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Fascial Space Infection part 2

Fascial Space Infection Part - 2 retropharyngeal space, ludwigs angina, pharyngeal space, cavernous sinus thrombosis, mediastinitis

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DEEP FASCIAL SPACE 
INFECTIONS 
PART-2 
ARJUN SHENOY 
DEPT OF OMFS
• MASSETRIC SPACE 
• LUDWIGS ANGINA 
• PHARYNGEAL SPACE 
• RETROPHARYNGEAL SPACE 
• CAVERNOUS SINUS THROMBOSIS 
• MEDIASTINITIS 
• CONCLUSION 
• REFERENCES
MASTICATORY SPACE 
MASSETRIC + PTERYGOID + TEMPORAL
MASTICATOR SPACE 
• Massetric, pterygoid and temporal- well differentiated 
• Communicate with each other 
• Also with 
• Buccal 
• Submandibular 
• Parapharyngeal 
• MASTICATOR SPACE CONTENTS- 
• Muscles of mastication 
• Internal maxillary artery 
• Mandibular nerve
Fascial Space Infection part  2
SUBDIVISION 
• MASSETRIC SPACE- 
• Lateral- masseter 
• Medial- mandibular ascending ramus 
• PTERYGOID- 
• Lateral-mandible 
• Medially- pterygoid muscle 
• Communication- 
• Superiorly- superficial and deep temporal space 
• Anteriorly- buccal space 
• Posteriorly- lateral pharyngeal space

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Fascial Space Infection part 2

  • 1. DEEP FASCIAL SPACE INFECTIONS PART-2 ARJUN SHENOY DEPT OF OMFS
  • 2. • MASSETRIC SPACE • LUDWIGS ANGINA • PHARYNGEAL SPACE • RETROPHARYNGEAL SPACE • CAVERNOUS SINUS THROMBOSIS • MEDIASTINITIS • CONCLUSION • REFERENCES
  • 3. MASTICATORY SPACE MASSETRIC + PTERYGOID + TEMPORAL
  • 4. MASTICATOR SPACE • Massetric, pterygoid and temporal- well differentiated • Communicate with each other • Also with • Buccal • Submandibular • Parapharyngeal • MASTICATOR SPACE CONTENTS- • Muscles of mastication • Internal maxillary artery • Mandibular nerve
  • 6. SUBDIVISION • MASSETRIC SPACE- • Lateral- masseter • Medial- mandibular ascending ramus • PTERYGOID- • Lateral-mandible • Medially- pterygoid muscle • Communication- • Superiorly- superficial and deep temporal space • Anteriorly- buccal space • Posteriorly- lateral pharyngeal space
  • 7. ORGIN molar (commonly 3rd molar) Contaminated injections Temporocranial flaps - neurosurgery Nearby contiguous spaces Circumzygomatic wiring in trauma TMJ surgery • Clinical hallmark- trismus • Exception- immunocompromised • Swelling – may not be prominent
  • 8. • Infectious process deep to muscles - • swelling less prominent • contrast to buccal space infections •
  • 9. SICHER’S APPROACH • Sicher suggested approach to all compartments – incision through pterygomandibular raphae • Feasible in cadavers - not trismus • Oral approach-compromise airway • purulent oozing pus • Difficult drain - loosening
  • 10. I & D • MASSETRIC + PTERYGOID SPACE- • Extra-oral – easier technically & prudent • Sharp dissection - external angle of the mandible • Allows dependent drainage of both spaces
  • 11. SURGICAL INTERVENTION • TEMPORAL SPACE – • Intra-oral- sichers-incision • Percutaneous- • incision -slightly superior-zygomatic arch
  • 12. LUDWIGS ANGINA Wilhelm Frederick von Ludwig
  • 13. DEFINITION • Ludwigs angina is a firm , acute, toxic cellulitis of the submandibular and sublingual spaces bilaterally and of the submental space • Three F’s • Feared • Not fluctuant • Fatal
  • 14. HISTORICAL PERSPECTIVE • Wilhelm Frederick von Ludwig first described in 1836 a potentially fatal, rapidly spreading soft tissue infection of the neck and floor of the mouth
  • 15. • Ludwig published his now-famous paper on Ludwig's angina with no title in 1836. • A colleague dubbed the condition "Angina Ludovici" (Ludwig's angina) a year later • Pre-antibiotic era- 50% mortality • 5%- use of penicillin • observed frequently in compromised host • Less than 1% of all OMFS admissions • Untreated- mortality rate 100%
  • 16. • Compound mandibular fracture • Puncture wounds of oral floor • Secondary infection of oral malignancies • Submandibular gland sialadenitis • Oral soft tissue lacerations • Reported in new born • Pseudo-ludwigs angina /phenomenon- non dental
  • 18. CLINICAL FEATURES • Bilateral infection of sublingual and submandibular spaces • brawny edema, • elevated tongue • airway obstruction • paucity of pus
  • 19. MICROBIOLOGY • Streptococci or mixed oral flora are commonly reported from cultures • Contemporary- Ecoli ,pseudomonas and anaerobes bacteroides and peptostreptococcus • Prevotello melaninogenicus, prevotella oralis, prevotella corrodens also isolated
  • 20. DIFFERENTIAL DIAGNOSIS • angioneurotic edema • lingual carcinoma • sub- lingual hematoma • salivary gland abscess • lymphadenitis • cellulitis • peritonsilar abscess
  • 21. TREATMENT • Establisment and maintainance of an adequate airway are the sine qua non of therapy • Early diagnosis,maintainance of patent airway, intense empirical and intra-venous prolonged antibiotic therapy, extraction of affected teeth, hydration, early surgical drainage, • Pencillinplus, metronidazole or clindamycin or imipenem
  • 22. TRACHEOSTOMY • Death more likely to occur from airway obstruction than sepsis • Tracheostomy most routine during most of twentieth century • Difficult to perform in late stage –massive neck oedema and tissue distortion
  • 23. BLIND NASAL INTUBATION • Swollen tongue and glottis oedema- time consuming , unsuccessful and fraught with danger especially if attempted by inexperienced anaesthesiologist. • Danger of rupturing a bulging lateral pharyngeal or retropharengeal abscess
  • 24. FIBRE-OPTIC ASSISTED INTUBATION • Cervical soft tissue plain films + CT scan • fiberoptic laryngeoscopy- premedicated +cooperative patient • Tracheal intubation under deep inhalation anaesthesia may be successful obliviating the need for tracheostomy
  • 26. SURGEONS PERSPECTIVE • Sedative and narcotic agents- rapid respiratory deterioration • Some authorities advocate high doses of antibiotic without surgery until fluctuance develops, in most surgeons experience prompt and deep surgical incision is required since fluctuance is uncommon and late • Diffuse cellulitis of deep spaces – 70% cases require surgical intervention and drainage • “A chance to cut is a chance to cure”
  • 27. INCISION • Horizontal incision midway between the chin and the hyoid bone - classic approach to the surgical drainage - ludwigs angina • “cut-throat”incision unaesthetic and unnecessary
  • 28. • Platysma and supra-hyoid fascia incised by this approach • Fascia of submandibular gland also entered • Mylohyoid muscle divided and sublingual space entered • A closed clamp is inserted through the median raphae of mylohyoid muscle and advanced to the hyoid bone at the base of the tongue
  • 29. NEEDLE ASPIRATION • Needle aspiration of deep fascialspace infection has been attempted obliviating need for open drainage • Ludwigs angina not amenable to this technique even if needle is CT guided • may result in reinfection • adequate drainage or premature closure of surgical
  • 30. DRAIN PLACEMENT • Bilateral incision into the submandibular spaces with blunt dissection to the midline suffices if a through and through drain or bilateral drains meeting in midline are placed combined with drainage of sublingual space • Relieves intense pressure of oedematous tissue on the airway and provides specimen for culture
  • 31. SCAR REVISION • Secondary revision of scarring may be necessary for cosmetic or to repair the stenosis of whartons duct • Disseminated intravascular coagulation-well recognized but fortunately uncommon sequelae of severe infection
  • 33. PHARYNGEAL SPACE • Lateral neck space shaped like a inverted cone • Base at skull and apex at the hyoid bone • Medial wall contiguous with carotid sheath ,lies deep to pharyngeal constrictor muscle • Divided into anterior and posterior compartments
  • 34. CAUSES • Pharyngitis • tonsillitis • parotitis • otitis • mastoiditis • dental infection • Herpetic gingivostomatitis involving pericoronal tissue
  • 35. CLINICAL FEATURES • Anterior compartment- • Pain, fever,chills • Medial bulging of the lateral pharengeal wall • Deviation of palatal uvula from midline • Dysphagia, swelling below angle of mandible • Posterior compartment- • Visible swelling with absence of trismus • Respiratory obstruction • Septic thrombosis of internal jugular vein • Carotid artery haemorrhage - later stage
  • 36. TREATMENT • CT more useful than standard radiographs • Therapy-antibiotic, surgical drainage, tracheostomy if indicated • Surgical approach – oral - incision of the lateral wall • External approach- exposure of carotid sheath-lateral tip • of sternocleidomastoid- retraction of sternocleidomastoid
  • 37. • Blunt dissection along posterior border of digastric muscle leads to lateral pharengeal space • Combined intra-oral + extraoral approach – mucosal incision – lateral to pterygomandibular raphae , large curved clamp passed medial to medial pterygoid muscle in a posterior-inferior direction. • Tip of clamp delivered through skin- cutaneous incision between the angle of the mandible and the sternocleidomastoid muscle
  • 39. RETROPHARYNGEAL SPACE • Space lies behind the esophagus and pharynx and extends inferiorly to the upper mediastinum and superiorly – base of skull • Orgin- nasal or pharyngeal infection in children • Oesophageal trauma, foreign bodies, tuberculosis • Symptoms- • Dysphagia • Dyspnea • Nuchal rigidity • Eosophageal regurgititation • fever
  • 40. • Visualization of pharynx- bulging of posterior wall – more prominent unilaterally • Adherance of median raphae to prevertebral fascia • Lateral soft tissue radiographs useful • widening of retropharyngeal space • >3-6mm adults >14mm children (2nd vertebra) • Presence of gas in prevertebral soft tissue • Loss of normal lordtic curvature of cervical spine • CT- inferior extent + plain films
  • 41. TREATMENT • Early cases 10-40% resolve with medical management • Prompt surgical drainage – protocol • Tracheostomy indicated • Transoral approach- Extreme trendelenburg position and constant suction- under LA
  • 42. CONTINUED • Transoral- incision through midline of posterior pharyngeal mucosa-blunt dissection • Exernal approach- dependent • Incision- anterior border of STM • Muscle+carotid sheath retracted medially • Blunt finger dissection deeply • Upto level of hypopharynx • Deep drains placed + maintained • Overall mortality rate – approx. 10%
  • 43. CAVERNOUS SINUS THROMBOSIS • Orgin- ascending rom maxillary teeth, upper teeth, nose or orbit • Through valveless anterior and posterior fascial veins • Extremely high mortality rate
  • 44. INITIAL SIGNS • Proptosis • Fever • Obtunded state of consciousness • Ophthalmoplegia • Paresis of – • occulomotor • trochlear + abducens nerve
  • 45. MEDIASTINITIS • Extension of infection from deep neck spaces into the mediastinum • C/F – • Chestpain, fever • Severe dyspnea • Mediastinal widening • IV drug abusers- greater risk
  • 46. CONTINUED • Late complication • Progressive septicemia-mediastinal abscess-pleural effusion-empyema-pericarditis • Necrotizing mediastinitis- aerobic+anaerobic • Treatment- extensive long term antibiotic therapy and surgical drainage of mediastinum • Emergency neurosurgical intervention
  • 47. CONCLUSION • Incidence and severity have diminished with advent of antibiotic therapy • To be alert to the potential seriousness of these infections-never to be dismissed as simple dental abscess • Deep fascial infections must be recognized promptly and treated as an emergency • Repeat diagnostic and therapeutic measures may be necessary until the very end point
  • 48. REFERENCES • R.G Topazian , Oral & Maxillofacial Infections 4th edition • Journal of Oral and Maxillofacial Surgery, Volume 72, Issue 9, Supplement, September 2014, Pages e83-e84 • The Journal of Emergency Medicine, Volume 43, Issue 4, October 2012, Pages 605-611 • Journal of Plastic, Reconstructive & Aesthetic Surgery, Volume 60, Issue 4, April 2007, Pages 372-378 • Journal of Infection, Volume 50, Issue 1, January 2005, Pages 34-40 • Emergency Medicine Clinics of North America, Volume 18, Issue 3, 1 August 2000, Pages 481-519