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Space infection 2 /certified fixed orthodontic courses by Indian dental academy

  1. 1. “Complex , intricate, elusive ,fascinating, yet alluring , amazing & alarming” INDIAN DENTAL ACADEMY Leader in continuing dental education
  2. 2. COMPARTMENTS OF THE HEAD AND NECK – SURGICAL ANATOMY & APPLIED ASPECTS Presenter : Dr. Kiran H.Y. Department of Oral & Maxillofacial Surgery, Under the guidance of Dr. David Tauro M.D.S. Department of Oral & Maxillofacial Surgery, S.D.M. College of Dental Sciences & Hospital.
  3. 3. What are Fascial compartments? “The facial spaces or compartments are regions of loose C.T. that fill the areas between facial layers”. The concept of fascial ‘spaces’ is based on anatomists knowledge that all ‘spaces’, exist only potentially, until fasciae are separated by pus, blood, drains or a surgeon’s finger.
  4. 4. Basic plan of the neck
  5. 5. How did the concept of facial spaces arise? “If I have seen further, it is by standing on the shoulder of Gaints”. • In the 1930s the classic anatomical studies of Grodinsky and Holyoke established the modern understanding of the fascial layers and the potential anatomical spaces through which infection can spread in head and neck.
  6. 6. What is fascia and its functions? • It is a sheet or layer of more / less condensed connective tissue. • Fascial layers are like tissue paper surrounding each item of clothing within a garment box, which allows them to pass over each other without their becoming unfolded.
  7. 7. Functions of the fascia • Acts as a musculovenous pump• Limits outward expansion of muscles as they contract. • Contraction of muscles compress the intramuscular veins (push the blood towards the heart). • Determine the direction of spread of infection
  9. 9. Superficial fascia Superficial fascia is not a fascial sheet in the classic sense, but rather a fatty loose connective tissue in which are embedded the voluntary muscles of facial expression and the platysma muscle.
  10. 10. Superficial fascia Skin + Superficial fascia + Platysma muscle Complex morphological unit Superficial musculoaponeurotic system (SMAS) Clinical considerations: 1. Surgeons consider SMAS most important component of rhytidectomy / face-lift surgery / plastic surgery of the face. 2. Necrotizing fascitis – Infection of this fascia causes necrosis of the tissues in the subcutaneous space leading to necrotizing fascitis.
  11. 11. Necrotising fascitis
  12. 12. Deep fascia Superficial layer of deep fascia Middle layer of deep fascia Deep layer of deep fascia
  13. 13. Superficial layer of deep cervical fascia
  14. 14. Superficial layer of deep cervical fascia
  15. 15. Middle layer of deep cervical fascia
  16. 16. Buccopharyngeal fascia
  17. 17. Deep layer of deep cervical fascia
  18. 18. Deep layer of deep cervical fascia
  19. 19. Carotid sheath
  20. 20. Schematic diagram showing the arrangement of deep neck spaces
  21. 21. Schematic diagram showing the arrangement of deep neck spaces
  22. 22. Anatomical basis for classification • • • The greatest clinical implication of cervical fascia is that it divides the neck into potential spaces that function as a unit but are anatomically separate. Hyoid bone is considered the most important structure limiting the spread of infection. For this reason infection are classified by dividing the potential spaces into 3 general divisions based on hyoid bone 1. 2. 3. Space of entire neck. Supra hyoid spaces. Infra hyoid spaces.
  23. 23. Classification of the spaces of Face & Neck REF:THE NECK- DIAGNOSIS&SURGERY WILLIAM.W.SHOCKLEY,HAROLD.C.PILLSBURY I Spaces of the Face A. Maxillary spaces 1. Buccal space. 2. Canine space. B. Mental space. II Spaces of neck A. Spaces involving the entire length of the neck. 1. Superficial space 2. Deep neck spaces (all involve only the posterior side of the neck) a) b) c) d) Retropharyngeal space (Space 3). Danger space (Space 4) Prevertebral space (Space 5) Visceral vascular space (within carotid sheath).
  24. 24. B. Suprahyoid spaces: 1) Mandibular space • • • • Submandibular space. Submental space. Sublingual space. Space of the body of the mandible. 2) Masticatory space. 3) Lateral pharyngeal space (Pharyngomaxillary, peripharyngeal / parapharyngeal). 4) Peritonsillar space. 5) Parotid space. C. Infrahyoid space (involves anterior side of the neck only). 1. Pretracheal space.
  25. 25. What are primary spaces? What are secondary spaces? Primary spaces: • Maxillary spaces • Mandibular spaces Secondary spaces: Masseteric,pterygomandibular,superficial & Deep temporal,lateral pharyngeal, retropharyngeal,prevertebral,parotid space
  26. 26. Concepts about space infections • The spaces are not empty they contain various organs, nerves, blood vessels, salivary glands, lymph nodes and fat surrounded by loose fibrous connective tissue. • The spaces of head and neck are not perfectly enclosed they are pathways around the muscles through which infection can spread.
  27. 27. Concepts about space infections • Infections within each space has its own diagnostic signs and tends to spread in an orderly, anatomic fashion from one space to another by continuous extension. • If the surgeon understands this process, he can anticipate the spread of infection into dangerous spaces and abort the process by timely incision and drainage.
  28. 28. General pathways of spread of maxillary and mandibular infection
  29. 29. Pathways of spread of dental infection Pericoronitis of third molar area Spread of infection from erupted and infected third molar area
  30. 30. Anatomical factors influencing the spread of infection Infection enters soft tissue through thinnest bone In respect to buccinator muscle
  31. 31. Anatomical factors influencing the spread of infection
  32. 32. Predisposing factors 1. Dental caries or diseases of the gums. 2. Lowered body resistance 3. Traumatic Primary signs & symptoms of these infections: - Localized pain. - Tenderness. - Redness. - Edema of the overlying tissue. - Loss of function - lymphadenopathy
  33. 33. Stages of infections • Stage I – Inoculation • Stage II –Acute stage-cellulitis,abscess • Stage III – Chronic stage-fistulous/sinus tract or osteomyelitis • Stage IV – Resolution
  34. 34. Differences between cellulitis and abscess Characteristics. Cellulitis. • Acute phase Duration. • Severe and Pain • • Chronic phase Localised generalised Size Localization Palpation Presence of pus Degree of seriousness Bacteria. Abscess. • • Large. Diffuse borders • • Small Well-demarcated • • Doughy/indurated No • • Fluctuant Yes • Greater • Less • Aerobic • Aerobic/mixed
  35. 35. Surgical anatomy of deep facial spaces of head and neck
  36. 36. Buccal space Clinical evaluation: Examination of the patient with the buccal space infection demonstrate swelling confined to the cheek with abscess forming beneath the buccal mucosa and bulging into the mouth. Repated buccal space infection suspect crohn’s disease
  37. 37. Canine space / Infraorbital space • • • • Clinical evaluation: Patient exhibits swelling lateral to the nose obliteration of the nasolabial fold, swelling of the upper lip, edema occurs in the upper and lower lid that may close the eye .
  38. 38. Differential diagnosis of upper face infections Dacrocystitis with minimal involvement of nasolabial fold. Odontogenic cellulitis. The nasolabial fold is effaced.
  39. 39. Suprahyoid spaces 1) Mandibular space • • • • Submandibular space. Submental space. Sublingual space. Space of the body of the mandible.
  40. 40. Mandibular spaces Submandibular space Clinical Evaluation: •Infection mostly arises from 2nd or 3rd molar. •Induration and erythema in the submandibular area obliterating the mandibular line and extending to the level of hyoid bone. •No trismus.
  41. 41. Submandibular space Spread of submandibular.S infection to Sublingual.S
  42. 42. Sublingual space Clinical evaluation: Edema and induration of the floor of the mouth on the affected side displacing tongue medially and superiorly. Hot potato voice. Elevation of tongue to palate causing airway compromise. Prevents patient from extending tongue beyond the vermilion border of upper lip.
  43. 43. Submental space Clinical evaluation: Swelling will be limited to the point of the chin & to the region immediately below it
  44. 44. Ludwig’s Angina Ludwig’s angina is a firm, acute, toxic cellulitis of the submandibular and sublingual spaces bilaterally and of the submental space. Three ‘fs’ of Ludwig’s Angina -feared -fatal (often) -fluctuant (rarely)
  45. 45. Ludwig’s Angina • The original description of the disease was given by Wilhelm Friedrich von Ludwig. 1. Rapidly spreading gangrenous cellulitis. 2. Originates in the region of submandibular gland but never involves one single space and 3. Arises from extension by continuity and not by lymphatics and 4. Produces gangrene with serosanguinous, putrid infiltration but very little or no frank pus.
  46. 46. Ludwig’s Angina - - Clinical evaluation: It is characteristically aggressive and rapidly spreading. Patient will appear toxic, fever, chills. Airway compromise occurring quickly and with little fore warning. Drooling, dysphagia, mouth pain and neck stiffness are not uncommon. Physical examination. Anteriorly protruding tongue induration and erythema Trismus is usually absent.
  47. 47. Principles of Management of Ludwig’s Angina • • • • • Hospitalization.-criterias(Flynn 2000) Securing the airway. Anaesthetic implications . Early I.V. antibiotics & hydration. External surgical exploration with division of mylohyoid muscle and drainage. • Medical supportive therapy • Review and re-evaluation in the post op period
  48. 48. Incision for surgical drainage of Ludwig’s Angina X
  49. 49. Masticator space The masticatory spaces are called secondary spaces and are combination of four smaller spaces. Clinically if one space is involved with infection, this usually implies that all spaces are involved. These are known as secondary spaces because they are usually involved with infection via spread from one of the primary spaces like buccal, sublingual or submandibular.
  50. 50. Clinical examination • Difficulty in swallowing. • Severe pain. • Swelling extending over the ramus of the mandible with obliteration of subungular depression. • Marked trismus. • Posterior portion of tongue is impossible to depress. • No fluctuance • Parotid secretions are clear. • Patient is not acutely illed.
  51. 51. Superficial temporal space Clinical appearance: Note the lack of swelling over the zygomatic arch causing a dumbell shaped configuration
  52. 52. Infratemporal space • Clinical features : • Marked Trismus • swelling of face in front of ear, over TMJ,behind zygomatic process • Eye is closed and proptosed
  53. 53. Lateral pharyngeal spaceinfection .
  54. 54. Lateral pharyngeal space infections • It lies immediately posterior and lateral to the pharynx • Anatomically the lateral pharyngeal space may be thought of as an inverted pyramid shape-the base of the pyramid being the skull base and the apex the hyoid bone. • In 1929 Mosher called this potential avenue of infection the “Lincoln highway” of the body.
  55. 55. Lateral pharyngeal/retropharyngeal space infection
  56. 56. Clinical evaluation • Firm induration with surrounding erythema lateral and anterior to sternocleidomastoid muscle. • Difficulty of flexing and turning of neck. • Trismus secondary pterygoid muscle involvement. • Dysphagia. • Dyspnea. • Extension into mediastinum along the carotid sheath. Diagnostic evaluation • Chest CT scan, radiographs Gram stain, Chest
  57. 57. Lateral pharyngeal space infections This space is further divided by the styloid process The prestyloid compartment contains fat, lymph nodes and internal maxillary artery. The post styloid compartment contains the carotid artery, internal jugular vein, cervical sympathetic chain and cranial nerves IX, X, XI, XII
  58. 58. Management • • • • Hospitalization with I.v. antibiotics. Airway protection. Rapid surgical drainage. Surgical approach always through neck not through oral cavity. • Incision is made at the level of hyoid bone across the sternocleidomastoid muscle. • If abscess not present that means the infection material had no time to form an abscess.
  59. 59. Drainage of lateral pharyngeal space
  60. 60. Complications • Suppurative jugular venous thrombosis. • Patient will have shaking chills, spiking fevers, prostration. • Tenderness at the mandibular angle and along sternocleidomastoid muscle. • Carotid artery rupture. • Internal carotid artery most commonly involved than external.
  61. 61. Pterygomandibular space • Clinical features : • • • • • Do not cause external swelling Limitation of mouth opening Dysphagia Medial displacement of lateral wall of pharynx Uvula displaced to unaffected side
  62. 62. Peritonsillar space infection 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)
  63. 63. Relationship showing lateral pharyngeal, peritonsillar and pterygomandibular spaces
  64. 64. Differantial diagnosis of spaces Pterygomandibular space Anatomy • Bet n mandible • &MT Lateral pharyngeal space Peritonsillar space • Bet n sup • Bet n MT and const sup const &mucous membrane Trismus • Extreme External swelling • Little • Moderate • Some • None • None
  65. 65. Parotid space infection • . • • • Clinical evaluation: The symptoms of parotitis include pain and induration over the involved gland. Purulent marked swelling of the angle of the jaw without associated trismus or pharyngeal swelling. Secretions may sometimes be expressed after massage from the parotid depth. Very characteristic pitting edema of the gland is pathognomic for parotid gland abscess. • •
  66. 66. Deep neck infections • All involve only posterior side of neck. a)Retropharyngeal space (space 3, posterior visceral space). b)Danger space (space 4). c)Prevertebral space (space 5). d)Visceral vascular space (within the carotid sheath)
  67. 67. Principles for Rx of the deep neck spaces Benjamin J. Gans, in his Atlas of oral 1. 2. 3. 4. 5. surgery, articulated these principles: Drain all significant deep space infections. Do not wait for fluctuance. Fluctuance is a late sign. Determine incision placement, incisions designed to avoid important anatomical structures, provide dependent drainage and leave cosmetically acceptable scar. Institute definitive treatment as soon as possible, Offending tooth to be removed. Check for systemic disease.
  68. 68. Retropharyngeal space Retropharyngeal space is the potential space sandwiched between alar and prevertebral layers of deep layer of the deep investing fascia. Extension Base of the skull Mediastinum Most dangerous of all types of deep neck infections Two compartments: Suprahyoid Sagittal section of retropharyngeal space Infrahyoid 1. Only fat 1. Lymph nodes and fat.
  69. 69. Oblique section of retropharyngeal space
  70. 70. Clinical Evaluation • Children less than 4 yrs commonly affected. • In adults it manifests as cold abscess. • Sore throat, dysphagia, odynophagia, difficulty handling secretions. • Hot potato voice. Early signs: Late signs •Refusal to take food. •Neck tilts towards involved side. •Cervical lymphadenopathy. •Hyperextended complete inability to flex the neck. •Slight neck rigidity. •Noisy breathing due to laryngeal edema. •Respiratory embarssment may occur if abscess not ruptured or drained.
  71. 71. Diagnosis of the soft tissue radiograph for retropharyngeal space infection ref:Diagnosis & treatment of the retropharyngeal abscess in adults BJOMS(1990)28,34-38 Step I: • Look at the prevertebral or retropharyngeal soft tissue shadow. • In the area of 2nd and 3rd CV, RP soft tissue shadow should be less than 7mm wide. • In the area of 6 cervical vertebra soft tissue shadow is behind the trachea and includes the thickness of esophagus making it approx. Children – 14mm wide adults – 22mm wide
  72. 72. Step II. The second feature that should be looked for in this radiograph is the presence of gas. Anaerobic bacteria will produce gas that can be seen as emphysema in the soft tissues of the neck Areas of Emphysema in the submandibular and lateral pharyngeal space region
  73. 73. Step III. - Finally, the lateral soft tissue radiograph will show the curve of the cervical spine - Loss of the lordotic curve is a strong indication of retropharyngeal space infection. - Tipping of the head forward in sniffing position to maintain an open airway.
  74. 74. Management of Retropharyngeal space infection
  75. 75. Danger space • Danger space or space for cannot be reliably differentiated from the retropharyngeal space on imaging and is therefore combined with retropharyngeal space for discussion.
  76. 76. Prevertebral space • • • Is formed by the deep cervical fascia. It extends from skull base to coccyx Facia attaches to the transverse process of the cervical vertebra dividing this space into anterior and posterior compartments. Anterior compartment contains: -Vertebral bodies. -Spinal cord. -Vertebral arteries. -Phrenic nerve. -Prevertebral and scalene muscles Posterior compartment contains: -Posterior vertebral elements. -Paraspinous muscles.
  77. 77. Lesions in prevertebral space • Arise in the vertebral body, intervertebral disc spaces Or Prevertebral / paraspinous muscles. E.g. vertebral osteomyelitis and metastatic rare lesions chondroma and nerve sheath tumors. Imaging: • Prevertebral lesions anteriorly displace the retropharyngeal space and Retropharyngeal tuberculous abscess anterior border of the prevertebral muscles. CT demonstrates hypodense fluid collection involving the • Posteriorly displace the retropharyngeal space (Asterisks) posterior triangle fat.
  78. 78. Carotid space / Visceral vascular space • The cylindrical space extends from base of the skull to the aortic arch. • It is invested with all three layers of the deep cervical fascia Thrombosed internal jugular vein Left IJV fails to fill with contrast. The lumen is hypodense Vascular complications: 1. Artery rupture – 20 to 40% mortality 2. Venous thrombosis – Life threatening problem
  79. 79. Complications of space infection • Scar formation Sinus tract formation
  80. 80. Complications of space infection cavernous sinus thrombosis • Venous congestion of the fundus of the right eye. • the same patient two weeks later. Clinically One eye experiences early involvement than the other. Cranial nerve most likely to be involved is abducens.
  81. 81. • Venous drainage of the head including the dural sinuses.
  82. 82. Diagnosis of cavernous sinus thrombosis • Eagleton’s six features. – Known site of infection. – Evidence of blood stream infection. – Early sign of venous obstruction in retina, conjunctiva or eyelids. – Paresis of III, IV, VI cranial nerves resulting from inflammatory edema. – Abscess forms and neighboring tissues and – Evidence of meningeal irritation.
  83. 83. Mediastinitis • Extension of infection from deep neck spaces into the mediastinum is heralded by – – – – chest pain severe dyspnea Unremitting fever, Radiographic demonstration of mediastinal widening.
  84. 84. Mediastinits, occurring 9 days after drainage of the retropharyngeal space CT Scan A-P view
  85. 85. Whom to consider for hospitalization? • Induviduals who show signs of systemic toxicity • who have CNS changes and • Presence of airway compromise
  86. 86. Signs of toxicity • • • • • • • • CNS symptoms Paleness Tachypnea Tachycardia Fever Appearance of illness Shivering Lethargy diaphoresis level of consiousness • Evidence of meningeal irritation(severehead ache,stiffneck,vomitin g) • Eyelid edema & abnormal eye signs •
  87. 87. Principles of incision and drainage • Incise in healthy skin and mucosa when possible. • Incision placed at the site of maximum fluctuance results in a puckered, unesthetic scar. • Place the incision in an esthetically acceptable area. • When possible place the incision in a dependent position to encourage drainage by gravity. • Dissect bluntly with closed surgical clamp or finger, through deeper tissues. • Place a drain and stabilize it with sutures.
  88. 88. Principles of incision and drainage • Consider use of through and through drains in bilateral submandibular space infections. • Do not leave drains in place for an overly extended period. • Remove them when drainage becomes minimal. • Clean wound margins daily under sterile conditions to remove clots and debris. • Another approach to drainage is the use of computed tomographic (CT) guided catheter.
  89. 89. Computed Tomography – Guided Percutaneous Drainage of a Head and Neck Infection – JOMS 1992 Left submandibular space abscess Percutaneous needle being guided into the abscess Radiopaque markers on the skin Aspiration to evacuate the abscess
  90. 90. Surgical incisions used to approach deep neck infections
  91. 91. Drainage of Submandibular space abscess
  92. 92. Drainage of parotid and Masseter space infection
  93. 93. Diagnostic Imaging of Fascial & Neck Spaces Plain film. CT. MRI Ultrasound
  94. 94. Plain Film • Diagnostic imaging starts with a plain film study of pharyngeal or cervical airways. • Views taken AP view – AP view – Lateral view • Plain film findings: - In the AP view the normal cervical airway should appear symmetrical over the middle third of the cervical spine. - Lateral view – In the adult the width of the prevertebral soft tissue should not exceed 7mm at the C3 level and 20mm at C7 level. Lateral view
  95. 95. Ultrasound • Not been used extensively • cannot penetrate osseous structures. • Useful in differentiating between solid and cystic masses • echomorphological classification of soft tissue head and neck swelling, consisting of edema, infiltrate, preabscess echo-poor and echofree abscess,. US of submandibular region demonstrating a branchial cleft cyst US of Rt parotid showing an echogenic shadowing sialolith in hilus of Rt parotid
  96. 96. MRI
  97. 97. References. • Oral &maxillofacial infections-Topazian • Oral & Maxillofacial Surgery-Laskin Vol.I&II • Killey & kay’s -Outline of oral surgery-Peter Banks • Contemporary Oral & maxillofacial surgeryPeterson • Head & neck Imaging –Peter.M.Som • The Neck –Diagnosis & SurgeryWilliam.W.Shockley, Harold .C .Pillsbury
  98. 98. Thank you For more details please visit