SELULITIS

If an abscess is not able to establish drainage through the surface of the

skin or into the oral cavity. it may spread diffusely th rough fascial pla nes of the
soft tiss ue. This acute and edematous spread of an acute in flam matory pro cess is
termed cellulitis . Although numerous patterns of cell ulitis can be seen from the
spread of denta l infec tions. two especially dangerous forms warrant further
discussion: (I) Ludwig's angina and (2) cavernous sinus thrombosis.
Ludwig's angina. named after the German physician who described the
seriousness of the disorder in 1836. refers to cellulitis of the submandibular region.
Angina comes from the Latin word angere, which means "to strangle" (an apt term
considering the clinical features described in the following section). Ludwig's
angina develops from spread of an acute infection from the lower molar teeth in
about 70% of cases. Other situations associated with this clinical presentation are
peritonsillar or parapharyngeal abscesses. Oral lacerations, fractures of the
mandible or submandibular sialadenitis. Although the process may occur in
otherwise healthy individuals. There is an increased prevalence in patients
immunocompromised secondary to disorders such as diabetes mellitus, organ
transplantation, AIDS, and aplastic anemia.
The cavernous sinus is a major dural sinus that is encased between the meningeal
and periosteal layers of the dura. The meningeal layer contains the trochlear and
oculomotor nerves and the maxillary and ophthalmic branches of the trigeminal
nerve. In addition, the internal carotid artery and abducens nerve travel within the
sinus. The sinus receives venous drainage from the orbit via the superior and
inferior ophthalmic veins. Infection of the sinus can produce a variety of clinical
symptoms related to the numerous anatomic structuresthat coursethrough this
site.
Cavernous sinus thrombosiscan occur when infection from maxillary premolar
or molar teeth perforates the buccal cortical plate and extends into the maxillary
sinus, the pterygopalatine space, or the infratemporal fossa, reaching the orbit via
the inferior orbita l fissure. In addition to affecting periorbital structures. the
infection then can spread into the cavernous sinus at the cranial vault and result
incavernous sinus thrombosis. Similar involvement which the infection perforates
the facial maxillary bone and affects the canine space with spread to the cavernous
sinus via veins of the face. Overall, cavernous sinus thrombosis is relat ively
uncommon and orodental infections are responsible in approximately 10% of the
cases.
Clinical Features
Ludwig's angina. Ludwig's angina is an aggressive and rapidly spreading
cellulitis that involves the sublingual, submandibular, and submental spaces. Once
the infection enters the submandibular space, it may extend to the lateral
pharyngeal space and then to the retropharyngeal space. This extension may result
in spread to the mediastinum with several serious consequences. Ludwig's
angina creates massive swell ing of the neck that often extends close to the
clavicles. Involvement of the sublingual space results in elevation. posterior
enlargement, and protrusion of the tongue (wo ody tongu e). Submandibular space
spread causes enlargement and tenderness of the neck above the level of the hyoid
bone (bull neck). Although init ially unilateral. spread to the contralateral neck
typically occurs. Pain in the neck and flo or of mouth may be seen in addition to
restri cted neck movement, dysphagia. dysphonia,