3. Fascial space infection DR. MUBANGA -Autosaved-.ppt

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1. FACIAL SPACE
INFECTION

2. MICROBIOLOGY OF ODONTOGENIC
INFECTIONS
Usually caused by endogenous bacteria
Aerobic bacteria alone rarely causative
agents
Streptococcus species are usually the
etiologic organisms if aerobic bacteria
present
Half odontogenic infections: anaerobes
Most odontogenic infections due to mixed
flora
Mixed infections may have 5-10 organisms
present

3. Continued….
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 10
11
/ml.

4. 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

5. Continued….
Possibly fatal infections may present
with respiratory impairment, dysphagia,
impaired vision, hoarseness, lethargy
and decreased level of consciousness
Exam findings: Toxic, CNS impairment
(decreased level of consciousness,
meningeal irritation, severe headache,
and vomiting), eyelid edema; and
ophthalmoplegia.

6. Continued….
Inspection, palpation, and percussion are
integral parts of the exam
Begin extraorally and then move inraorally
Skin of the face, head, and neck for
swelling, fluctuation, erythema, sinus or
fistula formation.
Assess for cervical lymphadenopathy and
fascial space involvement
Assess for the presence and magnitude of
trismus

7. Continued….
Inspect teeth for presence of caries and
large restorations, localized swellings,
fistulas, and mobility
Visualize Wharton’s and Stenson’s ducts
for quality of fluid (pus or saliva)
Ophthalmologic examination: extraocular
muscle function, proptosis, presence of
edema

8. Potential pathways of extension of deep fascial space infections of the head and neck

9. Continued….

10. Fascial Spaces
Fascial planes offer anatomic highways for
infection to spread superficial to deep
planes
Antibiotic availability in fascial spaces is
limited due to poor vascularity
Treatment of fascial space infections
depends on I and D
Fascial spaces are continuous and
infection readily spreads from one space to
another (open primary and secondary
spaces)
Despite I and D the etiologic agent (tooth)
must be removed

11. FASCIA SPACE ANATOMY
The fascia of the head and neck is composed of loose
fibrous connective tissue envelopes and may be divided into
the superficial and deep fascia.
The fibers of the matrix are filled with tissue fluid or ground
substance that can readily break down when invaded by
infection.
The loose fibrous connective tissue that makes up the fascia
of the head and neck is found in varying degrees of density
with a tensile strength somewhat less than dense fibrous
connective tissue located elsewhere in the body.

12. ANAT. cont
There are 16 fascial spaces of the
head and neck region divided into
four subtypes.
Fascial spaces of the face
Suprahyoid fascial spaces
Infrahyoid fascial spaces
Fascial spaces of the neck

13. FASCIAL SPACE SUBTYPES
SUBTYPE SUBTYPE COMPONENT
Fascial space of the face Canine
Buccal
Parotid
Infratemporal
Masticatory (Maseteric, Pterygomandibular,
Temporal(superficial and deep))
Suprahyoid fascia spaceSublingual
Submental
Submandibular
Lateral pharyngeal
Peritonsilar
Infrahyoid fascia spacePretarcheal
Fascia space of the neckRetropharyngeal
Danger

14. Fascia layers

15. Lateral Pharyngeal Space
Abscess & other deep spaces

16. Primary Mandibular Spaces
Submental space
1.Infection can result directly due to infected
mandibular incisor or indirectly from the
submandibular space
2.Borders:
1.Laterally - Anterior bellies of the digastric
muscle
2.Deeply - Mylohyoid muscle
3.Superiorly- Deep cervical fascia, the platysma
muscle, the superficial cervical fascia, and the
skin.
3.Dependent drainage – horizontal incision in the
most dependent area of the swelling extraorally
with a cosmetic scar being the result

17. Sub mental space incision

18. Submental space drainage

19. Continued….
Submandibular Space
1.Boundaries:
1.Superior-mylohyoid muscle and inferior border of
the mandible
2.Anteriorly-anterior belly of the digastric muscle
3.Posteriorly-posterior belly of the digastric muscle
4.Inferiorly-hyoid bone
5.Superficially-platysma muscle and superficial layer
of the deep cervical fascia
2.Infected mandibular 2
nd
and 3
rd
molars cause
submandibular space involvement since root
apices lay below mylohyoid muscle

20. Sub mandibular spsce

21. Submandibular Space Abscess

22. Sub mandibular space Incision
and drainage

23. Sublingual Space Infection

24. Sublingual space

25. Sub lingual space incision and
drainage .

26. Continued….
Buccal Space
1.Boundaries:
1.Lateral-Skin of the face
2.Medial-Buccinator muscle
2.Both a primary mandibular and maxillary
space
3.Most infections caused by posterior
maxillary teeth

27. Buccal Space Abscess

28. Secondary Mandibular Spaces
Referred to as secondary spaces since they
are infected after involvement of primary
mandibular spaces
Failure to treat a primary space infection or a
compromised host results in secondary space
involvement
Connective tissue fascia has poor blood
supply hence treatment usually surgical to
drain purulent exudates
The secondary mandibular spaces include the
masseteric, pterygomandibular, and temporal
spaces

29. Continued….
Masseteric Space
1.Location: between lateral aspect of the
mandible and the masseter muscle.
1.Involvement of this space generally occurs
from buccal space primary involvement
1.Signs;- trismus and posterior-inferior face
swelling

30. Masseteric space abscess

31. Drainage of Masseteric space

32. Infection in masseteric space

33. Continued….
Pterygomandibular Space
1.Location: between medial aspect of the
mandible and the medial pterygoid muscle
(communicates with infratemporal spaces)
2.2ndary infection results from spread from
the sublingual and submandibular spaces
3.Symptoms:
1.Trismus
2.Minimal swelling on exam

34. Pterygomandibular space

35. Pterygomandibular space

36. Continued….
Temporal Space
1.Location: posterior and superior to the
masseteric and pterygomandibular spaces
2.Bounded laterally by the temporalis fascia
and medially by the temporal bone
3.Two components:
1.Superficial temporal space: located
between temporal fascia and temporalis
muscle
2.Deep temporal space: located between the
temporalis muscle and the temporal bone
1.Continuous with the infratemporal space

37. Continued….
Masseteric, pterygomandibular, and
temporal spaces referred to as masticator
space due to delineation by the muscles of
mastication
1.Communicate freely with one another and
are simultaneously involved

38. Temporal space (superficial & deep)

39. Primary Maxillary Spaces
Canine Space
1.Location: between the levator anguli oris and the levator
labii superioris muscles
2.Involvement primarily due to maxillary canine tooth
infection
3.Long root allows erosion through the alveolar bone of the
maxilla
4.Signs:
1.Obliteration of the nasolabial fold
2.Superior extension can involve lower eyelid

40. Canine space

41. Drainage of the canine space

42. Primary Maxillary Spaces (cont.)
Buccal Space
1.Posterior maxillary teeth are source of most
buccal space infections
2.Results when infection erodes through bone
superior to attachment of buccinator muscle

43. Continued….
Infratemporal Space
1.Location: posterior to the maxilla
2.Boundaries:
1.Medial: lateral plate of the pterygoid process
of the sphenoid bone
2.Superior: skull base
3.Lateral: infratemporal space is continuous
with the deep temporal space
3.Rare involvement with odontogenic
infections, but when occurs related to 3
rd

maxillary molar infections

44. Infratemporal space

45. Infratemporal space

46. Continued….
Primary maxillary space (canine, buccal,
and infratemporal space) involvement can
ascend to cause orbital cellulitis
(preseptal or postseptal) or cavernous
sinus thrombosis
1.Ocular findings include erythema and swelling
of the eyelids, and ophthalmoplegia
2.Cavernous sinus thrombosis
1.Can result from hematogenous spread of
odontogenic infections
2.Bacterial routes of spread:
1.Posterior: via pterygoid plexus or emissary veins
2.Anterior: via angular vein and inferior or superior
ophthalmic veins to the cavernous sinus
3.Veins of the face and orbit valve less so retrograde
flow can occur

48. Orbital Abscess

49. Deep Neck Spaces
Extension of odontogenic infections beyond the
primary spaces of maxilla and mandible is uncommon
When occurs upper airway compromise and
descending mediastinitis are possible adverse
sequelae
Posterior spread of ptyerygomandibular space
infection is to lateral pharyngeal space
Lateral Pharyngeal space
1.Shape of an inverted cone with its base at the skull base
and its apex at the hyoid bone
2.Location: medial to the medial pterygoid muscle and lateral
to the superior pharyngeal constrictor muscle
3.Anterior: pterygomandibular raphe
4.Posterior: prevertebral fascia.

50. Continued….
Lateral pharyngeal space communicates with
retropharyngeal space.
The styloid process separates posterior
compartment of the lateral pharyngeal space that
contains the great vessels from the anterior space
Clinical presentation
1.Severe trismus
2.Lateral swelling of the neck
3.Bulging of the lateral pharyngeal wall
4.Rapid progression of infection in this space is common
5.Posterior compartment involvement can result in
thrombosis of the internal jugular vein, erosion of the
carotid artery or its branches, and interference with
cranial nerves IX to XII

51. Lateral Pharyngeal Space
Abscess & other deep spaces

52. Management of Odontogenic
Infections
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

53. REFERENCES
Malik, A. N., (2008). Textbook of Oral and
Maxillofacial Surgery. New Delhi: Jaypee
Brothers Medical Publishers (P) Ltd.
James R. Hupp(2019) Contemporary
Oral and Maxilofacial Surgery. 7
th

Edition,Elsevier.
Williams, S. N., Bailey & Love’s SHORT
PRACTICE of SURGERY 25
th
ed. London:
Edward Arnold (Publishers) Ltd.