Facial abscess and infection

Overview
Introduction.
Microbiology
Aetiology
Assessment
Investigations
Spread of infection
Fascial spaces
Treatment
Conclusion

Introduction

Facial infections are a relatively

common presentation

Most originate in superficial

structures (skin, subcutanous tissue
etc.) and are often easily diagnosed
and treated

Introduction

Infections originating in deeper

structures :

Severe
Rapidly progressive
Prolonged morbidity
Long term complications
Potentially endanger life.

Introduction

Efficient treatment requires

Accurate diagnosis
Early aggressive medical
treatment
And in most cases urgent
decisive surgical management.

Introduction

Complex and severe cases may require multidisciplinary

approach

GP
Dental surgeon
Radiologist
Oral and maxillo-facial surgeon / Plastic surgeon
ENT surgeon
Anaesthetist
Infectious diseases specialist
Intensivist.
Ophthalmology
Neurosurgery

Mycrobiology

Almost always polymicrobial with a

predominance of anaerobic organisms.
Aerobic-anaerobic composition
Aerobic gram + cocci (Streptococci)
Anaerobic gram + cocci (Strep,
Peptostrep, Pepto), gram + rods (Eubac,
Lacto), and gram - rods (Porphromonas or
Prevotella, Fusobacterium)

In severe cases Gram-ve organism tend

to be involved as well.

Aetiology of Mayor Facial Infections

Most originate in :
The jaws
Teeth
Surrounding periodontal soft
tissues
Paranasal sinuses
Major salivary glands

Aetiology of Mayor Facial Infections

Teeth can contribute by:

(1) Decay (caries) reaching the dental
pulp=pulpitis
(2) Periapical abscess may occur in
seemingly intact but devitalised teeth (trauma,
cracks or decay under fillings).
(3) Periodontal disease.
(4) Erupting teeth (especially partially
impacted lower third molars)
(5) Retained roots supragingival or
subgingival.

Aetiology of Mayor Facial Infections

The jaws:
(1) Can develop cysts or tumours
(2) Osteomyelitis
(3) Osteoradionecrosis occurs readily in irradiated
jaws.
(4) Rarer are tuberculosis, actinomycosis and
syphilitic osteomyelitis.
(5) Fractures / Extraction sites

Aetiology of Mayor Facial Infections

Paranasal sinuses
(1) Primarily infected, obstruct
(2) Infected secondary to infected teeth protruding
into the maxillary sinus (upper premolar and molar teeth often
do).
(3) Tumours or cysts
(4) Fractures such as the orbital floor are by definition
compound to the outside and may result in orbital cellulitis.

Aetiology of Mayor Facial Infections

Major salivary glands:

(1) May be the subject of either viral or bacterial infections
often superimposed on obstruction of ducts (stone, stricture,
etc).
(2) Tumours rarely also become secondarily infected.

Assessment
History
Presentation:

Onset
Duration
Rapidity
Previous treatment
Medically compromised
Physical exam

Assessment

History

: Additional attention to:

Increased pain and swelling on exposure to food

Recent dental treatment,
Any trauma to the face or teeth
Recent oral surgery
Past facial fractures fixation
Past salivary gland surgery.
History of head and neck cancer with possible radiotherapy
to the region
Upper respiratory tract viral infections, nasal
discharge, etc.

Assessment

Presentation
Swollen face and occasionally swollen neck.
Toothache or facial pain may or may not be a feature.
There is often general malaise and possibly rigors with
fever.
Patients may complain of trismus
Pain or difficulty in swallowing.
Drooling.
Sore throat
Boarse voice.

Assessment

Presentation

Submandibular space infection

with external drains in situ

Ludwigs angina: bilateral

submandibular/sublingual space
infection

Assessment

Physical Examination
Vital Signs
Temperature- systemic
involvement >101 F
Blood Pressure- mild elevation
Pulse- >100
Increased Respiratory Ratenormal 14-16

Assessment

Physical Examination
General appearance
Palpate the area of
swelling:
-Location of swelling,
-Size
-Fluctuance
-Pointing
-Lymph node
enlargement.

Intra-oral exam

Assessment

Physical Examination
Good oral examination should include:
Halitosis
Intraoral pus draining and where, any tongue elevation ,any
sublingual or submandibular swelling
Swelling in the mandibular or maxillary sulci
Palatal swelling especially of the soft palate or uvula
General dental state, patency of salivary outlets (parotid,
submandibular and sublingual)
Nature of saliva produced (clear, thick, pus?).

Assessment

Physical Examination

The neck should be

evaluated for
Swelling
Lymphadenopath
Possible tracheal
deviation.

Investigations

Careful history and examination will make

diagnosis clear.
Certain investigation will still be necessary
:

Plain X rays

Ultrasound

CT scan
MRI

Microbiology of any pus or discharge

The usual blood tests.

Investigations

Plain X rays:
The OPG
(orthopantomogram)
Displaying the teeth
Whole of mandible
Tooth bearing segment of the
maxilla
Parts of the maxillary
sinuses.
Suspected fractures of the
mandible
Periapical abscesses
Bony cysts and tumours
Impacted third molars
('wisdom teeth').

Investigations

Plain X rays:
Occipito-mental 15 and 30 degrees
(Waters view)
Both maxillary sinuses (effusion?)
Orbital floor and most fractures of the maxilla.

Investigations

Plain X rays:

Mandibular occlusal views and

lateral oblique views
Stones in the submandibular

gland.

Puffed cheek' view

Stones in the parotid duct.

Sialography:
Can be used for suspected gland
obstruction however CT sialogram is the
gold standard

Investigations

Ultrasound:
Confirming collections
Guide to aspiration.
Stones in salivary ducts and glands.

Investigations

CT scan:

Exact extent of the swelling

Potential airway compromise
Invaluable to both the surgeon
and anaesthetist.
However patients unwell enough to
potentially obstruct their airway should be
taken straight to theatre rather than risk an
emergency in the radiology dept.

Investigations

MRI
Advantages
Better soft tissue detail
Imaging in multiple planes
No artifact by dental fillings
Disadvantages
Increased cost
Increased exam time
Dependent on patient
cooperation
Availability

Spread of Infections

Spread occurs along planes of least resistance. Infections

may extend to potential fascial spaces in the orofacial
area ( orofacial space infections), or deep in the head and
neck ( peripharyngeal space infections). The latter is often
life-threatening.

Spread of Infections

Bony infection tends to perforate the cortical plates along

path of least resistance. Subsequent subperiosteal spread
tends to be directed by muscle and facial attachments.
Thus infections of mandibular molar teeth for example
tend to spread to the submandibular space.

Spread of Infections

A number of potential tissue spaces exist, the most

important being:
buccal space
sublingual space
submandibular space
parapharyngeal space
retropharyngeal space.
Spread can occur throughout these with airway
compression once the parapharyngeal and
retropharyngeal spaces are filled.

Spread of Infections
Orbital floor can be perforated by pus from the sinus

resulting in subperiosteal abscess or even orbital abscess.

Preseptal cellulitis may result from buccal space infections
and may progress to orbital cellulitis.
Lymphatic spread to the deep cervical lymphatics occurs
commonly.
Occasionally haematogenous spread may result in
bacteraemia
distant septic foci
cavernous sinus thrombosis.

Spread of Infections

Fascial spaces of the head and neck

Retropharyngeal space

Parotid gland
mandible

Parotid space

Masseteric space

Medial pterigoid muscle

Masseter muscle
Zygomatic arch

Lateral pharyngeal space

Buccinator muscle
Buccal space

Spread of Infections

Fascial spaces of the head and neck

Spread of Infections

Mandibular Infections
Potential pathways of
spread

Sublingual space
Submental space
Submandibular space
Masticator space
Lateral pharyngeal space
Retropharyngeal space

Spread of Infections

Maxillary Infections
Potential pathways of
extension

Canine space
Buccal space
Temporal space
Infratemporal space

Spread of Infections
Space infections

MASTICATOR
Masseteric and
pterygoid

Usual site of
origen

Clinical features
pain

trismus

Swelling

Dysphagia

Dyspnea

Molars (especially +
3rd)

+++

May not be
evident (deep)

Temporal

Post. Maxillary
molars

Face, orbit
( late)

BUCCAL

Bicuspids, molars

CANINE

Maxillary canines, ++
incisors

Cheek
(market)
Upper lip, canine fosa

INFRATEMPORAL

Post. Maxillary
molars

Face, orbit
( late)

SUBMENTAL
PAROTID
SUBMANDIBULAR

Mandibular
incisors
Masseteric
spaces
2nd, 3rd
mandibular
molars

++

+++

Chin
( firm)
Angle of jaw
(marked)
Submandibular ( brawny)

SUBLINGUAL

Spread of Infections
Masticator Space Infection

Masseteric,

Pterygomandibular
Temporal spaces

Spread of Infections
Masticator Space Infection

Masseteric,

Pterygomandibular
Temporal spaces

Spread of Infections
Temporal Space Infection

Spread of Infections
Space infections

MASTICATOR
Masseteric and
pterygoid

Usual site of
origen

Clinical features
pain

trismus

Swelling

Dysphagia

Dyspnea

Molars (especially +
3rd)

+++

May not be
evident (deep)

Temporal

Post. Maxillary
molars

Face, orbit
( late)

BUCCAL

Bicuspids, molars

CANINE

Maxillary canines, ++
incisors

Cheek
(market)
Upper lip, canine fosa

INFRATEMPORAL

Post. Maxillary
molars

Face, orbit
( late)

SUBMENTAL
PAROTID
SUBMANDIBULAR

Mandibular
incisors
Masseteric
spaces
2nd, 3rd
mandibular
molars

++

+++

Chin
( firm)
Angle of jaw
(marked)
Submandibular ( brawny)

SUBLINGUAL

Spread of Infections
Buccal Space Infection

Spread of Infections
Space infections

MASTICATOR
Masseteric and
pterygoid

Usual site of
origen

Clinical features
pain

trismus

Swelling

Dysphagia

Dyspnea

Molars (especially +
3rd)

+++

May not be
evident (deep)

Temporal

Post. Maxillary
molars

Face, orbit
( late)

BUCCAL

Bicuspids, molars

CANINE

Maxillary canines, ++
incisors

Cheek
(market)
Upper lip, canine fosa

INFRATEMPORAL

Post. Maxillary
molars

Face, orbit
( late)

SUBMENTAL
PAROTID
SUBMANDIBULAR

Mandibular
incisors
Masseteric
spaces
2nd, 3rd
mandibular
molars

++

+++

Chin
( firm)
Angle of jaw
(marked)
Submandibular ( brawny)

SUBLINGUAL

Spread of Infections
Canine Space Infection

Spread of Infections
Space infections

MASTICATOR
Masseteric and
pterygoid

Usual site of
origen

Clinical features
pain

trismus

Swelling

Dysphagia

Dyspnea

Molars (especially +
3rd)

+++

May not be
evident (deep)

Temporal

Post. Maxillary
molars

Face, orbit
( late)

BUCCAL

Bicuspids, molars

CANINE

Maxillary canines, ++
incisors

Cheek
(market)
Upper lip, canine fosa

INFRATEMPORAL

Post. Maxillary
molars

Face, orbit
( late)

SUBMENTAL
PAROTID
SUBMANDIBULAR

Mandibular
incisors
Masseteric
spaces
2nd, 3rd
mandibular
molars

++

+++

Chin
( firm)
Angle of jaw
(marked)
Submandibular ( brawny)

SUBLINGUAL

Spread of Infections
Temporal Space Infection

Spread of Infections
Space infections

MASTICATOR
Masseteric and
pterygoid

Usual site of
origen

Clinical features
pain

trismus

Swelling

Dysphagia

Dyspnea

Molars (especially +
3rd)

+++

May not be
evident (deep)

Temporal

Post. Maxillary
molars

Face, orbit
( late)

BUCCAL

bicuspids, molars

CANINE

Maxillary canines, ++
incisors

Cheek
(market)
Upper lip, canine fosa

INFRATEMPORAL

Post. Maxillary
molars

Face, orbit
( late)

SUBMENTAL
PAROTID
SUBMANDIBULAR

Mandibular
incisors
Masseteric
spaces
2nd, 3rd
mandibular
molars

++

+++

Chin
( firm)
Angle of jaw
(marked)
Submandibular ( brawny)

SUBLINGUAL

Spread of Infections
Submental Space Infection

Spread of Infections
Submental Space Infection

Spread of Infections
Space infections

MASTICATOR
Masseteric and
pterygoid

Usual site of
origen

Clinical features
pain

trismus

Swelling

Dysphagia

Dyspnea

Molars (especially +
3rd)

+++

May not be
evident (deep)

Temporal

Post. Maxillary
molars

Face, orbit
( late)

BUCCAL

bicuspids, molars

CANINE

Maxillary canines, ++
incisors

Cheek
(market)
Upper lip, canine fosa

INFRATEMPORAL

Post. Maxillary
molars

Face, orbit
( late)

SUBMENTAL
PAROTID
SUBMANDIBULAR

Mandibular
incisors
Masseteric
spaces
2nd, 3rd
mandibular
molars

++

+++

Chin
( firm)
Angle of jaw
(marked)
Submandibular ( brawny)

SUBLINGUAL

Spread of Infections
Submandibular Space Infection

Spread of Infections
Space infections

MASTICATOR
Masseteric and
pterygoid

Usual site of
origen

Clinical features
pain

trismus

Swelling

Dysphagia

Dyspnea

Molars (especially +
3rd)

+++

May not be
evident (deep)

Temporal

Post. Maxillary
molars

Face, orbit
( late)

BUCCAL

bicuspids, molars

CANINE

Maxillary canines, ++
incisors

Cheek
(market)
Upper lip, canine fosa

INFRATEMPORAL

Post. Maxillary
molars

Face, orbit
( late)

SUBMENTAL
PAROTID
SUBMANDIBULAR

Mandibular
incisors
Masseteric
spaces
2nd, 3rd
mandibular
molars

++

+++

Chin
( firm)
Angle of jaw
(marked)
Submandibular ( brawny)

SUBLINGUAL

Spread of Infections
Sublingual Space Infection

Spread of Infections
Ludwigs Angina
Celllulitis not abscess. Bilateral submandibular, sublingual, submental
spaces
Treat aggressively, potential airway compromise
Dysphagia, dyspnea, trismus.

Spread of Infections
Space infections

Usual site of origen

Clinical features
pain

trismus

Swelling

Dysphagia

Dyspnea

LATERAL PHARYNGEAL
Anterior

Mandibular
incisors

Posterior
RETROPHARYNGEAL

PRETRACHEAL

Floor of mouth
(tender)

+ if bilat.

+ if bilat.

Masticator spaces +++

+++

Angle of jaw

Masticator spaces

Post. pharynx

+++

Lateral pharybgeal +
space, distant via
lymphatics

Post pharynx
(Midline)

Retropharyngeal
space, anterior
esophagus

hipopharynx

+++

Spread of Infections
Space infections

Usual site of origen

Clinical features
pain

trismus

Swelling

Dysphagia

Dyspnea

LATERAL PHARYNGEAL
Anterior

Mandibular
incisors

Posterior

Masticator spaces +++

RETROPHARYNGEAL

Masticator spaces

PRETRACHEAL

Floor of mouth
(tender)

+ if bilat.

+ if bilat.

Angle of jaw

Post. pharynx

+++

Lateral pharyngeal +
space, distant via
lymphatics

Post pharynx
(Midline)

Retropharyngeal
space, anterior
esophagus

hipopharynx

+++

Spread of Infections
Lateral Pharyngeal Space
Retropharyngeal Space

Spread of Infections
Acute Orbital Cellulitis

Treatment
Medical support
Antibiotic therapy
Surgical treatment

Treatment

Medical support

Airway maintenance
Rehydration
Analgesia
Nutrition

Treatment

Antibiotic Therapy
Antibiotics alone will not cure most deep facial infection.
Polymicrobial infections : Aerobic Strep, anaerobes
Ampicillin/sulbactam with metronidazole
Beta-Lactam resistance in 17-47% of isolates
Alternatives
Third generation cephalosporins
Clindamycin
Culture and sensitivity

Treatment

Antibiotic Therapy: empiric antibiotic regimens for head

and neck infections
Normal host
Ampicillin-sulbactam, 2 g IV Q 6h or
Penicillin G, 2-4 MU IV Q 4-6h plus either
Metronidazole, 500 mg IV Q 6h or
Clindamycin, 600 mg IV Q 6h

Compromised host
One of the following an aminoglycoside)
Cefotaxime, 2 g IV Q 6h or
Ceftizoxime, 4 g IV Q 6h or
Ticarcillin-clavulanate 3 g IV Q 4h or
Piperacillin-tazobactam, 3 g IV Q 4h or
Imipenem-cilastatin, 500 mg IV Q 6h or
Meropenem, 1 g IV Q 8h.

Treatment

Surgical treatment
Removal of the cause and drainage of
accumulated pus will prevent worsening and
recurrence.
In early cases the surgical treatment may be as
simple as root canal treatment of the tooth suspected
or alternatively simple tooth extraction by the
patients dentist followed by oral antibiotics.

Treatment

Surgical treatment
More advanced cases need urgent admission for
intravenous antibiotics followed by urgent surgery to
remove the cause as well as achieve incision and
drainage of tissue spaces involved.
These cases may need expert fiberoptic
endotracheal intubation with prolonged (few days)
intubation and occasionally emergency surgical
airway access such as cricothyrotomy or
tracheostomy may be needed.
These cases will need ICU postoperatively until the
safety of airway is assured.

Treatment

Surgical treatment
Surgically most cases can be approached
transorally.
One should avoid the temptation to cut through
facial skin for reasons of facial nerve preservation as
well as to avoid the ugly puckered scar that
invariably results.

Treatment

Surgical treatment
Submandibular and submental spaces full of pus
need to be drained trancutanously via neck
incisions with drains insertion.
The patient should be on triple IV antibiotics
covering aerobic Strep species as well as
anaerobes as well as Gram-ve organisms.

Treatment

Surgical treatment : external approach

Incision along Langers lines

Treatment

Surgical treatment : external approach

Facial nerve
Facial vessels
Parotid gland
Stenon duct

Treatment

Surgical treatment : external approach

External incisions for drainge

1. Lindemanns Parotid 2. Submandibular angle 3. Lower submaxillar 4.Upper
submaxillar .
5. Horizontal submaxillar 6 Oblique temporal .

Treatment

Surgical treatment: surgical approach for drainage

Vestibular abscess
Upper vestibular abscess
vessels.

infraorbitary nerve and angular

Lower vestibular abscess

mentonian nerve

Treatment

Surgical treatment: surgical approach for drainage

Lingual abscess

Treatment

Surgical treatment: surgical approach for drainage

Palatine abscess

Treatment
1.

Surgical treatment: surgical approach for drainage

1. 1. Masseteric space
1.Masseteric space
. 2. Pterygomandibular space

Treatment
1.

Surgical treatment: surgical approach for drainage

1.Ludwings angina

Treatment
1.

Surgical treatment: surgical approach for drainage

1.Submental space

1. Submaxilary abscess
2. Parotid abscess

Treatment
1.

Surgical treatment: surgical approach for drainage

1.Submental space

1.Paramandibular
space

Treatment
1.

Surgical treatment: surgical approach for drainage

1.Temporal space

Treatment
1.

Surgical treatment: surgical approach for drainage

1.Superficial
temporal space

1.Deep temporal
space

1.External
view of
intraoral
incision

Conclusion
Early diagnosis, prompt antibiotic treatment , together
with early removal of the cause should prevent most
complications and result in early recovery

Thank you