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Infections of head and neck

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Infections of head and neck

  2. 2. Index  Introduction  Classification of infection  Stages of infection  Microbiology of odontogenic infections  Management of odontegic infections  Classification of fascial planes  Progression of infection  Space infections of maxilla  Space infections of mandible  Space infections of neck  Principles of treatment  Management  Refrences
  3. 3. Introduction  Potential or actual space between fascia and muscles containing nerves, blood vessels and connective tissue but this becomes pathway of infection in presence of infection  Infection may be defined as invasion and multiplication of microorganisms in body tissues, especially that causing local cellular injury due to competitive metabolism, toxins, intracellular replication, or antigen-antibody response  Fascial space infections are a relatively common presentation to both general medical and dental practitioners.  Infections originating in deeper structures can be severe, rapidly progressive and may cause prolonged morbidity, long term complications as well as potentially endanger life.
  4. 4. Classification of infections  According to the clinical appearance: a) Acute infections b) Chronic infections c) Acute exacerbation of a chronic infection  Depending on the etiological agent: a) Bacterial b) Viral c) Fungal  According to source of infection: a) Odontogenic b) Secondary infections of lesions such as cyst or tumors c) Infections arises from contaminated wound/trauma d) Iatrogenic infections
  5. 5. Stages of infections  Stage I: Initiation of infection • Mostly odontogenic in origin, • Periapical/periodontal/pericoronal infection • Mildly symptomatic or asymtomatic.  Stage II: Entry of infection in medullary bone • Symptomatic, patient seeks treatment • Tender on percussion • No space for pus to drain starts effecting the medullary bone  Stage III: Path of drainage • Pus follow path of least resistance • Perforates cortex that is thinner • Appears in soft tissues, extra oral swelling • May lead to cellulitis or abscess formation  Stage IV: Spread of infection • Spreads to another space along anatomical barriers • May perforate the skin to form sinus
  6. 6. Microbiology of odontogenic infections  Bacterial composition 1. 5%-aerobic bacteria 2. 60%-anaerobic bacteria 3. 35% mixed aerobic and anaerobic bacteria  Commonly cultured organisms: alpha- hemolytic Streptococcus, Peptostreptococcus, Peptococcus, Eubacterium, Bacteroides (Prevotella) melaninogenicus, and Fusobacterium.  Quantitative estimations of the number of microorganisms in saliva and plaque range as high as 1011/ml.
  7. 7. Microbiology – aerobic  Gram-positive cocci 85%  Streptococcus spp.  Streptococcus (group D) spp.  Staphylococcus spp.  Eikenella spp.  Gram-negative cocci  (Neisseria spp.) 2%  Gram-positive rods  (Corynebacterium spp.) 3%  Gram-negative rods  (Haemophilus spp.) 6%  Miscellaneous and undifferentiated 4%
  8. 8. Microbiology- Anaerobic  Gram-positive cocci 30%  Streptococcus spp.  Peptostreptococcus spp.  Staphylococcus spp.  Gram-negative cocci  (Veillonella spp.) 4%  Gram-positive rods 14%  Eubacterium spp.  Lactobacillus spp.  Actinomyces spp.  Clostridia spp.  Gram-negative rods 50%  Bacteroides spp.  Fusobacterium sp.
  9. 9. Management of odontogenic infections  Determine the severity of the infection  Complete history  Physical examination  State of the patients host defense  Treat the infection surgically  Support the patient medically  Choose the appropriate AB  Re-evaluate the patient frequently
  10. 10. Severity of infection  How the patient feels  Previous treatment  Self treatment  Past Medical History  Complete History  Chief Complaint  Onset  Duration  Symptoms
  11. 11. Clinical presentation  History-previous toothaches (onset, duration), presence of fever, and previous treatments (antibiotics ) important  Patients may complain of trismus, dysphagia and have shortness of breath should be investigated.  Findings vary from mild swelling and pain to life-threatening airway compromise and CNS impairment
  12. 12.  Inspection, palpation, and percussion are integral parts of the exam  Begin extraorally and then move intraorally  Skin of the face, head, and neck for swelling, erythema, sinus or fistula formation.  Assess for cervical lymphadenopathy and fascial space involvement  Assess for the presence and magnitude of trismus
  13. 13.  Examine quality and consistency:  Soft to fluctuant (fluid filled) to hard (indurated)  Normal vs abnormal tissue architecture:  Distortion of mucobuccal fold  Soft palate symmetric with uvula in midline (deviation → involvement of lateral pharyngeal space)  nasolabial fold, circumorbital areas
  14. 14.  Identify causative factors:  Tooth, root tip, foreign body, etc.  Vital signs should be taken:  Temperatures > 101 to 102°F accompanied by an elevated heart rate indicate systemic involvement of the infection and increased urgency of treatment.
  15. 15.  Imaging studies can further substantiate diagnosis – Panorex, Plain Films , CT , MRI  Computerized tomograms should be obtained when infection has spread into fascial spaces in the orbit or neck  Infections, well-localized to oral cavity do not require special imaging studies with a panorex being sufficient for diagnosis and treatment
  16. 16. Host – Defense mechanisms  Local defenses  Intact anatomic barrier  Indigenous bacteria  Humoral defenses  Immunoglobulins  Complement  Cellular defenses  Phagocytes  Lymphocytes
  17. 17. Medically compromised patients  Uncontrolled metabolic diseases  Diabetes  Alcoholism  Malnutrition  Suppressing diseases  Leukemia  Lymphoma  Malignant Tumors  Suppressing drugs  Chemotherapeutic agents  Immunosuppressives
  18. 18.  One of the most common & difficult problems  Range from low-grade to severe, life- threatening  Most are easily managed with minor surgery and antibiotics
  19. 19. Common types of infection:  Periapical, periodontal, postsurgical, pericoronal May begin as well-delineated, self-limiting condition with potential to spread and result in a major fascial space infection. Life-threatening sequelae can ensue:  Septicemia, cavernous sinus thrombosis, airway obstruction, mediastinitis
  20. 20. Progression of Odontogenic Infections  Periapical  Periodontal  Soft tissue involvement Determined by perforation of the cortical bone in relation to the muscle attachments  Cellulitis- acute, painful, diffuse borders  Abscess- chronic, localized pain, fluctuant, well circumscribed.
  21. 21. Cellulitis: initial stage of infection  Diffuse, reddened, soft or hard swelling that is tender to palpation.  Inflammatory response not yet forming a true abscess.  Microorganisms have just begun to overcome host defenses and spread beyond tissue planes.
  22. 22. True abscess formation  As inflammatory response matures, may develop a focal accumulation of pus.  May have spontaneous drainage intraorally or extraorally.
  23. 23. Differences between cellulitis & abscess Cellulitis Abscess Duration Acute Chronic Pain Severe generalized Localised Size Large Small Localization Diffuse borders Well circumscribed Palpation Doughy indurated Fluctuant Presence of pus No Yes Degree of seriousness Greater Less Bacteria Aerobic anaerobic
  24. 24. Classification of fascial spaces  Based on mode of involvement I. Direct involvement (Primary spaces) – maxillary spaces , mandibular spaces II. Indirect involvement (Secondary spaces ) – Lateral pharyngeal space  Based on clinical significance by Topazian I. Face – buccal, canine, masticatory, parotid II. Suprahyoid – sublingual, submandibular (submaxillary, submental) pharyngomaxillary (lateral pharyngeal) peritonsillar III. Infrahyoid – anterovisceral (pretracheal) IV. Spaces of total neck – retropharyngeal, space of carotid sheath
  25. 25.  BASED ON FASCIA I. Superficial fascia II. Deep cervical fascia 1. Anterior layer • Investing fascia ( over the neck) • Parotidomasseteric • Temporal 2. Middle layer • Sternohyoid - omohyoid division • Sternothyroid - thyrohyoid division • Visceral division – • Buccopharyngeal • Pretracheal • Retropharyngeal 3. Posterior layer • Alar division • Prevertebral division
  26. 26.  According to Grodinsky & Holyoke in 1938 I. Space 1 – potential space superficial and deep to the platsyma muscle II. Space 2 – space behind the anterior layer of deep cervical fascia III. Space 3 – pretracheal space, ant to layer of deep cervical fascia IV. Space 3A – viscerovascular space; is the carotid sheath from the jugular foramen and carotid canal at the base of skull to the pericardium (lincoln’s highway) V. Space 4 – ‘Danger space’ potential space b/w alar and prevertebral fascia. Extends from base of skull to the prevertebral fascia VI. Space 5 – it is the space enclosed by the prevertebral fascia posterior to transverse processes of vertebrae
  27. 27.  According to killey and kay 1. In relation to lower jaw: 1. Submental 2. Submandibular 3. Sublingual 4. Buccal 5. Submassetric 6. Parotid 7. Pterygomandibular 8. Lateral pharygeal 9. Peritonsillar 2. In relation to the upper jaw: a) Canine space b) Palatal space c) Maxillary antrum d) Infratemporal space e) Subtemporal space
  28. 28. SPACE OF BURNS : The Suprasternal Space The superficial fascia splits below the level of the hyoid bone to form 2 spaces - Forms lower part of the roof of the post triangle, the fascia splits into two layers, attached to clavicle - Forms lower part of the roof of the ant triangle and fascia splits to form the suprasternal space
  29. 29. Spaces involved in odontogenic infections  Primary maxillary spaces – canine, palatal, and infratemporal spaces  Primary mandibular spaces – submental, buccal, submandibular and sublingual spaces  Secondary fascial spaces – masseteric, pterygomandibular, superficial & deep temporal, lateral pharyngeal, retropharyngeal, prevertebral , parotid
  30. 30. Maxillary Odontogenic Infections  Canine space  Palatal space  Infratemporal space  Subtemporal space
  31. 31. Canine space infection/ Infraorbital space infection  This is a potential space present on the anterior surface of the maxilla in the region of canine fossa  Appear commonly as labial sulcus swelling  Levator anguli oris and levator labii superioris muscle overlies apex of canine root  Origin: canine fossa.  Insertion: angle of mouth
  32. 32.  Boundries: • superiorly: a) Levator angulii oris b) Levator labii superioris • Posteriorly: a) Buccal space • Inferiorly: a) Orbicularis muscle Contents: infrorbital nerve and its branches
  33. 33. Canine space infection Signs: • Obliteration of the nasolabial fold • Drooping of angle of mouth • Superior extension can involve lower eyelid • Open in relation to medial canthus of eye
  34. 34. Incision for canine space infection  Intra-oral approach, high in labial vestibule by sharp and blunt dissection  Percutaneous drainage – lateral to the nose
  35. 35.  Differential diagnosis: a) Maxillary sinusitis b) Dacryocystitis
  36. 36.  Palate is covered by tightly adherent mucoperiosteum  Periosteum is tightly bound to the mucosa, periodontal membrane of the adjacent teeth and to the suture in the midline  Pus tends to accumulate between periosteum and bone  Infections begin in lateral incisor or upper post tooth  It is in the subperiosteal space of palate  Exquisitely painful due to rich innervations of the periosteum Palatal space infection
  37. 37.  Signs and symptoms  circumscribed fluctant swelling confined to one side  May discharge from the gingival sulcus  Infection does not cross midline  Infection from: • Upper lateral incisor • Palatal pocket in premolars or molars • Infection of palatal root
  38. 38.  Management:  Incision should be in AP direction to avoid injury to anterior palatine nerve  Treatment of offending tooth  Differential diagnosis:  Extravasation cyst  Gumma  Pleomorphic adenoma  Carcinoma of maxillary antrum
  39. 39. Infratemporal space infection  Odontogenic infections of maxillary posterior teeth  Odontogenic infections involving the pterygomandibular space or infection from buccal space coursing along the masticatory fat pad.  Anatomical boundries: a. laterally: ramus of mandible, temporalis muscle and temporalis tendon b. Medially: lateral pterygoid plate c. Superiorly: infratemporal surface of the greater wing of sphenoid d. Inferiorly: lower head of lateral pterygoid muscle
  40. 40.  Contents: a. Origin of pterygoid muscles b. Pterygoid venous plexus c. Internal maxillary artery d. Mandibular nerve and its branches  Signs and symptoms: a. Infected upper molar teeth b. Severe trismus is universal finding c. extraoral swelling over the sigmoid notch, intra oral swelling in the tuberosity area
  41. 41.  Management: a. Intravenous antibiotics b. Incision in upper buccal sulcus in third molar region c. Use of sinus forceps along medial surface of coronoid and temporalis upwards and backwards
  42. 42. Mandibular Space Infections  Sublingual space  Submental space  Submandibular space  Ludwigs angina  Masticator space  Lateral pharyngeal space  Temporal space
  43. 43. Submental space  Potential space present just below the chin region on the medial surface of the mandible  It is a midline structure bordered laterally by the anterior bellies of digastric muscle  Infections begin in the anterior mandibular teeth  Secondarily Infected skin wounds or anterior mandibular fractures may also cause infections
  44. 44.  BORDERS: • Anterior – inf border of mandible • Posterior – hyoid bone • Superior – mylohyoid muscle • Inferior – investing layer of deep cerical fascia • Deep/Lateral - ant. bellies of digastric muscle Contents: • Submental lymphnodes • Anterior juglar veins • Adipose tissue
  45. 45.  Signs and symptoms: • Firm circumscribed swelling beneath the chin • Patient complains of discomfort and difficulty in swallowing  Management: • Incision is made bilaterally through the skin, subcutaneous tissue and platsyma muscle at the most inferior aspect of swelling • A hemostat is inserted through one incision and then exited through the second incision
  46. 46. Incision for submental abscess
  47. 47. Sublingual space  It is a potential space present in the anterior part of the floor of the mouth  It almost always involved with submandibular space  Only loose connective tissue separates right and left sublingual spaces and infection spreads easily from side to the other  Boundries: • Anteriorly and laterally– medial surface of mandible • Posteriorly – submandibular space • Superiorly – sublingual mucosa • Inferiorly – mylohyoid muscle • medially - genioglossus, geniohyoid, styloglossus muscles • Superficial – muscles of tongue • Deep – ant.bellies of digastric muscle
  48. 48.  The styloglossus muscle passes b/w superior & middle pharyngeal constrictor muscles in this region to enter the tongue  The seperation b/w these pharyngeal constrictors formed by the styloglossus muscle is termed BUCCOPHARYNGEAL GAP
  49. 49. Sublingual space Elevation of floor of mouth Tongue raised Respiratory difficulty
  50. 50.  Incision is placed at the base of the alveolar process in the lingual sulcus so that the sublingual gland, lingual nerve & submandibular duct are not injured  A hemostat is inserted through the incision in an ant & post direction & beneath the sublingual gland to evacuate the pus Incision for Sublingual space infection
  51. 51. Submandibular space  It is a potential space present on the medial surface of the posterior aspect of the mandible  Anatomical boundries: • Anteriorly – ant. belly of digastric muscle • Posteriorly - post. belly of digastric muscle, stylohyoid muscle, stylopharyngeus muscle • Superior – inf & medial surfaces of mandible • Inferior – digastric tendon • Superficial – platsyma muscle, investing fascia • Deep – mylohyoid, hypoglossus, sup constricting muscles • Laterally – bounded by skin, superficial fascia, platysma  Contents: • Submandibular salivary gland • Lymph nodes • Facial artery • Lingual and hypoglossal nerves
  52. 52. Submandibular space  Triangular swelling  Begins at the lower border of mandible, extends to level of hyoid bone  Brawny induration  Usually associated with lowermolar infection
  53. 53.  Two stab incisions are placed at the inf aspect of swelling in the shadow of the mandible  Extended through the skin & superficial fascia  Dissection is bluntly done through one incision with a curved hemostat, which is inserted through the platsyma muscle & deep fascia in abscess for drainage Submandibular incision
  54. 54.  A hemostat is passed thru the cavity and out the other incision  A thin rubber drain is inserted through the wound beaks of the hemostat & withdrawing the Instrument Dressing is placed
  55. 55. Ludwig’s angina  First described by wilhelm fredreich von ludwig in 1836.  Its rapidly spreading in nature  Ludwig’s angina is a form of firm, acute, toxic and severe diffuse cellulitis that spreads rapidly, bilaterally, affecting the submandibular, sublingual and submental spaces and resulting in a woody swelling
  56. 56. Clinical features  Bilateral suprahyoid swelling with hard cardboard like consistency, non fluctuating & painful on palpation  Swelling is characterized by rapid onset  Difficulty in breathing (dyspnea),  Difficulty in swallowing (odynophagia)  Restricted tongue movements, elevated tongue ,inability to open the mouth, salivation  Patients may exhibit muffled voice due to edema of vocal apparatus (hot potato voice)
  57. 57.  Eitiology  Odontogenic infections  Traumatic injuries  Infective conditions like osteomyelitis  Pathology:  Infection from the source reaches the submandibular space  The submental spaces gets involved via the lymphatics  It’s a cellulitis it rapidly spreads reaches the epiglottis producing edema and inflammation of laryngeal inlet.  Spreads to pterygomandibular, massetric and lateral pharyngeal spaces  Patient may die with in 24 hours due asphyxia if not treated  May die from septic shock, aspiration of pus or mediastinitis
  58. 58.  Signs and symptoms: a. Pyrexic b. Dehydration c. Dysphagia d. Rapid shallow breathing e. Hoarseness of voice  Extra oral features: a. Hard to firm brawny, board like swellin b. Skin is shiny stretched and erythmatous c. Tender swelling with local rise in temperature d. Unable to close the mouth and drooling of saliva e. Evident respiratory distress, use of accessory muscle of respiration f. Trismus  Intra oral features: a. Floor of mouth is raised b. Tongue appears swollen and raised upwards towards the palate c. Increased salivation
  59. 59. The cardinal signs of Ludwig’s angina are: 1. Bilateral involvement of more than a single deep tissue space 2. Gangrene with serosanguinous, putrid infiltration but little or no frank pus 3. Involvement of connective tissue, fascia, and muscle but not glandular structures 4. Spread via fascial space continuity rather than by lymphatic system Danger signs: 1. Dysapnoea 2. Dysphagia 3. Hoarseness of voice 4. Stridor 5. Swelling below the clavicles
  60. 60. Diagnosis & investigations  UltraSonography: Used to identify fluid collection in the soft tissues.  C.T. Scan  M.R.I
  61. 61. UltraSonography:  Effective diagnostic tool in treatment of acute odontogenic fascial space infections and cellulitis  Micro convex probe of 6.5Mhz is used  Probe is applied over skin, covering the swelling in transverse and axial sections  Echoing of sound from the fluids is absent thereby detecting the fluid collection
  62. 62. Differential diagnosis  Angioneurotic edema  Lingual carcinoma  Sub lingual hematoma  Salivary Gland abscess  Peri-tonsillar abscess
  63. 63. Complications  Septicemia  Carotid blow out  Obstruction of upper respiratory airways  Aspiration pneumonia  Spread of infection into Para pharyngeal spaces-mediastinum-produce thoracic empyema  Death due to airway compromise
  64. 64.  TREATMENT :  Early diagnosis of incipient cases  Maintenance of patent airway  Intense & prolonged antibiotic therapy  Extraction of affected teeth  Hydration  Early surgical drainage
  65. 65. “ A chance to cut is a chance to cure ” Classic approach / Cut- throat approach: Horizontal incision midway b/w chin & hyoid bone. Bilateral incision into the submandibular spaces with blunt dissection to the midline Through and through drain or bilateral drains meeting at the midpoint
  66. 66. Buccal space infection  Buccal space occupies portion of subcutaneous space b/w facial skin & buccinator muscle  Maxillary & mandibular premolar and molar teeth tend to drain in lateral & buccal direction  Relation of root apices to buccinator muscle determines path of infection : intraorally in buccal vestibule or deeply in buccal space
  67. 67.  BORDERS:  Anterior – corner of mouth  Posterior – masseter muscle, pterygomandibular space  Superior – maxilla, infraorbital space  Inferior – mandible  Medial – subcutaneous skin  Lateral – buccinator muscle
  68. 68. BUCCAL SPACE INFECTION Signs and symptoms: •Dome shaped swelling beginning at lower border of mandible • extending upwards to level of zygomatic arch •Diagnosed because of marked cheek swelling associated with diseased molar/premolar tooth •Not associated with trismus
  69. 69. Management  Intra – oral drainage:  Is done with the incision made through the buccinator muscle  It is difficult in maintaining a patent opening for drainage because contraction of muscle fibres tend to close it off  Hence a horizontal rather than a vertical incision is made just above the depth of the vestibule  Extra oral drainage:  Inferior to point of fluctuance with blunt dissection  Incisions are placed below the lower border of mandible  2 stab incisions are made with a no.11 blade through the skin & subcutaneous tissue  A curved hemostat is inserted thru the anterior incision into the buccal space and then turned & exited through the posterior incision  Beaks of hemostat are opened, strip of rubber drain is grasped. Hemostat is withdrawn carrying drain through the tissues  Ends are fastened, dressing placed
  70. 70. Submasseteric space  Earliear this space was considered to between masseter and the lateral aspect of the ramus of the mandible.  Now it is found to be between three layers of the masseter muscle itself  Submasseteric swellings can be differentiated from parotid swellings as these produce marked Trismus overlying masseter muscle  Obscure earlobe or elevation of ear lobe in frontal view
  71. 71.  BORDERS:  Anterior– buccal space  Posterior – Parotid gland  Superior – zygomatic arch  Inferior – pterygomassetric sling  Medial – ascending ramus of mandible  Lateral – masseter muscle  Infection can spread from lower third molars  Signs and symptoms: • External facial swelling confined to masseter muscle • Swelling usually does not extend beyond the posterior border of the masseter into the postauricular area • Swelling acutely tender • Almost complete trismus • Overlying skin reddened and stretched • Pus may drain at the angle of the mandible
  72. 72. Management:  Intraorally:  Drainage is done through a vertical incision along the ext oblique line of the mandible  Starting at the level of the occlusal plane and extending downward & forward in the buccal sulcus to a point opp the second molar  A hemostat is inserted and passed posteriorly along the lateral aspect of the ramus to point beneath masseter muscle  Beaks are opened  Rubber drain is inserted & sutured  Extraorally: • Incision is made behind the angle of the mandible (retromandibular incision) • Hemostat is inserted and passed along the lateral aspect of the ramus • Rubber drain is inserted
  73. 73. Pterygomandibular space Most frequently affected anatomical compartment Correlated highly with pericoronitis & mandibular third molar secondary infection results from spread from the sublingual and submandibular spaces Symptoms: • Trismus – due to edema & inflamm of med pterygoid • Swollen ant tonsillar pillar • Deviation of uvula to opposite side
  74. 74.  Communications: • Deep temporal space: By passing around the lateral pterygoid muscle superiorly, running from the mandibular condyle neck and the articular disc to the medial pterygoid plate. • Lateral pharyngeal space:by along the anterior border of medial border of medial pterygoid muscle following postereolateral surface of the buccinator and the superior pharyngeal constrictor muscles
  75. 75. Rt.Pterygomandibular Space Infection
  76. 76.  BORDERS: • Anteriorly – pterygo mandibular raphae,buccal space • Inferior – inf border of mandible upto attachment of medial pterygoid muscle, pterygomassetric sling • Superior – Lateral pterygoid muscle • Posterior – deep lobe of parotid gland • Superficial – lateral pterygoid muscle • Deep – ascending ramus of mandible • Medially – medial pterygoid muscle • Laterally – ascending ramus of the mandible  Contents: • Inferior alveolar nerve • Lingual nerve • Nerve to mylohyoid • Inferior alveolar artery and vein
  78. 78. Management  Extra oral mandibular block is given  Incision is placed through the mucosa in the area b/w medial aspect of the ramus & pterygomandibular raphe.  Abscess is opened by blunt dissection and Drain is placed
  79. 79. Temporal space  Two divisions: a. Superficial – It is between superficial temporal fascia and lateral aspect of temporalis muscle b. Deep – It is between the medial surface of the temporalis muscle and periosteum of temporal bone.  Inferiorly the temporal space is limited to the attachments of the temporalis muscle and fascia. Inferiorly, it communicates with the pterygomandibular space  Its contains loose connective tissue and vessels supplying the temporalis muscle
  80. 80.  Signs and symptoms: • Swelling confined to the shape of the muscle extending from the lateral orbital rim, above the zygomatic arch, covering the lateral aspect of tempral bone. • swelling more prominent in a superficial temporal space infection. • severe trismus  Deep temporal abscess  Produce less swelling  Lies deep to temporalis muscle  Less fluctuant  Management:  Intra oral sicher’s incision along the anterior border of the ramus of the mandible  Extra oral cutaneous incision slightly above the zygomatic arch made parallel to zygomatic arch followed by blunt dissection and placement of drain
  81. 81. Lateral pharyngeal space  Also known as Pharyngomaxillary/ parapharyngeal space  Lateral neck space shaped like an inverted cone  Base is uppermost at the base of the skull  Apex is at the greater horn of the hyoid bone  Infections may result from – pharyngitis, tonsilitis, parotitis, otitis, mastoiditis and dental infection
  82. 82. Pharyngomaxillary space  Suprahyoid • superior—skull base • Inferior—hyoid • Anterior—ptyergomandibular raphe • Posterior—prevertebral fascia • Medial—buccopharyngeal fascia • Lateral—superficial layer of deep fascia • Prestyloid  Muscular compartment  Medial—tonsillar fossa  Lateral—medial pterygoid  Contains fat, connective tissue, nodes  Poststyloid  Neurovascular compartment  Carotid sheath  Cranial nerves IX, X, XI, XII  Sympathetic chain  Stylopharyngeal aponeurosis of Zuckerkandel and Testut  Alar, buccopharyngeal and stylomuscular fascia.  Prevents infectious spread from anterior to posterior.
  83. 83.  Borders:  Anterior – sup & middle pharyngeal constrictor muscles  Medially – superior constrictor, styloglossus muscle, stylopharyngeus and middle constrictor muscle  Posterior – carotid sheath & scalene fascia  Superior – skull base  Inferior – hyoid bone  Superficial – pharyngeal constrictors, retropharyngeal space  Deep – medial pterygoid muscle  Signs and symptoms:  For surgical & anatomical purposes, it is divided into anterior & posterior compartments  Ant comp infection pt exhibits pain, fever, chills, medial bulging of lat pharyngeal wall with deviation of palatal uvula from midline, dysphagia, swelling below the angle of the mandible  Post comp has absence of trismus & visible swelling, BUT resp obstruction, septic thrombosis of int jugular vein and carotid artery hemorrhage
  84. 84.  Severe trismus  Lateral swelling of the neck  Bulging of the lateral pharyngeal wall pushed to midline  Usually no extra oral swelling  Rapid progression of infection in this space is common Lateral pharyngeal space infection
  85. 85. Management  Aggressive antibiotic therapy  If the mouth can be opened, intra oral incision medial to the anterior border of the ramus  Extra orally  The incision is placed 1cm below and behind the angle of the mandible. Sinus forceps are inserted into the space between submandibular and parotid gland and passed medial to mandible and upwards along the inner aspect of medial pterygoid muscle.drain is inserted
  86. 86. Peritonsillar Space  The peritonsillar space consists of loose connective tissue between the capsule of the palatine tonsil and the superior constrictor muscle. The anterior and posterior tonsillar pillars contribute to its anterior and posterior borders, respectively. The posterior tongue forms the inferior boundary. Peritonsillar infections may readily spread to the parapharyngeal space.
  87. 87. Quincy
  88. 88. Peri-tonsillar space Clinical evaluation:  3-7 days H/o pharyngitis .  Severe sore throat, dysphagia, Odyonophagia and referred otalgia.  The speech is muffled and classically described as hot potato voice.  Trismus is not present  In recent literature,needle aspiration instead of open incision and drainage (JOMS,Vol 51,1993)
  89. 89. Parotid Space  Formed by the superficial layer of deep cervical fascia surrounding the gland  Boundaries : Swelling extends from level of zygomatic above to lower border of mandible Anteriorly it ends at the anterior border of mandible Posteriorly it extends into the retromandibular region
  90. 90. Parotid space  Superficial layer of deep fascia  Dense septa from capsule into gland  Direct communication to parapharyngeal space  Contains  External carotid artery  Posterior facial vein  Facial nerve  Lymph nodes
  91. 91.  C/F  Everted ear lobule  Severe pain referred to the ear, accentuated by eating  Trismus
  92. 92. Spaces of the neck 1. Retropharyngeal space 2. Prevertebral space 3. Mediastinitis
  93. 93.  Retropharyngeal ,danger space and prevertebral spaces lie between deep cervical fascia the surrounds the pharynx and oesophagus anteriorly and vertebral spine with its muscle attachments posteriorsly
  94. 94.  Retropharyngeal space Anatomical boundries: 1. anteriorly: constrictor muscles of the neck and their fascia 2. Posteriorly: alar layer of deep cervical fascia which extends from the base of the skull to the superior mediastinum A midline septum exists between the right and left retropharyngeal spaces that is crossed easily. Contents 1. Adenoidal tissues draining posterior pharyngeal wall 2. Lymphnodes draining waldeyers ring
  95. 95.  Prevertebral space:  extends from base of the skull to the coccyx  anteriorly bounded by prevertebral fascia  For spaces of the neck the infections may arise from nasal, pharyngeal, dental infections
  96. 96. Clinical features of space of neck  Drooling  Fever  Irritatibility  Nuchal rigidity –  neck siffness  Irritability light  Head ache  Dyapnoea  Dysphagia  Bulging in the posterior pharyngeal wall may be there
  97. 97.  Dangers involves  severe laryngeal edema  Rupture of abscess leading to aspiration pnemonia or asphyxia  Mediastinitis
  98. 98. Management  Tracheostomy  Extreme trendelburg position  Surgical intervention  Intra oral: through posterior pharyngeal wall  Extra oral:  inferior to hyoid parallel to sternocleidomastoid, retraction of muscle and carotid sheath, blunt dissection till hypopharynx.  Deep dissection to carotid sheath between it and inferior constrictor muscles rupture retropharyngeal abscess  Deep drains inserted
  99. 99. Principles in Treatment of Oral and Paraoral Infections a) Remove the cause. b) Establish drainage. c) Institute antibiotic therapy. d) Supportive care, including proper rest and nutrition.
  100. 100. Management of Odontogenic Infections General principles  Goals of management of odontogenic infection: 1. Airway protection 2. Surgical drainage 3. Medical support of the patient 4. Identification of etiologic bacteria 5. Selection of appropriate antibiotic therapy
  101. 101.  Airway protection 1.Floor of mouth and tongue elevation or narrowing can cause respiratory distress 2.Expedient assessment and diagnosis of airway compromise is the most important initial step in managing odontogenic infections 3.Airway loss is primary cause of death in these patients
  102. 102. • Initially intact airway must be continuously reevaluated during treatment • Signs and findings of airway compromise: inability to assume a supine position, stridor, and restlessness etc. • Surgeon must decide the need, timing and method to establish an emergency airway
  103. 103.  Surgical drainage 1. Administration of intravenous antibiotics without drainage of pus may not allow for resolution of an abscess 2. Starting antibiotic therapy without Gram's stain and cultures may result in failure to identify pathogens 3. Important to drain all primary spaces as well as explore and drain potentially involved secondary spaces
  104. 104. • CT scans may help identifying spaces involved • Panorex can help identify putative teeth involved
  105. 105. • Canine, sublingual and vestibular abscesses are drained intraorally • Masseteric, pterygomandibular, and lateral pharyngeal space abscesses can be drained with combination intraoral and extraoral drainage • Temporal, submandibular, submental, retropharyngeal, and buccal space abscesses may mandate extraoral incision and drainage
  106. 106.  Technique: 1. Small incision are made in a dependent area 2. Placement of a hemostat in the abscess cavity with entry into all loculations of the abscess 3. drains inserted into cavity to allow for postoperative drainage of the abscess
  107. 107. PURPOSES OF SURGICAL DRAINAGE & INCISION  Rid the body of toxic purulent material  Decompress the tissues  Allowing better perfusion of blood containing antibiotics and defensive elements  Increased oxygenation of the infected area
  108. 108. Dependent drainage of the space is performed by placing a horizontal incision in the most dependent area of the swelling extraorally / intraorally with a cosmetic scar being the result
  109. 109.  Medical support of the patient 1. Rehydrate patient as dehydration may be present 2. Treat conditions that predispose patient to infection (DM) 3. Oral pain, trismus , and swelling can be addressed by appropriate analgesia and treatment of underlying infection
  110. 110.  Identification of etiologic bacteria 1. Expected causes are alpha hemolytic streptococci and oral anaerobes 2. Cultures should be performed on all patients undergoing incision and drainage and sensitivities ordered if patient is not progressing well (possible antibiotic resistance) 3. An aspirate of the abscess can be performed and sent for culture and sensitivities if incision and drainage delayed
  111. 111. Antibiotic Therapy  Removal of the cause, drainage, and supportive care more important than antibiotic therapy.  Infections are cured by the patient’s defenses, not antibiotics.  Risks of allergy, toxicity, side effects, resistance and superinfection causing serious or potentially fatal consequences must be considered.
  112. 112. Principles of antibiotic use  – Necessity  – Empirical therapy  – Narrow spectrum  – Low toxicity  – Bacteriocidal  – Administer properly  – Cost
  113. 113. Antibiotic therapy, con’t.  Oral infections are typically polymicrobial.  Antibiotic effectiveness dependent upon adequate tissue (not serum) concentration for an appropriate amount of time.  Antibiotics should be prescribed for at least one week – adequate tissue concentration achieved in 24-48 hours, with bacteriocidal activity occurring over the next 3-5 days.
  114. 114. EMPIRIC ANTIBIOTIC TREATMENT Modified from Flynn TR. The swollen face. Severe odontogenic infections.Emerg Med Clin N Am 2000;18:  Early infection (first 3 days of symptoms or mildly immunocompromised) Penicillin Clindamycin Cephalexin (or other first-generation cephalosporin)
  115. 115.  Late infection (after 3 days of symptoms or moderately to severely immunocompromised) Clindamycin (maximum dose) Penicillin and metronidazole Ampicillin and sulbactam Cephalosporin (first or second generation) Mild, moderate, and severe compromise is based on CD4/viral loads, glycemic control, and the degree of alcoholic related disease.
  116. 116. Antibiotic therapy, con’t.  Penicillin (bacteriocidal) drug of choice for treatment of odontogenic infections (5% incident of allergy).  Clindamycin (bactericiodal) 1st line after penicillin; effective against anaerobes;  Cephalosporin (slightly broader spectrum and bacteriocidal); cautious use in penicillin- allergic patients → cross-sensitivity; if history of anaphylaxis to penicillin, do not use.
  117. 117. Antibiotic therapy, con’t.  Erythromycin (bacteriostatic) good 2nd line drug after penicillin; use enteric-coated to reduce GI upset.  Metronidazole (bacteriocidal) excellent against anaerobes only.  Augmentin (amoxicillin + clavulanic acid) kills penicillinase-producing bacteria that interferes with amoxicillin; expensive.
  118. 118. Selection of antibiotic therapy 1.Penicillin 2.Metronidazole in combination with penicillin can be used in severe infections 3.Clindamycin for penicillin-allergic patients Causes for clinical failure include inadequate drainage or antibiotic resistance
  119. 119. COMPLICATIONS  Brain Abscess : Etiology – bacteremia accompanying any odontogenic infection C/F – headache, nausea, vomiting, Other symptoms : hemiplegia, pappiloedema, aphasia, convulsions, hemisensory deficit
  120. 120. Drug Therapy – antibiotics & steroids Mannitol to reduce to edema Chloramphenicol ; antibiotic of choice Surgery to provide drainage
  121. 121.  MENINGITIS Most common neurological complication C/F : headache, fever, stiffness of neck & vomiting Kernig’s sign – passive resistance to extend the knee from flexed thigh position Brudzinski’s sign – abrupt neck flexion in supine resulting in involuntary flexion of knees Diagnosis : lumbar puncture
  122. 122.  Rx : chloramphinicol + penicillin G  Hydration  Electrolyte balance  Control of cerebral edema  Avoidance of vascular collapse and shock
  123. 123.  MEDIASTINITIS Late complication due to delayed diagnosis & inadequate surgical drainage It is a descending cervical cellulitis that arises from submandibular space infection, parapharyngeal space, pterygomandibular space or buccal space
  124. 124. S/S : unremitting high fever, tachycardia, tachypnoea & hypotension Brawny edema, induration of neck n chest and crepitus may be palpable Rx :early recognition , airway control, agg surgical intervention (transthoracic or cervicomediastinal approach), app antibiotic therapy, supportive systemic care & hyperbaric oxygen therapy
  125. 125.  CAVERNOUS SINUS THROMBOPHLEBITIS : External route – danger area of face Internal route – odontogenic infection from post maxillary region through pterygoid plexus C/F : Initial – swelling of face with involvement of eyelids Pulsating exopthalmos
  126. 126. Cranial nerve involvement (oculomotor, trochlear, abducens, opthalmic & carotid sympathetic plexus) Late – thrombophlebitis Advanced – toxaemia , meningitis, + Kernig’s sign and brudzinski’s sign Septicimia
  127. 127. Rx : antibiotic therapy  Heparinization – heparin 20,000 units in 1500ml off 5% dextrose or Dicumarol 200mg  Neurosurgical consultation  Mannitol  Anticoagulants  Surgical drainage
  128. 128. Early recognition of orofacial infection and prompt , appropriate therapy is absolutely necessary A thorough knowledge of anatomy of the face and neck is necessary to predict pathways of spread and to drain these spaces adequately
  129. 129. THANK YOU
  130. 130.  REFERENCES:  Topazian , Oral & maxillofacial infections , Vol 4  Daniel M Laskin , text book of oral & maxillofacial surgery vol II  Peterson ,text book of oral & maxillofacial surgery  Neelima malik, text book of oral & maxillofacial surgery
  131. 131. Fasciae of head and neck