Fascial spaces, neurological manifestations to infection, and fatal complications.

1. Subjects
 Fascial spaces infection of Max.Fac. Region.
 Neurologic considerations of Max.Fac.infection
 Fatal complications of MaxFac. Infection.
Time allowed:
4 hours.
Atef Fouda
Prof. of Oral and maxillofac.Surg.
10/13/19

2. Relation between fascial spaces
PART I

3. Mandibular spaces
Submandibular
space
Submental
space

4. Submandibular
space
Sublingual
space
Submental
space
Mandibular spaces

5. Mandibular spaces
Spread of
infection
between
sublingual and
submandibular
spaces

6. Sublingual infection
push the tongue
backward narrowing
the airway
Mandibular spaces

7. Mandibular spaces
 Sub masseteric space
 Pterygo Mandibular space
 Superficial temporal space
 Deep temporal space.
 Infratemporal space.
Masticator spaces

8. Maxillary spaces
Maxilary anterior
teeth and
premolars.
Canine space

9. Maxilary posterior
teeth.
Buccal space
Maxillary spaces

10. Lateral(para)pharyngeal
space
is the continuation
of
buccal space.
Maxillary spaces

11. Maxillary spaces

12. Lateral(para)pharyngeal
space is the continuation of
Infratemporal space
&
buccal space.
And
Pterygomandibular space
Maxillary spaces

13. Retropharyngeal
space
is the continuation
of Lateral
(para)pharyngeal
space
Maxillary spaces

14. Retropharyngeal space
lead to
Danger space
Mediastinal
space.
C6
Maxillary spaces

15. Para-pharyngeal
Submental
Pterygo
mandibular
Masseteric
Buccal
Retro-
pharyngeal
Mediastinal
Sublingual
Sub
mandibular
Dangerous
Mandibular infection

16. Para-pharyngeal
Submental
Pterygo
mandibular
MassetericBuccal
Retro-
pharyngeal
Mediastinal
Sub
mandibular
Dangerous
Maxillary infection
Infra-
Temporal
Canine
Deep
Temporal
Superficial
Temporal
Intra-cranial
Sub
lingual

17. Transmission
of
infection
to
cavernous sinus
Maxillary spaces
Infra-
Temporal
Canine

18.  Mediastinal
infection
 [vital organs].
 Lateral pharyngeal
space infection
[vascular problems]
Submandibular-Sublingual-Submental
[Air-way].
Fatal complications of maxillofacial infection
Canine-Infratemporal
Neurological & [Brain damage].

19. Cavernous sinus thrombosis
Sensory nerves:
 Ophthalmic
nerve.
 Maxillary
nerve.
Motor nerves:
 Oculomotor nerve.
 Trochlear nerve.
 Abducent nerve.
Vascular structures:
 Internal carotid artery.
 Venous drainage.
G08

20. Cavernous sinus thrombosis
Neurological manifestations:
Sensory deficits [V1 & V2]
 Ophthalmic nerve.
 Maxillary nerve.
Hypoesthesia or hyperesthesia of
the ophthalmic and maxillary
branch of the fifth nerve is
common.
Periorbital sensory loss and
impaired corneal reflex.

21. Cavernous sinus thrombosis
Neurological manifestations:
Motor cranial nerves:
 Oculomotor nerve.[III]
 Trochlear nerve. [IV]
 Abducent nerve. [VI]

22. Cavernous sinus thrombosis
Eyelid drooping (ptosis)
pupil dilation (mydriasis)
 Oculomotor nerve.[III]
ptosis
Mydriasis
 Trochlear nerve. [IV]
 Abducent nerve. [VI]
Diplopia

23. Vascular structures:
 Internal carotid artery.
 Venous drainage.
Chemosis
Papilledema,
retinal hemorrhages,
and decreased visual acuity .
progressing to blindness due to
venous congestion within the
retina.
Chemosis
Increase of intracranial pressure:
Migraine headache
carotid artery aneurysm or fistula
Orbital cellulitis

24. Chemosis
ptosis
Mydriasis
Papilledema
Exophthalmos
Periorbital cellulitis

25. MRI including magnetic resonance
angiography is more sensitive than
CT scan and is the imaging of choice
to diagnose CST.
Diagnosis:

26. Anticoagulant:
Early heparinization [to achieve an INR of 2 to 3]
• Intracranial hemorrhage should first be ruled out before initiating heparin therapy.
Unilateral affection.
Steroid therapy helpful when progression to pituitary insufficiency
occurs.
Steroid
• Vancomycin plus ceftriaxone.
• Metronidazole IV should be added if anaerobic bacterial infection is suspected
(dental or sinus infection).
Antimicrobials
Treatment:

27. 11/14/2019
PART II

28. Ludwig’s Angina
 Nasal intubation under sedation with topical anesthesia is
the preferred method of airway control.
 Guided Oral or direct laryngoscopy can be particularly
difficult because of the inability to retract the tongue into the
submandibular space and posterior displacement of the
tongue by the infection.
 Emergent tracheostomy may be necessary in patients with
Ludwig's angina if flexible endoscopic intubation cannot be
accomplished. Cricothyrotomy may be technically difficult
due to anatomic distortion and opens tissue planes that
increase the risk of spreading infection into the mediastinum.
 Hospitalization:
 Air way management:

29. C.T
MRI

30. parapharyngeal space infection
Lateral(para)pharyngeal
space is the continuation of
Infratemporal space
&
buccal space.
And
Pterygomandibular space

31. Complications
 Carotid artery rupture.
 Jugular vein coagulopathy.
 Retropharyngeal extension [dangerous
space].
 Necrotizing fasciitis.
Carotid artery angiography

32. Retropharyngeal extension [dangerous space]
Retropharyngeal space
is the continuation of
Lateral(para)pharyngeal
space
and
Infratemporal space

33. Complications
 Extension to dangerous space.
 Mediastinitis.
 Necrotizing fasciitis.

34. Mediastinitis.
 Pressure on vital organs.
 Major blood vessels coagulopathy.
 Transmission of infection to vital
organs.

35. Necrotizing fasciitis.
 A vascularity of the area due
to infection.
 Mainly in compromised
patients.
 Antimicrobial agents.
 Surgical debridement.
 Hyperbaric oxygen.
Management:

36. Lab investigations.
 Blood cell count.
 Culture and sensitivity.
 C-reactive protein.
 PCR [New].
Imaging.
 X-ray.
 MRI
 C.T
 Ultra-sound.
Diagnostic aids:

37. Drawbacks of culture and sensitivity testing:
4-Delayed treatment [72 hours].
5-Economic status of the patient not taken into consideration.[price of antibiotic].
6-Errors of sampling may affect results.
7-Viral and fungal infections may be neglected.
8-Change of domain infective organism by time.
9-Most of viral infections couldn’t be cultured.
10-Systemic conditions of the patient may interfere with the results.
11-Availability of antibiotic should be taken into consideration.
12-Quality depend on the laboratory procedure.
1-Couldn’t test the ability of the antibiotic to reach the site of infection.
2-Host's immune system may affect antibiotic selected [bactericidal-bacteriostatic].
3-Problem of mixed infection.

38.  CRP is a protein found in blood which rises in response to infection in order to activate
the complement system.
 CRP binds to the surface of dead cells and some bacteria which activates the
complement system and promoting phagocytosis by macrophages, which clears necrotic
cells and bacteria.
 Normal concentration in healthy human serum is between 5 and 10 mg/L.
 bacterial infection (40–200 mg/L) and in severe infection (>200 mg/L).
C-reactive protein.

39. Interferon alpha inhibits CRP production from liver cells which may explain the relatively
low levels of CRP found during viral infections compared to bacterial infections.
Diagnostic use:
Measuring and charting CRP values can prove useful in determining disease progress or the
effectiveness of treatments.
CRP is a more sensitive and accurate reflection of the acute phase response than the ESR.
CRP returns to normal more quickly than ESR in response to therapy.

40. genetic testing can be used to detect genes in the microorganism that cause resistance to certain
antimicrobial drugs Methicillin-Resistant Staphylococcus Aureus (MRSA) bacteria can be identified by
testing for the bacterial genes.
If a microorganism is difficult to culture or identify by other methods, doctors can do tests to identify pieces
of the microorganism’s genetic material. This genetic material consists of nucleic acids: deoxyribonucleic
acid (DNA) or ribonucleic acid (RNA).
The polymerase chain reaction (PCR) is an example of this type of test. The PCR technique is used to
produce many copies of a gene from a microorganism, making the microorganism much easier to identify.
Most nucleic acid–based tests are designed to identify the presence of a microorganism (called qualitative
testing). However, a few of these tests can measure the amount of genetic material present (called
quantitative testing) in certain microorganisms, such as HIV and hepatitis C, and thus determine how
severe the infection is. Quantitative tests can also be used to monitor how well treatment is
working[prognosis].
New trends in diagnosis:
Polymerase chain reaction [PCR].

41. New trends in diagnosis:
Polymerase chain reaction [PCR].

42. New trends in diagnosis:
Polymerase chain reaction [PCR].
Infectious disease applications:
• PCR allows for rapid and highly specific diagnosis of infectious diseases, including those
caused by bacteria or viruses.
• PCR also permits identification of non-cultivatable or slow-growing microorganisms such
as mycobacteria, anaerobic bacteria, or viruses from tissue culture.
• Some organisms are difficult to sample from patients and slow to be grown in the
laboratory[T.B] . PCR-based tests have allowed detection of small numbers of disease
organisms (both live or dead), in convenient samples.
• PCR tests have been developed that can detect as little as one viral genome. Infections can
be detected earlier.

43. • Donated blood can be screened directly for the virus.
• Detailed genetic analysis can also be used to detect antibiotic resistance, allowing
immediate and effective therapy.
• The spread of a disease organism through populations can be monitored by PCR testing.
• In many cases, the appearance of new virulent sub-types can be detected and monitored.
• The high sensitivity of PCR permits virus detection soon after infection and even before
the onset of disease. Such early detection may give physicians a significant lead time in
treatment. The amount of virus in a patient can also be quantified by PCR-based DNA
quantitation techniques.
New trends in diagnosis:
Polymerase chain reaction [PCR].
Infectious disease applications:

44. In modern laboratories, bacteria are usually identified by
characterization of the genome: identifying the characteristics of the
DNA and RNA of a sample species. This type of testing is generally
considered more reliable (and soon, less expensive) than actually
growing bacterial cultures and exposing them to various types of
antibiotics to see which drugs kill or inhibit the bacterial growth.
New trends in diagnosis:
Polymerase chain reaction [PCR].
Infectious disease applications:
• Expensive, not widely available.
• Each genetic test is specific to only one specific microorganism.

45. Imaging:
osteomyelitis
Simple plain x-ray usually more than enough to give required data for source and spread infection.
In few cases advanced imaging required to detect Spread of infection into:
• Hidden spaces.
• Soft tissue vital structures.
• Sequestration of bone.
• Lymph nodes condition.
• Air way endangering.
Infra-temporal
space infection
S.g infection
Peritonsilar
abscess
MRI-Lymph nodes