Space Infection

Dr. Amit T. Suryawanshi

Oral and Maxillofacial Surgeon
Pune, India

Contact details :
Email ID -
amitsuryawanshi999@gmail
.com
Mobile No - 9405622455
 Content
• Introduction s
• History
• Anatomy of fascia
• Host defense and infection
• Microbiology and antibiotic therapy
• Stages of infection
• Definition of fascial spaces
• Classification of fascial spaces
• Anatomy of fascial spaces
• Diagnosis of Space infection
• Complications
• Controversies
• Recent advances
• Conclusion
• Reference
 Introduction
Space infections of head and neck are very common
in Oral and maxillofacial practice. Although most of
the infections can be managed successfully with
minimal or no complication, some can produce
serious morbidity or even death. Depending on the
virulence of microorganisms and host resistance,
bacterial infections have the potential to spread
beyond the bony confines of jaw bones into
surrounding sof tissues.
They flow following the path of least resistance ,
into loose areolar connective tissue of fascia
surrounding the muscles. This tissue is destroyed by
hyaluronidases and collagenases produced by
bacteria, thus opening the potential SPACES
surrounding the muscles. Thus such innocuous
periapical infections have a potential to develop
into life-threatening deep fascial infections.
 Early extraction of offending tooth and incision
and drainage tend to shorten the usual course of
infection and minimize the chances of further
complications.

In new era of antibiotics, incidence of death

due to infection is reduced but due to developing
drug resistance, there is outbreak of new range of
infections requiring invention of newer antibiotics.
 For accomplishment of proper management,
maxillofacial surgeon must understand
physiologic and anatomic factors that influence
the spread and localization of dental infections.
 History
Burns (1811) first described fascial space as an
anatomical entity and gave their clinical significance.

In 1836 Wilhelm Frederick von Ludwig described his

observations concerning repeated occurrences of
inflammation of throat. Hence most severe orofacial
Infection at that time was named as Ludwigs angina.

Greek author Parker(1879) gave vivid descriptions of

infections which produced inflammation oral cavity,
tonsil and larynx.
The term “ Quinsy “ was given by Muckleston in
1928.

In 1929 Mosher called Viscerovascular space as

“Lincoln highway”

Space of the body of mandible is described

by Coller & Iglesias. (1935)
Anatomy of fascia
 Functions of the fascia
• Acts as a musculovenous pump-
• Limits outward expansion of muscles as they
contract.
• Contraction of muscles compresses the
intramuscular veins (push the blood towards the
heart).
• Determine the direction of spread of
infection
 Infections and Host defense
• In establishing presence of an infection, interaction
occurs among three factors.

1. Host
2. Environment
3. Microorganism

In state of Homeostasis , balance exists among

these three and disease occurs when imbalance
exists.
Host vs Microbe relationship
Infection occurs when
host is immunocompromised
or when pathogenesity
and number of microbes
Invading host is more.
 Stages of infection
Infections generally pass through these 4 stages before they
undergo complete resolution.

• Stage I – Inoculation
Time between exposure of microorganism and the first set of
symptoms . During 1-3 days, Swelling is sof, mildly tender,
doughy in consistency

• Stage II – cellulitis
Chronic stage-fistulous/sinus tract or osteomyelitis
During 3-7 days, centre of lesion begins to sofen
Stage III –Afer day 5 underlying abcess undermines
skin or mucosa making it compressible.

Stage IV - Finally there is resolution of abcess that

may be spontaneous or afer surgical drainage. During
resolution phase, the involved region is firm on
palpation due to process of removing tissue
and bacterial debris.
 Differences between cellulitis and abscess
Characteristics Cellulitis Abscess

Duration. Acute phase Chronic phase

Pain Severe and generalised Localised

Size Large. Small

Localization Diffuse borders Well-demarcated

Palpation Doughy / indurated Fluctuant

Presence of pus No Yes

Degree of seriousness Greater Less

Bacteria. Aerobic Anaerobic/mixed

 Microbiology –Space infection
Aerobic bacteria (25%)
Gram positive cocci (85%)–
Streptococcus species( 90% ) -
• S.Milleri
• S.sanguis
• S.Salivarius
• S.Mutans
Staphylococcus species (6 %)

Anaerobic bacteria (75%)

Gram positive cocci (30%)–
Peptococcus species
33%
Pepto Streptococcus species 33%
Gram pasitive bacilli (50%) –
Prevotella species,
Porphyromonas species
Ref(75%)
– Micro-organisms and Odontogenic infections 2009
Fusobacterium -20%
Staphylococcus causes –osteomyelitis and abscess
Streptococcus causes- cellulitis

• In an abscess, common causative organisms are

anaerobic (Higher percentage) & Aerobic.

• Fusobacterium + strep. Milleri – cause

aggressive
infections. Eg.,.mediastinum.infections.
 Fascial spaces
Definition -
The fascial spaces in head and neck are the
potential spaces between the various layers of
fascia normally filled with loose connective
Tissue and bounded by anatomical barriers,
usually
of bone, muscle or fascial layers.

(Ref – Moore-
1975)
 CLASSIFICATION OF FASCIAL SPACES
GRODINSKY AND HOLYOKE (1938)

Space 1 – Superficial to superficial fascia

Space 2 – Group of spaces surrounding cervical strap muscles
lying superficial to sternothyroid-thyrohyoid division
of middle layer of deep cervical fascia.
Space 3 – Space lying superficial to visceral division of middle
layer of deep cervical fascia
Space 3A – Carotid sheath space or viscerovascular space
(Lincoln’s High way)
Space 4 – Space lies between alar & prevertebral division of
posterior layer of deep cervical fascia (Danger space)
Space 4A – Posterior triangle space posterior to carotid sheath
Space 5 - Prevertebral space
Space 5A- Space enclosed by Prevertibral fascia.
• Hollinshead’s classification(1958)
Infrahyoid spaces -
1.Visceral compartment
A) Pretracheal / previsceral
B) Retrovisceral
2. Visceral space
3. Other space
I. Cavity within carotid sheath
II. Space between 2 layers of prevertebral fascia
BASED ON MODE OF INVOLVEMENT
1. Direct Involvement. (Primary Spaces)
» Maxillary Spaces – Canine, buccal infratemporal
» Mandibular Spaces – Submental,
Submandibular, Sublingual, Buccal
2. Indirect involvement (Secondary
Spaces)
» Masseteric
» Pterygomandibular
» Superficial and deep temporal
» Lateral and retro pharyngeal
» Prevertebral, parotid, carotid
sheath,peritonsillar and danger spaces.
Surgical anatomy of deep facial
spaces of head and neck
 Buccal space
The buccal space occupies the portion of subcutaneous space
between the fascial skin and buccinator muscle.

BOUNDARIES:-

• ANTERIORLY - Corner of mouth

• POSTERIORLY-
Masseter muscle, Pterygomandibular space
• SUPERFICIAL- skin and Subcutaneous
tissue

• DEEP- Buccinator muscle

• SUPERIORILY - Maxilla, Infraorbital space

• INFERIORLY - Lower border of

 Cause
Infection from maxillary premolars, molars
and mandibular premolars

Relation of root with buccinator muscle

 Buccal space

Clinical features:
Dome shaped swelling on the
anterior aspect of cheek extending
anteroposteriorly from corner of
mouth to angle of mandible and
superoinferiorly from level of
zygomatic arch to inferior border of
mandible.
• CONTENTS OF BUCCAL SPACE:-
• Buccal pad of fat
• Stensons (Parotid duct)
• Anterior and transverse facial artery and vein.

MUSCLE RELATED – Buccinator muscle

Neighboring spaces-
Infraorbital, pterygomandibular,
infratemporal space
TREATMENT:- (I & D)
• Antibiotic prophylaxis.
• Intra oral horizontal vestibular
incision.
• Extra oral (2 stab) incisions
below the lower border of the
mandible with No. 11 blade.
• Drainage – Hemostat is passed
from anterior incision and
taken out from the posterior
incision then the rubber drain
is inserted and secured with
pins and dressing is done.
 Canine space / Infraorbital space
Boundaries –

Anteriorly – Nasal cartilage

Posteriorly- Buccal space
Superficially – Quadratus labi superioris
Deep- Lavator anguli oris, anterior
surface of maxilla
Medially –
Levator labi superioris alaque
n
asi
Laterally –
Zygomaticus major, Superiorly –
Quadratus labi superioris Inferiorly -
ETIOLOGY -

• Maxillary canine, rarely from maxillary first

premolar.
• Rarely from nasal & upper lip infections.
 Canine space / Infraorbital space
• Clinical features:

• Swelling lateral to the nose

over cheek.
• Obliteration of the
nasolabial fold,
• Swelling of the
upper lip,
• Oedema occurs in lower
eyelid leading to closure of
eye.
• Contents – Angular artery and vein,
Infraorbital nerve

• Neighboring spaces – Buccal space

 TREATMENT:-

• Antibiotic prophylaxis
• Incision is made intraorally high in the
maxillary labial vestibule.
• Small hemostat is inserted through levator
anguli oris into abcess cavity.
• Drainage with drain secured.
 Submandibular space
BOUNDARIES:-
ANTERIORLY – Anterior bellly of digastric
muscle
POSTERIORLY – Posterior bellly of digastric
muscle, stylohyoid, stylopharyngeous
muscle.
LATERALL -skin, superficial fascia,
Y platysma

SUPERFICIAL- Platysma, Investing fascia

DEEP- Myelohyoid, Hyoglossus,
superior
constrictor
INFERIORILY -Anterior & posterior
bellies of the diagastric
SUPERIORIL -Inferiormedial aspect
Y of
muscle mandible & mylohyoid
Cause -
• Infection from Mandibular molars.
• From sublingual space
• Infections from middle third of the tongue,
posterior part of floor of the mouth.
• From submental space / submental lymph
nodes
• Infection from the submandibular gland
Clinical Evaluation:
Swelling begins at lower
border of mandible
extends to the level of
hyoid bone in a shape of
inverted cone.
No trismus.
Contents -
• Superficial lobe of submandibular salivary gland
& submandibular lymph nodes, facial artery &
vein

Neighboring spaces –
Submental, sublingual, lateral pharyngeal, buccal
and submandibular space of other side.
TREATMENT

• I & D through Extra-oral

incision.
• Incision – 2 stab incisions
are given over the
dependent part below the
lower border of mandible
in the neck (shadow) of the
mandible
• Curved hemostat is
inserted & Blunt dissection
through subcutaneous fat
not to damage facial A,
anterior facial vein and the
facial nerve
• Drainage – Drain is placed
& dressing is given
 Sublingual space
• BOUNDARIES:-

• ANTERIORLY - Lingual
surface of mandible
• POSTERIORLY -
Submandibular
space
• INFERRIORLY - Mylohyoid
muscle
• SUPERIORIL -oral mucosa
• MEDIALLY- - geniohyoid,
genioglossus & styloglossus
• LATERALLY - lingual aspect of
mandible
 CAUSE
• Mandibular premolars and molars, trauma
 Sublingual space
Clinical evaluation:
•Swelling in anterior part of
floor of the mouth on the
affected side displacing
tongue medially and
superiorly.

•Interferes with swallowing

and is extremely painful.

•Elevation of tongue to
palate
causes airway compromise.
• CONTENTS:-

• Sublingual artery and vein

• Lingual nerve.
• Deep part of submandibular salivary gland and its duct
anteriorily.
• Sublingual salivary gland

Neighboring spaces –

Submandibular, Lateral pharyngeal, visceral(trachea,

esophagus)
TREATMENT:-

• Antibiotic prophylaxis

• Incision is made Intraorally over lingual sulcus at the base

of the alveolar process.

• Haemostat is passed beneath sublingual gland in an

antero posterior dissection and drain is placed.

• When infection crosses midline, same incision is made

bilaterally, hemostat is passed through floor of mouth
from one side to other & drain is placed
Submental space
BOUNDARIES:-
ANTERIORLY – Inferior border of
mandible
POSTERIORLY – Hyoid bone
• LATERALLY – Anterior bellies of the
digastric m.
• SUPERIORILY – Mylohyoid muscle
• INFERIORILY – skin, investing fascia
• SUPERFICIAL – Investing fascia
• DEEP – Anterior bellies of digastric
ETIOLOGY:-
• From lower anteriors.
• Secondarily due to infection from submental
lymph nodes which drain lower lip, skin
overlying chin, anterior part of floor of the
mouth, tip of the tongue & sublingual tissues.
• Symphysis fracture.
 Submental space
Clinical evaluation:

Swelling is limited to the

point of the chin & to the
region immediately below
it
• MUSCLE RELATED – mentalis muscle

• CONTENTS – submental lymph nodes and anterior

jugular vein.
• TREATMENT:-

Extraoral Incisions are made bilaterally (two

stab incisions) through skin, subcutaneous
tissue and platysma muscle at most inferior
aspect of swelling.

Drain & dressings are placed.

Ludwig’s Angina
 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.

4. Produces gangrene with serosanguinous, putrid infiltration

but very little or no frank pus.
 Ludwig’s Angina
Ludwig’s angina is acute, aggressive
and rapidly spreading cellulitis of
the submandibular and
sublingual spaces bilaterally and
of the
submental space.

Clinical evaluation:
Bilateral swelling below chin
extending inferiorly at the level of
hyoid bone.
Fever, chills.
- Airway compromise occurquickly
and with little fore warning.
- Drooling, dysphagia and neck stiffness
are common.
- Anteriorly protruding tongue is present
- Trismus is usually absent.
 Principles of Management of Ludwig’s
Angina
• Hospitalization.
• Securing the airway.
• Antibiotics & hydration.
• External surgical exploration with bilateral
through and through
drainage of the submandibular spaces with
simultaneous exploration of the submental and
sublingual spaces.
• Medical supportive therapy
• Review and re-evaluation in the post op period
 Incision for surgical drainage of Ludwig’s Angina

Classic method – Not used nowadays Bilateral through and though drainage
of spaces
- Ref – Laskin Vol. 2 pg no. 249
 Masticatory space
There are 5 masticatory spaces .
1. Superficial temporal space
2. Infratemporal space
3. Deep temporal space
4. Submassetric space
5. Pterygomandibular space
 Superficial temporal space

Boundaries –
• Superiorly & Laterally  Temporal fascia
• Inferiorly – Zygomatic arch
• Medially Lateral surface Temporalis muscle
 cause
• Infection from maxillary and mandibular
molars.
Superficial temporal space
Clinical evaluation:

•swelling above & below

the zygomatic arch
causing a dumbell shaped
appearance

• Severe pain & trismus

• Contents- Temporal fat pad, temporal branch
of the facial nerve.

• Neighboring spaces – Buccal , Deep

temporal.
 TREATMENT:-
Intraorally vertical incision made medial to the upper
extent of the anterior border of the mandibular ramus.

• Haemostat  passed superiorily along the lateral aspect

of the coronoid process to enter superficial temp. space

• Intra oral approach  good

• Extra-oral incision  horizontal incision

• Haemostat is passed medially to enter

superficial temporal space.

• Drainage  drain is placed, dressing is given.

 Deep Temporal space

Boundaries -
• Laterally  medial surface of temporalis m.
• Medially  Temporal bone
• Below the level of zygomatic arch both the
spaces communicate with each other and with
the infratemporal space.
 Cause
• Infection from maxillary molars
Clinical features
Mild swelling over temporal
Region.

Difficult to diagnose.
• Contents – Pterygoid plexus, Internal maxillary
artery and vein.

• Neighboring Spaces – Buccal,

superficial
temporal, inferior petrosal sinus
 TREATMENT:-
• Intraorally vertical incision made medial to the
upper extent of the anterior border of the
mandibular ramus.

• Haemostat  passed supero-medially to

enter
deep temporal space.

• Through blunt dissection deep temporal space

is
approached through temporalis muscle
 Infratemporal space
Boundaries –

• Anteriorly, -Infratemporal surface of the maxilla

• Posteriorly,- the articular tubercle of the temporal
bone, mandibular condyle
• Superiorly, - Greater wing of the sphenoid below
the infratemporal crest
• Inferiorly, - Medial pterygoid muscle
• Medially - lateral pterygoid plate
• Laterally, - Ramus of mandible
 Cause
• Infection from maxillary molars
 Infratemporal space

• Clinical features :
• Marked Trismus
• swelling of face in front of ear, over TMJ & zygomatic
arch
• Eye is closed and proptosed
• Contents – Pterygoid plexus, Internal maxillary
artery and vein.

• Neighboring Spaces – Buccal,

superficial
temporal, inferior petrosal sinus
 TREATMENT:-
• Intraoral and extraoral approach
• Intraorally, incision is made into buccolabial fold
lateral to maxillary third molar. (Kruger)
• Curved hemostat is inserted behind max.
tuberosity superomedially within the cavity
and drain is inserted.
• Intraorally vertical incision made medial to the
upper extent of the anterior border of the
mandibular ramus.(Laskin)
• Curved hemostat is passed superiorly into
infratemporal region and drain is inserted.
• Extraoral approach in presence of severe
trismus.
It consists of horizontal incision above the
zygomatic arch and then curved hemostat is
directed in inferior and medial direction to
enter infratemporal space followed by
insertion of drain.
 SUBMASSETERIC SPACE
• BOUNDARIES:
Anteriorily Buccal space
Posteriorily  parotid fascia and retromandibular portion of the
parotid gland
Laterally  masseter muscle
Medially  lateral surface of the mandibular ramus
Superiorily  zygomatic arch Inferiorly –
Inferior border of mandible
 ETIOLOGY:-
•
– Periocoronal infection, periapical infection with
mandibular third molars (linguoversion with root
buccally placed)
- Fracture of angle of mandible
 CLINICAL FEATURES:-
– Swelling over the angle of mandile from
the level of the zygomatic arch to
inferior border of mandible , anteriorily
to anterior border of masseter and
posteriorly to posterior border of
mandible.
– Deep seated severe throbbing pain
– Trismus
– Tenderness over the mandibular
ramus,.
CONTENTS -
• Masseteric artery and vein

Neighboring spaces-
• Buccal, pterygomandibular, superficial
temporal, parotid space
 TREATMENT:-
• Incision  Intra oral approach - vertical incision along the
external oblique line of the mandible starting at the level of the
occlusal plane and extending downward and forward in buccal
sulcus opposite 2nd molar.

Haemostat is passed along lateral aspect of ramus beneath

masseter muscle to enter submasseteric space. drainage is
done.

• Incision  Extra oral incision - beneath angle of mandible.

• Blunt dissection through masseter muscle fibres.
– Drainage with plastic or rubber catheter to withstand muscle
contraction.
Pterygomandibular space
• BOUNDARIES:

– Anterior  Buccal space

– Posterior  deep portion of
parotid gland
– Laterally  medial surface of
ramus of mandible
– Medially  Lateral aspect of
the medial pterygoid m.
– Superiorly  lateral
pterygoid
muscle
– Inferiorly – Inferior border of
 ETIOLOGY-

Infection from impacted mandibular molars

, from contaminated needle during I.A.N.B
CLINICAL FEATURES:
– Trismus, Dysphagia, Dyspnoea
– No external evidence of swelling
– Anterior bulging of half the sof palate and the anterior
tonsillar pillar with deviation of uvula to the unaffected side.
– If Peritonsillar abscess (Less trismus, no dental involvement)
• CONTENTS:
– Mandibular division of trigeminal nerve
– Inferior alveolar artery and vein

• Neighboring spaces -
– Deep temporal spaces
– Lateral pharyngeal space
– Buccal space
– Submasseteric space
– Parotid space
 TREATMENT: I & D
• If trismus is severe.
-Extraoral mandibular nerve block or G.A. is given

• Incision  intra oral incision in the mucosal area between

medial aspect of ramus and the pterygomandibular
raphae.

• Blunt dissection using hemostat.

• Drainage.

• Extra oral incision is made below the angle of

mandible.
 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.
• BOUNDARIES:-

– Superiorly  Base of skull

– Inferiorly  Hyoid bone
– Medially  superior pharyngeal
constrictor
– Laterally  medial pterygoid
m.,
capsule of parotid gland
– Posteriorly  carotid sheath
,styohyoid, styloglossus, &
stylopharyngeus.

This is a cone – shaped

• ETIOLOGY:-
Spread from
– Sublingual spaces
– Submandibular spaces
– Pterygomandibular spaces
– Lateral spread from tonsillar abscess, pharyngitis,
parotitis, otitis, mastoiditis
– Abcess from the region of 38,48
– Surgical displacement of roots of 38,48 into this
space
•
• CONTENTS:
– Anterior compartment:
• Ascending pharyngeal A.
• Loose areolar connective tissue.
– Posterior compartments:-
• Cervical sympathetic trunk
• Carotid sheath with its contents

Neighboring spaces -
Pterygomandibular, submandibular, sublingual,
peritonsillar, retropharyngeal space.
Lateral pharyngeal space infection

Clinical evaluation
• Firm swelling with
surrounding erythema lateral
and anterior to
sternocleidomastoid muscle.
• Difficulty in flexing and
turning of neck.
• Trismus secondary
pterygoid
muscle involvement.
• Dysphagia.
 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.
 Complications
• Suppurative jugular venous thrombosis.
• Patient will have shaking chills, high fever.
• Tenderness at the mandibular angle and along
sternocleidomastoid muscle.
 Peritonsillar space infection

Clinical evaluation:
• pharyngitis .
• Severe sore throat, dysphagia,
and referred otalgia.
• The speech is muffled and
classically described as
hot potato voice.
• Trismus is not present
• According to recent
literature,needle aspiration is
done instead of incision and
drainage .
• (JOMS,Vol 51,2009)
 Parotid space infection
BOUNDARIES:-
• superiorly zygomatic arch
• Inferiorly lower border of mandible
• Anteriorly  posterior border of the mandible
• Posteriorly  Retromandibular region

– Space formed by splitting of the superficial layer surrounding the

parotid gland and lies posterior to the masticator space.

• CONTENTS:
– Parotid gland
– Parotid lymph nodes
– Facial n.
– Retromandibular vein
– External carotid artery
• ETIOLOGY:
– From extension of infection from submasseteric,
pterygomandibular, lateral pharyngeal spaces,
– Blood-borne infection, retrograde infections through the
stensons duct.
Parotid space infection
.

Clinical evaluation:

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 afer
massage from the parotid depth.
Very characteristic pitting edema of the gland is
pathognomic for parotid gland abscess.
Drainage of parotid space infection
 Deep neck infections
• All involve only posterior side of neck.
a)Retropharyngeal space
b)Danger space
c) Prevertebral space
d)Visceral vascular
space (within the
carotid
sheath)
 Retropharyngeal space
Retropharyngeal space is the potential space
sandwiched
between alar and prevertebral layers of deep layer of
the
deep investing fascia.
Mediastinum
Extension Base of the skull

Most dangerous of all types of deep

neck infections (Danger space)

Two compartments: Sagittal section of retropharyngeal space

Suprahyoid
Infrahyoid
1. Lymph nodes and fat. 1. Only fat
 Clinical Evaluation
• Children less than 4 yrs commonly affected.
• Sore throat, dysphagia,
• Hot potato voice.

Clinical features Late Clinical features -

•Refusal to take food.
•Cervical lymphadenopathy.
•Slight neck rigidity.
•Noisy breathing due to
laryngeal edema.
•Neck tilts towards involved
side.
•Hyperextended complete
inability to flex the neck.
•Respiratory embarrassment
may occur if abscess is not
ruptured or drained.
 Diagnosis of the sof tissue radiograph for
retropharyngeal space infection

Step I:
• Look at the prevertebral or
retropharyngeal sof
tissue shadow.
• In the area of 2nd and 3rd CV,
shadow should be less than 7mm
in width.
• In the area of 6 cervical vertebra
sof tissue shadow is behind the
trachea and includes the thickness
of esophagus making it approx.
Children – 14mm wide
adults – 22mm wide
Step III.
- Finally, the lateral radiograph will show the curve of the cervical spine
- Loss of the 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
 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.
Diagnostic Imaging for Space infections

Plain film. MRI

 Plain Film
AP view
• Diagnostic imaging starts with a plain film study
of pharyngeal or cervical airways.
• Views taken
– 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
- 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.
MRI
 Complications of space infection

• Osteomyelitis
• Mediastenitis
• Brain abcess
• Meningitis
• Cavernous sinus thrombosis
• Scar formation
• Sinus tract formation
 Who should be hospitalized
???
Signs & symptoms of CNS symptoms
toxicity
• Dyspnoea
•
• level of consciousness
Dysphagia
• Paleness • Evidence of meningeal
• Tachypnoea irritation
• Tachycardia (severe headache)
• Fever • Eyelid edema & abnormal
• Lethargy eye signs
 Controversies
• Does the Investing Layer of the Deep Cervical Fascia
Exist?
- Nash, Lance M.Sc November 2005
Journal of American society of anesthesiologists

The placement of the superficial cervical plexus block

has been the subject of controversy. Although the
investing cervical fascia has been considered as an
impenetrable barrier, clinically, authors went on a trial and
found that the placement of the block deep or superficial to
the fascia provides the same effective anaesthesia.
 Controversies
• Conclusion of study:
This study provides anatomical evidence to
indicate that the so-called investing cervical fascia
does not exist in the anterior triangle of the neck.
Here the author’s findings strongly suggest that
deep potential spaces in the neck are directly
continuous with the subcutaneous tissue.
 Controversies
• Surgical vs ultrasound-guided drainage of deep neck space
abscesses: a randomized controlled trial: surgical vs
ultrasound drainage
-Vincent L Biron, George Kurien
Journal of Otolaryngology - Head and Neck Surgery 2013,

• Introduction -
Deep neck space abscesses are relatively common head and
neck surgery emergencies and can result in significant
morbidity . Traditionally, surgical incision and drainage (I&D)
with antibiotics has been the mainstay of treatment. Some
reports have suggested that ultrasound-guided drainage
is a less invasive and effective alternative in selected cases.
Results
• Seventeen patients were recruited .They found a
significant difference in mean Length of hospital
stay between patients who underwent USD
(3 days) vs I&D (5 days).They identified
significant
cost savings (41%) in comparison to I&D.

• Conclusions
Ultrasound drainage of deep neck space
abscesses in a certain cases is effective, cost
saving & safe as it is less invasive. Still this
remains a controversial topic whether to follow
Incision and drainage or ultrasound drainage.
 Recent advances
Effective antibiotics for severe infections caused
by resistant bacteria are needed urgently. The
speed with which bacteria develop resistance to
antibiotics, in contrast with the slow development
of new drugs, has led some experts to develop
newer antibiotics.
 FDA approved newer antibiotics
Compound name Targeted Microorganisms
(Brand name )
Quinupristin/ dalfopristin (1999) methicillin-susceptible S. aureus and
(Synercid) Streptococcus pyogenes

Moxifloxacin (1999 ) G+ and G-, including multi-drug resistant

(Avelox) Streptococcus pneumoniae

Linezolid (2000) G+; including MRSA

(Zyvox)

Cefditoren pivoxil (2001) methicillin-susceptible S. aureus and

(Spectracef) Streptococcus pyogenes

Daptomycin (2003 ) G+, including MRSA

(Cubicin)

Tigecycline (2005 ) G+ and G-

( Tigacil)

Dalbavancin (2004 ) G+ (including VRE and

MRSA)
Compound name Targeted Microorganisms
(Brand name )
Faropenem (2005) G+ and G-
(medoxomil )

Telavancin (2007) G+ (including MRSA)

Cefobiprole (2007) G+ and G-

Oritavancin (2011) G+ (including MRSA)

Iclaprim (2012) G+ (including MRSA)

 Conclusion
We being Oral & maxillofacial surgeons must
understand anatomy of fascial spaces, spread of
infection and proper management for the
prevention of further complications and betterment
of health of the patient.
 References.
Books -
• Oral &maxillofacial Infections-Topazian
• Oral & Maxillofacial Surgery-Laskin Vol. II

Articles –
1. Does the Investing Layer of the Deep Cervical Fascia Exist?
- Nash, Lance M.Sc November 2005 Journal of American society
of anesthetist

2. Surgical vs ultrasound-guided drainage of deep neck space

abscesses: a randomized controlled trial: surgical vs ultrasound
drainage
-Vincent L Biron, George Kurien Journal of Otolaryngology - Head and Neck
Surgery 2013,
 References
.
Head and Neck space infections (Dissertation )
University of sydney.

Websites -
http://www.upd8.org.uk
Thank
you