surgery

• Life-threatening complications of orofacial infections

  • Ludwig’s angina
  • Mediastinitis
  • Involvement of carotid sheath
  • Intracranial complications like cavernous sinus thrombosis, brain abscess, dural meningitis, and osteomyelitis of the skull
  • Retrobulbar cellulitis leading to blindness
• Ludwig’s angina is related to the lower jaw


  Ludwig’s angina is a firm, acute, toxic, and severe diffuse cellulitis/induration that spreads rapidly, bilaterally affecting the submandibular, sublingual, and submental spaces
• Wilhelm Friedreich Von Ludwig coined the term ‘Ludwig’s angina’ in 1836
• Classic Ludwig angina

  • Definite bilateral involvement of all three spaces: submandibular, sublingual, and submental spaces
• In classic Ludwig angina, it was to be feared, rarely became fluctuant, and was often fatal
• Other names for Ludwig’s angina

  • Marbus strangulatorius: chocking effect of the disease
  • Angina maligna
  • Garrotillo: Spanish version for Hangman’s knot (noose)
• Odontogenic infections account for 90% of Ludwig’s angina cases, mainly affecting the second and third mandibular molars
• Aetiology of Ludwig’s angina

  • Odontogenic infection
  • Traumatic injuries of orofacial region
  • Submandibular and sublingual sialadenitis
  • Secondary infections of oral malignancies
  • Pharyngeal infection or tonsillitis
  • Iatrogenic: Use of contaminated needle for giving local anaesthesia
  • Cervical lymphoid tissues
  • Miscellaneous: Foreign bodies such as fish bone
• Pseudo-Ludwig’s angina/pseudo-Ludwig’s phenomena are cases of non-dental origin
• Microbiology of Ludwig’s angina

  • Streptococci
  • Mixed oral flora including staphylococci, E. coli, Pseudomonas, and anaerobes like Bacteroides, Peptostreptococcus, Prevotella species, fusospirochetes
• Clinical features of Ludwig’s angina


  • General constitutional symptoms: looks toxic, very ill, dehydrated
  • Chills and malaise
  • Marked pyrexia
  • Difficulty in swallowing (dysphagia)
  • Impaired speech and hoarseness of voice
• Extraoral examination findings in Ludwig’s angina

  • Bilateral suprahyoid swelling
  • Swelling is firm/hard, brawny, nonpitting
• Bacteria


  • fusospirochetes
• Isolation conditions

  • Anaerobes
• Clinical features

  • General constitutional symptoms: looks toxic, very ill, dehydrated
  • Chills and malaise
  • Marked pyrexia
  • Difficulty in swallowing (dysphagia)
  • Impaired speech and hoarseness of voice
• Extraoral examination

  1. Bilateral suprahyoid swelling

  2. Swelling is firm/hard, brawny, nonpitting, not-fluctuating and tender on palpation

  3. Airway obstruction and cyanosis may occur

  4. Difficulty in swallowing and breathing

  5. Early presentation has no suppuration but...
• Extraoral examination

  • Mouth remains open
  • Shallow breathing
  • Restricted mouth opening
  • Fatal death, 10–24 h due to asphyxia
• Intraoral examination

  1. Swelling develops rapidly

  2. Increased salivation, stiffness of tongue, difficulty in swallowing with hot potato speech is noted

  3. Drooling of saliva

  4. Backward spread of infection leading to oedema of the glottis

  5. Development of Stridor
• Potential complications

  • Septicaemia, upper respiratory airway obstruction and provoke oedema of the epiglottis
  • Mediastinum, producing thoracic empyema
  • Aspiration pneumonia and vascular erosion
  • Common cause of mortality is acute obstruction of the airways
  • Reach close to carotid sheath
  • Pterygopalatine fossa, leading to cavernous sinus thrombosis
  • Fatal within 12–24 h due to asphyxia
• Diagnosis


  Clinical findings, although CT studies
• Treatment

  1. Early with administration of antibiotics

  2. Prophylactic incision

  3. Airway must also be controlled
• Surgical management

  1. In case of rise of tissue tension, little amount of pus is evacuated

  2. Bilateral drainage of submandibular spaces with the drainage of sublingual and submental spaces

  3. Drain sublingual and submental spaces separately to avoid perforation of the mylohyoid muscle
• Distant spread

  1. Spread can occur by means of the bloodstream

  2. Via internal jugular vein

  3. Cardiac colonization

  4. Cavernous sinus

  5. Encephalic abscesses and meningitis
• Fascia


  A band or sheet of connective tissue, primarily collagen, beneath the skin that attaches, stabilizes, encloses, and separates muscles and other internal organs
• Shapiro defined fascial spaces as potential spaces between the layers of fascia. These spaces are normally filled with loose connective tissues and various anatomical structures like veins, arteries, glands, lymph nodes, etc.
• Maxillary primary spaces

  • Canine space
• Involvement in Canine space

  • Odontogenic infections
  • Nasal infections; less frequent
• Teeth frequently giving rise to abscess in the area

  • Maxillary canines
  • Premolars
  • Mesiobuccal root of first molars
• Contents of Canine space

  • Angular artery and vein
  • Infraorbital nerve
• Clinical features of Periapical abscess of canine

  1. Present as labial sulcus swelling and less commonly as palatal swelling

  2. Swelling of the cheek and upper lip (vestibular abscess)

  3. Obliteration of the nasolabial fold (pus accumulation in the nasolabial fold)

  4. Oedema of the lower eyelid

  5. Marked periorbital oedema forcing the eyelid to close

  6. Marked tenderness and redness in the facial tissue
• Surgical management of Periapical abscess of canine

  The incision is made intraorally high in the maxillary labial vestibule. Insert a small haemostat through the levator anguli oris into the abscess cavity, place a rubber drain and suture into the lower margin of the vestibular incision
• Involvement in Palatal abscess

  • Periodontal abscesses from palatal pockets and apical abscesses from the palatal roots
• Surgical anatomy of Palatal abscess

  Boundaries: cortical plate of hard palate inferiorly, and the overlying periosteum and mucosa superiorly; and laterally by the alveolar process of maxilla and the teeth
• Involvement in Buccal Space

  • Buccinator and masseter muscle
• Boundaries of Buccal Space

  • Superior: Zygomatic arch
  • Inferior: Inferior border of mandible
  • Anterior: Posterior border of the zygomatic bone above and depressor angulioris below
  • Posterior: Anterior border of the masseter muscle
  • Medial: Buccinator muscle and its fascia
  • Lateral: Skin and subcutaneous tissue
• Buccal space

  The potential space between buccinator and masseter muscle
• Boundaries of the buccal space

  • Superior - Zygomatic arch
  • Inferior - Inferior border of mandible
  • Anterior - Posterior border of the zygomatic bone above and depressor angulioris below
  • Posterior - Anterior border of the masseter muscle
  • Medial - Buccinator muscle and its fascia
  • Lateral - Skin and subcutaneous tissue
• Contents of the buccal space

  • Space filled with buccal pad of fat (adipose tissues)
  • Parotid duct
  • Anterior and transverse facial artery and vein
• Surgical management of spread

  1. Continuation with pterygomandibular space

  2. To infratemporal space along the fascia accompanying the Stenson's duct

  3. To submasseteric space if infection tracks backwards and penetrates the paratidomassetric fascia
• Infratemporal space


  Also called as 'retro-zygomatic space' as it is partly situated behind the zygomatic bone