MANDIBULAR SPACE MANDIBULAR SPACE INFECTION AND ITS INFECTION AND ITS

MANAGEMENTMANAGEMENT

SURABHI DESAISURABHI DESAI

FACIAL SPACEFACIAL SPACE

Facial spaces in head and neck are Facial spaces in head and neck are the potential spaces between the the potential spaces between the various layers of fascia normally various layers of fascia normally filled with loose connective tissue filled with loose connective tissue and bounded by anatomical barrier and bounded by anatomical barrier usually of bone,muscle or facial usually of bone,muscle or facial layer.layer.

Potential spaces between the layers Potential spaces between the layers of fasciaof fascia

In an infection, interaction occurs among the factors.

1.Host2.Microorganism

MICROBIOLOGY OF MICROBIOLOGY OF ODONTOGENIC INFECTIONS ODONTOGENIC INFECTIONS

Usually caused by endogenous bacteria.Usually caused by endogenous bacteria. Most odontogenic infections due to mixed flora.Most odontogenic infections due to mixed flora. StreptococcusStreptococcus species(alpha hemolytic) are species(alpha hemolytic) are

usually the etiologic organisms if aerobic bacteria usually the etiologic organisms if aerobic bacteria present.present.

Anaerobes- prevotella, bacteroids, fusobacterium Anaerobes- prevotella, bacteroids, fusobacterium also involved.also involved.

PATIENT EVALUATIONPATIENT EVALUATION History of present illness?History of present illness? Evaluation of host defense(medical Evaluation of host defense(medical

history)?history)? History of toothache?History of toothache? History of chills?History of chills? Recurrent infection?Recurrent infection? Previous trauma?Previous trauma? History of recent increase in extent of History of recent increase in extent of

swelling airway difficulty?swelling airway difficulty?

RADIOGRAPHIC RADIOGRAPHIC EXAMINATIONEXAMINATION

Conventioal radiographyConventioal radiography OPG,IOPA,LATERAL OBLIQUE OPG,IOPA,LATERAL OBLIQUE

VIEW OF MANDIBLE,AP LATERAL VIEW OF MANDIBLE,AP LATERAL VIEW OF NECKVIEW OF NECK

OtherOther CTSCAN,MRI,XERORADIOGRAPHYCTSCAN,MRI,XERORADIOGRAPHY

ETIOLOGYETIOLOGY

ODONTOGENIC:ODONTOGENIC: Pulp diseasePulp disease Periodontal diseasePeriodontal disease Secondarily infected cyst odontomesSecondarily infected cyst odontomes Remaining root fragmentRemaining root fragment Pericoronal infectionPericoronal infection

PERIAPICAL ABSCESS,PERIODONTAL ABSCESS,INFECTED CYST,PERICORONAL ABSCESS

ETIOLOGYETIOLOGY

Traumatic: penetrating wounds Traumatic: penetrating wounds Implant surgeryImplant surgery Reconstructive surgeryReconstructive surgery Contaminated needle puncturesContaminated needle punctures Secondary to oral malignanciesSecondary to oral malignancies Nasal infection common in childrenNasal infection common in children

Course of odontogenic Course of odontogenic abscessabscess

INFECTIONS GENERALLY PASS THROUGH THESE 4 STAGES BEFORE THEYUNDERGO COMPLETE RESOLUTION.

STAGE I – INOCULATIONTIME BETWEEN EXPOSURE OF MICROORGANISM AND THE FIRST SET OFSYMPTOMS . DURING 1-3 DAYS, SWELLING IS SOFT, MILDLY TENDER,DOUGHY IN CONSISTENCY

STAGE II – CELLULITISCHRONIC STAGE-FISTULOUS/SINUS TRACT OR OSTEOMYELITIS DURING 3-7 DAYS, CENTRE OF LESION BEGINS TO SOFTEN

Course of odontogenic Course of odontogenic abscessabscess

Stage III Stage III –After day 5 underlying abcess –After day 5 underlying abcess underminesundermines

skin or mucosa making it compressible.skin or mucosa making it compressible.

Stage Stage IV - Finally there is resolution of abcess IV - Finally there is resolution of abcess thatthat

may be spontaneous or after surgical drainage. may be spontaneous or after surgical drainage. DuringDuring

resolution phase, the involved region is firm onresolution phase, the involved region is firm on

palpation due to process of removing tissuepalpation due to process of removing tissue

and bacterial debris.and bacterial debris.

Classification of Fascial SpacesClassification of Fascial Spaces Based on mode of involvement-Based on mode of involvement- Primary spaces.(direct involvement)Primary spaces.(direct involvement) Secondary spaces.(indirect involvement)Secondary spaces.(indirect involvement)

Primary mandibular spaces- Primary mandibular spaces- submental, sublingual, submental, sublingual, buccal, submandibular.buccal, submandibular.

Secondary spaces- Secondary spaces- masseteric, pterygomandibular, masseteric, pterygomandibular, superficial & deep temporal, lateral pharyngeal, superficial & deep temporal, lateral pharyngeal, retropharyngeal, parotid, prevertebral spacesretropharyngeal, parotid, prevertebral spaces

Submental SpaceSubmental Space

Boundaries-Boundaries- SUPERIOR: SUPERIOR: mylohyoid muscle.mylohyoid muscle. Inferior: Inferior: deep cervical fascia, platysma, superficial fascia & skin.deep cervical fascia, platysma, superficial fascia & skin. Laterally:Laterally: anterior belly of digastric. anterior belly of digastric. Posteriorly:Posteriorly: submandibular space. submandibular space.

Contents-Lymph nodes, anterior jugular vein.Etiology-Infected mandibular incisors.Anterior extension of submandibular space.Clinical Features-•Chin appears glossy & swollen.•Pain & discomfort on swallowing.

treatmenttreatment

Transverse incision in skin below Transverse incision in skin below symphysis of mandible.symphysis of mandible.

Blunt dissection by kellys or sinus Blunt dissection by kellys or sinus forcepsforceps

A small piece of corrugated rubber A small piece of corrugated rubber drain is inserted and is secured to drain is inserted and is secured to one margin of wound with sutureone margin of wound with suture

Sublingual SpaceSublingual SpaceBoundaries-Boundaries- Superiorly:Superiorly: mucosa of floor of mouth. mucosa of floor of mouth. Inferior:Inferior: mylohyoid muscle. mylohyoid muscle. Posteriorly:Posteriorly: body of hyoid bone. body of hyoid bone. Anteriorly & laterally: Anteriorly & laterally: inner aspect of mandibular body.inner aspect of mandibular body. Medially: Medially: geniohyoid,styloglossus,genioglossus musclegeniohyoid,styloglossus,genioglossus muscle

Contents-Deep part of Submandibular gland.Wharton’s duct.Sublingual gland.Lingual & hypoglossal nerves.Terminal branches of lingual artery.

Etiology-Etiology- Infected mandibular premolar & 1Infected mandibular premolar & 1stst molar. molar.

Clinical Features-Clinical Features- Swelling of floor of mouth.Swelling of floor of mouth. Elevated tongue.Elevated tongue. Pain & discomfort on swallowing.Pain & discomfort on swallowing.

treatmenttreatment

Intraoral:incision close to lingual cortical Intraoral:incision close to lingual cortical plate,lateral to sublingual plicaplate,lateral to sublingual plica

Important structure:Important structure:

Sublingual nerve,whartons Sublingual nerve,whartons duct,sublingual artery and vein,lingual duct,sublingual artery and vein,lingual nerve.nerve.

Extraorally:drained via skin incision Extraorally:drained via skin incision placed in submental region.placed in submental region.

Submandibular SpaceSubmandibular SpaceBoundaries-Boundaries- Superiorly: Superiorly: mylohyoid muscle, inferior border of mandible.mylohyoid muscle, inferior border of mandible. Inferior: Inferior: anterior & posterior belly of digastric.anterior & posterior belly of digastric. Laterally: Laterally: deep cervical fascia, platysma, superficial fascia & skin.deep cervical fascia, platysma, superficial fascia & skin. Medially: Medially: hyoglossus,styloglossus,mylohyoid muscle.hyoglossus,styloglossus,mylohyoid muscle. Posteriorly: Posteriorly: to hyoid bone.to hyoid bone. Anteriorly: Anteriorly: submental space.submental space.

Contents-Submandibular salivary gland.Proximal portion of Wharton’s duct.Lingual & hypoglossal nerves.Branches of facial artery- palatine,tonsillar,glandular,submental.

Etiology- Infected mandibular 2nd & 3rd molars. From submental,sublingual spaces.

Clinical Features-• Indurated swelling in submandibular region.• Usually bulges over lower border of mandible.

TREATMENTTREATMENT

I & D through Extra-oral incision.I & D through Extra-oral incision. Incision – 2 stab incisions are given over the Incision – 2 stab incisions are given over the

dependent part below the lower border of dependent part below the lower border of mandible in the neck (shadow) of the mandible in the neck (shadow) of the mandiblemandible

Curved hemostat is inserted & Blunt Curved hemostat is inserted & Blunt dissection through subcutaneous fat not to dissection through subcutaneous fat not to damage facial A, anterior facial vein and the damage facial A, anterior facial vein and the facial nervefacial nerve

Drainage – Drain is placed & dressing is Drainage – Drain is placed & dressing is givengiven

EiologyEiology

SUBMENTAL Six anterior teeth

Secondarily involved due to infected submental lymph node.

SUBLINGUAL Incisors,canines,premolar,first molar.

submandibular Mandibular molar extention from submental space Middle third of tongue ,floor of mouth,maxillary sinus

SUBMENTAL Swelling beneth chin,skin board like taut.fluctuation may be present.

Anterior teeth are nonvital,fractured,carious pop positive,mobility

SUBLINGUAL Little swelling or noLymph node enlarged tender

Firm swelling in floor of mouth,raised,airway obstruction

SUBMANDIBULAR Swelling below inferior border of mandible,submandibularegion,redness of overlying skin

Teeth pop positive,dysphagia,mild trismus

Clinical featuresClinical features

Pterygomandibular SpacePterygomandibular SpaceBoundaries-Boundaries- Superiorly: Superiorly: lower head of lateral pterygoid muscle.lower head of lateral pterygoid muscle. Laterally: Laterally: medial surface of ramus.medial surface of ramus. Medially: Medially: medial pterygoid muscle.medial pterygoid muscle. Posteriorly: Posteriorly: deep part of parotid.deep part of parotid. Anteriorly: Anteriorly: pterygomandibular raphe.pterygomandibular raphe.

superiorly

medial

Contents-Inferior alveolar neurovascular bundle.Lingual & auriculotemporal nerves.Mylohyoid nerve & vessels.

Etiology-Etiology- Infected mandibular 3Infected mandibular 3rdrd molars(mesioangular/horizontal) molars(mesioangular/horizontal) Pericoronitis.Pericoronitis. Infected needles or contaminated LA solution.Infected needles or contaminated LA solution.

Clinical Features-Clinical Features- Absence of extra-oral swelling.Absence of extra-oral swelling. Severe trismus.Severe trismus. Difficulty in swallowing.Difficulty in swallowing. Anterior bulging of half of soft palate & tonsillar pillars with Anterior bulging of half of soft palate & tonsillar pillars with

deviation of uvula to unaffected side.deviation of uvula to unaffected side.

Spread of Infection-Spread of Infection- Superiorly to infratemporal space.Superiorly to infratemporal space. Medially to lateral pharyngeal space.Medially to lateral pharyngeal space. To submandibular space.To submandibular space.

treatmenttreatment

Intraoral:vertical incision is made Intraoral:vertical incision is made near ramus of mandible.near ramus of mandible.

Extraoral:incision in skin below Extraoral:incision in skin below angle of mandible.sinus forcep angle of mandible.sinus forcep insertedinserted

PAROTID SPACEPAROTID SPACE

BOUNDARIES:BOUNDARIES: Inferiorly:stylomandibular ligament.Inferiorly:stylomandibular ligament. CONTENTS:parotid gland,parotid lymph CONTENTS:parotid gland,parotid lymph

node,facial nerve,retromandibular node,facial nerve,retromandibular vein,external artery.vein,external artery.

Clinical features:pain,referred to ear Clinical features:pain,referred to ear accentuated by eating.presence of accentuated by eating.presence of swelling over masseter muscleear lobe swelling over masseter muscleear lobe seems to be everted upseems to be everted up

Incision drainageIncision drainage Dradinage require external Dradinage require external

approach.retromandibular incision is used.an approach.retromandibular incision is used.an incision is placed in the skin behind the incision is placed in the skin behind the posterior border of mandible extending from posterior border of mandible extending from the level of inferior aspect of lobule of ear to the level of inferior aspect of lobule of ear to just above mandible.A sinus forcep is just above mandible.A sinus forcep is inserted,and with blunt dissection the parotid inserted,and with blunt dissection the parotid fasia is reached.a rubber drain is inserted and fasia is reached.a rubber drain is inserted and secured to skin with a suture.secured to skin with a suture.

Spread to submasseteric,pterygomandibular,lateral pharyngeal Spread to submasseteric,pterygomandibular,lateral pharyngeal spacesspaces

SUBMASSETERIC SPACESUBMASSETERIC SPACEBoundaries-Boundaries- Superiorly: Superiorly: zygomatic arch.zygomatic arch. Inferiorly: Inferiorly: inferior border of mandible.inferior border of mandible. Laterally: Laterally: masseter muscle.masseter muscle. Medially: Medially: ramus of mandible.ramus of mandible. Posteriorly: Posteriorly: parotid gland & its fascia.parotid gland & its fascia. Anteriorly: Anteriorly: buccal space & buccopharyngeal fascia.buccal space & buccopharyngeal fascia.

Clinical Features-

Swelling limited to masseter muscle. Severe trismus & throbbing pain.

Contents-Masseteric artery & vein.Etiology-Mandibular 3rd molars(pericoronitis).

etiologyetiology

PTERYGO M parotid PTERYGO M parotid submassetericsubmassetericRetrograde

infection through stensons duct

Infection from submasseteric,pterygomandibular,lat phyngeal space

Pericoronitis,contaminated needle for IAB or psa.

Third molar,

Clinical featuresClinical features Pterygo parotid Pterygo parotid

submassetericsubmasseteric

Swelling outliine masseter muscle,swelling from lower border of mandible to zygomatic arch,trismus,fluctuation is absent,ischemic changes,osteomyelitis sequestrum may take place,subperiosteal bone formation

Pain,referred to ear on eating,swelling over masseter muscles,from zygomatic arch to lower border of mandiblenear lobe lifted upEscape of pus from stenson duct

Severe trismus,tenderness redness edema uvula is swollen.difficulty in breathing.

Lateral Pharyngeal SpaceLateral Pharyngeal Space

Boundaries-Boundaries- Shape of an Shape of an inverted cone or pyramidinverted cone or pyramid, the base is at sphenoid , the base is at sphenoid

bone and the apex at hyoid bone. bone and the apex at hyoid bone. Anteriorly: Anteriorly: pterygomandibular raphe. pterygomandibular raphe. Posteriorly: Posteriorly: extends to prevertebral fascia.extends to prevertebral fascia. Laterally: Laterally: fascia covering medial pterygoid muscle, parotid & fascia covering medial pterygoid muscle, parotid &

mandible.mandible. Medially: Medially: buccopharyngeal fascia on lateral surface of buccopharyngeal fascia on lateral surface of

superior constrictor muscle.superior constrictor muscle. Styloid process divides the space into Styloid process divides the space into anterior muscular anterior muscular and and

posterior vascular posterior vascular compartment.compartment.

Contents- Anterior compartment: fat, muscle, lymph nodes and connective tissue. Posterior compartment: carotid sheath(carotid artery,internal

jugular vein,vagus nerve), cranial nerves IX through XII.

Etiology- Infected mandibular 3rd molars. Tonsillar infections. Pharyngitis. Parotitis.

Spread of Infection- To retropharyngeal space. To peritonsillar space.

Clinical Features-Clinical Features- Anterior compartment:Anterior compartment:

Trismus.Trismus.

Induration & swelling at angle of jaw.Induration & swelling at angle of jaw.

Fever.Fever.

Pharyngeal bulging.Pharyngeal bulging. Posterior compartment:Posterior compartment:

Posterior tonsillar pillar deviation.Posterior tonsillar pillar deviation.

Neurological involvement.Neurological involvement.

Thrombosis of internal jugular vein.Thrombosis of internal jugular vein.

Erosion of carotid vessels may occur.Erosion of carotid vessels may occur.

TreatmentTreatment

Intraoral;vertical incision over Intraoral;vertical incision over pterygomandibular raphe .sinus pterygomandibular raphe .sinus forcep passed through forcep passed through pterygomandibular raphe.pterygomandibular raphe.

Retropharyngeal SpaceRetropharyngeal Space

Posteromedial to lateral pharyngeal space and anterior to the Posteromedial to lateral pharyngeal space and anterior to the prevertebral space .prevertebral space .

Boundaries-Boundaries- Anterior: Anterior: posterior pharyngeal wall. posterior pharyngeal wall. Posterior: Posterior: prevertebral fascia. prevertebral fascia. Superior: Superior: skull base.skull base. Inferior: Inferior: mediastinum.mediastinum. Laterally: Laterally: lateral pharyngeal space.lateral pharyngeal space.

Etiology-Etiology- Nasal & pharygeal infections.Nasal & pharygeal infections. Spread from odontogenic infections.Spread from odontogenic infections.

Clinical Features-Clinical Features- Stiffness of neck.Stiffness of neck. Dysponea.Dysponea. Dysphagia.Dysphagia. Bulging of posterior pharyngeal wall.Bulging of posterior pharyngeal wall.

Complications-Complications- Airway obstruction.Airway obstruction. Aspiration pneumonia.Aspiration pneumonia. Acute mediastinitis.Acute mediastinitis. Can spread to Danger space.Can spread to Danger space.

Prevertebral SpacePrevertebral Space

Potential space between two layers of prevertebral Potential space between two layers of prevertebral

fascia (fascia (alar and prevertebral layersalar and prevertebral layers). ).

ETIOLOGYETIOLOGYLATERAL PHARYNGEAL LATERAL PHARYNGEAL RETROPHARYNGEAL RETROPHARYNGEAL Third molar

From sublingual submandibular and pterygomandibular space,tonsillar abscess

Extention of infection from lateral pharyngeal space

CLINICAL FEATURESCLINICAL FEATURES

LATERAL LATERAL RETROPHARYNGEAL RETROPHARYNGEAL Septicemia,edema

of larynx malaise pyreexia

Acute infection of the throatSwelling in pharynx can lead to snoring chocking dyspnea unilateral cervical adenitis is seen voice same as in quinsy

Routes of SpreadRoutes of Spread

Direct spread-Direct spread-a)a) Spread into superficial soft tissues as-Spread into superficial soft tissues as-

Abscess-Abscess- pathological thick walled cavity filled with pus. pathological thick walled cavity filled with pus.

Cellulitis-Cellulitis- diffuse subcutaneous/submucous inflammation of diffuse subcutaneous/submucous inflammation of soft tissues. Tends to spread along fascial planes.soft tissues. Tends to spread along fascial planes.

b)b) Spread into adjacent fascial spaces.Spread into adjacent fascial spaces.

c)c) Into deep medullary spaces of bone- osteomyelitisInto deep medullary spaces of bone- osteomyelitis

Indirect spread-Indirect spread-a)a) Lymphatic routes to regional nodes.Lymphatic routes to regional nodes.

b)b) Hematogenous route to other organs such as brainHematogenous route to other organs such as brain..

Pathway of Odontogenic InfectionPathway of Odontogenic Infection

Acute-chronic periapical infection

Intraoral soft tissue abscess

Cellulitis

Deep fascial space infection

Bacteremia- septicemia

Sinus or Fistula

Ascending fascial cerebral infection

Medullary spaces of bone-osteomyelitis

Clinical FeaturesClinical Features

Rubor- (rednessRubor- (redness) cutaneous surface involved due to vasodilatation ) cutaneous surface involved due to vasodilatation

effect of inflammation.effect of inflammation.

Tumor-(swellingTumor-(swelling) due to the accumulation of pus or fluid exudate.) due to the accumulation of pus or fluid exudate.

Calor-(heatCalor-(heat) is the result of increased blood flow to the area due to ) is the result of increased blood flow to the area due to

the vasodilatation. the vasodilatation.

Dolor-(or pain) Dolor-(or pain) results from pressure on sensory nerve endings from results from pressure on sensory nerve endings from

tisssue distention caused by edema or infection. tisssue distention caused by edema or infection.

Functiolaesa-(loss of function) Functiolaesa-(loss of function) problems with function.problems with function.

Lymphadenopathy-Lymphadenopathy- nodes enlarged,soft & tender in acute nodes enlarged,soft & tender in acute

infection. Firm & enlarged in chronic.infection. Firm & enlarged in chronic.

Halitosis. Halitosis.

Fever & headache. Repeated chills.Fever & headache. Repeated chills.

Presence of draining sinuses/fistulae.Presence of draining sinuses/fistulae.

Increased salivation.Increased salivation.

Trismus.Trismus.

Difficulty in swallowing. Difficulty in swallowing.

Changes in phonation.Changes in phonation.

Difficulty in breathing.Difficulty in breathing.

Management of Odontogenic InfectionsManagement of Odontogenic Infections

Goals of management of odontogenic infection:Goals of management of odontogenic infection:

1.1. Airway protection.Airway protection.

2.2. Surgical drainage.Surgical drainage.

3.3. Identification of etiologic bacteria.Identification of etiologic bacteria.

4.4. Selection of appropriate antibiotic therapy.Selection of appropriate antibiotic therapy.

5.5. Medical & supportive therapy.Medical & supportive therapy.

Selection of Antibiotic therapySelection of Antibiotic therapy

Parenteral penicillin.Parenteral penicillin.

Metronidazole Metronidazole in combination with penicillin can be used in combination with penicillin can be used

in severe infections. in severe infections.

Clindamycin for penicillin-allergic patients.Clindamycin for penicillin-allergic patients.

Cephalosporins (1Cephalosporins (1stst & 2 & 2ndnd generation cephalosporins). generation cephalosporins).

Antibiotics do not substitute for incision and drainage in Antibiotics do not substitute for incision and drainage in

cases of significant odontogenic infections.cases of significant odontogenic infections.

Causes for clinical failure include inadequate drainage or Causes for clinical failure include inadequate drainage or

antibiotic resistance.antibiotic resistance.

Surgical ManagementSurgical Management Surgical treatment may range from simply opening Surgical treatment may range from simply opening

tooth & extirpation of pulp to complex incision & tooth & extirpation of pulp to complex incision & drainage.drainage.

Primary goal Primary goal in surgical management is to remove in surgical management is to remove cause of infection.cause of infection.

Secondary goal Secondary goal is to provide drainage of accumulated is to provide drainage of accumulated pus & necrotic debris.pus & necrotic debris.

Extraction provides both removal of cause of infection Extraction provides both removal of cause of infection and drainage of pus & debris.and drainage of pus & debris.

Incision & DrainageIncision & Drainage

Incision & drainage helps-Incision & drainage helps- To get rid of toxic purulent material.To get rid of toxic purulent material. To decompress odematous tissues.To decompress odematous tissues. To allow better perfusion of blood, containing antibiotics & To allow better perfusion of blood, containing antibiotics &

defensive elements.defensive elements. To increase oxygenation of infected area.To increase oxygenation of infected area.

Removal of the cause; such as infected tooth, a segment of Removal of the cause; such as infected tooth, a segment of

necrotic bone, a foreign body should be done at the time of necrotic bone, a foreign body should be done at the time of

I & D procedureI & D procedure..

Hilton’s method of I & DHilton’s method of I & D

1.1. Topical anesthesia achieved with spray or infiltration.Topical anesthesia achieved with spray or infiltration.

2.2. Stab incision given through skin & s/c tissue.Stab incision given through skin & s/c tissue.

3.3. If pus is not encountered, further deepening of surgical site If pus is not encountered, further deepening of surgical site done with sinus forceps.done with sinus forceps.

4.4. Abscess cavity is entered and forceps opened in direction Abscess cavity is entered and forceps opened in direction parallel to vital structures.parallel to vital structures.

5.5. Explore the entire cavity for additional loculi.Explore the entire cavity for additional loculi.

6.6. Cavity irrigated with saline & antiseptic solutions.Cavity irrigated with saline & antiseptic solutions.

7.7. Placement of drain.Placement of drain.

8.8. Dressing.Dressing.

Drainage of Fascial SpacesDrainage of Fascial Spaces

.M.Massetericasseteric, , PterygomandibularPterygomandibular, , BuccalBuccal and and Lateral Lateral

Pharyngeal space Pharyngeal space abscesses can be drained with abscesses can be drained with

combination of intraoral and extraoral drainage.combination of intraoral and extraoral drainage.

TemporalTemporal, , SubmandibularSubmandibular, , SubmentalSubmental, , Retropharyngeal Retropharyngeal and and

Parotid space Parotid space abscesses may mandate extraoral incision and abscesses may mandate extraoral incision and

drainage. drainage.

Medical & Supportive TherapyMedical & Supportive Therapy

Administration of antibiotics.Administration of antibiotics.

Hydration of patient by I/V route.Hydration of patient by I/V route.

Soft or liquid diet rich of high proteins.Soft or liquid diet rich of high proteins.

Analgesics & NSAIDs.Analgesics & NSAIDs.

Antiseptic mouthwashes.Antiseptic mouthwashes.

Complete bed rest.Complete bed rest.

LUDWIG’S ANGINA::

DEFINITION– IT IS A FIRM, ACUTE,TOXIC CELLULITIS OF THE SUBMANDIBULAR,SUBLINGUAL SPACES BILATERLLY & OF THE SUBMENTALIS SPACE.

-- FRIST DISCRIBED BY WILHELM FREDREICH VON LUIDWIG IN 1836 ETIOLOGY: 1. PERIAPICAL,PERICORONAL OR PERIODONTAL INFECTION OF A LOWER THIRD MOLAR 2. TRAUMATIC INJURIES & INFECTED LESIONS 3. INFECTIVE CONDITIONS SUCH AS OSTEOMYELITIS MAY MENIFEST AS LUDWIG’S ANGINA 4. CYSTS OR TUMORS IN THIRD MOLAR REGION PATHOLOGY: 1. INFECTION FROM LOWER THIRD MOLAR REACHES THE SUBMANDIBULAR SPACES 2. FROM HERE INFECTION SPREADS ALONG THE SUMANDIBULAR SALIVARY GLANDS ABOVE THE MYLOHYIOD MUSCLE TO REACH THE SUBLINGUAL SPACE

CLINICAL FEATURES - SYSTEMIC FEATURES- PYREXIA , DEHYDRATION , DYSPHAGIA , DYSPNOEA , HOARSENESS OF VOICE AND STRIDOR

EXTRA ORAL FEATURES – HARD TO FIRM BROWNY INDURATED SWELLING SKIN OVER THE SWELLING APPEARS ERYTHMATOUS AND STRETCHED

SWELLING IS TENDER WITH LOCAL RISE IN TEMPERATURE

Difficulty in closing the mouth and drooling of salivaRespiratory distress

INTRA ORAL FEATURES – Trismus , floor of the mouth is raised , tongue raised upwards , increased salivation

MANAGEMENT - 1.Airway maintainence- Tracheostomy and Cricothyroidectomy

is advisable

2. Parentral antibiotics - Penicillin antibiotic of choice Amoxycillin + Cloxacillin Metronidazole in anaerobic infection 3.Surgical decompression – performed under L.A Decompression improves vascularity and potentiates the action of antibiotics. Bilateral submandibular incision with a midline submental incision pus

should be drained

4.Hydration of the patient – It is necessary to put the pt on i.v. fluids 5. Removal of cause - The offending tooth is removed

COMPLICATIONS – • Death due to airway compromise• septicemia• mediastinitis• carotid blow out

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