a presentation on principles of management of complex maxillofacial infections

1. OROFACIAL INFECTIONS
Dr Kiprop.J (BDS UoN), MDS-OMFS- (UoN)

2. Presentation Outline
• Objectives
• Introduction
• Applied anatomy-fascial spaces
• Specific entities- aetiology, microbiology, pathogenesis
• Principles of management
• Complications
• Sample Clinical Cases
• References
5/24/2023 Dr. Kiprop J. (OMFS) 2

3. Objectives
• To understand the relevant anatomy
• To diagnose and distinguish between the common maxillofacial
infections
• To identify and manage key risk factors
• To manage common maxillofacial infections
• To make appropriate decisions including appropriate referrals
5/24/2023 Dr. Kiprop J. (OMFS) 3

4. Introduction
• Infection is the invasion of an organisms body tissues by disease
causing agents, their multiplication, and the reaction of host
• Chain of infection: 6 components- pathogen, reservoir, portal of exit,
mode of transmission, portal of entry, susceptible host.
• Infections Global burden
• Local picture
5/24/2023 Dr. Kiprop J. (OMFS) 4

5. Fascial Spaces
• Potential tissue spaces made of delicate meshwork or loose CT
• Primary and secondary fascial spaces
• Primary-become directly involved /infected directly from odontogenic
sources
• Maxillary- infratemporal, canine, buccal
• Mandibular- buccal, perimandibular (sub-mental,sublingual, submandibular)
• Secondary-communicate with primary spaces
eg masticator spaces- 4 compartments-superficial and deep
temporal,infratemporal,masseteric, pterygomandibular(pterygoid) and
Deep cervical fascial spaces eg lateral pharyngeal,retropharngeal,
prevertebral.
• Fascial spaces -are they good or bad?
5/24/2023 Dr. Kiprop J. (OMFS) 5

6. Fascial Spaces Diagram
5/24/2023 Dr. Kiprop J. (OMFS) 6

7. Cervical Spaces- Oblique Coronal Cut
5/24/2023 Dr. Kiprop J. (OMFS) 7

8. Sub-maxillary Space Infection
5/24/2023 Dr. Kiprop J. (OMFS) 8

9. Buccal Space Infection
5/24/2023 Dr. Kiprop J. (OMFS) 9

10. Ludwig’s Angina
It is an acute,overwhelming and rapidly spreading septic cellulitis, involving peri-
mandibular spaces bilaterally.
ETIOLOGY:
• Odontogenic infection-Extension of infection from mand. 2nd & 3rd molar
teeth into the floor of mouth
• Trauma-soft tx laceration & punctured wounds of oral floor
• Submand. gland sialadenitis & infected malignancy
• Salivary calculi
• Osteomyelitis-e.g compound mand. fracture
5/24/2023 Dr. Kiprop J. (OMFS) 10

11. Ludwig’s Angina
BACTERIOLOGY: Polymicrobial
• Most common-streptococci viridans and staph.aureus.
• Others-Alpha hemolytic streptococci, peptostreptococci, bacteriodes,
klebsiella, fusiform bacilli & E-coli.
C/F:
• The terrible Ds- dyspnea, dysphagia, odynophagia, drooling, dysarthria,
• Diffuse painful swelling with no signs of localization, Neck pain
• Floor of mouth appears erythematous & edematous, redness of neck
• Fever with chills
• Weakness, fatigue, confusion
5/24/2023 Dr. Kiprop J. (OMFS) 11

12. Necrotizing Fasciitis Syndrome
• Distinct entity from Ludwig’s angina.
• Rapidly progressive inflammatory infection of the fascia with secondary
necrosis of the subcut. tissues.
• Polymicrobial- anaerobic and gram negative bacteria -symbiosis and
synergy maybe responsible for rapid progress
• Monomicrobial- Group A beta hemolytic streptococcus.
• Spreads along fascial spaces
• Lack of classical tissue inflammatory signs
5/24/2023 Dr. Kiprop J. (OMFS) 12

13. Necrotizing Fasciitis Syndrome..cont.
• M>F 2-3:1, 4-5th decades, Rare in children(malnutrition, vascular lymphatic
malformations
• Risk factors- DM (20-40%), Ca, ISS, Alcoholism, liver dx (cirrhosis), neutropenia,
organ transplants, vascular disease.
• Note- Approx. 50% of strep. fasciitis occur in young healthy people
• Is preceded by excruciating pain disproportionate with the actual tissue destruction
• Fascial tissue necrosis is often more advanced than it appears
• Putrid discharge, bullae, anaesthesia of overlying skin
• Emphysema- air in tissues- H, N, HS
5/24/2023 Dr. Kiprop J. (OMFS) 13

14. Necrotizing Fasciitis Syndrome..cont.
• High morbidity and mortality(20-80%)- aggressive treatment indicated
• Late intervention- involvement of deeper muscle layers- myositis,
myonecrosis.
• Prognostic factors- pt characteristics, pathogens , infection site, speed of
treatment
• Poor prognosis- liver and renal dysfunction, gram negative, age
5/24/2023 Dr. Kiprop J. (OMFS) 14

15. Necrotizing Fasciitis Syndrome..cont.
• Surgery is the primary Rx- wide extensive debridement
• Clindamycin work better than penicillin
• Hemodynamic instability may worsen the skin necrosis
• Resurfacing of the wound done once healthy granulation tissues occurs
5/24/2023 Dr. Kiprop J. (OMFS) 15

16. Necrotizing Fasciitis Syndrome.. pathogenesis
• Entry of microbes-enzymes and toxins production, bacterial surface protein
expression M1, M3 allows for adherence of strep. to tissues and evasion of
phagocytosis by PMNs, thrombosis, vascular occlusion, ishaemia- necrosis
– damage of superficial nerves- septicemia+ systemic toxicity
• Streptococcus pyrogenic exotoxins (SPEs) A,B,C are directly toxic and
together with streptococcus superantigen lead to production of cytokine
and hypotension.
• Staph. aureus maybe caused by Panton- Valentine leukocidin toxin
5/24/2023 Dr. Kiprop J. (OMFS) 16

17. Principles of Management
• Prompt diagnosis
• Air management and protection
• Fluid resuscitation and optimal nutrition
• Source control
• Aggressive iv antibiotic therapy-empiric, then definitive after C/S
5/24/2023 Dr. Kiprop J. (OMFS) 17

18. Principles of Management
• Decompression/Incision and drainage - copious amounts of normal
saline
• Debridement
• Analgesia and management of inflammation
• Identification and management of the risk factor
• Appropriate and early referral
5/24/2023 Dr. Kiprop J. (OMFS) 18

19. Complications
• Airway obstruction
• Dehydration
• Empyema thoracis, Mediastinitis, aspiration pneumonia, and pleural
effusion
• Cavernous sinus thrombosis, orbital and cerebral abscesses ± meningitis
• Septic shock- MOD if not managed
• Death
• Others- carotid arterial rupture, thrombophlebitis of the IJV, pericardial effusion, osteomyelitis
of the mandible, subphrenic abscess, Lemierre syndrome
Preventive dental care is the best way- regular dental reviews and treatment and good oral hygiene practices.
5/24/2023 Dr. Kiprop J. (OMFS) 19

20. 5/24/2023 Dr. Kiprop J. (OMFS) 20

21. Patient 1: It Is Possible
5/24/2023 Dr. Kiprop J. (OMFS) 21

22. Patient 2
5/24/2023 Dr. Kiprop J. (OMFS) 22

23. Patient 2
5/24/2023 Dr. Kiprop J. (OMFS) 23

24. Patient 2
5/24/2023 Dr. Kiprop J. (OMFS) 24

25. Thank You.
Questions?
5/24/2023 Dr. Kiprop J. (OMFS) 25