or vital structures)
Submental
Sublingual
Pterygomandibular
Submasseteric
Superficial temporal
Deep temporal (or infratemporal)

79. Severity Scores of Facial Space Infections
Severity Score Anatomic Space
Severity Score = 3
Lateral pharyngeal
(high risk to airway or vital structures)
Retropharyngeal
Pretracheal
Severity Score = 4
Danger space (space 4)
(extreme risk to airway or vital structures)
Mediastinum
Intracranial infection

80. Principles in Treatment of Facial Space Infections
Secure the airway
Institute antibiotic therapy
Remove causative agent
Establish drainage.
Supportive care, including nutrition and proper rest .

81. Treatment Airway first priority of treatment may involve observation,
Intubation
endotracheal or
nasotracheal , 
tracheostomy, or
cricothyroidotomy for emergent situations.

82. Treatment
intubation
may be extremely difficult even in experienced hands
potential for abscess rupture, leading to
aspiration,
acute airway obstruction, or
death.

83. Treatment tracheostomy
cases with impending respiratory distress should undergo a tracheostomy to secure a safe airway
should be performed before any attempts at surgical drainage
safer,
preferable

84. Treatment Medical Therapy
Cultures of
abscess fluid
blood
to help direct antimicrobial therapy
Volume and metabolic resuscitation
Identify and address metabolic derangements
other concurrent medical problems

85. Treatment Medical Therapy
Intravenous antibiotics
parenteral antibiotics
empiric regimens 
based on the local resistance patterns
to cover the most likely organisms.
modify antibiotics according to culture and sensitivity results.
administer IV antibiotics
until the patient is clinically improving and
afebrile for at least 48 hours.
oral antibiotics can follow thereafter

86. Treatment Surgical Therapy
Incision and drainage
is mainstay of treatment
for
any frank abscess with impending complications
absence of improvement after hours of IV antibiotics
commonest approach employed is
transcervical
approach must ensure
adequate exposure and access
drainage without compromising surrounding structures.

87. OVERVIEW 87

88. Background Diagnosis and treatment Infections remain difficult and
challenged physicians and surgeons for centuries because of the
complexity and the
deep location of this region.
Infections remain
an important health problem
with significant risks of morbidity and mortality. 88

89. Background Previously high rates of morbidity and mortality
reduced with
advent of modern microbiology and hematology,
development of sophisticated diagnostic tools (eg, CT, MRI),
effectiveness of modern antibiotics, and the
continued development of medical intensive care protocols and surgical techniques. 89

90. Factors that make these infections a challenging problem
underestimation by Clinical examination (70%)
Deep location within the neck:
makes diagnosis difficult
because are
covered by a substantial amount of unaffected superficial soft tissue,
difficult to palpate and
impossible to visualize externally.
Complex anatomy:
precise localization of difficult. 90

91. Problem
Access:
risk of injury to intervening neurovascular and soft tissue structures
Proximity:
surrounding network of structures
become involved in inflammatory process,
causing complications
Communication:
with each other,
allow spread 91

92. Submental space situated on the superficial surface of mylohyoid muscle, medial to the anterior belly of the digastric muscle (highlighted in green).

93. Management – Diagnosis and Workup Imaging Studies
Clinical examination alone
CT scan with contrast
CT findings combined with clinical exam findings 93

94. Treatment most important preoperative considerations
stabilization of the airway,
volume and metabolic resuscitation, and
initiation of antibiotics.
Surgical approach depends on
precise location of the abscess,
its relation to the great vessels and other important anatomic structures of the neck
size of the collection 94

95. Right submandibular space situated on the superficial surface of mylohyoid muscle, between the anterior and posterior bellies of the digastric muscle(highlighted in green).

96. Treatment Postoperatively,
closely observe the patient for signs of a response to therapy
recognize reaccumulation of fluid
cultures and sensitivities
patient's airway
signs of impending complications 96

97. nonsurgical management
Treatment
nonsurgical management
IV antibiotics
until the patient is clinically improving and
has been afebrile for at least 48 hours.
oral antibiotics can follow thereafter
patients with small fluid collections and no respiratory compromise
surgical drainage
patients who do not improve within 48 hours of initiation of broad-spectrum intravenous antibiotics
image-guided surgical drainage
areas that are otherwise difficult to reach 97

98. No absolute contraindications However,
establishing a safe airway takes priority and
should be addressed before initiating surgical drainage procedures. 98

100. Referral or not ?
100

102. Follow-up complete resolution reaccumulation of abscess
redevelopment of infection
surgical site healing
102

103. Complications Those at risk delay in diagnosis and treatment
untreated or inadequately treated
extension to other deep neck spaces
higher risk and more severe clinical course
females,
existing neck swelling
associated respiratory symptoms
underlying systemic diseases
103

104. or during endotracheal intubation Vascular complications
Airway obstruction
Aspiration
Spontaneously
due to perforation of a retropharyngeal abscess with drainage of pus into the airway
or during endotracheal intubation
Vascular complications
thrombosis of the internal jugular vein,
carotid artery erosion and rupture)
104

105. Complications Mediastinitis from inferior spread along fascial lines
Septic emboli
can lead to pulmonary, brain, or joint seeding and
resultant abscesses.
Septic shock
Necrotizing cervical fasciitis
has particularly high morbidity and mortality rates.
Osteomyelitis
105

106. Outcome and Prognosis
fully recovery expected for timely and properly treated cases
delay results in
prolonged course of recovery and
more complications.
Once fully resolved, no particular predisposition exists for recurrence.
106

107. Future and Controversies
greatest controversy
surgical treatment or
medical treatment
selected cases
no signs of respiratory distress or
other impending complications,
IV antibiotics alone should suffice
surgical therapy
patients whose symptoms do not respond within 48 hours
However, debate continues
clinical judgment must be used with each individual patient.
107

108. Summary
The management of infections within the head and neck region continues to be a challenge.
Mortality has decreased significantly in the postantibiotic era
Knowledge of anatomical boundaries, and overall evaluation of etiology can help clinicians manage head and neck infections by predicting their spread
Proper radiologic evaluation is paramount to properly diagnose the extent of infection and improves surgical treatment planning.
Clinical examination, correct empiric antibiotic selection, and appropriate surgical intervention are the cornerstones of proper management  
Airway management techniques are an important part of the management of infection within the neck. 
108

109. Thanks For Your Attention
109

110. References
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