Fascial spaces of the jaws and its management

Fascial spaces of jaw - seminar
Dr. Abhishek Roy

1. F ascial spaces of the jaws and its management Abhishek Roy II MDS

2. Contents Introduction Classification Primary maxillary spaces Primary mandibular spaces Secondary spaces Microbiology of Odontogenic Infections Management of Odontogenic Infections Ludwig’s Angina Conclusion References

3. Introduction Fascia is defined as layers of fibrous connective tissue underlying the skin and surrounding muscles, bones, vessels, nerves and organs Fascial spaces are potential spaces that exist between the fasciae and underlying organs and other tissues. Infection of orofacial & neck region , particularly those of odontogenic origin, have been one of the most common diseases in human being

4. Primary Maxillary Spaces

5. Canine Space

6. Boundaries Superiorly: levator labii superioris alaque nasi and levator labii superioris Inferiorly : Levator anguli oris Medially : anterolateral surface of maxilla Posteriorly : buccinator muscle Anteriorly : orbicularis oris

7. Content It is the region between anterior surface of maxilla and overlying levator muscles of upper lip Contains angular artery, vein and infraorbital nerve Etiology - Maxillary canine & 1st premolar infection - sometimes mesiobuccal root of first molars

8. Clinical Features Swelling of cheek, lower eyelid & upper lip Drooping of angle of mouth Nasolabial fold obliterated Oedema of lower eyelid

9. Buccal Space

10. Boundaries Anteromedially : buccinator muscle Posteromedially : masseter overlying the anterior border of ramus of mandible Laterally : by forward extension of deep fascia from the capsule of parotid gland and by platysma muscle. Inferiorly : limited by the attachment of the deep fascia to the mandible and by depressor anguli oris. Superiorly : the zygomatic process of the maxilla and the zygomaticus major and minor muscles.

11. Content Buccal pad of fat Stenson's (parotid)duct Facial artery Etiology - infected maxillary & mandibular pre-molar & molars

12. Clinical Features Obliteration of nasolabial fold Angle of the mouth shifted to opposite side Swelling in the cheek extending to corner of mouth Buccal space associated with temporal space : dumb-bell shaped appearance due to lack of swelling over zygomatic arch

13. Infratemporal Space

14. Boundaries Superiorly : infratemporal surface of greater wing of sphenoid Inferiorly : lateral pterygoid muscle Laterally : temporalis tendon & coronoid process Medially : lateral pterygoid plate & lateral pharyngeal wall Posteriorly : condyle & lateral pterygoid muscles Anteriorly : Infratemporal surface of maxilla & posterior surface of zygomatic bone

15. Content Mandibular nerve & its branches Maxillary artery Pterygoid venous plexus Etiology - infected maxillary 3rd molar Infected needle

16. Clinical Features Extra oral swelling over sigmoid notch area Intra oral swelling in tuberosity area Trismus

17. Spread of Infection

18. Primary Mandibular Spaces

19. Submental Space

20. Boundaries Superiorly : Mucosa of floor of Mouth Inferiorly : Mylohyoid Muscle Posteriorly : Body of Hyoid bone Anteriorly & laterally : Inner Aspect of Mandibular Body Medially : Geniohyoid, Genioglossus, Styloglossus Muscle

21. Content Deep Part of submandibular gland W harton's duct Sublingual Gland Terminal Branches Of Lingual Artery Etiology - Infected Mandibular Premolar &1st Molar

22. Clinical Features Swelling Of Floor Of Mouth Elevated Tongue Pain & Discomfort On Swallowing

23. Submandibular Space

24. Boundaries Superiorly : Mylohyoid muscle, inferior border of mandible Inferior : anterior & posterior belly of digastric Laterally : deep cervical fascia, platysma, superficial fascia & skin Medially : hyoglossus , styloglossus, mylohyoid muscle Posteriorly : to hyoid bone Anteriorly : submental space

25. Content sub mandibular gland facial vein & artery Etiology - infected mandibular 2nd & 3rd molars. sub lingual spaces

26. Spread of Infection A cross midline to contralateral space To contiguous pharyngeal space

27. Sublingual Space

28. Boundaries Superiorly : mucosa of floor of mouth Inferior : mylohyoid muscle Posteriorly : body of hyoid bone Anteriorly & laterally : inner aspect of mandibular body Medially : Geniohyoid, styloglossus, genioglossus muscle

29. Content Deep part of Submandibular gland Wharton’s duct Sublingual gland Lingual & hypoglossal nerves Terminal branches of lingual artery

30. Clinical Features Etiology - Infected mandibular premolar & 1st molar. Swelling of floor of mouth Elevated tongue Pain & discomfort on swallowing

31. Secondary Spaces

32. Masseteric Space

33. Boundaries Superiorly : zygomatic arch Inferiorly : inferior border of mandible Laterally : masseter muscle Medially : ramus of mandible Posteriorly : parotid gland & its fascia Anteriorly : buccal space & buccopharyngeal fascia

34. Content Massetric artery and vein Etiology – Mandibular 3 rd molar ( pericoronitis )

35. Clinical Features Swelling limited to masseter muscle Severe trismus & throbbing pain

36. Pterygomandibular Space

37. Boundaries Superiorly : lower head of lateral pterygoid muscle Laterally : medial surface of ramus Medially : medial pterygoid muscle Posteriorly : deep part of parotid Anteriorly : Pterygomandibular raphe

38. Content Inferior alveolar neurovascular bundle Lingual & auriculotemporal nerves Mylohyoid nerve & vessels Etiology - Infected mandibular 3rd molars Pericoronitis Infected needles or contaminated LA solution

39. Clinical Features Absence of extra-oral swelling Severe trismus Difficulty in swallowing Anterior bulging of half of soft palate & tonsillar pillars with deviation of uvula to unaffected side

40. Spread of Infection Superiorly to infratemporal space Medially to lateral pharyngeal space To submandibular space

41. Temporal Spaces

42. Boundaries Superficial temporal- Laterally : temporalis fascia Medially : temporalis muscle Deep temporal- Laterally : temporalis muscle Medially : temporal bone & greater wing of sphenoid

43. Clinical Features Superficial temporal - S welling limited by outline of temporalis fascia Trismus Severe pain Deep temporal - less swelling, difficult to diagnose and trismus Etiology - From infratemporal or Pterygomandibular space

44. Lateral Pharyngeal Space

45. Boundaries Shape of an inverted cone or pyramid, the base is at sphenoid bone and the apex at hyoid bone Anteriorly : Pterygomandibular raphe Posteriorly : extends to prevertebral fascia Laterally : fascia covering medial pterygoid muscle, parotid & mandible Medially : buccopharyngeal fascia on lateral surface of superior constrictor muscle Styloid process divides the space into anterior muscular and posterior vascular compartment

46. Content Anterior compartment : fat, muscle, lymph nodes and connective tissue Posterior compartment : carotid sheath(carotid artery, internal jugular vein , vagus nerve), cranial nerves IX through XII Etiology : Infected mandibular 3rd molars Tonsillar infections Pharyngitis Parotitis

47. Clinical Features Anterior compartment: Trismus Induration & swelling at angle of jaw Fever Pharyngeal bulging Posterior compartment: Posterior tonsillar pillar deviation Neurological involvement Thrombosis of internal jugular vein Erosion of carotid vessels may occur

48. Spread of Infection To retropharyngeal space To peritonsillar space

49. Retropharyngeal Space

50. Boundaries Posteromedial to lateral pharyngeal space and anterior to the prevertebral space Anterior : posterior pharyngeal wall Posterior : prevertebral fascia Superior : skull base Inferior : mediastinum Laterally : lateral pharyngeal space

51. Clinical Features Stiffness of neck Dyspnea Dysphagia Bulging of posterior pharyngeal wall Etiology - Nasal & pharyngeal infections Spread from odontogenic infections

52. Complications Airway obstruction Aspiration pneumonia Acute mediastinitis Can spread to Danger space

53. Parotid Space

54. Boundaries Formed by superficial layer of deep cervical fascia surrounding the parotid gland Gland is strongly attached to fascial covering and there is very little loose connective tissue Etiology – Blood borne infections Retrograde infections through Stenson’s Duct Rare spread from submassetric, Pterygomandibular or lateral pharyngeal space

55. Clinical Features Swelling from zygomatic arch to lower border of mandible superoinferiorly Anterior border of mandible to retromolar region anteroposteriorly Lobule of ear may be everted Severe pain while mastication leads to less consumption and dehydration Possible escape of pus from duct during milking of parotid gland

56. Microbiology of Odontogenic Infections

57. Causative Organisms Usually caused by endogenous bacteria Most odontogenic infections due to mixed flora Streptococcus species(alpha haemolytic) are usually the etiologic organisms if aerobic bacteria present Anaerobes - prevotella, bacteroids, fusobacterium are also involved

58. Factors affecting spread of infection Microbial factors- Level of virulence No. of organisms introduced Host factors- General state of health Integrity of surface defence Level of immunity Capacity for inflammatory & immune response Impact of medical intervention Combination of both factors.

59. Routes of spread Direct spread a) Spread into superficial soft tissues as- Abscess - pathological thick walled cavity filled with pus Cellulitis – diffuse erythematous subcutaneous / submucous inflammation of soft tissues b) Spread into adjacent fascial spaces. c ) Into deep medullary spaces of bone- osteomyelitis Indirect spread a) Lymphatic routes to regional nodes. b) Hematogenous route to other organs such as brain

60. Investigations Routine laboratory investigations. Special laboratory investigations. Radiological examination IOPA OPG Lateral oblique view mandible A-P & Lateral view of neck for soft tissues can be useful in detecting retropharyngeal space infection Ultrasound of swelling CT scan, MRI help in diagnosing extension of infection beyond maxillofacial region

61. Management of Odontogenic Infections

62. Goals of management Airway protection Surgical drainage Identification of etiologic bacteria Selection of appropriate antibiotic therapy Medical & supportive therapy

63. Antibiotic Therapy Parenteral penicillin Metronidazole in combination with penicillin can be used in severe infections Clindamycin for penicillin-allergic patients Cephalosporins Antibiotics do not substitute for incision and drainage in cases of significant odontogenic infections. Causes for clinical failure include inadequate drainage or antibiotic resistance

64. Surgical Management Incision & drainage helps- To get rid of toxic purulent material To decompress oedematous tissues To allow better perfusion of blood, containing antibiotics and defensive elements To increase oxygenation of infected area Removal of the cause; such as infected tooth, a segment of necrotic bone, a foreign body should be done at the time of I & D procedure

65. Hilton’s method Stab incision is made over a point in the most fluctuant area along the skin creases, through skin & subcutaneous tissue I f pus is not encountered, further deepening of surgical site is achieved with sinus forceps Closed forceps are pushed through the tough deep fascia and advanced towards the pus collection Abscess cavity is entered and forceps opened in a direction parallel to vital structures Pus flows along side of the beaks Explore the entire cavity for additional loculi

66. Hilton’s method Placement of drain : A corrugated rubber drain is inserted into the depth of the cavity and fixed with the help of suture Drain left for at least 24 hours Dressing : Dressing is applied over the site of incision taken extraorally without pressure

67. Drainage Canine , Sublingual and Vestibular abscesses are drained intraorally Massetric, Pterygomandibular, Buccal and Lateral Pharyngeal space abscesses can be drained with combination of intraoral and extraoral drainage Temporal , Submandibular, Submental, Retropharyngeal and Parotid space abscesses may mandate extraoral incision and drainage

68. Supportive Therapy Administration of antibiotics Hydration of patient by I/V route Soft or liquid diet rich of high proteins Analgesics & NSAIDs Antiseptic mouthwashes Complete bed rest

69. Ludwig’s Angina

70. Definition I t is a firm, acute, toxic cellulitis of the submandibular, sublingual spaces bilaterally and of the submental space Described by WILHELM FREDREICH VON LUIDWIG IN 1836

71. Etiology P eriapical, pericoronal or periodontal infection of a lower third molar T raumatic injuries and infected lesions I nfective conditions such as osteomyelitis may manifest as Ludwig's angina C ysts or tumors in third molar region

72. Pathology Infection from lower third molar reaches the submandibular spaces From here infection spreads along the submandibular salivary glands above the mylohyoid muscle to reach the sublingual space

73. Clinical Features Pyrexia Dehydration Dysphagia Dyspnoea Hoarseness of voice Stridor

74. Extraoral Features Hard to firm brown indurated swelling skin over the swelling appears erythematous and stretched Swelling is tender with local rise in temperature Difficulty in closing the mouth D rooling of saliva Respiratory distress

75. Intraoral Features Trismus Floor of the mouth is raised Tongue raised upwards Increased salivation

76. Management Airway maintenance- tracheostomy and cricothyroidectomy is advisable Parenteral antibiotics - amoxicillin + metronidazole Surgical decompression (under LA) - decompression improves vascularity and potentiates the action of antibiotics Bilateral submandibular incision with a midline submental incision Pus should be drained Hydration of the patient – it is necessary to put the patient on IV fluids Removal of cause - t he offending tooth is removed

77. Complications Death due to airway compromise Septicaemia Mediastinitis Carotid blow out

78. Conclusion Misdiagnosis of such conditions can prove extremely deleterious to the patient Proper knowledge of fascial spaces is very important for correct diagnosis and definitive treatment plan

79. References Oral & maxillofacial Infections – Topazian Textbook of oral & maxillofacial surgery – Laskin Online Sources