Fascial Spaces and Spread of Odontogenic Infection

Dr. Sahar Aldisi

Fascia

Fascia : is defined as layers of fibrous connective

tissue underlying the skin and surrounding muscles , bones , vessels , nerves and organs .

Fascia of the head and neck is divided into :1-Superficial Fascia.2-Deep Fascia.

1-Superficial Fascia: attached intimately deep to the skin (elastic).

Function : separation of skin from deeper structures making the skin move independently (elastic).

Contents :- Fat.- Cutaneous vessels . - Cutaneuos nerves. -Lymph nodes. -Platysma muscle (covering the anterior triangle )

(covered by superficial cervical fascia).- The muscles of facial expression.

2-Deep Fascia is divided into :a-Deep fascia of the face and jaws.b-Deep cervical fascia.

2-Deep Fascia of the face and jaws: covering deeper structures such as bones ,muscles ,vessels and nerves. (Inelastic and dense fibrous tissue )

Layers of deep fascia of the face are divided into :1-Temporal fascia : covering the Temporalis muscle and

structures superior to the zygomatic arch.2- Massetric-parotid : covering the Masseter and structures

inferior to the zygomatic arch surrounding the parotid gland. 3-Pterygoid fascia covering the medial surface of medial

pterygoid muscle .(Those 3 layers are continuous with each other and with the

investing layer of deep cervical fascia )

b- deep cervical fasciaLayers of deep cervical fascia of the neck are

divided into1- investing fascia (most external )2-pretracheal fascia3-prevertebral fascia4-carotid sheath 5-buccopharyngeal fascia

1- Investing layer of deep cervical fascia :Surrounding the neck like a collar .It splits around 2 muscles : Sternocleidomastoid and

Trapezius .Anteriorly it is attached inferiorly to the hyoid bone. Superiorly attached to the lower border of mandible

anteriorly Laterally at the mastoid processPosteriorly it is attached to the superior nuchal line

and external occipital protuberance

*Between the angle of the mandible and the tip of mastoid process it splits to enclose the parotid .

The Superficial part blend with the massetric-parotid until it reaches the zygomatic arch and the deep part attaches with the stylomandibular ligament until it reaches the base of the skull .

Inferiorly , the investing layer of deep cervical fascia is

attached to the spine and acromion of the scapula and clavicle with the Trapezius and to the clavicle and the manubrium of sternum with Sternocleidomastoid .

The investing layer is continuous with the deep fascia of the face.

The Investing layer of deep cervical fascia splits around 2 salivary glands : parotid and submandibular salivary glands

And 2 muscles : Sternocleidomastoid and Trapezius.

2- Prevertebral fascia Is firm and tough membrane that covers the

prevertebral muscle extending from the base of the skull until it reaches t4 vertebra .

It covers muscles that form the floor of the posterior triangle of the neck and all the cervical nerve roots .

In front of this fascia is retropharyngeal space.

3-Pretracheal fascia Thin fascia lying deep to the infrahyoid strap muscle (sternothyroid

, sternohyoid and omohyoid ) Its upward attachment is at the body of hyoid bone and oblique

line of thyroid cartilage . It splits to enclose the thyroid cartilage and adheres to it at the

back of the isthmus 2,3,4 the ring of trachea . Laterally it fuses with the front of carotid sheath on the deep

surface of sternocleidomastoid muscle . It also surrounds the pharynx , esophagus , larynx and trachea .

Behind prevertebral fascia is the prevertebral space .

4- Carotid sheath Is situated deep to the investing fascia and

sternocleidomastoid muscle and at the base of the neck –thorax.

Contents (internal carotid artery , common carotid

artery , internal jugular vein and the vagus nerve (X).

Carotid sheath Contains an areolar tissue surrounding the common carotid artery and

internal carotid artery and internal jugular vein and deep cervical lymph nodes.

Thin layer surrounding the internal jugular vein to allow its dilation

during increase blood flow . Attached to the base of the skull at the margins of the carotid canal and

jugular fossa and continued downward blending with the aortic arch .Anteriorly its lower part fuses with the fascia of the deep surface of the

sternocleidomastoid muscle It blends with the pretracheal fascia laterally . Behind the carotid sheath there is thin layer of loose areolar tissue

between it and prevertebral fascia .Cervical sympathetic trunk lies in front of the prevertebral fascia.

5-buccopharyngeal fascia . Lateral to the pharynx continuous with the fascia covering the buccinator and the superior constrictor muscle of the pharynx till the pterygomandibular raphe .

Fascial Spaces

Fascial spaces

are potential spaces found between layers of fascia. Facial spaces contain loose areolar connective

tissue making them potential spaces and not actual spaces, unless infection in those spaces occur leading to displacement of the loose connective tissues .Also , during surgeries these spaces are opened up .

Facial Spaces are divided into (according to their position) :A-Spaces of the face and jaws 1-vestibular spaces2-canine space 3-buccal space 4-parotid space5-masticator space 6-submandibular space 7-sublingual space 8-Submental space 9-palatal space B-spaces of the neck 1-parapharyngeal (lateral pharyngeal ) space 2-retropharyngeal space

Another classification of the facial spaces (according to direct spread of infection )Primary spacesare the spaces that directly adjacent to the origin of odontogenic infection :1-vestibular spaces 2-canine space 3-buccal space 4-submandibular space 5-submental space 6-sublingual space 7-palatal space8-Infratemporal space Secondary spaces Are spaces that become involved following spread of infection to primary spaces .1-masticator tissue spaces 2-pharyngeal spaces 3-prevertebral space

Vestibular Space

1-vestibular space of the maxilla ( the space of upper jaw) Found Medial to the buccinator muscle below the

muscle attachment along alveolar process of the maxilla . Its lateral wall is the oral mucosa .

Communication : with maxillary teeth and periodontium of maxillary teeth .

2-Vestibular space of the mandible between the buccinator

muscle and oral mucosa above the attachment of buccinator muscle to the mandible

Communication :with mandibular teeth and their periodontium .

Canine Space

3 –Canine space (infraorbital space ) Located superior to the upper lip and lateral to the apex of the maxillary canine .Between the skin and muscles of facial expression levator labi superioris and zygomaticus minor

and canine fossa .-Boundaries : anteriorly : orbicularis oris muscle.Posteriorly :levator anguli muscle -Communicates with buccal space and cavernous sinus via venous communications . -Contents Infraorbital nerve Angular artery and vein -Source of infection is the Maxillary canine tooth . Clinical features1-loss of nasolabial fold 2-oedema of the lower eyelid3-swelling of cheek upper lip4-drooping of the corner of the mouth 5-sometimes spontaneous drainage from medial canthus of the eye . -Surgical management Incise high in the maxillary labial vestibule , Haemostat advanced through levator anguli muscle

and place a rubber drain and suture into the lower margin of vestibular incision.

Buccal Space.

Buccal spaceBetween buccopharygeal fascia of buccinator muscle and Masseter muscle. -Boundaries :Superiorly : the zygomatic arch Inferior : the inferior border of the mandible(That’s why both boundaries are palpable in buccal space infection)Medially : buccopharyngeal fascia surrounding the buccinators muscle .Laterally : covered by skin , superficial fascia , partially by the platysma (the inferior part) and the Massetric-Parotid fascia .Posteriorly : anterior border of the Masseter .Anteriorly : orbicularis oris muscle .- Contents :fat pad Parotid duct Anterior facial artery and veinTransverse facial artery and vein - Communication : canine space , pterygomandibular space -Source of infection :maxillary and mandibular premolars and molars -Clinical features Dumb-bell –shaped swelling due to lack of swelling of zygomatic arch and inferior border of the mandible -Surgical management Intraoral incision :horizontal incision above the depth of vestibule (the most prominent bulge of buccal mucosa ) avoiding the

injury to parotid duct .Extraoral incision :cutaneous drainage inferior to point of fluctuation for dependant drainage.

Parotid Space

Parotid Space -Boundaries Laterally : Skin , superficial fascia , Masstric-Parotid fascia. Medially :Investing layer of deep cervical fascia Posteriorly :sternocleidomastoid muscle Anteriorly :posterior border of the ramus -CommunicationLateral pharyngeal , submassetric and pterygomandibular spaces .Contents :Superficial and deep portion of parotid gland .Facial nerve External carotid artery Retromandibular vein Parotid lymph nodes -Clinical features Firm swelling (because pus is enclosed within this thick layer of deep cervical fascia )Evertion of the ear lobule. Oozing of pus from duct .No trismus *Extension of odontogenic infections to this space is difficult since the fascial covering is firmly attached to the gland -Surgical ManagementIntraoral :Through the buccinator muscle and advancing the of Haemostat superiorly .Extraoral : inverted (L) incision 1-2 cm made at that hair line in the retromandibular area from the lower aspect of ear lobule to

the angle of the mandible .Blunt dissection with Haemostat cautiously to avoid facial nerve injury by dissection parallel to the facial nerve

Masticator Space

Masticator Tissue Space :Space enclosed by deep fascia of the face covering muscles of mastication and the ramus of the mandible .

Masticator tissue spaces :1.Submassetric Space2.Pterygomandibular Space 3.Infratemporal Space 4.Temporal space

The 4 spaces of the masticator tissue space ,

communicate with each other and with Submandibular and parapharyngeal space .

Trismus is a common clinical feature found in

the 4 spaces of masticator space infection. Also , pain and swollen tonsillar pillars .

Submassetric Space

1.Submassetric space : between the ramus of the mandible and the Masseter muscle-Boundaries Anteriorly :buccal space ,parotid-massetric fascia Posteriorly :parotid Gland and the investing layer of deep cervical fasciaSuperiorly :zygomatic archInferiorly :Inferior border of the mandible Medially :Ramus of the mandible Laterally : Masseter muscle

-Contents :Massetric artery and vein -Source of infection :Mandibular 3rd molars .

-Clinical features :swelling of the angle of the mandible. Obliteration of the mandibular sulcus posteriorly Trismus and throbbing pain Osteomyelitis due to relation of the massetric muscle which is responsible for blood supply of

ramus of the mandible supplied by the mandibular artery leading to occurrence of ischemia in the bone denuded by the periosteum by abscess leading to osteomyelitis and sequestrum formation .

A common clue for the diagnosis of submassetric space infection is the subperiosteal new bone deposition beneath the periosteum .

Pterygomandibular Space

2.Pterygomandibular Space : between the ramus and the medial pterygoid muscle laterally Anteriorly : Buccal space , Parotid massetric fascia Inferiorly :Inferior border of the mandible .Superiorly : zygomatic arch and the inferior head of lateral pterygoid muscle .Anteriorly : the muscle fibers of buccinators arising from pterygomandibular raphe and below it is the tendon of Temporalis muscle . Posteriorly: Parotid Gland covered by investing layer of deep cervical fascia and parotid gland .Laterally :medial surface of the Ramus of the mandible Medially : lateral surface of medial pterygoid muscle

-Communication :Submandibular and parapharyngeal Spaces. -Contents :Inferior alveolar artery and vein Mandibular division of trigeminal nerve .

-Source of infection:Mandibular 3rd molars (especially with mesiongular or horizontal impaction )Fracture of the angle of the mandible . -Clinical features :Swelling is not obvious extraorally Intraorally :Swelling on the same side of the soft palate , tonsillar pillars, and deviation of the uvula to the other side .Dysphagia Fever Lymphadenitis -Surgical Management Intraoral incision : vertical incision along the external oblique line of the mandible .Blunt dissection and opening of the Haemostat when it reaches lateral aspect of the ramus beneath the Masseter muscle .Extraoral approach : small incision beneath the angle of the mandible on the medial aspect of the ramus and pterygomandibur raphe.In cases of trismus , general anaesthesia is indicated or administration of mandibular nerve block by an extraoral approach .

InfraTemporal Space

Infratemporal : the upper extremity of the pterygomandibular space behind the maxilla . Boundaries :Medially : lateral pterygoid plate .Anteriorly : maxillary tuberosityLaterally :medial surface of the mandible and the Temporalis muscle.Superiorly :Infratemporal surface of the greater wing of sphenoid Inferiorly : Lateral pterygoid musclePosteriorly :mandibular condyle -Contents Internal Maxillary arteryPterygoid Plexus Mandibular nerve

Source of infection : maxillary molars Local infiltration of maxillary nerve Mandibular nerve and its branches Pterygoid plexus (which may cause cavernous sinus infection because the cavernous sinus emissary veins are in contact

with pterygoid plexus) Cavernous sinus infection clinical features (headache , photophobia , irritability , vomiting and drowsiness) -Clinical features :Severe trismus and pain .If the swelling is present over the tuberosity area then extraorally it can be seen over tempro-mandibular joint and

zygomatic arch.

Temporal Space

Temporal space Divided into 2 spaces :Superficial space Deep space Both spaces of temporal space is separated by the Temporalis muscle . Superficial Temporal Space :Boundaries Laterally : Skin ,and Superficail fascia .Medially :lateral surface of the Temporalis muscle Superiorly: Superior Temporal lineInferiorly :zygomatic arch Deep temporal space :Boundaries Laterally : Medial surface of the Temporalis muscle Medially : Temporal bone Superiorly : Greater wing of sphenoid bone -Contents :Temporal fat padTemporal branch of facial nerve -Clinical features :Trismus Dysphagia ,dyspnea, airway compromise , severe pain Dumb-bell shaped swelling due to the inferior boundary of the zygomatic archSwelling is more obvious in the superficial temporal space infection because it's only restrained by fascia laterally .

Masticator Space Surgical Management

Palatal Space

Palatal Space : Infection of this space usually originates from maxillary teeth whose

roots lie close to it e.g. maxillary lateral incisors (causing anterior palatal abscess) and palatal roots of molars (causing posterior palatal abscess ).

This infection perforates the palatal alveolar bone and pus accumulates beneath the palatal mucoperiosteum

Usually localization of infection and fluctuation is hard to achieve due to the thick palatal mucoperiosteum that is firmly attached to the underlying bone

-Surgical management Intraoral incision done along the palatal mucoperiosteum down to the bone

.the incision is made at right angles of to the long axis of the teeth carried out antro-posteriorly carefully avoid injury of the palatal arteries that’s why the incision is done on the alveolar mucosa rather the palatal mucosa .

.

Submandibular Space

Submandibular Space Found between anterior and posterior bellies of digastrics.It is located lateral and posterior to the submental space on each side of the jaw, The cross section is triangular with the mylohyoid muscle superior-medially .Boundaries :Superiorly :mylohyoid muscle Anteriorly Anterior belly of digastric muscle Inferiorly :hyoid bone posteriorly .and Anteriorly skin , superficial fascia ,platysma , the investing layer of deep cervical fascia anteriorly (that’s why abscess

in this region does not normally drains through the skin . Laterally :medial surface of the mandible below the mylohyoid line Medially :mylohyoid , hyoglossus musclePosteriorly: posteriorly belly of digastric -Content : Submandibular lymph nodes Submandibular salivary gland Facial artery and vein and submental branch Nerve to mylohyoid -CommunicationsInfratemporal SpaceSubmental SpaceSublingual spaceParapharyngeal space -Source of infection :Mandibular molarsClinical featuresFirm swelling of the inferior border of the mandible at point where the facial artery crossesObliteration of the angle of the mandibleDysphagia due to restricted mouth openingsExtension of the swelling starts from the lower border of the mandible down till the level of hyoid bone in a shape of an inverted cone Systemic signs of sepsis may be found -Surgical Management Extraoral incision :2 cm below and parallel to the lower border of the mandible through the skin, superficial fascia , platysma and investing layer of deep

cervical fascia.2 cm is left below the inferior border of the mandible to avoid injury to the marginal mandibular branch of facial nerve Blunt dissection is done cautiously to avoid injury to the facial artery anterior to the facial vein and nerve.

Sublingual Space

Sublingual spaceBoundaries

Superiorly :oral mucosa of the floor of the mouth Inferiorly : mylohyoid muscleMedially: the tongue and its intrinsic muscle Laterally :medial surface of the mandible above mylohyoid line Anteriorly :lingual surface of the mandible Posteriorly :Body of the hyoid boneContents : Sublingual salivary gland and ductDuct of the submandibular salivary gland Lingual nerve and artery Deep portion of submandibular salivary gland Communications Submental spaceSubmandibular space Source of infection Mandibular premolar and molars Trauma

Clinical features :No visible features extraorally Painful swelling of the floor of the mouth on the affected side thereby raising the tongue and deflecting it to the opposite side and decreasing its mobilityDysphagia and DyspneaSalivary glands become more prominent Systemic signs of Sepsis

Surgical management Intraoral incision of the base of the alveolar process of the lingual sulcus or 1.5 cm away from the lingual cortical plate taking care not to injure sublingual

gland or lingual nerve Haemostat inserted in an anterior-posterior direction beneath the sublingual gland .

Submental Space

Submental Space Midline space between symphysis and hyoid bone BoundariesAnteriorly :lingual surface of the Mandible Posteriorly :Hyoid bone Inferiorly :skin, superficial cervical fascia , platysma , investing layer of deep cervical fasciaSuperiorly :mylohyoid muscle covered by investing fasciaMedially : midline space Laterally :2 diverging anterior bellies of digastrics -Contents:Submental lymph nodes Anterior jugular vein -CommunicationSubmandibular space Sublingual space -Source of infectionMandibular anterior teeth -Clinical features : Hard midline swelling under the chinDysphagia Signs of sepsis -Surgical management Extraoral incision through skin , superficial cervical fascia , platysma , investing layer of deep cervical fascia at the most

inferior aspect of the swelling for a more dependant drainage .

Pharyngeal Space

Pharyngeal Space Is divided into 1. Peripharyngeal space (around the

pharynx)a.parapharyngeal space(laterally)b.retropharyngeal space (posteriorly) -Both spaces are considered (Danger Spaces )2.intrapharyngeal space (within the pharynx)

Lateral pharyngeal space (parapharyngeal )A cone shaped space with its base is at the base of the skull superiorly and its apex is at the greater horn of the hyoid bone Borders: Anteriorly: Superior and middle constrictor of the pharynx and the pterygomandibular raphe and communicating anteriorly with the pterygomandibular spaceMedially: Superior constrictor of the pharynxLaterally : medial pterygoid muscle and pterygoid fascia and parotid capsule Superiorly :Base of the skull Inferiorly :Hyoid boneAlso it communicate along the carotid sheath with the superior mediastinum .Posteriorly :carotid sheath and prevertebral fascia . -Contents :Carotid artery Internal jugular vein Vagus nerve Cervical sympathetic chain Source of infectionMandibular 3rd molar Tonsillar infections Pharyngitis and parotitis -Clinical features Severe Pain on the affected side of throat Displacement of the tonsil , tonsillar pillars and uvula to the medial side The four cardinal signs of pharyngeal abscess : 1.trismus 2.Induration Swelling of the angle of the jaw leading to ability to palpate the angle of the mandible 3.Fever 4. Pharyngeal bulging DysphagiaInability to palpate angle of the mandible Tension of the sternocleidomastoid muscle due to rotation of the neck away from the side of swelling -Complication :septic jugular vein thrombophlebitis Cavernous sinus thrombosis , meningitis and brain abscess -Surgical Management :Intraoral incision is done in the retromolar triangle lateral and parallel to the pterygomandibular space extending between the ramus and the posterior and medial aspect of the medial pterygoid muscle where blunt dissection is performed Intraoral incision are contraindicated if there has been hemorrhage no matter how minimal it is . Extraoral incision :2cm along the anterior border of sternocleidomastoid muscle Combined approach (intraoral and extraoral)Lateral mucosal incision and curved Haemostat is passed lateral to the superior constrictor muscle and medial to medial pterygoid and the tip of the Haemostat is palpated extraorally (anterior to the sternocleidomastoid ) and a cutaneous incision is

made over the tip .This approach provides direct access into lateral pharyngeal space and aids in placement of a correct extraoral incision in a swollen face .

Retropharyngeal Space(Danger Space )

Retropharyngeal space Midline space lying posterior to the pharynx and anterior to the prevertebral fascia extending upward to the base of the skull inferior to the retrovisceral space (Danger space )BordersAnteriorly :Posterior pharyngeal wall Posteriorly :prevertebral fascia Superiorly : Base of the skull Inferiorly :Mediastinum Medially :common midline spaceLaterally :lateral pharyngeal space -Source of infectionSuppurative adenitis Dental infection diffusing through adjacent spacesNasal or pharyngeal infections -Clinical features :PainFever Stiffness of the neck Drooling and dysphagia Supraglottic edema causing airway obstruction Aspiration pneumonia Acute mediastinitis leading to empyema and pericardial effusion -Surgical management Drainage will not be dependant Intraoral incision : vertical incision lateral to the midline of pharyngeal walls Intraoral is more dependantExtraoral incision :Along the anterior border of Sternocleidomastoid muscle and inferior to the hyoid and the muscle . Carotid sheath and the sternocleidomastoid is retracted labially .Blunt dissection is done between the carotid sheath and the Inferior constrictor .

Prevertebral Fascia

The prevertebral spaceBoundaries Anteriorly :prevertebral fascia Laterally :attachment of the prevertebral fascia to the

transverse processes of the vertebra Posteriorly : anterior longitudinal ligament , the vertebral

bodies and musculature .It extends through the entire length of the vertebral column.

Spread of Odontogenic Infections.

Routes of odontogenic infection: 1-Direct continuity through bone (direct spread) of

infection through bone and soft tissue spaces (above or below) muscles and facial attachments to reach potential surgical spaces and their communications.

2-Haematogenous spread (by vascular system)3-Lymphatic spread4-spread to paranasal sinuses

Infection initially spreads in the spongiosa with jaw bone until it reach and perforates the nearest and thinnest cortical plate , once outside the bone further spread will occur following the path of least resistance such as loose connective tissue .The inflammatory exudates will be guided by layer of dense fascia or muscles and will not penetrate them .

Factors influencing direction and destination of direct spread of infection

1-Position of teeth in the alveolar bone and thickness of related cortical plates of bone.

2-Adjacent Muscles attachment relations3-Attachments of layers of deep fascia where infection

also spreads along but does not penetrate these layers.

4- Proximity of anatomical structures and potential spaces

1.Position of teeth in the alveolar bone and thickness of related cortical plates of bone.

The bone is first locally limiting barrier to further spread of a

periapical infection. The thin cortex surrounding the periapical abscess will be penetrated before the thicker one.

Direct spread within bone is affected by:a-the roots length b-proximity to buccal, lingual or palatal cortical plates c- Thickness of cortical plate in different parts of jawsd-relation to certain anatomical structures such as the floor of the

nose and maxillary sinus.e –anatomic structure F-stage of development

Maxilla

The incisors, canines, buccal roots of the premolar and molars are covered (labially by a thin layer of cortical bone) a thin layer of cancellous bone .Therefore, infection will tend to readily perforate the labial or buccal plates.

Lateral incisors in some orthodontic cases are inclined labially , thereby the roots will

be directed palatally so infection will be palatally related . Palatal roots of first and second molars are related to the palatal cortical plate . Incisors are related to the nasal cavity floorPremolar and molar are related to the floor of the maxillary sinus Canine is in the neutral position between the two cavity .

Mandible :

In incisor , canine area both inner and outer cortical plates are thin and increasing as we go distally in thickness.

Premolar and first molar are closer in relation to the

buccal cortical plate. 2nd and 3rd molars are related to the lingual cortical

plates due to medial shift of the alveolar process in relation to the body of the mandible and external oblique ridge (thick outer cortical plate)

2-Adjacent Muscles attachment relations E.g. . Mylohyoid , buccinators and constrictor muscle

of the pharynx Infection spreads along muscles and does penetrate

them , thereby muscles guide infection along its fibers.

Maxillary anterior region : infection will be directed towards the labial sulcus due to the form of muscle strips with the intervening superficial fascia where infection will track those slits of muscle towards labial sulcus .

Premolar and molar area the attached of the buccinators will

guide the spread of infection. If the apices of roots are below the attachment , infection will spread to the buccal sulcus . While in case of higher position of the root apices in relation to the attachment of buccinators facial cellulitis.

The long root of the canine may direct infection to infraorbital

region causing infraorbital cellulitis .

Mandible

Mandibular anterior region labial sulcus (vestibule ) Skin of the lower border of the

mandible. Premolar and 1st molar root apices lying above buccinators

buccal sulcus . 2nd and 3rd molars If apices are above mylohyoid muscle sublingual Space If apices are below the mylohyoid attachments

Submandibular Space.

3.Attachments of layers of deep fascia where infection also spreads along but does not penetrate these layers.

4. Proximity of anatomical structures and potential spaces

Ludwig’s Angina

First described by Ludwig in 1836 . 

•Infection of 5 spaces; submental, and bilateral submandibular and sublingual spaces .

 •brauny edema of the spaces . •paucity of pus .

 •Edema of neck, floor of mouth & epiglottis. •Dyspnea, loss of airway.

 •Spread to involve masticator, pharyngeal space Dysphonia

–“Hot potato” voice –Odynophagia –Drooling –Tongue swelling –Pain in floor of mouth –Restricted neck movement –Unilateral sore throat

Concern for asphyxiation •If no respiratory difficulties –Maintain in sitting position –Continuous monitoring –Must be prepared to intubate –Airway complications must be anticipated as concurring supraglottic edema, trismus may interfere with

securing the airway•If signs of impending respiratory compromise •Fiberoptic nasal intubation is preferred route –The ability to displace the soft tissues of the pharynx anterior to the line of vision on direct

laryngoscopy depends on the compliance of the submandibular tissue –Ludwig's angina can decrease the compliance of the tissue so severely that the airway structures

cannot be visualized •Ludwig's can distort the anatomy to such a degree that there is soft tissue displacement of the trachea •Antibiotics •Uncertain value of steroids •Reasons for surgery –Unresponsive to medical therapy –Patient in whom suppurative infections develop –Presence of crepitus, fluctuance and soft tissue gas

2-Haematogenous spread (by vascular system) Through general circulation leading to bacteremia ,

septicemia and pyaemia due to infected emboli that may develop into metastatic infection or emboli abscess elsewhere in the body . E.g. Infective Endocarditis

Spread to cavernous sinus caused by thrombophlebitis of the vein due to valve-less facial veins making the infection able to travel against the normal pattern , favored by septic thrombosis .

Infection reaching cavernous sinus may lead to thrombosis or brain abscess

Death is common .

3-Lymphatic spread : through the lymphatic vessels to regional lymph nodes reaching eventually to the general circulation .

Submandibular nodes are the primary nodes for all teeth and associated tissue except 3rd molars (which drains to the superior deep cervical nodes and mandibular incisors to submental nodes then drains to superior deep cervical nodes emptying to inferior deep cervical nodes or directly into the jugular trunk then to the vascular system making the spread accessible to other tissues , structure and organs .

Lymphadenopathy Lymph nodes infection characterized by lymph nodes

hypertrophy and change in consistency making it palpable

4-spread to paranasal sinuses Most commonly infection of the maxillary sinus

(maxillary sinusitis ) resulting from spread of infection from periapical abscess of maxillary premolars and molars perforating the sinus floor to involve sinus mucosa .

Infection of paranasal sinuses may also spread to

other sinuses or the nasal cavity and may also spread further to reach cranial cavity and brain .

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