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Deep fascial space infection of oral and maxillofacial region of odontogenic orgin
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DEEP FASCIAL SPACE INFECTIONS
ARJUN SHENOY
DEPT OF OMFS
• HISTORY
• PRINCIPLES OF EXAMINATION
• CLASSIFICATION OF SPACES
• ANATOMICAL CONSIDERATIONS
• PATHWAYS OF SPREAD
• DIAGNOSTIC AIDS
• SPACES
• COMPLICATIONS
• CONCLUSION
• REFERENCES
“The concept of fascial spaces is based on the anatomist’s knowledge that all “spaces” exist only potentially, until fasciae are separated by
pus, blood, drains, or a surgeons finger”
INTRODUCTION
Shapiro defined fascial spaces as potential spaces between the layers of the fascia
Filled by connective tissue
HISTORY
• 1938 landmark article - Grodinsky & Holyoke - modern understanding
Injection dyed gelatinCadaversSelective portals
HYPOTHESIS- spread hydrostatic pressureGuided tissue resistance
• 1939- Ashbel Williams – 31cases Ludwigs angina (54%)
• 1979- Hough et al – (4%)
PRINCIPLES OF EXAMINATION
Rapid initial assesment
Complete history Physical examination Imaging and laboratory data
Immediate hospitalization with
aggressive intervention
DATABASE
TOXICITY SIGNS
• Paleness
• Tachypnea
• Tachycardia
• Fever
• Shivering
• Lethargy
• diaphoresis
Decreased level of consciousness
Evidence of meningeal irritation-1) Severe headache2) Stiff neck3) vomiting
PATHWAYS OF SPREAD
ANATOMICAL CONSIDERATIONS
• MUSCLE ATTACHMENTS-
• Posteriors= Buccinator- midroot level
• Anteriors –intrinsic lip muscles & risorius
BUCCINATOR & ODONTOGENIC INFECTION
In maxilla Above the attachment
Root apex Extraoral
Below the
attachment
Intraoral swelling
(In Mandible it is vice versa)
MYLOHYOID & ODONTOGENIC INFECTIONS
Anteriors Posteriors
(Root apex below) (Root apex below)
Intraoral Extraoral
(Floor of the mouth) (submandibular)
Infection enters tissue spaces
Areolar connective tissue in tissue spaces undergoes
necrosis
Replaced by cellulitic fluid and then by pus
Vascular dilation, Transudation, and Exudation draw fluid into the region, thus increasing
the hydrostatic pressure
pressure applied to the borders of the space, the advancing front of the infection
may bypass the contiguous spaces
DIAGNOSTIC IMAGING
• ACCURATE DIAGNOSIS
• GUIDING DRAINAGE PROCEDURES
• EXTENT
• DETECTING COMPLICATION
PLAIN FILM OPG
• Extent of pathology of
odontogenic orgin
• AP/LATERAL CERVICAL
• Lesser penetration c-spine
• Pharyngeal/ cervical
airway
COMPUTED TOMOGRAPHY
• Widely used - 5mm increments
• Contrast enchanced - 95% sensitivity
• Assess integrity cortical bone
• Short time –extent , epicentre
• Availability
• Relative low cost
ULTRASONOGRAPHY
• Superficial
• inability-osseous penetration
• Parotid /submandibular/ neck
• Differentiates solid / cystic
MAGNETIC RESONANCE IMAGING
• Not uncommon
• Coronal and saggital planes
• T1- anatomic detail
• T2- disease process sensitive
• Intravenous contrast agents- safer
• T1 + gadolinium
FASCIAL SPACES OF CLINICAL SIGNIFICANCE*FACE
o Buccalo Canineo Masticator Massetric compartment Pterygoid compartment Zygomaticotemporal compartment
SUPRAHYOIDSublingualSubmandibularLateral pharyngealPeritonsillar
* RICHARD G TOPAZIAN , ORAL & MAXILLOFACIAL INFECTION 4TH EDITION
CONTINUED
INFRAHYOID Anterovisceral (paratracheal)
SPACE OF TOTAL NECKRetropharyngealDanger spaceSpace of carotid sheath
RICHARD G TOPAZIAN , ORAL & MAXILLOFACIAL INFECTION 4TH EDITION
DIRECT INVOLVEMENT (Primary spaces)
Maxillary spaces - canine, buccal, and infratemporal . .
Mandibular spaces - submental, buccal, submandibular, and
sublingual .
INDIRECT INVOLVEMENT (Secondary spaces)
Masseteric, Pterygomandibular, Parotid, Superficial and deep temporal, Lateral pharyngeal, Retropharyngeal and Prevertebral spaces
Based on mode of involvement
ACCORDING TO THEIR RELATION TO THE HYOID BONE
Most important anatomic structure - limits the spread of infection-
Suprahyoid (above the hyoid)
Infrahyoid (below the hyoid)
Fascial spaces traversing the length of the neck
TRIVIA• Diffusion- antibiotics- limited
• Grossly distorted anatomy
• Poor vascularity - thick walls
• Adequate open dependent drainage
• Spreads readily one to another
• Secondary-primary both to be drained
ANTIBIOTIC THERAPY• EXCEPTIONS
• Well localized- easily drained –dentoalveolar abscess
• INCLUSION
• Poorly localized
• Extensive abscess
• Diffuse cellulitis
• Immunocompromised
• Systemic signs
INCISION AND DRAINAGE
• Incison- healthy skin/ mucosa- natural crease
• Site- max fluctuance- unaesthetic scar
• Dependent –
• Dissection- blunt- full extent
• Stabilize drain
• Remove on time
RECENT ADVANCES
• Two mini incisions, 4-5 mm each, far apart
• Abscess probed, pus drained.
• Abscess was irrigated -normal saline
•
• loop drain was passed through one incision, brought out through the other, and tied to itself.
BUCCAL SPACE
BOUNDARIES• Superiorly: zygomatic arch.
• Inferior: inferior border of mandible.
• Laterally: skin & subcutaneous tissue.
• Medially: buccinator muscle ,
• Posteriorly: anterior edge of
masseter.
• Anteriorly: posterior border of
zygomaticus major
& depressor anguli oris.
C/F
• Marked cheek swelling
• Diseased premolars/molars
• Fluctuance
• DD-complication of crohns
disease, H Influenzae
BUCCAL SPACE
• Contents-
• Buccal fat pad.
• Stenson’s duct.
• Facial artery.
• Communications
• Submasseteric Space
• Pterygomandibular Space
• Superficial Temporal Space
• infratemporal space
• Lateral Pharyngeal Space
• Carotid sinus
TREATMENT
• Intra-oral
• Attempts to direct- futile
• Drainage difficult
• Cutaneous
• Inferior to point of fluctuance
• Incision- stensons duct
• Blunt dissection- extreme borders
H INFLUENZAE
• Infants and children <3 yrs
• High fever 24 hours prior onset
• Otitis media - recent
• Augmentin/cephalosporin
SUBMENTAL SPACE
BOUNDARIES
• Boundaries:
• Ant - inferior border of mandible
• Post - hyoid bone
• Sup - mylohyoid bone
• Inf - skin and investing fascia
• Lat -investing fascia
• Med-Anterior belly of digastric.
Source of infection
incisors submandibular
• Intra-oral – non dependent
• Through mentalis –labialvestibule
• Percutaneous-
• horizontal incision-
• most inferior portion of the chin- natural skin crease
CANINE SPACE
• Infrequent
• Levator muscle – upper lip
• Perforates lateral cortex-
Potential canine space
True fascial space/muscular compartment??
Marked cellulitis of eyelids
• Drainage – intra-oral approach
• High maxillary vestibule- sharp blunt dissection
• Approach- extension of apicectomy- canine root
Percutaneous drainage
visible scar non dependent drainage
SUBMANDIBULAR + SUBLINGUAL SPACE
• Anatomically distinct
• Proximity + frequent dual involvement
SUBLINGUAL SPACE• Sublingual space is defined superiorly by the mucosa
of the mouth floor and inferiorly by the mylohyoid muscle
• Boundaries:
• Ant – Lingual surface of mandible
• Post - Submandibular space
• Lat - Muscles of tongue
• Med - Lingual surface of mandible
• Sup - Oral mucosa
• Inf - Mylohyoid muscle
• CONTENT
• sublingual gland, submandibular duct, hilum of the submandibular gland, lingual nerve, and sublingual artery and vein.
• C/F - Brawny, erythematous, tender swelling of the floor of the mouth, elevation of the tongue may be noted in late cases.
TREATMENT• Surgical drainage, antibiotics
• Definitive care of the primary dental infection
• INTRAORAL-
• by an incision through the mucosa parallel to Wharton's duct bilaterally.
• blurring of the tracheal air shadow and symmetric narrowing of the subglottic air shadow- characteristic "church steeple" sign on anteroposterior films.
SUBMANDIBULAR SPACE• Odontogenic infections of this space commonly are
caused by the second and third molar teeth
• Infection beginning in the mandibular molars is likely to perforate the thin lingual plate of the mandible to enter the submandibular space directly
• Influence of mylohyoid muscle attachment
BOUNDARIES
• Ant - Anterior belly of digastric muscle
• Post - Posterior belly of digastric muscle,
• Stylohyoid Stylopharyngeus muscle
• Med - Mylohyoid, hypoglosus, superior constricting muscles
• Lat - Platysma muscle, Investing fascia
• Sup - Inferior and medial surfaces of mandible
• Inf - Digastric tendon
• Contents - submandibular salivary gland and its lymph nodes,
• the facial artery,
• -the proximal portion of Wharton's duct,
• -lingual and hypoglossal nerves
TREATMENT• Incision - through the skin below and parallel to the
mandible.
• Blunt dissection-avoid damage to the submandibular gland, the facial artery, and the lingual nerve.
• Contralateral space - through and- through drain can be placed into both sides
• Communication
• Sublingual space
• Submental space
• Lateral pharyngeal space
• Contralateral spaces
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
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