of Maxillofacial Infections

div epub:type=”chapter” role=”doc-chapter”>

© Springer Nature Switzerland AG 2021

R. Reti, D. Findlay (eds.)Oral Board Review for Oral and Maxillofacial Surgerydoi.org/10.1007/978-3-030-48880-2_3

3. Management of Maxillofacial Infections

Thomas R. Flynn1  , William Gilmore2, Robert Reti3, Trina Sengupta4 and Damian Findlay5

Harvard School of Dental Medicine (ret.), Department of Oral and Maxillofacial Surgery, Reno, NV, USA

Tufts Medical Center/Tufts University, School of Dental Medicine (ret.), Oral and Maxillofacial Surgery, Lake View, NY, USA

Southwest Oral Surgery, St. Louis, MO, USA

Jamaica Hospital Medical Center, Department of Dentistry/Division of Oral and Maxillofacial Surgery, Jamaica, NY, USA

Oral Facial Surgery Institute, St. Louis, MO, USA

Odontogenic infectionsOrbital infectionsSepsisCavernous sinus thrombosisNecrotizing fasciitisDanger spaceRetropharyngeal fasciaAbscessCellulitisPrimary fascial spaceSecondary fascial spacesDeep fascial spacesSystemic inflammatory response syndrome (SIRS)SEPSISPreseptal cellulitisRetroseptal abscessMucormycosis (zygomycosis)MediastinitisOsteomyelitis

Odontogenic Infections
  • Treatment of odontogenic infections is based on medical management, surgical treatment, and antibiotic therapy.

  • Odontogenic infections are polymicrobial in nature and are normally composed of more anaerobic bacteria.

  • Results from:

    • Dental caries

    • Dentoalveolar infections (infections of the pulp and periapical abscesses)

    • Gingivitis

    • Periodontitis

    • Perimplantitis

    • Pericoronitis

  • Factors that determine the spread include thickness of the cortical plate and the relationship of the adjacent muscle attachment with the apices of the offending teeth.

  • Infections spread via hydrostatic pressure along the path of least resistance. These paths tend to be composed of loose connective areolar tissue that is enclosed by fascial layers.

  • The cervical fascia is a fibrous connective tissue that envelops and divides the muscles of the neck and creates potential spaces.

  • There is a synergistic interdependence between aerobic and anaerobic bacteria thought to be necessary for the development of an abscess.

  • Respiration of aerobic bacteria -> depletes the local environment of oxygen -> creates an oxygen-poor and nutrient-rich habitat -> anaerobic bacteria growth increases -> anaerobes proliferate and secrete toxins and enzymes which results in tissue destruction.

Path of Third Molar Infection to Mediastinum
  • Periapical abscess erodes through thinnest cortical plate (lingual) into the submandibular space.

  • As the submandibular space is filled, the infection travels through the buccopharyngeal gap between the middle and superior pharyngeal constrictors to the lateral pharyngeal space. A direct connection to the lateral pharyngeal space is via spread directly around the posterior belly of the digastric muscle.

  • There is no barrier between lateral pharyngeal space and retropharyngeal space.

  • Retropharyngeal space fuses with alar fascia between C6 and T4 (Figs. 3.1 and 3.2).

  • The infection normally enters danger space at the fusion of alar and prevertebral fascia.

  • Danger space is continuous with posterior mediastinum.

Fig. 3.1

Axial view demonstrating the fascial cervical spaces at the level of the sixth cervical vertebrae. (Reprinted with permission from Flynn [1])

Fig. 3.2

Sagittal section of the neck demonstrating fascial spaces and danger spaces. (Reprinted with permission from Flynn [1])

Principles of Management of Odontogenic Infections
  • Determine severity: anatomic location, rate of progression, and airway compromise.

  • Evaluate host factors: evaluate immunocompetence and systemic reserve of the patient.

  • Decide on setting: inpatient criteria – fever, dehydration, need for general anesthesia, deep space infection, or control of systemic disease.

  • Treat surgically.

  • Support medically.

  • Choose and administer the appropriate antibiotic.

  • Evaluate the patient frequently.

  • Odontogenic infections pass through three stages: inoculation, cellulitis, and abscess (Table 3.1).

  • Cellulitis is more severe than abscess as cellulitis continues to spread.

  • Abscess formation is the beginning of localization.

Table 3.1

Characteristics of cellulitis vs. abscess [2]

Cellulitis vs. abscess





3–5 days

5–7 days


Hard and very tender

Fluctuant and tender

Skin quality


Thin, shiny




Tissue fluid






Primary Fascial Spaces (See Table 3.2)
Primary fascial spaces are those that are directly adjacent to the origin of odontogenic infections. Infection spread by direct invasion from the source. These spaces include the following:

  • Buccal

  • Submandibular

  • Canine

  • Submental

  • Vestibular

  • Sublingual

Table 3.2

Borders of the deep fascial spaces of the head and neck






Superficial or Medial*

Deep or Lateral*


Corner of mouth

Masseter muscle Pterygomandibular space

Maxilla Infraorbital space


Subcutaneous tissue and skin

Buccinator muscle


Nasal cartilages

Buccal space

Quauratus labii superioris muscle

Oral mucosa

Quadratuc labii superiors muscle

Levator anguli oris muscle Maxilla


Anterior belly digastric muscle

Posterior belly digastric muscle Stylohyoid muscle Stylopharyngeus muscle

Inferior and medial surfaces of mandible

Digastric tendon

Platysma muscle Investing fascia

Mylohyoid muscle Hyoglossus muscle Superior constrictor muscles


Inferior border of mandible

Hyoid bone

Mylohyoid muscle

Investing fascia

Investing fascia

Anterior bellies of digastric muscles*


Lingual surface of mandible

Submandibular space

Oral mucosa

Mylohyoid muscle

Muscles of tongue*

Lingual surface of mandible*


Buccal space

Parotid gland

Lateral pterygoid muscle

Inferior border of mandible

Medial pterygoid muscle*

Ascending ramus of mandible*


Bucall space

Parotid gland

Zygomatic arch

Inferior border of mandible

Ascending ramus of mandible*

Masseter muuscle*

Lateral pharyngeal

Superior and middle pharyngeal constrictor muscles

Caroid sheath and scalene fascia

Skull base

Hyoid bone

Pharyngeal constrictors and retropharyngeal Space*

Medial pterygoid muscle*


Superior and middle pharyngeal constrictor muscles

Alar fascia

Skull base

Fusion of alar and prevertebral fasciae at C6-T4


Carotid sheath and lateral pharyngeal space*


Sternothyroid-thyrohyoid fascia

Retropharyngeal space

Thyroid cartilage

Superior mediastinum

Sternothyroid-thyrohyoid fascia

Visceral fascia over trachea and thyroid gland

Reprinted with permission from Topazian RG, Goldberg MH, Hupp JR. Oral and maxillofacial infections. Saunders; 2002

*Medial border

*Lateral border

Secondary Fascial Spaces (See Table 3.2)
Secondary Fascial space infections are those that become involved via spread of infection from the primary fascial spaces. These spaces include the following:

  • Pterygomandibular

  • Infratemporal

  • Masseteric

  • Masticator (see Fig. 3.3)

  • Lateral pharyngeal (see Fig. 3.4)

  • Retropharyngeal (see Fig. 3.5)

  • Prevertebral

Fig. 3.3

The masticator space is made up of the temporal space, pterygomandibular space, and masseteric space. The pterygomandibular space lies between the medial aspect of the mandible and the medial pterygoid muscle. The masseteric space lies between the lateral body of the mandible and the masseter muscle. The temporal space is posterior and superior to the masseteric space and pterygomandibular space. It is bound by the temporalis fascia laterally and the skull medially. (Reprinted with permission from Flint et al. [4])

Fig. 3.4

The lateral pharyngeal space is shaped like an inverted cone with its base as the skull base and the apex at the hyoid bone. It is located between the medial pterygoid muscle laterally, the superior pharyngeal constrictor superiorly, the pterygomandibular raphe anteriorly, and the retropharyngeal space posteriorly. The styloid processes and its attachments divide the space into anterior compartments (containing muscles) and posterior compartments (containing the carotid sheath and cranial nerves). (Reprinted with permission from Flint et al. [4])

Fig. 3.5

(a) Retropharyngeal space is located posterior and medial to the lateral pharyngeal space. It is bounded superiorly by the base of skull, anteriorly by the superior pharyngeal muscle, posteriorly by the alar fascia, and extends inferiorly to the level of C7 or T1 (fusion of alar and buccopharyngeal fascia at the level of the posterior mediastinum). Involvement of the prevertebral space (danger space no. 4) may communicate to the region of the diaphragm. (b) Access to the retropharyngeal space. Incision is made parallel to the anterior border of the sternocleidomastoid (SCM) muscle inferior to the hyoid bone. The SCM and carotid sheath are retracted laterally. The loose connective tissue is bluntly dissected between the carotid sheath and the esophagus to gain access to the retrophrangyeal space. (Reprinted with permission from Kademani and Tiwana [5])

Workup for the Odontogenic Infection Patient

History of Present Illness
  • Need to determine onset, duration, symptoms of infection, and any antibiotics previously prescribed.

  • NPO (Nil Per Os (nothing by mouth)) status.

  • Assessment of concerning signs:

    • Dysphagia – difficulty swallowing

    • Dysphonia – difficulty speaking

    • Dyspnea – difficulty breathing

    • Odynophagia – pain on swallowing

    • Mental status changes

    • Trismus

    • Fevers/chills

Past Medical History
  • Important to assess if there are any disease processes that render the patient immunocompromised—e.g., HIV, DM, hepatitis, alcoholism, malignancy, chemotherapy, malnutrition, patients on steroids, or immunosuppressants

  • IV drug users have a higher incidence of MRSA infection

Physical Exam

  • Vital Signs

    • Temperature – elevated temperatures can be indicative of serious infection with systemic involvement. Normal oral adult temperature is on average 98.6 °F/37 °C. Rectal temperature tends to be 1 °F higher and axillary is 1–3 °F lower.

    • Heart rate – tachycardia can be indicative of systemic involvement. Each degree increase in °F tends to correlate with an increase of 10 BPM of heart rate.

    • Respiratory rate (normal 12–20 breaths/min) – elevated rate could suggest respiratory compromise or acid-base imbalance suggestive of SIRS.

    • Blood pressure – hypertension can be present secondary to pain. Hypotension can be seen in septic patients.

    • Oxygen saturation – patients unable to maintain an oxygen saturation greater than 96 on room air may have airway compromise (if no underlying pulmonary disease).

  • Inspection (global view of the patient)

    • Look for facial/cervical swelling and asymmetry.

    • Assess whether or not the patient has a toxic appearance such as pallor, sweat, (diaphoretic), shivering, lethargy, etc.

    • Assess whether the patient can tolerate their secretions (concern for airway swelling). Are they sitting in a tripod position to allow collection of saliva, open a constricted airway, and prevent dirtying clothes?

    • Signs of respiratory distress such as labored breathing (dyspnea) or noisy breathing (stridor) or inability to tolerate being in a supine position. Does the patient have hoarseness to their voice (dysphonia)? If outpatient setting, activate emergency response system for transfer. Does the airway need to be secured prior to imaging? Look for patient posturing to improve airway patency by aligning upper and lower airways (e.g., sniffing position).

  • Head and Neck Exam Assessment

    • Measure maximal incisal opening . A concerning sign is opening less than 30 mm.

    • Palpate for tenderness, warmth, induration (firm), crepitus (sensation of crackling suggestive of gas), or fluctuance (fluid wave on bidigital palpation suggestive of pus). Note any parulis or fistula of skin.

    • Lymphadenopathy can aid in determination of origin.

    • Decreased mobility of neck. Normal flexion 70–90°, extension 55°, and rotation 70°. Nuchal rigidity may be a sign of retropharyngeal space infection.

    • Attempt to palpate if trachea is midline; in severe infection there can be deflection and markings for emergency cricothyrotomy/tracheostomy may be off-center.

    • Inability to palpate inferior border of mandible (indicative of submandibular space involvement).

    • Floor of the mouth and tongue elevation (indicative of sublingual space involvement). If the patient is able to extend tongue past vermillion border of the upper lip, there is less of a chance that the sublingual space is involved.

    • Deviation of uvula to the opposite side (indicative of the lateral pharyngeal/pterygomandibular/peritonsillar space involvement; also may be indicative of an oropharyngeal malignancy). Swelling of lateral neck between the sternocleidomastoid and mandibular angles, just above hyoid, is suggestive of lateral pharyngeal space involvement.

    • Look for carious, periodontally involved or abscessed teeth and their relation to the region of involvement.

    • Look for erythema and crepitus spreading to chest and neck for spread of infection/mediastinitis/necrotizing fasciitis. Consider serial markings of skin in area of erythema to monitor spread.

    • Look for use of accessory muscles of respiration.

    • Dimpling over zygomatic arch can be seen with temporal space involvement due to adherence of temporal fascia to periosteum.

    • Cranial exam to examine for intracranial extension.

  • Cardiopulmonary Exam

    • Tachycardia may be appreciated in the setting of an infection due to an increase in sympathetic tone.

    • Pulmonary rales may be appreciated in the setting of acute respiratory distress syndrome secondary to sepsis.

    • Distant heart sounds, murmurs, and pericardial friction rub may be indicative of mediastinal spread.


  • Complete Blood Count

    • Look for leukocytosis with a left shift. Leukopenia can also be seen in a serious infection. WBC count can also be trended to assess for resolution of an infection. A thrombocytosis can also be appreciated in the setting of infection (acute phase reactant).

    • Left shift/bandemia refers to the presence of immature white blood cells released into bloodstream denoting an acute infection.

  • Basic Metabolic Panel

    • BUN/creatinine ratio can be used to assess the volume status of the patient. Patients may display prerenal (denoted by a BUN/CR ratio of greater than 20) or renal azotemia.

    • Renal baseline function is important to know as certain antibiotics are nephrotoxic which may have implications on dosing. Creatinine levels are also necessary prior to obtaining CT with contrast due to the risk of contrast-associated nephropathy.

    • Hyperglycemia or hypoglycemia (if no oral intake) may be present in diabetics which may need to be treated. Blood sugar below 200 mg/dL is imperative for good infection control.

    • Electrolyte disturbances may also be present with long-term malnutrition.

  • C-Reactive Protein

    • Marker of inflammation that rises in response to inflammation (acute phase reactant). Can be trended to assess for resolution of an infection.

  • Blood Cultures

    • Routine culturing is not practiced . Should be reserved for those with signs of septicemia to prevent false-negative results.

Systemic Inflammatory Response Syndrome (SIRS)

SIRS is defined by having two or more of the following:

  1. 1.

    Fever >38 °C or <36 °C

  2. 2.

    Heart rate >90 beats per minute

  3. 3.

    Respiratory rate >20 breaths per minute or PaCO2 <32 mm Hg

  4. 4.

    Abnormal WBC count (>12,000/mm3 or <4000/mm3 or >10% bands)



Sepsis – life-threatening organ dysfunction caused by a dysregulated host response to infection

  • Organ dysfunction  – based on sequential organ failure assessment (SOFA) scores. Points are given to abnormalities in cardiovascular, coagulation, pulmonary, liver, renal, and brain panels. A score of two or more denotes organ dysfunction.

  • Infection  – based on clinical signs (e.g., SIRS) and supportive microbiologic and radiological data.

  • Imaging

    • CT with contrast – image must extend from the skull base to the thoracic inlet. 3 mm cuts in the neck and 5 mm below the hyoid. Contrast used to delineate collections manifested as ring-enhancing collections noted on CT. Fat stranding can also be appreciated. Also can assess for radiographic evidence of airway embarrassment and lymphadenopathy.

    • Panorex – plain scout film used to assess for causative teeth of the odontogenic infection. Can also see resorptive changes that could be indicative of apical periodontitis or osteomyelitis.

    • Plain Neck Films – screening for retropharyngeal and pretracheal spaces. Normal retropharyngeal tissue 7 mm at C-2; 14 mm for children and 22 mm for adults at C-6. Largely supplanted by CT.

    Only gold members can continue reading. Log In or Register to continue

Jul 23, 2021 | Posted by in Oral and Maxillofacial Surgery | Comments Off on of Maxillofacial Infections
Premium Wordpress Themes by UFO Themes