ODONTOGENIC INFECTIONS OF HEAD AND NECK

FASCIAL SPACE

• Potential space situated between planes of fascia which form natural pathways along which infection may spread producing a cellulitis or within which infection may be come localized with actual abscess formation

GENERAL FACTORS

• PATIENT RESISTANCE
• BACTERIAL QUANTITY
• VIRULENCE

LOCAL FACTORS

• ALVEOLAR BONE-LIMITING BARRIER
• CORTICAL PLATES
• PERIDONTIUM
• ADJACENT MUSCLES AND FASCIA
• ANATOMICAL SPACES IN HEAD AND NECK
• DEEPER REGIONS OF NECK
• MEDIASTINUM

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PATHWAYS OF DENTAL INFECTION

Pathways of spread of infection

Progression of acute odontogenic infection

• PERIAPICAL OSTEITIS –INFECTION WITHIN ALVEOLAR BONE

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• CELLULITIS 1)INFECTION INTO SURROUNDING SOFT TISSUE
• 2)AREA BECOMES SWOLLEN DUE TO INFLAMMATORY EDEMA
• 3)LITTLE TISSUE DESTRUCTION &PUS FORMATION

ABSCESS

• SUPPURATION
• INFECTION LOCALIZES
• TISSUE DESTRUCTION
• AREA IS SOFTER &FLUCTUATION IS ELICITED

DIAGNOSIS

• HISTORY
• GENERAL EXAMINATION
• EXTRA ORAL EXAMINATION
• INTRA ORAL EXAMINATION
• CLINICAL FEATURES -

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RADIOGRAPHS

• IOPA,OPG
• CT SCAN
• CT GUIDED NEEDLE ASPIRATION
• MRI

ROLE OF CT

• COMPLETE EXTENT OF INFLAMMATORY PROCESS
• EPICENTRE OF INFLAMMATORY PROCESS
• STATUS OF AIR WAY
• EXTENT OF BONE INVOLVEMENT

INTERVENTIONAL PROCEDURE

• FINE NEEDLE ASPIRATION OF FLUID

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• ABSCESS DRAINAGE &DRAIN PLACEMENT

MAXILLARY CENTRAL & LATERAL INCISORS

• SPREAD INFLUENCED BY ORBICULARIS ORIS MUSCLE

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• INTRA ORAL SWELLING

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• APICES LIE CLOSER TO LABIAL THAN PALATAL

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PALATAL ABCESS

• ROOT APICES LOCATED CLOSE TO PALATAL ALVEOLAR PROCESS

MAXILLARY CANINE

• INFLUENCED BY LEVATOR ANGULI ORIS
• IF INFECTION BELOW THE ATTACHMENT OF THE MUSCLE-INTRA ORAL
• IF ABOVE- CANINE SPACE INFECTION

BOUNDARIES

• BETWEEN ANTERIOR SURFACE OF MAXILLA AND OVERLYING LEVATOR MUSCLES OF UPPER LIP

CLINICAL FEATURES

• SWELLING LATERAL TO NOSE WHICH OBLITERATES THE NASOLABIAL FOLD
• EDEMA OF THE LOWER EYELID

INCISION

• MUCOSA OF BUCCAL VESTIBULE IN THE REGION OF LATERAL INCISOR & CANINE
• MOSQUITO FORCEPS INSERTED ABOVE THE ATTACHMENT OF CANINUS MUSCLE

MAXILLARY PREMOLAR

• ZYGOMATICUS MAJOR, MINOR, LEVATOR LABII SUPERIORIS LOCALISES INFECTION WITHIN ORAL CAVITY
• PERFORATION-CANINE SPACE
• PALATAL ROOT- PALATAL ABSCESS

MAXILLARY MOLAR

• BUCCINATOR ATTACHMENT DETERMINES WHETHER INTRA ORAL OR EXTRA ORAL.
• IF PERFORATION ABOVE -BUCCAL SPACE INFECTION
• IF BELOW –INTRA ORAL VESTIBULE

BUCCAL SPACE INFECTION

• LATERALLY BY SKIN AND SUBCUTANEOUS TISSUE
• MEDIALLY BY BUCCINATOR MUSCLE AND BUCCOPHARYNGEAL FASCIA
• ANTERIORLY BY THE POSTERIOR BORDER OF ZYGOMATICUS MAJOR
• POSTERIORLY BY THE MASSETER MUSCLE

• SUPERIORLY BY ZYGOMATIC ARCH
• INFERIORLY BY LOWER BORDER OF MANDIBLE

CONTENTS

• BUCCAL PAD OF FAT
• STENSON’S DUCT
• FACIAL ARTERY

CLINICAL FEATURES

• EXTRA ORAL DOME SHAPED SWELLING

INCISION

• INTRA ORAL INCISION ABOVE THE DEPTH OF THE VESTIBULE
• EXTRA ORAL DRAINAGE PLACED BELOW THE LOWER BORDER OF THE MANDIBLE

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SPREAD

• INTO PTERYGOMANDIBULAR SPACE
• BACKWARDS INTO SUBMASSETERIC SPACE

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MANDIBULAR ANTERIORS

• RELATIONSHIP OF MENTALIS TO ROOT APICES DETERMINE THE COURSE OF INFECTION
• IF ABOVE THE ATTACHMENT -ORAL VESTIBULE
• IF BELOW -SUB MENTAL SPACE

SUB MENTAL SPACE

• LATERALLY BY ANTERIOR BELLIES OF DIGASTRIC
• SUPERIORLY BY MYLOHYIOD
• INFERIORLY BY SKIN,PLATYSMA

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Clinical features

• Swelling beneath the chin
• Anterior tooth non vital or carious.

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INCISION

• EXTRA ORAL INCISION BELOW THE SYMPHYSIS OF THE MANDIBLE

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SPREAD

• POSTERIORLY TO SUBMANDIBULAR SPACE

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MANDIBULAR FIRST MOLAR

• INFECTION EXIT FROM BUCCAL ASPECT BELOW THE ATTACHMENTOF BUCCINATOR MUSCLE –BUCCAL SPACE
• ABOVE -ORAL VESTIBULE

LINGUAL ASPECT

• IF APICES OF PREMOLAR,MOLAR BELOW THE ATTACHMENT OF MYLOHYOID.
• INFECTION PERFORATES LINGUAL PLATE BELOW MYLOHYOID –SUBLINGUAL SPACE

SUB LINGUAL SPACE

• INFERIORLY BY MYLOHYOID MUSCLES
• SUPERIORLY BY THE MUCOSA OF THE ORAL CAVITY
• MEDIALLY BY THE GENIOHYOID, GENIOGLOSSUS
• LATERALLY BY THE LINGUAL ASPECT OF MANDIBLE

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CONTENTS

• DEEP PART OF SUBMANDIBULAR GLAND AND DUCT
• SUBLINGUAL SALIVARY GLAND
• LINGUAL NERVE
• HYPOGLOSSAL NERVE

CLINICAL FEATURES

• SWELLING ON THE FLOOR OF THE MOUTH
• ELEVATION OF THE TONGUE
• AIRWAY OBSTRUCTION

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INCISION

• INTRAORALLY AT THE BASE OF THE ALVEOLAR PROCESS IN THE LINGUAL SULCUS
• EXTRAORALLY SKIN INCISION PLACED IN THE SUBMENTAL REGION. SINUS FORCEPS PASSED THROUGH MYLOHYOID MUSCLE

SPREAD

• CROSSES THE MIDLINE AND AFFECTS THE SPACE IN THE OPPOSITE SIDE
• SPREAD AROUND THE SUBMANDIBULAR GLAND INTO THE SUBMANDIBULAR SPACE
• INTO THE SUBMENTAL SPACE THROUGH LYMPHATIC SPREAD
• POSTERIORLY INTO PTERYGOMANDIBULAR SPACES

MANDIBULAR SECOND MOLAR

• SAME AS MANDIBULAR FIRST MOLAR
• PERFORATION BELOW THE MYLOHYOID MUSCLE PRODUCES SUBMANDIBULAR SPACE INFECTION

SUBMANDIBULAR SPACE INFECTION

• INFECTIONS FROM SUBMANDIBULAR SALIVARY GLAND
• INFECTIONS FROM SUBMENTAL SPACE, SUBMENTAL LYMPHNODES
• INFECTIONS FROM POSTERIOR PART OF SUBLINGUAL SPACE

BOUNDARY

• ROOF BY THE SKIN, PLATYSMA
• FLOOR MYLOHYOID,HYOGLOSSUS
• ANTEROINFERIORLY ANTERIOR BELLY OF DIGASTRIC
• POSTEROINFERIORLY POSTERIOR BELLY OF DIGASTRIC
• SUPERIORLY BASE OF MANDIBLE

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CLINICAL FEATURES

• SWELLING IN THE SUBMANDIBULAR REGION
• TENDERNESS AND REDNESS OF THE OVERLYING SKIN
• TRISMUS
• DYSPHAGIA

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INCISION

• INCISION 2cm BELOW THE LOWER BORDER OF THE MANDIBLE
• INCISION THROUGH SKIN, SUPERFICIAL FASCIA & PLATYSMA
• HEMOSTAT PASSED THROUGH THE CAVITY & RUBBER DRAIN PLACED

SPREAD

• BETWEEN SUBMANDIBULAR, SUBMENTAL SPACE THROUGH THE MIDLINE
• POSTERIOR BORDER OF MYLOHYOID INTO THE SUBLINGUAL SPACE
• BACKWARD INTO THE PARAPHARYNGEAL SPACE

SPREAD INTO DIFFERENT SPACES

MANDIBULAR THIRD MOLAR

• MESIOANGULAR OR HORIZONTALLY POSITIONED TOOTH, INFECTION SPREADS BEYOND THE POSTERIOR EXTEND OF MYLOHYOID MUSCLE INTO THE PTERYGOMANDIBULAR SPACE

PTERYGOMANDIBULAR SPACE

OTHER CAUSES

• CONTAMINATED NEEDLES FOR INFERIOR ALVEOLAR NERVE BLOCK
• PERICORONITIS OF MANDIBULAR THIRD MOLAR

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BOUNDARIES

• LATERALLY -MEDIAL SURFACE OF THE RAMUS
• MEDIALLY - MEDIAL PTERYGOID MUSCLE
• ANTERIORLY- PTERYGOMANDIBULAR RAPHAE
• POSTERIORLY-PAROTID GLAND

CLINICAL FEATURES

• BULGING OF SOFT PALATE, ANTERIOR TONSILLAR PILLAR
• DEVIATION OF UVULA TO THE UNAFFECTED SIDE
• TRISMUS
• DIFFICULTY IN SWALLOWING

D/D:- PERITONSILLAR ABSCESS

INCISION

• INCISION BETWEEN THE MEDIAL ASPECT OF RAMUS AND PTERYGOMANDIBULAR RAPHAE, WHERE NEEDLE IS INSERTED FOR INFERIOR ALVEOLAR NERVE BLOCK

SPREAD

• SUPERIORLY-INFRATEMPORAL FOSSA
• POSTERIORLY-INTO THE LATERAL PHARYNGEAL SPACE
• FRONT OF THE RAMUS TO INVOLVE THE BUCCAL SPACE

SUBMASSETERIC SPACE

• THIRD MOLAR- PERIAPICAL INFECTION FROM LINGUOVERSION OR CURVATURE OF THE ROOT SO THAT THE APEX IS CLOSE TO THE BUCCAL SURFACE

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BOUNDARIES

• LATERALLY- MASSETER
• MEDIALLY- THE LATERAL SURFACE OF THE MANDIBLE
• SUPERIORLY- ZYGOMATIC ARCH
• POSTERIORLY- PAROTID GLAND
• ANTERIORLY- MASSETER & BUCCINATOR

CLINICAL FEATURES

• SWELLING OVER THE ANGLE OF THE MANDIBLE MAY EXTEND TO THE LEVEL OF ZYGOMATIC ARCH
• TRISMUS
• TENDERNESS OVER THE MANDIBULAR RAMUS

INCISION & DRAINAGE

• VERTICAL INCISION ALONG THE EXTERNAL OBLIQUE LINE OF THE MANDIBLE EXTENDING DOWNWARDS INTO THE BUCCAL SULCUS OPPOSITE TO SECOND MOLAR
• HEMOSTAT PASSED ALONG THE LATERAL ASPECT OF THE RAMUS BENEATH THE MASSETER MUSCLE

MASTICATORY SPACE

• PTERYGO MANDIBULAR SPACE
• SUBMASSETERIC SPACE
• TEMPORAL SPACE – SUPERFICIAL

DEEP

SECONDARY SIGNS OF SPREAD OF ODONTOGENIC INFECTION

• PAROTID SPACE INFECTION
• INFRATEMPORAL SPACE INFECTION
• TEMPORAL SPACE INFECTION
• PHARYNGEAL SPACE INFECTION

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INFRATEMPORAL SPACE

• INFECTION FROM PTERGOMANDIBULAR SPACE SUPERIORLY
• BUCCAL SPACE

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BOUNDARIES

• LATERALLY – BY THE RAMUS OF THE MANDIBLE & TEMPORALIS MUSCLE.
• MEDIALLY- BY THE LATERAL PTERYGOID PLATE & LATERAL PTERYGOID MUSCLE.
• SUPERIORLY- INFRATEMPORAL SURFACE OF THE GREATER WING OF SPHENOID.

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• ANTERIORLY – BY THE INFRATEMPORAL SURFACE OF THE MAXILLA & ZYGOMATIC BONE.
• POSTEROLATERAL- MANDIBULAR CONDYLE, LATERAL PTERYGOID MUSCLES

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CONTENTS

• INTERNAL MAXILLARY ARTERY
• MANDIBULAR NERVE & BRANCHES
• PTERYGOID PLEXUS OF VEINS

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CLINICAL FEATURES

• EXTRAORAL SWELLING OVER THE REGION OF SIGMOID NOTCH
• INTRAORAL SWELLING IN THE TUBEROSITY
• TRISMUS

INCISION & DRAINAGE

• INTRAORAL INCISION MADE JUST MEDIAL TO THE UPPER EXTEND OF THE ANTERIOR BORDER OF THE MANDIBULAR RAMUS
• HEMOSTAT IS PASSED ALONG THE MEDIAL ASPECT IF THE CORNOID PROCESS INTO THE INFRATEMPORAL REGION

INTRA ORAL DRAINAGE

EXTRA ORAL DRAINAGE

• HORIZONTAL INCISION AT THE JUNCTION OF FRONTAL & TEMPORAL PROCESS OF ZYGOMA. FORCEPS IS PASSED UPWARDS & MEDIALLY

SPREAD

• SPREAD THROUGH THE PTERYGOID PLEXUS OF VEINS UPWARDS TO THE CAVERNOUS SINUS THROUGH DEEP FACIAL OR EMISSARY VEINS
• UPWARDS TO TEMPORAL SPACE
• INFERIORLY INTO THE LATERAL PTERYGOID SPACE

TEMPORAL SPACE

• SUPERFICIAL TEMPORAL SAPCE
• DEEP TEMPORAL SPACE
• SECONDARY TO PTERYGOPALATINE & INFRATEMPORAL SPACE INFECTION

BOUNDARIES

• SUPERFICIAL TEMPORAL SPACE IS BOUNDED LATERALLY BY THE TEMPORAL FASCIA & MEDIALLY BY THE TEMPORALIS MUSCLE.
• DEEP TEMPORAL SPACE BOUNDED LATERALLY BY THE MEDIAL SURFACE OF THE TEMPORALIS MUSCLE & MEDIALLY BY THE TEMPORAL BONE.

CLINICAL FEATURES

• SWELLING OVER THE TEMPORAL REGION
• PAIN
• TRISMUS

INCISION & DRAINAGE

• INTRAORALLY SAME INCISION USED FOR INFRATEMPORAL SPACE INFECTION.
• EXTRAORALLY INCISION IN THE TEMPORAL REGION 45⁰ TO THE ZYGOMATIC ARCH

PAROTID SPACE

• RETROGRADE INFECTIONS FROM STENSON’S DUCT
• INFECTIONS FROM SUBMASSETERIC, PTERYGOMANDIBULAR & LATERAL PHARYNGEAL SPACES

BOUNDARIES

• BY THE SUPERFICIAL LAYER OF THE DEEP CERVICAL FASCIA SURROUNDING THE PAROTID GLAND

CLINICAL FEATURES

• SWELLING FROM THE LEVEL OF THE ZYGOMATIC ARCH TO THE LOWER BORDER OF THE MANDIBLE
• TENDS TO EVERT THE LOBULE OF THE EAR
• SEVERE PAIN REFERRED TO THE EAR
• PAIN INCREASED BY CHEWING

INCISION & DRAINAGE

• RETROMANDIBULAR INCISION
• EXPLORATION OF VARIOUS PARTS OF THE GLAND BY BLUNT DISSECTION TO AVOID INJURY TO FACIAL NERVE
• LOCULATED DISTRIBUTION OF PUS REQUIRES EXPLORATION & MULTIPLE DRAINS TO BE INSERTED

PHARYNGEAL SPACE INFECTION

INCLUDES

• LATERAL PHARYNGEAL
• RETROPHARYNGEAL SPACES
• INFECTIONS FROM PTERYGOMANDIBULAR, SUBMANDIBULAR & SUBLINGUAL SPACE SPREADS POSTERIORLY

LATERAL PHARYNGEAL SPACE

BOUNDED

• MEDIALLY BY THE LATERAL WALL OF PHARYNX
• LATERALLY BY THE FASCIA OF MEDIAL PTERYGOID & DEEP CAPSULE OF PAROTID GLAND
• SUPERIOR EXTEND IS THE BASE OF THE SKULL
• INFERIORLY BY THE HYOID BONE

CLINICAL FEATURES

• SEVERE PAIN ON THE AFFECTED SIDE OF THE THROAT
• PAIN ON SWALLOWING
• PAIN REFERRED TO THE EAR
• TRISMUS

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D/D:- PERITONSILLAR ABSCESS

SPREAD

• THROUGH VARIOUS FORAMINAS AT THE BASE OF THE SKULL CAUSES CAVERNOUS SINUS THROMBOSIS & MENINGITIS

INCISION & DRAINAGE

• INTRAORALLY SAME INCISION AS THE PTERYGOMANDIBULAR SPACE
• HEMOSTAT PASSED POSTEROMEDIALLY ALONG THE DEEP SURFACE OF THE MEDIAL SURFACE OF THE MEDIAL PTERYGOID MUSCLE INTO THE LATERAL PHARYNGEAL SPACE.

RETROPHARYNGEAL SPACE

• LIES BEHIND OESOPHAGUS, EXTENDS FROM BASE OF THE SKULL TO THE UPPER MEDIASTINUM
• INVOLVING BY EXTENSION OF INFECTION FROM LATERAL PHARYNGEAL SPACE

BOUNDARIES

• ANTERIORLY- BY THE POSTERIOR WALL OF PHARYNX
• POSTERIORLY- BY THE VERTEBRAL COLUMN
• LATERALLY – COMMUNICATES WITH THE LATERAL PHARYNGEAL SPACE

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CLINICAL FEATURES

• PAIN
• DYSPHAGIA
• DYSPNEA
• NUCHAL RIGIDITY
• DIAGNOSIS BY LATERAL RADIGRAPHS & CT WHICH SHOWS WIDENED RETRO PHARYNGEAL SPACE.

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INCISION

• INTRAORALLY THROUGH THE MUCOSA OF THE PHARYNGEAL WALL LATERAL TO MIDLINE
• EXTRAORALLY ALONG THE ANTERIOR BORDER OF THE STERNOCLEIDO MASTOID INFERIOR TO THE HYOID BONE. DISSECTION BETWEEN THE CAROTID SHEATH & INFERIOR CONSTRICTOR MUSCLE OF HYPO PHARYNX

MEDIASTINITIS

• DOWNWARD EXTENSION OF RETROPHARYNGEAL SPACE INFECTION
• SEVERE DYPNEA & CHEST PAIN
• CHEST X-RAY SHOWS MEDIASTINAL WIDENING

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CAROTID SHEATH INFECTION

• TENDER SWELLING IN THE LATERAL ASPECT OF THE NECK UNDER THE STERNO CLEIDO MASTOID.
• PAIN ON PALPATION & LATERAL ROTATION OF THE NECK

COMPLICATIONS

• MEDIASTINITIS
• THROMBOSIS OF INTERNAL JUGULAR VEIN
• EROSION OF INTERNAL CAROTID ARTERY
• SEPTICEMIA

LUDWIG’S ANGINA

• FIRST DESCRIBED BY VON LUDWIG(1836).
• BILATERAL INVOLVEMENT OF SUBLINGUAL, SUBMANDIBULAR & SUBMENTAL SPACE.

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PATHOLOGY

• DIFFUSE INFLAMMATION OF SOFT TISSUES
• SPREADING INFECTION OCCURS IN THE PRESENCE OF ORGANISM THAT PRODUCE HYALURONIDASE & FIBRINOLYSINS.

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MICROBIOLOGY

• MIXED ORAL FLORA
• PRESENCE OF STAPHYLOCOCCI, STREPTOCOCCI.
• GRAM NEGATIVE SUCH AS ECOLI, PSEUDOMONAS
• ANEROBES, BACTERIODS

CLINICAL FEATURES

• SWELLING DEVELOPS & SPREADS RAPIDLY.
• BRAWNY, NON FLUCTUANT, TENDER,
• FLOOR OF THE MOUTH & TONGUE BECOMES ELEVATED
• DIFFICULTY IN RESPIRATION
• EDEMA OF THE TONGUE

• DEGLUTTION & SPEECH DIFFICULTY
• DROOLING OF SALIVA
• TRISMUS

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GENERAL EXAMINATION

• PATIENT IS DEHYDRATED
• FEVER
• CHILLS
• LUDWIG’S ANGINA IF UNTREATED IS FATAL.
• CAUSES SEPTICEMIA. MEDIASTINITIS, ASPIRATION PNUEMONIA
• DEATH

PRINCIPLES OF TREATMENT

• EARLY DIAGNOSIS
• MAINTENANCE OF AIRWAY
• INTENSE & PROLONGED ANTIBIOTIC THERAPY
• SURGICAL DRAINAGE OF FACIAL SPACES
• EXTRACTION OF OFFENDING TEETH

SURGICAL DRAINAGE

• BILATERAL SUBMANDIBULAR INCISIONS, SUBMENTAL INCISIONS.
• DIVISION OF DEEP FASCIA & MYLOHYOID MUSCLE TO ENTER INTO SUBLINGUAL SPACE

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ANTIBIOTIC THERAPY

• PENICILLIN G 2-4 MILLION UNITS IV 4-6 HOURLY.
• GENTAMYCIN 80 mg BD IV
• METRONIDAZOLE 400 mg 8^th HOURLY IV

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HILLTON’S METHOD OF INCISION & DRAINAGE

ENSURES NO VESSEL OR NERVE IS DAMAGED.

STEPS

• TOPICAL ANESTHESIA
• STAB INCISION IN THE MOST DEPENDANT AREA
• DEEPENING BY SINUS FORCEPS

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• ABSCESS CAVITY OPENED IN THE DIRECTION PARALLEL TO THE VITAL STRUCTURES.
• PLACEMENT OF DRAIN TO THE DEPTH OF THE ABSCESS CAVITY & SECURED WITH A SUTURE.
• DRAIN LEFT FOR AT LEAST 24 HRS.

HILTON’S METHOD OF DRAINAGE OF ABCESS

NEUROLOGICAL COMPLICATIONS OF ODONTOGENIC INFECTIONS

• CAVERNOUS SINUS THROMBOSIS
• BRAIN ABSCESS
• MENINGITITS

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CAVERNOUS SINUS THROMBOSIS

• CAUSED BY DIRECT EXTENSION THROUGH THE VENOUS SYSTEM.
• FEVER, CHILLS, RAPID PULSE, SWEATING.
• VENOUS OBSTRUCTION CAUSES EDEMA OF EYELIDS, LACRIMATION, PROPTOSIS, CHEMOSIS.

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• CRANIAL NERVE INVOLVEMENT RESULTS IN OPTHALMOPLEGIA, ABSENCE OF CORNEAL REFLEX, DILATATION OF PUPIL, PTOSIS.
• TOXEMIA
• MENINGITIS

BRAIN ABSCESS

• MICRO ORGANISMS REACHING BRAIN PRODUCES INFLAMATION, EDEMA & SEPTIC THROMBOSIS.
• CLINICALLY PRESENTS AS HEADACHE, NAUSEA, VOMITING, CONVULSIONS
• HEMIPLEGIA

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DIAGNOSIS:-

• CT SCAN

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TREATMENT:-

• ANTIBIOTICS, STEROIDS & MANNITOL TO REDUCE EDEMA.
• SURGERY TO PROVIDE DRAINAGE.

MENINGITIS

• NEUROLOGICAL COMPLICATION

CLINICAL FEATURES

HEADACHE,FEVER

STIFFNESS OF NECK,VOMITTING.

CONVULSIONS

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KERNIG’S SIGN

• RESISTANCE WHEN AN ATTEMPT IS MADE TO EXTEND THE KNEE FROM FLEXED THIGH POSITION

BRUDZINSKI SIGN

• ABRUPT NECK FLEXION IN SUPINE POSITION RESULT IN INVOLUNTARY FLEXION OF KNEES

DIAGNOSIS

• LUMBAR PUNCTURE-CLOUDY
• CONTAINS POLYMORPHONUCLEARELLS,PROTEIN HIGH.
• GLUCOSE REDUCED

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TREATMENT

• COMBINATION OF PENCILLIN G& CHLORAMPHENICOL.