OUTLINE

• Background • Epidemiology• Etiology• Pathophysiology• Relevant Anatomy

– Fascial planes– Deep neck spaces

• Presentation • Management• Overview

CASE REPORT 1CASE REPORT 1A 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.

• 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

• A clinical impression of Ludwig’s Angina was made.

• Haematological Baseline, blood chemistry, and pus MCS could not be done for financial reasons.

• 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

• 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.

• 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.

• 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.

CASE REPORT 2CASE REPORT 2

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

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

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

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.

•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.

•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

•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.

EpidemiologyEpidemiology• Frequency

– 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.

EtiologyEtiology• odontogenic origin

• 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

EtiologyEtiology

• 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.

PathophysiologyPathophysiology• 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.

PathophysiologyPathophysiology

• 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

PathophysiologyPathophysiology• MICROBIOLOGY

–mixed aerobic and anaerobic organisms, and both gram-positive and gram-negative organisms may be cultured

PathophysiologyPathophysiology• 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 

PathophysiologyPathophysiology

• 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.

Relevant AnatomyRelevant 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.

Fascial planesFascial planes• Two main fascial divisions exist,

–superficial cervical fascia and

–deep cervical fascia.

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.

Fascial planesFascial 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.

Fascial planesFascial 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.

Fascial planesFascial 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

Fascial planesFascial 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.

Spaces involved in odontogenic Spaces involved in odontogenic infectionsinfections

• Primary maxillary spaces.Primary maxillary spaces.– Canine

– Buccal

– Infratemporal

Spaces involved in odontogenic Spaces involved in odontogenic infectionsinfections• Primary mandibular spacesPrimary mandibular spaces.

– Submental

– Buccal

– Submandibular

– Sublingual

Spaces involved in odontogenic Spaces involved in odontogenic infectionsinfections• Secondary fascial spacesSecondary fascial spaces

– Masseteric

– Pterygomandibular

– Superficial and deep temporal

– Lateral pharyngeal

– Retropharyngeal

– Prevertebral

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

Potential Complications of Spread of Oral Infections

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

Parapharyngeal spaceParapharyngeal 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

Parapharyngeal SpaceParapharyngeal Space

Parapharyngeal space• connects with

– 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

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

Retropharyngeal spaceRetropharyngeal 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

Retropharyngeal abscessRetropharyngeal abscess

Lateral radiograph of the neck

Danger spaceDanger 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.

Danger SpaceDanger Space

Masticator spaceMasticator 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.

MasticatorMasticator Space with Subspaces Space with Subspaces

Submandibular spaceSubmandibular 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.

Submandibular spaceSubmandibular 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.

Anatomic relationships in submandibular infections

Ludwig angina 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

Ludwig’s AnginaLudwig’s Angina

Ludwig angina 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.

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

EXAMINATIONEXAMINATION• 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,

EXAMINATIONEXAMINATION

• 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

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, • suggestive of

– septic embolization– internal jugular vein thrombophlebitis

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

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

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

Diagnosis and Workup Imaging Studies

Irregularity of the abscess wall on CT is predictive of pus within the cavity

Diagnosis and Workup Diagnosis and Workup Imaging StudiesImaging 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.

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)

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

Principles in Treatment of Facial Space Infections Principles in Treatment of Facial Space Infections

1. Secure the airway

2. Institute antibiotic therapy

3. Remove causative agent

4. Establish drainage.

5. Supportive care, including nutrition and proper rest .

Treatment Treatment

• Airway– first priority of treatment– may involve

• observation, • Intubation

– endotracheal or – nasotracheal , 

• tracheostomy, or • cricothyroidotomy for emergent situations.

TreatmentTreatment

• intubation

– may be extremely difficult even in experienced hands

• potential for abscess rupture, leading to

–aspiration,

–acute airway obstruction, or

–death.

TreatmentTreatment

• 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

Treatment Treatment Medical TherapyMedical Therapy

• Cultures of– abscess fluid– blood

to help direct antimicrobial therapy

• Volume and metabolic resuscitation– Identify and address metabolic derangements – other concurrent medical problems

Treatment Treatment Medical TherapyMedical 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

Treatment Treatment Surgical TherapySurgical Therapy

• Incision and drainage– is mainstay of treatment – for

• any frank abscess with impending complications • absence of improvement after 48-72 hours of IV

antibiotics– commonest approach employed is

• transcervical – approach must ensure

• adequate exposure and access • drainage without compromising surrounding

structures.

BackgroundBackground• Diagnosis and treatment 

– 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.

BackgroundBackground

• 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.

ProblemProblemFactors 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.

ProblemProblem– 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

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

Management – Diagnosis and Workup Imaging Studies

• Clinical examination alone

• CT scan with contrast

• CT findings combined with clinical exam findings

TreatmentTreatment– 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

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

Treatment 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

Treatment 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

ContraindicationsContraindications

• No absolute contraindications

• However,

– establishing a safe airway takes priority and

– should be addressed before initiating surgical drainage procedures.

Referral or not ?Referral or not ?

Follow-upFollow-up• complete resolution

–reaccumulation of abscess

–redevelopment of infection

• surgical site healing

ComplicationsComplications• 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

ComplicationsComplications• 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)

ComplicationsComplications• 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

Outcome and PrognosisOutcome 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.

Future and ControversiesFuture 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.

SummarySummary• 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. 

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