6 orofacial & neck infections

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6 orofacial & neck infections

  1. 1. Orofacial & neck infections INSTRUCTOR – DR.JESUS GEORGE 1
  2. 2. ETIOLOGY  1-Odontogenic  Pulp disease  Periodontal disease  Secondarily infected cyst & odontomes  Remaining root fragment  Pericoronal infection  2-Trauma  3-Implant Surgery  4-Reconstructive Surgery 2
  3. 3. Cont.  Contaminated Needle Puncture  Infections Of Maxillary Antrum  Infections of salivary glands  Secondary to oral malignancies 3
  4. 4. Pathways of odontogenic infections Invasion of dental pulp by bacteria after decay of a tooth  Inflammation, edema & lack of collateral blood supply  Venous congestion or avascular necrosis (pulpal tissue death) 4
  5. 5. Cont. Reservoir of bacterial growth(anaerobic)  Periodic egress of bacteria into surrounding alveolar bone 5
  6. 6. MICROBIOLOGY  Aerobic gram positive cocci bacteria- streptococci milleri, strep. Sanguis, strep. Salivarius, strep. Mutans.  Anaerobic Cocci-peptostreptococcus.  Bacteriodes-porphyromonas, prevotella 6
  7. 7. TYPES  A/c  C/c  Acute stage - 3 forms  1.Abscess  2.cellulitis  3.fulminating infection 7
  8. 8. Abscess  It is a circumscribed collection of pus in a pathologic tissue space.  Infections are characterised by sphylococci. 8
  9. 9. CELLULITIS  It is spreading infection of loose connective tissues.  It is a diffuse, erythematous, mucosal or cutaneous infection.  It is the result of streptococcal infection.  It does not result in accumulation of large amount of pus. 9
  10. 10. Cont.  Streptococcus produces streptokinase, hyaluronidase & streptodornase which break down fibrin, connective tissue ground substance & lyse cellular debris, which facilitate rapid spread of bacteria. 10
  11. 11. FULMINATING INFECTIONS  Here the infection involves secondary spaces involving vital structures. 11
  12. 12. Chronic stage  C/c fistulous tract or sinus formation  Abscesses neglected for a long time may discharge intraorally or extra orally 12
  13. 13. Treatment  Medical treatment  Soft or liquid diet  Adequate hydration  Diet rich in protein  Analgesics  Antiseptic mouthwash  Antibiotics 13
  14. 14. Cont.  In a non compromised patient, with well localized abscess, surgical drainage with dental therapy will resolve the infection.  In poorly localized, extensive abscess & cellulitis antibiotic therapy is needed.  In compromised patients & patients with trismus, airway obstruction & fever antibiotic therapy is must. 14
  15. 15. Cont.  Penicillin is the drug of choice.  Penicillin+metronidazole Can Also Be Used.  Clindamycin  Amoxycillin+clavulanic Acid  First & Second Generation Cephalosporins 15
  16. 16. Cont.  Surgical treatment  It involves blunt exploration of the anatomic space or abscess.  Abscess cavity is then irrigated with betadine & saline.  A drain is inserted into the space.  Hilton`s method of incision & drainage ◦ No blood vessel or nerve is damaged. ◦ Topical anaesthesia is obtained. 16
  17. 17. Cont. ◦ Stab incision is made over the point of maximum fluctuation in the most dependent area along the skin creases, through skin & subcutaneous tissue. ◦ If pus is not encountered deepening of surgical site is done with artery forceps. ◦ Closed forceps are pushed through deep fascia & advanced towards the pus collection. ◦ Abscess cavity is entered & forceps is opened parallel to vital structures. 17
  18. 18. Cont. ◦ Pus flows along the beaks of the forceps. ◦ A rubber drain is inserted into the depth of cavity & secured to the wound margin with the help of sutures. ◦ Drain is left for 24 hrs. ◦ Dressing is given without pressure. ◦ Drain allows discharge of tissue fluids & pus from the wound. ◦ Drain is removed when the drainage is completely ceased 18
  19. 19. ACUTE PERIAPICAL ABSCESS  Etiology ◦ Caries ◦ Contamination of traumatic exposure of pulp. ◦ Chemical or thermal damage to pulp.  The entry to periapical tissues is by ◦ Apical foramina, ◦ Accessary canals, ◦ Endodontic perforation, ◦ Opening in the floor of pulp chamber, 19
  20. 20. Cont.  Clinical features ◦ Severe throbbing pain in the affected tooth ◦ The offending tooth may be sensitive to percussion. ◦ Mobility may or may not be present.  Radiographic features ◦ Tooth has caries with periapical pathology, root # or erosion. ◦ There may be periapical radiolucency. 20
  21. 21. Cont.  Treatment ◦ Antibiotics ◦ Analgesics ◦ Drainage through pulp chamber ◦ Extraction of tooth ◦ Endodontic treatment 21
  22. 22. Acute dentoalveolar abscess  Etiology  Continuation of periapical abscess.  Clinical features  Pain  Submucosal swelling in the sulcus on the outer aspect of alveolar process.  If left untreated, swelling bursts & produces a sinus. 22
  23. 23. Cont.  Radiologic features  More marked radiolucency than periapical abscess.  Treatment  Same as periapical abscess.  Extraoral incision & drainage may be required. 23
  24. 24. Acute periodontal abscess  Etiology  Periodontitis with periodontal pockets.  Clinical features  Dull pain  Pus discharge via gingival pocket  Sinus either on the outer or inner aspect of alveolar process. 24
  25. 25. Spread of oral infection  Routes of spread  Direct continuity through tissues  By lymphatics to the lymph nodes.From lymph nodes to tissues results in secondary areas of cellulitis or tissue space abscess.  By blood stream-local thrombophlebitis may spread via the veins entering the cranial cavity producing cavernous sinus 25
  26. 26. Cont.  Factors influencing spread ◦ General factors  Host resistance  Virulance of micro organism  Combination of both ◦ Local factors  Anatomic barriers-  Alveolar bone  Periosteum  Adjacent muscles & fascia 26
  27. 27. General clinical features in patient with orofacial infection  Redness due to vasodialtation  Swelling due to accumulation of exudate or pus  Temperature over the infected area due to increased blood flow & increased metabolism  Pain due to pressure in nerve endings & release of mediators of pain.  Fever 27
  28. 28. Cont.  Head ache  Lymphadenopathy ◦ Acute infection-soft, tender, enlarged, surrounding tissues are edematous& overlying skin is erythematous ◦ Chronic infection-firm, nontender enlarged lymph nodes.  Presence of draining sinus & fistula  Difficulty in opening mouth 28
  29. 29. Cont.  Increased salivation  Change in phonation  Difficulty in breathing  Bad breath 29
  30. 30. Radiologic examination  IOPA  Lateral oblique view of mandible  PA & lateral view of neck  CT  MRI 30
  31. 31. General principles of management of a/c orofacial infections  Immediate hospitalization  Medical treatment  Surgical management 31
  32. 32. Medical management  Antibiotics  Hydration of the patient through iv route  Analgesics  Bed rest  Mouth rinses  Opening of tooth for drainage 32
  33. 33. Surgical management  Needle decompression  Done in case of pterigomandibular, peritonsillar,lateral pharyngeal space infection that is likely to rupture during passage of endotracheal tube.  Extraction of tooth  Early extraction leads to early resolution of infection by eliminating the source of infection & provides a portal of drainage 33
  34. 34. Cont.  Surgical drainage-  Incision is placed on the most dependent areas.  Incision should be parallel to skin creases  Incision should lie in aesthetically acceptable site as far as possible.  Incision should be supported by healthy underlying dermis & subcutaneous tissue. 34
  35. 35. Cont.  Intraoral incision should not be placed over frenal attachments, should be placed parallel to nerve fibers in the region of mental nerve.  Removal cause such as infected tooth, segment of necrotic bone, foreign body, if not already done, then is done at the time of drainage procedure 35
  36. 36. Classification of fascial spaces Primary maxillary spaces  Canine  Buccal  Infratemporal Primary mandibular spaces  Submental  Buccal  Submandibular  Sublingual 36
  37. 37. Cont. Secondary fascial spaces  Masseteric  Pterigomandibular  Superficial & deep temporal  Lateral pharyngeal  Retropharyngeal  Prevertebral  Parotid space 37
  38. 38. Canine space infection Etiology  Infection of maxillary canine, premolar & mesiobuccal root of 1st molar. Boundaries  Inferiorly-caninus muscle  Anteriorly-orbicularis oris muscle  Posteriorly-buccinator muscle  Medially-anterolateral surface of maxilla 38
  39. 39. Cont.  Clinical features  Swelling of cheek & upper lip  Obliteration of nasolabial fold  Drooping of angle of mouth  Edema of lower eyelids  Marked Periorbital Edema  Redness & Marked Tenderness Of Facial Tissues 39
  40. 40. Cont.  In c/c stage-fistula near the medial canthus eye.  Offended tooth is mobile & tender to percussion  Treatment  Incision & drainage-  Through the mucosa of buccal vestibule in the region of lateral incisor & canine. 40
  41. 41. Cont.  A curved mosquito artery forceps is inserted, pus is evacuated & a drain is inserted & is secured with suture 41
  42. 42. Buccal space infection Etiology  Infection of maxillary & mandibular premolars & molars  Pericoronitis of lower 3rd molar. Boundaries  Anteromedially-buccinator muscle  Posteromedially-masseter muscle  Laterally-deep fascia from parotid capsule & platysma muscle 42
  43. 43. Cont.  Inferiorly-deep fascia & depressor anguli oris  Superiorly-zygomatic process of maxilla & zygomaticus major & minor muscles Contents  Buccal pad of fat  Stenson`s duct  Facial artery 43
  44. 44. Cont.  Clinical features  Gum boil in vestibule  Swelling extending from lower border of mandible to infraorbital margin, from anterior border of masseter to angle of mouth  Edema of lower eyelid 44
  45. 45. Cont.  Spread  To pterigomandibular space  Infratemporal space  Submasseteric space  Treatment  Incision & drainage through mucosa of cheek in premolar molar region. 45
  46. 46. Infratemporal space infection  Also called retrozygomatic space because it is situated behind the zygomatic bone.  Etiology  Infection of buccal roots of maxillary 2nd &3rd molars  LA injection with contaminated needles in the area of tuberosity  Spread from other spaces 46
  47. 47. Cont.  Boundaries  Laterally - by ramus of mandible, temporalis muscle & its tendon .  Medially - medial pterygoid plate , lateral pterygoid muscle , medial pterygoid muscle ,lower part of temporal fossa of the skull & lateral wall of pharynx .  Superiorly - greater wing of sphenoid & by zygomatic arch . 47
  48. 48. Cont.  Inferiorly - lateral pterigoid muscle  Anteriorly - infra temporal surface of maxilla  Posteriorly- parotid gland  Contents  Medial & lateral pterigoid muscle  Pterigoid venous plexus  Maxillary artery  Mandibular nerve 48
  49. 49. Cont.  Middle meningeal artery  Clinical features  Limitation of mouth opening  Swelling in front of ear on the affected side  Proptosis of eye  Swelling in the area of tuberosity  Elevation of temperature 49
  50. 50. Cont.  Incision & drainage  Incision is given in buccal vestibule opposite the 2nd & 3rd molars  In severe infection incision is made at the upper posterior edge of temporalis muscle.  Sinus forceps is directed upwards & medially. 50
  51. 51. Cont.  In case of failure to improve mouth opening temporalis myotomy or excision of coronoid process is done. Spread  To temporal space  Pterigomandibular space  Cavernous sinus 51
  52. 52. Abscess of upper lip Etiology  Infection of upper incisors & canine Clinical features  Swelling in the base of the upper lip  Swelling in vestibule Treatment  Antibiotics  Incision & drainage  Extraction of offending tooth or RCT 52
  53. 53. Palatal abscess Etiology  Periodontal abscess from palatal pockets  Apical abscess from palatal roots of posterior teeth usually from the lateral incisor Boundaries  Inferiorly-hard palate  Superiorly-periosteum & mucosa  Laterally-alveolar process of maxilla &53
  54. 54. Cont. Clinical features  Fluctuant swelling in palate near the offending tooth  Offending tooth is tender to percussion Incision & drainage  Anterioposterior incision is made through the mucosa down to bone 54
  55. 55. Submental space infection Etiology  Infection from 6 mandibular anterior teeth  Infection of submental lymph nodes Boundaries  Laterally-lower border of mandible, anterior belly of digastric muscle  Superiorly-mylohoid muscle 55
  56. 56. Cont.  Inferiorly-deep cervical fascia, platysma, superficial fascia, skin Contents  Submental lymph nodes  Anterior jugular vein Clinical features  Distinct ,firm swelling in midline ,beneath the chin 56
  57. 57. Cont.  Skin overlying the swelling is board like & taut  Fluctuation of swelling  Nonvital, fractured or carious anterior teeth  Offending tooth is tender on percussion& sometimes mobile 57
  58. 58. Cont. Incision & drainage  Transverse incision in skin below symphysis of mandible. Spread  Submandibular space 58
  59. 59. Submandibular space infection Etiology  Infection From Mandibular Molars  Infection Of Submandibular Salivary Gland  Infection From Submental Space  Infection From Submental Lyph Nodes  Infection From Sublingual Space  Infection from middle 1/3 of tongue, posterior part of floor of mouth, maxillary teeth, cheek, maxillary sinus59
  60. 60. Cont. Boundaries  Anteromedially-mylohyoid Muscle  Posteromedially-hyoglossusmuscle  Superolaterally-medial Surface Of Mandible  Anteroposteriorly-anterior belly of digastric  Posterosuperiorly-posterior belly of digastric,stylohyoid ,stylopharyngeus musle 60
  61. 61. Cont.  Laterally-platysma & skin  Contents  Submandibular salivary gland  Submandibular lymphnodes  Facial artery & vein  Clinical features  Firm swelling in submandibular region  Constitutional symptoms 61
  62. 62. Cont.  Tenderness of swelling  Redness of overlying skin  Teeth Are Sensitive To Percussion & Mobile  Dysphagia  Moderate Trismus 62
  63. 63. Cont.  Incision & drainage  Incision of 1.5 to 2cm length is made 2cm below the lower border of mandible in the skin creases.  Skin & subcutaneous tissues are incised.  Spread  Submental space  Submandibular space of opposite side  Sublingual space 63
  64. 64. Sublingual space infection Etiology  Infection from mandibular incisors, canines, premolars & molars Boundaries  Inferiorly-mylohyoid muscle  Laterally-medial side of mandible  Medially-hyoglossus, genioglossus, geniohyoid muscles  Posteriorly-hyoid bone 64
  65. 65. Cont.  Contents  Geniohyoid, genioglossus, mylohyoid muscle  Deep part of submandibular salivary gland  Sublingual salivary gland  Lingual nerve  Hypoglossal nerve 65
  66. 66. Cont.  Clinical features  Enlarged tender lymph nodes.  Pain & discomfort on deglutition  Speech is affected  Painful swelling in floor of mouth  Tongue may be pushed superiorly  Incision & drainage  Incision made close to lingual cortical plate. 66
  67. 67. Cont.  Spread  Sublingual space of opposite side  Submandibular space  Pterigomandibular space  Parapharyngeal space  Submental & submandibular lyphnodes 67
  68. 68. Temporal space  Etiology  Secondary to the involvement of infratemporal space  Boundaries  Superficial temporal space-b/w temporal fascia & temporalis muscle.  Deep temporal space-b/w temporalis muscle & skull 68
  69. 69. Cont.  Clinical features  Pain  Trismus  Swelling over temporal region  Incision & drainage  Incision in temporal region in hairline 45 to zygomatic arch 69
  70. 70. Parotid space  Etiology  Infection through stenson`s duct  Blood borne infection  Infection from submasseteric,pterigomandibular & lateral pharyngeal space  Boundaries  Inferiorly-stylomandibular ligament  Anteriorly-masseteric space 70
  71. 71. Cont.  Space formed by splitting deep cervical fascia around the parotid gland  Contents  Parotid gland  Parotid lymph nodes  Facial nerve  Retromandibular vein  External carotid artery 71
  72. 72. Cont.  Clinical features  Severe pain referring to ear accentuated by eating  Swelling extending from zygomatic arch to lower border of mandible.  Ear lobe may be lifted up  Pus escapes from stenson`s duct when gland is milked 72
  73. 73. Cont.  Incision & drainage  Incision is made on skin behind the posterior border of mandible extending from inferior aspect of lobule of ear to just above mandible  Spread  Submasseteric space  Pterigomandibular space  Lateral pharyngeal space 73
  74. 74. Submasseteric space infection  Etiology  Infection Of Lower 3rd Molar  Boundaries  Anterior-anterior border of masseter & buccinator muscle  Posterior-parotid gland,posterior part of masseter  Inferior- attachment of masseter to lower border of mandible 74
  75. 75. Cont.  Medial-lateral surface of ramus of mandible  Lateral-medial surface of masseter muscle  Contents  Masseteric Nerve  Superficial Temporal Artery  Transverse Facial Artery 75
  76. 76. Cont.  Clinical Features  Moderate swelling extending from lower border of mandible to zygomatic arch, anteriorly to anterior border of masseter, posteriorly to posterior border of mandible  Tenderness over angle of mandible  Complete Limitation Of Mouth Opening  Pyrexia & Malaise 76
  77. 77. Cont.  Incision & drainage  Intraoral-incision is made vertically over the lower part of anterior border of ramus of mandible, deep to bone  Extraoral-incision is placed in skin behind the angle of mandible 77
  78. 78. Pterigo - mandibular space infection  Etiology  Pericoronitis related to the mandibular third molar .  Inferior alveolar nerve block using contaminated needle .  Infection form maxillary third molar .  Boundaries .  Posterior - parotid gland . 78
  79. 79. Cont.  Medial - lateral surface of medial pterygoid muscle .  Lateral - medial surface of ramus of mandible .  Anterior -pterygomandibular raphae .  Superior - lateral pterygoid muscle .  Contents .  Lingual nerve .  Mandibular nerve . 79
  80. 80. Cont.  Inferior alveolar artery .  Mylohyoid muscle  Clinical features .  Limitation of mouth opening .  Tenderness & swelling medial to anterior border of ramus of the mandible .  Dysphagia .  Difficulty in breathing 80
  81. 81. Cont.  Incision & drainage .  Intraoral – a vertical incision; approximately 1.5 cm in length , is made on the anterior & medial aspect of the ramus of mandible .  Extraoral - an incision is taken in the skin below the angle of the mandible .  Spread .  Infra temporal space 81
  82. 82. Cont.  Lateral pharyngeal space .  Retropharygeal space .  Submandibular space . . 82
  83. 83. LATERAL PHARYNGEAL SPACE .  Etiology  Mandibular third molar area .  Sublingual , submandibular & ptergomandibular space infection .  Boundaries .  Inferiorly - hyoid bone .  Anteriorly - pterygomandibular raphe  Laterally - ascending ramus of mandibular  Medially - pharyngeal wall . 83
  84. 84. Cont.  Posteriorly - styloid muscle , upper part of carotid sheath , prevertebral fascia .  Contents  Anterior compartment - lymph nodes , facial artery , loose areolar connective tissue .  Posterior compartment - carotid sheath , internal carotid artery , glossopharyngeal nerve , cervical 84
  85. 85. Cont.  Clinical Features .  Respiratory Embarrassment Due To Edema Of The Larynx .  Malaise .  Pyrexia .  Brawny Induration Of The Face .  Trismus .  Severe pain  Dysphagia 85
  86. 86. Cont.  Incision & drainage  Extraoral - an incision is made along the anterior border of sternocleidomastoid muscle , extending from below the angle of the mandible , to the middle third of submandibular gland .  Intraoral - a vertical incision is placed over the pterygomandibular raphe . 86
  87. 87. Retropharyngeal space (prevertebral space )  Etiology  Infection from the iateral pharyngeal space  Boundaries .  Laterally - carotid sheath  Inferiorly-6th thoracic vertebra  Clinical features .  Painful deglutition .  Snoring . 87
  88. 88. Cont.  Choking .  Stertorous breathing .  Incision & drainage .  Same as lateral pharyngeal space 88
  89. 89. Pericoronitis  Definition  An inflammatory process involving the soft tissue covering the crown of partially erupted or unerupted teeth  Etiology  Impacted teeth .  Trauma to the overlying gingivae from the cusps of an opposing tooth . 89
  90. 90. Cont.  Clinical features  Dull pain  Swollen ,red,tender gingival pad  Pus discharge from the gingival pad  Foetor oris  Indentations of cusps of upper teeth  Discomfort on swallowing  Restriction of oral opening 90
  91. 91. Cont.  Enlarged tender submandibular lymph nodes  Pyrexia/fever  Malaise  Anorexia  Spread  Buccal space  Submandibular space  Pterigomandibular space 91
  92. 92. Ludwig`s angina  Definition  A massive, firm, brawny, cellulitis or induration & acute toxic stage involving simultaneously submandibular, sublingual & submental spaces bilaterally.  Etiology  Odontogenic- ◦ A/c dentoalveolar abscess ◦ A/c periodontal abscess 92
  93. 93. Cont. ◦ Pericoronal abscess ◦ Infected mandibular cyst  Iatrogenic ◦ La using contaminated needles  Trauma in orofacial region  Osteomyelitis  Submandibular & sublingual sialadenitis  Secondary infections of oral malignancies 93
  94. 94. Cont.  Tonsillitis  Foreign bodies like fish bone  Oral soft tissue lacerations  Clinical features  Pyrexia .  Anorexia  Chills .  Malaise .  Dysphagia . 94
  95. 95. Cont.  Impaired speech .  Hoarseness of voice .  Firm or hard brawny swelling in bilateral submandibular & submental regions extending to the clavicles .  Swelling is non pitting , non fluctuant ,tender with ill defined borders .  Restricted mouth opening .  Air way obstruction . 95
  96. 96. Cont.  Mouth remains open due to edema of sublingual tissues  Reduced tongue movements .  Increased respiratory rate .  Cyanosis .  Raised floor of mouth .  Tongue is raised against palate .  Increased salivation .  Drooling of saliva . 96
  97. 97. Cont.  Spread  Submasseteric space .  Pterygomandibular space .  Parapharyngeal space .  Paratonsillar space .  Mediastinum .  Cavernous sinus thrombosis . 97
  98. 98. Cont.  Treatment  Maintenance of air way . ◦ Nasotracheal intubation  Surgical decompression. ◦ Bilateral submandibular incision s & a midline submental incision 1cm below inferior border of mandible for drainage .  Extraction of offending tooth . 98
  99. 99. Cont.  Antibiotic therapy . ◦ Aqueous penicillin G 2 - 4 million units , i v 4-6 hourly or 500mg 6 hourly orally ◦ Ampicillin or amoxycillin 500mg 6 & 8 hourly i v & orally respectively . ◦ Cloxacillin 500mg orally 8 hourly . ◦ Erythromycin 600mg 6- 8 hourly . ◦ Gentamycin 80mg i m bd . ◦ Clindamycin i v 300mg 600mg 8 hourly . or orally 99
  100. 100. Cont. ◦ Metronidazole 400mg 8 hourly orally or i v .  Hydration of the pt .  Hydro therapy ◦ Cold application decreases inflammation , exudates , edema .  Complications  Osteomyelitis .  Maxillary Sinusitis .  Septicaemia . 100
  101. 101. Cont.  Mediastinitis .  Pericarditis .  Jugular vein thrombosis .  Meningitis .  Brain abscess .  Cavernous sinus thrombosis 101

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