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292 PART V ORAL AND MAXILLOFACIAL SURGERY
A
B
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Temporal
Vestibular
Palatal
Buccal
Parotid
Subcutaneous
Subperiosteal
Submental
Parotid
Submasseteric
Buccal
Figure 28-1. Anatomy of the deep space infections. A, Coronal, and B, Axial sections of the head showing most of the
deep fascial spaces of the head and neck. (Adapted from Eycleshymer AC, Schoemaker DM: Cross-section anatomy,
New York, 1911, D. Appleton & Company.)
Lateral
pharyngeal
Sublingual
Submandibular
Retropharyngeal
Pterygomandibular
CHAPTER 28 OROFACIAL INFECTIONS AND ANTIBIOTIC USE 293
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Table 28-1. Species of Bacteria Responsible for Odontogenic Infections
ORGANISM PERCENTAGE
Aerobic* 25
Gram-positive cocci 85
Streptococcus spp. 90
Streptococcus (group D) spp. 2
Staphylococcus spp. 6
Eikenella spp. 2
Gram-negative cocci (Neisseria spp.) 2
Gram-positive rods (Corynebacterium spp.) 3
Gram-negative rods (Haemophilus spp.) 6
Miscellaneous and undifferentiated 4
Anaerobic
†
75
Gram-positive cocci 30
Streptococcus spp. 33
Peptococcus spp. 33
Peptostreptococcus spp. 33
Gram-negative cocci (Veillonella spp.) 4
Gram-positive rods 14
Eubacterium spp.
Lactobacillus spp.
Actinomyces spp.
Clostridia spp.
Gram-negative-rods 50
Bacteroides spp. 75
Fusobacterium spp. 25
Miscellaneous 6
*49 different species.
†
119 different species.
Adapted from Peterson LJ: Principles of management and prevention of odontogenic infection. In Peterson LJ,
Ellis E, Hupp J, et (eds): Contemporary oral and maxillofacial surgery, ed 2, St Louis, 1998, Mosby.
12. What is an abscess?
An abscess is a pocket of tissue containing necrotic tissue, bacterial colonies, and dead white cells.
The area of infection may or may not be fluctuant. The patient is often febrile at this stage. Cellulitis,
which may be associated with abscess formation, is often caused by anaerobic bacteria.
13. What is the difference between an abscess and cellulitis?
See Table 28-3.
14. What are the signs and symptoms of a serious orofacial infection?
Serious infection occurs when the infection extends beyond the local area of infection and presents
life-threatening systemic manifestations, including airway compromise, bacteremia, septicemia, fever,
lethargy, fatigue, malaise, and dehydration. Swelling, induration, fluctuation, trismus, rapidly progressing infection, involvement of secondary spaces, dysphagia, odynophagia, and drooling are also signs
and symptoms of serious orofacial infection.
15. What factors influence the spread of odontogenic infection?
• Thicknessofboneadjacenttotheoffendingtooth
• Virulenceoftheorganism
294 PART V ORAL AND MAXILLOFACIAL SURGERY
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Table 28-2. The Relation of Morphologic Findings to Bacterial Categories
MORPHOLOGIC FINDINGS BACTERIAL SPECIES
Gram-positive cocci, single or clumps Micrococcus, Peptococcus, Staphylococcus
Gram-positive cocci, pairs and chains Enterococcus, Peptostreptococcus, Streptococcus
Gram-positive rods, large Bacillus, Clostridium
Gram-positive rods, small Arachnia, Bacterionema, Bifidobacterium,
Gram-positive rods, branching Actinomyces, Nocardia
Gram-negative rods, large Enterobacteriaceae
Gram-negative rods, thin, uniform Pseudomonas
Gram-negative rods, small, coccobacillary Bacteroides, Bordetella, Brucella, Capnocytophaga,
Gram-negative rods, nonspecific morphology Alcaligenes, Campylobacter, Cardiobacterium, Fla-
Gram-negative cocci, pairs Acinetobacter, Moraxella, Neisseria
Gram-negative cocci Veillonella
Adapted from Bartlett RC: Laboratory diagnostic techniques. In Tobazian RG, Goldberg MH (eds):
Oral and maxillofacial infections, ed 3, Philadelphia, 1994, Saunders.
Table 28-3. A Comparison of Cellulitis and Abscess
CELLULITIS ABSCESS
Duration Acute Chronic
Pain Severe and generalized Localized
Size Large Small
Localization Diffuse borders Well circumscribed
Palpation Doughy to indurated Fluctuant
Presence of pus No Ye s
Degree of seriousness Greater Less
Bacteria Aerobic Anaerobic
Adapted from Peterson LJ: Principles of management and prevention of odontogenic infection. In Peterson LJ,
Ellis E, Hupp J, et (eds): Contemporary oral and maxillofacial surgery, ed 2, St Louis, 1998, Mosby.
Corynebacterium, Erysipelothrix, Eubacterium,
Lactobacillus, Listeria, Propionibacterium
Cardiobacterium, Eikenella, Fusobacterium,
Haemophilus, Pasteurella
vobacterium, Pectobacterium, Chromobacterium,
Helicobacter, Vibrio, Yersinia
• Positionofmuscleattachmentinrelationtoroottip
• Statusofpatient’simmunesystem
16. What are the primary fascial spaces?
The primary spaces are the spaces directly adjacent to the origin of the odontogenic infections.
Infections spread from the origin of the infection into these spaces, which are:
• Buccal
• Submandibular
• Canine
• Submental
• Sublingual
• Vestibular
CHAPTER 28 OROFACIAL INFECTIONS AND ANTIBIOTIC USE 295
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Retropharyngeal
space
Buccopharyngeal fascia
Alar fascia
Prevertebral fascia
Prevertebral
space
Mediastinum
Figure 28-2. Retropharyngeal and prevertebral spaces, with the potential for spread of infection to the mediastinum
from these spaces. (From Peterson LJ: Odontogenic infections. In Cummings CW, Fredrickson JM, Harker LA, et al [eds]:
Otolaryngology: head and neck surgery, ed 3, St Louis, 1998, Mosby.)
17. What are the secondary fascial spaces?
Fascial spaces that become involved following spread of infection to the primary spaces (Fig. 28-2).
The secondary spaces are:
• Pterygomandibular
• Supercialanddeeptemporal
• Infratemporal
• Retropharyngeal
• Masseteric
• Masticator
• Lateralpharyngeal
• Prevertebral
18. What is the danger space?
Also called space 4 of Grodinsky and Holyoke, it is the potential space between alar and prevertebral
fascia. Its superior limit is the skull base, and it extends inferiorly into the posterior mediastinum.
19. What are the seven spaces of Grodinsky and Holyoke in the head and neck?
1. Space 1: between platysma and investing fascia
2. Space 2: between investing and infrahyoid fascia
3. Space 2a: space among infrahyoid muscles
4. Space 3: the pretracheal and retrovisceral spaces
5. Space 4: danger space and between prevertebral and alar fascia
6. Space 4a: between prevertebral and investing fascia above clavicle
7. Space 5: space within prevertebral fascia
20. Which teeth are likely to be the cause of space infections? What are the surgical
approaches for incision and drainage of these spaces?
See Table 28-4 and Fig. 28-3.
Table 28-4. Teeth Likely to Cause Fascial Space Infections, with Surgical Approaches
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FASCIAL SPACE
Canine Between canine fossa, zygomaticus,
Buccal Check area between buccinators and
Sublingual Above mylohyoid muscle. Roof of space is
ANATOMIC BOUNDARIES
OF SPACE
orbicularis oris, levator labii superioris,
and levator anguli oris
buccopharyngeal fascia medially, overlying skin laterally, zygomatic muscle
and despressor muscles anteriorly,
zygomatic arch superiorly, lower border
of mandible inferiorly, and pterygomandibular raphe posteriorly
mucosa of floor of mouth; floor is made
by mylohyoid, genioglossus, geniohyoid,
and styloglossus muscles, tongue, and
lingual frenum (medial raphe).
LIKELY SOURCE
OF INFECTION SWELLING SITE SITE OF I & D
Maxillary canines, especially
with very long roots and apex
situated above attachment of
muscles. May also be caused
by central, lateral or premolar
teeth.
Upper premolars, upper molars,
and lower premolars
From teeth of root apices above
mylohyoid muscle attachment,
namely lower premolars and
sometimes first molars
Extraoral swelling just lateral to
nose, obliterating nasolabial
fold, and may extend upward,
causing periorbital cellulitis.
May be in labial sulcus.
Extraoral swelling over cheek
area between inferior border
of mandible and zygomatic
arch. Typically, if inferior
border of mandible palpable,
it is buccal space; if inferior
border is not palpable, then
involved space is submandibular.
Infection spread lingual in floor
of mouth causing sublingual
swelling involving contralateral side (because barrier
between two sides is very
weak)
296 PART V ORAL AND MAXILLOFACIAL SURGERY
Intraoral incision in horizontal
direction in mucobuccal
fold. Rarely, space is drained
extraorally.
Intraoral by a transverse incision
to depth of buccinator muscle
passing through mucosa,
submucosa, and buccinator
muscle, avoiding injury to
important anatomic structures, such as parotid duct.
Drainage also accomplished
by extraoral inscision near
point of fluctuance below
Stensen’sduct.
Intraoral incision parallel to
Worton’sductandlingual
cortex in anteroposterior
direction, as close as possible
(within 1 cm) to lingual cortical bone because sublingual
fold contains sublingual gland
and ducts of submandibular
gland. Intraoral-extraoral approach may be used.
Submandibular Below mylohyoid muscle. Lies inferior to
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mylohyoid muscle; inferior boundary is anterior and posterior bellies of
digastric muscles. Medially, mylohyoid
hyoglossus and styloglossus muscles
bound space. Lateral boundary is skin,
superficial fascia, platysma muscle,
superficial layer of deep cervical fascia,
and lateral border of mandible.
Submental Between hyoid bone and symphysis, at
site of attachment of anterior belly
of digastric muscle. Roof of space is
mylohyoid muscle, floor is skin, laterally
is anterior belly of digastric muscle.
Lower molars, especially lower
second and third molars
Lower incisors and canines, or
from trauma such as symphyseal fracture
Swelling mostly extraoral due to
pus accumulation between
skin and mylohyoid muscle.
Swelling begins by obliterating inferior border of mandible, then extends medially
to anterior belly of digastric
and posterior to hyoid bone.
Mostly extraoral. Chin and
submental areas swollen. Pus
situated between digastric
muscle, mylohyoid muscle,
and skin. Rarely, there is submental swelling only. Usually
submental and submandibular
swelling because boundaries
between two spaces are
not definitive (only digastric
muscle), so pus travels
posteriorly to submandibular
region.
Through extraoral incision
parallel to inferior border of
mandible, kept at least 1 cm
from border to avoid injury to
mandibular branch of facial
nerve, submandibular gland,
facial artery, and lingual nerve
Extraoral transverse incision
midway between symphysis
and hyoid bone.
Continued on following page
CHAPTER 28 OROFACIAL INFECTIONS AND ANTIBIOTIC USE 297
Table 28-4. Teeth Likely to Cause Fascial Space Infections, with Surgical Approaches—(Continued)
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FASCIAL SPACE
Masseteric Between outer surface of ascending
Pterygomandibular Between ascending ramus and medial
ANATOMIC BOUNDARIES
OF SPACE
ramus medially and masseter muscle
laterally
pterygoid muscle medially; laterally
is inner surface of ascending ramus.
Superiorly, space bound by lateral
pterygoid muscle, posteriorly by parotid
gland, and anteriorly by pterygomandibular raphe and superior constrictor
of pharynx.
LIKELY SOURCE
OF INFECTION SWELLING SITE SITE OF I & D
Can spread from a buccal space
infection site of attachment of
buccinators muscle. Also from
pericoronitis of lower third
molars, or from fracture of
angle of mandible.
Can result from infection of mo-
lar teeth, especially third molar; spread from infratemporal
space, which communicates
freely with pterygomandibular
space; septic inferior dental
nerve block with contaminated needle or solution;
pericoronitis; spread from
submandibular space infection; spread from sublingual
space
Extraoral swelling over area oc-
cupied by masseter muscles,
which is over ascending
ramus and angle of mandible.
Infection of this space characterized by trismus due to
involvement of muscles of
mastication.
Intraoral swelling of mucosa
over medial aspect of the
ascending ramus. Extraorally,
swelling is extremely rare,
but if seen is found near
mandibular angle area.
Sometimes no extraoral
swelling at all, only trismus
due to involvement of medial
pterygoid muscle, especially
when infection is caused by
inferior dental nerve block.
298 PART V ORAL AND MAXILLOFACIAL SURGERY
Approximately 4-cm-long inci-
sion made below and behind
angle of ascending ramus.
Dissection carried through
skin, superficial fascia, and
platysma muscles. When
inserting, artery forceps
should remain in contact with
outer aspect of ascending
ramus. Incision can be used
to approach two spaces
(masseteric and pterygoid
mandibular). Masseteric
space can also be drained
through an intraoral incision
or a combined intraoralextraoral approach.
Can be drained extraorally at angle
of mandible. When inserting,
artery forceps should remain
in contact with inner surface of
ascending ramus. This space
can also be drained through
intraoral incision placed just
medial to pterygomandibular
raphe and by dissecting posteriorly along medial surface of
ramus of mandible. Incision can
also be used to drain lateral
pharyngeal space and inferior
portion of infratemporal space.
Temporal Muscle divides into two spaces: superficial
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temporal between temporalis muscle
and temporal fascia, and deep temporal
space (infratemporal space) between
temporalis muscle and bony wall
of skull medially. Temporal space is
contiguous pterygomandibular and
masseteric spaces.
Infection usually originates from
upper and lower molars, or
from extension of infection
from masseteric or pterygomandibular spaces through
infratemporal space, or from
spread of infection from
posterior superior alveolar
nerve block
Extraoral swelling just behind
lateral orbital rim and above
zygomatic arch
Infection of this space is almost
always associated with
trismus: thus is difficult to
approach intraorally. Extraoral
approach more practical, but
intraoral is preferred. Intraoral
site for I & D is placed at
anterior border of ascending
ramus, with forceps inserted
on outer aspect of ascending ramus and directed up.
Extraoral incision is through
transverse incision starting
slightly superior to zygomatic
arch and extending posteriorly
between lateral orbital rim
and hairline. Incision is made
parallel to it to avoid zygomatic branch of facial nerve.
Continued on following page
CHAPTER 28 OROFACIAL INFECTIONS AND ANTIBIOTIC USE 299
Table 28-4. Teeth Likely to Cause Fascial Space Infections, with Surgical Approaches—(Continued)
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FASCIAL SPACE
Lateral pharyngeal Inverted cone shape extending from base
ANATOMIC BOUNDARIES
OF SPACE
of skill to hyoid bone. Situated just medial to pterygomandibular space. Lateral wall made up of medial pterygoid
muscle and superior constrictor muscle.
Posteriorly, boundary is parotid gland,
and anteriorly is pterygomandibular
raphe. Medial wall is continuous with
carotid sheath. Styloid process divides
this space into two compartments:
anterior compartment, which contains
mainly muscles, and posterior compartment, which contains several important
structures, namely carotid sheaths
inside which are external carotid artery,
internal jugular vein, and CN X. Outside
sheaths are CN IX, XI, and XII.
LIKELY SOURCE
OF INFECTION SWELLING SITE SITE OF I & D
Infection can result from
infection of lower and upper
molars by way of neighboring
spaces, such as submandibular or pterygomandibular
spaces. Can also result from
nonodontogenic sources, such
as palatine tonsils, infected
parotid gland, and infected
lymph nodes. If infection of
this space is not treated at
early stage, it can readily
spread to retropharyngeal and
prevertebral spaces.
Most common site is an intraoral
swelling of lateral pharyngeal
wall (very characteristic).
Medial displacement of uvula
and palatal draping may also
be present. Extraoral lateral
swelling of neck immediately
below angle of mandible and
anterior to anterior border of
sternocleidomastoid muscle
also possible.
300 PART V ORAL AND MAXILLOFACIAL SURGERY
Intraoral drainage of anterior
compartment via a similar
incision to that of intraoral
incision for drainage of
pterygomandibular space.
Incision made through mucosa, and dissection directed
medially and posteriorly
along medial side of medial
pterygoid muscle. Extraoral
approach through horizontal
incision made at level of hyoid
bone just anterior to sternocleidomastoid. Dissection
made superiorly and medially
between submandibular gland
and posterior belly of digastric
muscle until medial surface
of medial pterygoid muscle
reached. Dissection carried
along surface of muscle into
space. Space can also be
drained using through-andthrough drainage.
Retropharyngeal Extending from base of skull superiorly to
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upper mediastinum inferiorly (level of C6
or T1 behind posterior pharyngeal wall).
Anteriorly, space is bounded by posterior
wall of pharynx, and posterior to it lies
danger space, which communicates
with posterior mediastinum.
CN, Cranial nerve; CT, computed tomography.
Spreads from upper and lower
molars by extension from
lateral pharyngeal space by
way of pterygomandibular,
submandibular, or sublingual
spaces. Retropharyngeal and
lateral pharyngeal spaces
separated by thin layer of fascia, which can easily rupture
and cause spread of infection.
Infection of retropharyngeal
space may also result from
nasal and pharyngeal infection in children, esophageal
trauma, foreign bodies, and
tuberculosis.
If able to visualize pharynx,
bulge of posterior pharyngeal
wall will be noticed—usually
unilateral. Lateral soft tissue
radiographs or CT will better
delineate extent of swelling.
Extraoral approach by incision
parallel to and along anterior
border of sternocleidomastoid
muscle below hyoid bone.
Muscle and carotid sheath
are retracted laterally, and a
finger is inserted posterior
to inferior constrictor. A soft
noncollapsible rubber drain
is preferred because of deep
location of this space.
CHAPTER 28 OROFACIAL INFECTIONS AND ANTIBIOTIC USE 301
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