space infection.pptx

ORAL INFECTION

1. Space infection DR DAVIS NADAKKAVUKARAN .M.D.S READER MALABAR DENTAL COLLEGE

2. CONTENTS INTRODUCTION CLASSIFIACTION SUPRASTERNAL SPACE PRIMARY FASCIAL SPACE - RELATED TO UPPER JAW - RELATED TO LOWER JAW SECONDARY FASCIAL SPACE LIFE THREATENING COMPLICATIONS CONCLUSION REFERENCE

3. INTRODUCTION Soft tissue infections of head and neck are commonly encountered in routine practice of oral and maxillofacial surgery, In case of infection the classic signs and symptoms—pain, swelling, surface erythema, lymphadenopathy, and systemically-fever , malaise, toxic appearance, and an elevated white blood cellcount is present DEFINITION Shapiro defined fascial spaces as potential spaces between the layer of fascia . These spaces are normally filled with loose connective tissues and various structures like veins, arteries, glands, lymph nodes, etc.

4. CLASSIFICATION OF FASCIAL SPACE BASED ON CLINICAL SIGNIFICANCE Primary maxillary spaces Canine ( infraorbital ) Buccal Infratemporal Primary mandibular spaces Submental Submandibular Sublingual Buccal

5. Secondary fascial spaces Masseteric Pterygomandibular Superficial and deep temporal Lateral pharyngeal Retropharyngeal Prevertebral

6. TOPAZIAN CLASSIFICATION

7. GRODINSKY & HOLYOKE CLASSIFICATION Space 1 : potential space superficial & deep to platysma muscle Space 2 : space behind the anterior layer of deep cervical fascia Space 3 : pretracheal space lies anterior to trachea Space 3 A : viscera vascular space( lincolns highway as coined by Mosher) Space 4 : Danger area b/w alar & prevertebral fascia

8. BASED ON MODE OF INVOLVEMENT Direct involvement : Primary spaces 1. Maxillary spaces 2. Mandibular spaces Indirect involvement: Secondary spaces

9. Anatomic spaces of head & neck

10. SUPRASTERNAL SPACE( OF BURNS) The suprasternal space (of Burns) is a space of the inferior neck. Superficial fascia splits below the level of the hyoid bone to form two spaces: 1. It forms the lower part of the root of the posterior triangle, the fascia splits into two layers, both of which are attached to the clavicle. 2. It forms the lower part of the roof of the anterior triangle and the fascia splits in form the suprasternal space or the space of the ‘burns’.

11. CONTENTS Sternal head of sternocleidomastoid muscle Anterior Jugular vein anastomoses Lymph nodes Interclavicular ligament

12. PRIMARY FASCIAL SPACES SPACES RELATED TO UPPER JAW CANINE SPACE ETIOLOGY: Odontogenic infection nasal infection, less frequent BOUNDARIES: Superficial and superior— Quadratus labii superioris Inferior—Orbicularis oris Deep— Levator anguli oris , anterior surface of maxilla Medial— Levator labii superioris alaeque nasi Lateral— Zygomaticus major

13. CONTENT: Angular artery and vein Infraorbital nerve TEETH INVOLVED Maxillary canine, 1st premolar infection and sometimes mesiobuccal root of first molars CLINICAL FEATURES • Periapical abscess of canine usually present as labial sulcus swelling and less commonly as palatal swelling • Swelling of the cheek and upper lip (vestibular abscess) • Obliteration of the nasolabial fold • Oedema of the lower eyelid. • Marked periorbital oedema forcing the eyelid to close. • Marked tenderness and redness in the facial tissue.

14. SURGICAL MANAGEMENT The incision is made intraorally high in the maxillary labial vestibule. Insert a small haemostat through the levator anguli oris into the abscess cavity place a rubber drain and suture into the lower margin of the vestibular incision .

15. BUCCAL SPACE BOUNDARIES Superior— Zygomatic arch Inferior—Inferior border of mandible Anterior—Posterior border of the zygomatic bone above and depressor angulioris below Posterior—Anterior border of the masseter muscle Medial— Buccinator muscle and its fascia Lateral—Skin and subcutaneous tissue.

16. CONTENTS Space filled with buccal pad of fat (adipose tissues ) Parotid duct Anterior and transverse facial artery and vein . TEETH INVOLVED Maxillary and mandibular premolars and molars. CLINICAL FEATURES -Pus acumination leads to gum boil seen in vestibule -Prominent extra oral swelling -swelling extending from lower border of mandible to infraorbital margin & from anterior margin of masseter to corner of mouth. -Edema of lower eyelid.

17. SURGICAL MANAGEMENT Horizontal incision through the oral mucosa of the cheek in the premolar molar region If the pus is lateral to the muscle, then the muscle is penetrated with curved mosquito forceps to enter the buccal space Drain is placed & secured with suture

18. INFRATEMPORAL SPACE Also called as retrozygomatic space as it is partly situated behind the zygomatic bone BOUNDARIES Superior—Skull base-sphenoid crest Inferior—Lateral pterygoid muscle Medial—Lateral pterygoid plate Lateral—Temporalis muscle and tendon Anterior—Maxillary tuberosity Posterior—Mandibular condyle

19. CONTENTS -Internal maxillary artery (second part) - Pterygoid venous plexus - Mandibular division of trigeminal nerve -Medial and lateral pterygoid muscles INVOLVEMENT Infratemporal fossa may also become secondarily infected from infections of the submasseteric , parotid and lateral pharyngeal spaces.

20. CLINICAL FEATURES EXTRA ORAL- trimus - bulging of temporalis muscle - marked swelling of the face - eye is closed & often proptosed INTRAORAL – swelling in the tuberosity zone

21. SURGICAL MANAGEMENT Infratemporal space can be reached either intraorally or extraorally . -Internal approach (Kruger) consists of an incision made in the buccolabial fold lateral to the maxillary third molar . -A curved haemostat is introduced carefully behind the tuberosity of the maxilla and directed medially andsuperiorly within the cavity. -A drain is then inserted. -According to Laskin , a vertical incision is made medial to the upper extentof the anterior border of ramus of the mandible . - A haemostat is introduced and passed superiorly into the infratemporal region and a drain is introduced.

22. SPACES RELATED TO LOWER JAW SUBMENTAL SPACE BOUNDARIES Superior— Mylohyoid muscle Inferior—Skin and subcutaneous tissue, platysma and deep cervical fascia Medial—Single midline space with no medial wall Lateral—Anterior belly of digastric (bilateral) Anterior—Mandible Posterior—Hyoid bone

23. CONTENTS no vital structures Lymph nodes and anterior jugular veins INVOLVEMENT Infection from lower incisors, lower lip, chin, tip of the tongue and anterior part of floor of the mouth CLINICAL FEATURE Extraoral findings- Distinct, -firm swelling in midline,beneath the chin. -Skin overlying the swelling is board-like and taut. - Fluctuation may be present.

24. Intraoral findings: The anterior teeth are either nonvital , fractured or carious . The offending tooth may exhibit tenderness to percussion and may showmobility . The patient may experience considerable discomfort on swallowing . SURGICAL MANAGEMENT -The incision for drainage is made bilaterally through the skin, subcutaneous tissue and platysma muscle at the most inferior aspect of the swelling. - Rubber drain is inserted through one incision, exited through the other and secured with the help of sutures and dressing applied

25. SUBMANDIBULAR SPACE BOUNDARIES Lateral—Skin, superficial fascia, investing fascia, platysma Medial— Mylohyoid , hyoglossus , superior constrictor, styloglossus muscles Superior—Inferior and medial surface of the mandible and attachment of mylohyoid muscle Inferior—Anterior and posterior belly of digastrics muscle

26. CONTENTS -Submandibular salivary gland and lymph nodes - Facial artery - Lingual nerve -Lymph nodes INVOLVEMENT -Infection from the mandibular molars, most commonly second and third molar -Infection from submental and sublingual spaces -Infection from the submandibular salivary gland -Infection from the middle third of the tongue, posterior part of the floor of the mouth, maxillary teeth, cheek, maxillary sinus and palate

27. CLINICAL FEATURE Extraoral : - Firm swelling in submandibular region,below the inferior border of mandible , - generalizedconstitutional symptoms . - some degree oftenderness , - redness of overlying skin. Intraoral: - Teeth are sensitive to percussion Teeth are mobile -dysphagia - moderate trismus .

28. SURGICAL MANAGEMENT -Two stab incisions are made at the inferior aspect of the swelling in the shadow of the mandible . - The dissection is carried out through one of the incisions with the curved haemostat in the abscess cavity. -Blunt dissection avoids the risk of injuring the facial artery, anterior facial vein and facial nerve. -The haemostat is passed through one incision and out through the other. -A thin rubber drain is passed through the stab incisions with the help of the haemostat . -The ends of the drain are sutured to prevent dislodgement.

29. SUBLINGUAL SPACE BOUNDARIES: Superior—Mucosa of the floor of the mouth Inferior—Superior surface of mylohyoid muscle Medial—Midline raphae Lateral—Medial surface of mandible

30. CONTENTS: -Deep part of submandibular gland, sublingual gland and their draining ducts (Wharton’s duct and ducts of Rivinus ) - Lingual nerve CLINICAL FEATURE: Extraoral : - There is little or no swelling. -The lymnhnodes may be enlarged and tender . - Pain and discomfoon deglutition . - Speech may be affected.

31. Intraoral: Firm , painful swelling seen in the floor of themouth on the affected side. -The floor of the mouth is raised. - The tongue may be pushed superiorly . - airway obstruction. - The ability to protrudethe tongue beyond the vermillion border of upper lip is affected . SURGICAL MANAGEMENT: Drainage of the abscess is obtained through Extra oral approach—an external transverse skin incision between the hyoid bone and the inferior border of the mandible.

32. Intra oral approach—Drainage can be obtained transorally by incising the mucosa in the anterior part of the floor of the mouth, the incision should be placed parallel to the submandibular duct. Blunt dissection is indicated so as to not injure the lingual nerve or the submandibular gland

33. SECONDARY FASCIAL SPACES TEMPORAL SPACE Temporal space has two compartments: superficial and deep . BOUNDARIES: Superficial compartment: Laterally—Temporal fascia Medially—Lateral surface of the temporalis muscle Deep compartment: Laterally—Medial surface of the temporalis muscle Medially—Temporal bone

34. CONTENTS: Superficial temporal vessels, auriculotemporal nerve and temporal fat pad . CLINICAL FEATURE: Pain and swelling Swelling over the temporal region SURGICAL MANAGEMENT: -extra oral incirion in temporal region, above hairline 45 degree to zygomatic arch -hemostat is entered above & below the temporalis muscle

35. PAROTID SPACE Parotid space is enclosed by the superficial layer of the deep cervical fascia surrounding the parotid gland . BOUNDARIES -Space is formed by splitting of superficial layer of deep cervical fascia surrounding parotid gland - lies posterior to masticatory space. Inferiorly : stylomandibular ligament separates parotid from mandibular space. CONTENTS: - parotid gland &lymph nodes -facial nerve - retromandibular vein -external carotid artery

36. CLINICAL FEATURE: -Swelling. Swelling everts the lobule of the ear and presents with severe pain especially while eating . - Intraorally pus may be milked from the parotid duct . MANAGEMENT -Large incision is made in the retromandibular area from lower aspect of lobule of the ear to angle of the mandible . -Blunt dissection with a haemostat is done avoiding injury to the branches of the facial nerve. -Multiple drains are used for drainage of the pus. -A curved incision at the angle of the mandible can also be made; blunt dissection is done with a haemostat and a drain is placed.

37. SUBMASSETERIC SPACE BOUNDARIES: Anterior— Buccal space, parotidomasseteric fascia Posterior—Parotid gland and its fascia Superior— Zygomatic arch Inferior—Inferior border of mandible Superficial or medial—Ascending ramus Deep or lateral—Masseter muscle CONTENTS Masseteric artery & vein

38. CLINICAL FEATURE: - Extraorally , the swelling is seen mainly over the angle of the mandible . -severe trismus and throbbing pain -Chronic submasseteric space infection can be punctuated by recurrent exacerbation - subperiosteal new bone deposition beneath the periosteum , an important clue to the diagnosis .

39. SURGICAL MANAGEMENT -A vertical incision is made intraorally along the external oblique line of the mandible. -A haemostat is inserted through this incision and passed posteriorly along the lateral aspect of the ramus beneath the masseter muscle and the beaks are opened for free escape of the pus . -A rubber drain is inserted and sutured to the incision margin. -Extraoral approach involves a small incision beneath the angle of the mandible and blunt dissection is done with the help of the haemostat . - A rubber catheter is inserted in the wound for drainage

40. PTERYGOMANDIBULAR SPACE BOUNDARY: Anterior— Buccal space Posterior—Parotid gland with lateral pharyngeal space Superior—Lateral pterygoid muscle Inferior—Inferior border of mandible Superficial or medial—Lateral surface of medial pterygoid muscle Deep or lateral—Medial surface of ascending ramus of mandible

41. CLINICAL FEATURE - Extraorally swelling - Intraorally , there is visible swelling of the soft palate on the same side -swelling of the anterior tonsillar pillar -deviation of the uvula to the opposite side -severe trismus and dysphagia.

42. SURGICAL MANAGEMENT -The incision for drainage is made between medial aspect of the ramus of mandible and the pterygomandibular raphe, - the abscess cavity is opened by blunt dissection using a haemostat . - Rubber drain is placed and sutured to one of the margins of the incision to prevent dislodgement. -This would help in sufficientdrainage .

43. LATERAL PHARYNGEAL SPACE BOUNDARIES: Anterior—Superior and middle pharyngeal constrictor Posterior—Carotid sheath, stylohyoid , styloglossus and stylopharyngeus Superior—Skull base Inferior—Hyoid bone Superficial or medial—Superior pharyngeal constrictors and retropharyngeal space Deep or lateral—Medial pterygoid muscle and capsule of parotid gland

44. CLINICAL FEATURE -Severe pain on the affected side of throat and dysphagia are present -tonsil , tonsillar pillar and uvula are displaced to the medial side. -The four cardinal signs of lateral pharyngeal abscess are trismus , induration and swelling of angle of the jaw, fever and pharyngeal bulging. -Rotation of the neck away from the side of the swelling causes severe pain -Complications of lateral pharyngeal abscess include septic jugular thrombophlebitis and carotid artery erosion. -Inequality of the pupils due to involvement of cervical sympathetic and bleeding from nose, mouth or ear can be a warning of such a disastrous sequel. -infections have a potential to spread upwards causing cavernous sinus thrombosis, meningitis and brain abscess. -They can also spread into theretropharyngeal space.

45. SURGICAL MANAGEMENT - intraoral,extraoral and a combination of both. -Intraoral incision can be either transpharyngeal or lateral. The transpharyngeal approach is made through the tonsillar fossa , -Extraoral submandibular incision is the safest approach and should be used if there is any involvement of posterior compartments. -In the combined intraoral and extraoral approach, the lateral mucosal incision is made and a large curved haemostat is passed lateral to the superior constrictor and medial to the medial pterygoid muscle. A blunt dissection is carried out posteroinferiorly below the angle of the mandible.

46. RETROPHARYNGEAL SPACE BOUNDARIES: Anterior—Superior and middle constrictors Posterior—Alar fascia Superior—Skull base Inferior—Fusion of alar and prevertebral fascia at T4 Superficial or medial—Common space, no wall Deep or lateral—Carotid sheath and lateral pharyngeal space CONTENTS: Lymph node, no major structures

47. CLINICAL FEATURES: -symptoms include pain, fever, stiffness of the neck, dyspnoea , drooling and dysphagia . - Bulging of the posterior pharyngeal wall - Retropharyngeal abscess is considered the most dangerous deep neck space abscess, because complications include supraglottic oedema with airway obstruction, aspiration pneumonia due to rupture of the abscess and acute mediastinitis .

48. MANAGEMENT -an intraoral approach is made. -A vertical incision is made on the pharyngeal wall lateral to the midline. - Using a haemostat , abscess cavity is opened by blunt dissection while the patient is in Trendelenburg position to avoid aspiration of the pus. -In case of concern about the rupture of the abscess, extraoral approach is used for drainage.

49. PERITONSILLAR ABSCESS ( QUINSY) - Peritonsillar abscess or quinsy is a deep neck infection usually secondary to contiguous spread from the local sites or as a complication of acute tonsillitis -rarely life threatening in itself CLINICAL FEATURE -The infection is characterised by swelling of the tonsils -uvular displacement - trismus and muffled voice . -Quinsy is usually unilateral -Most abscesses occur in younger patients who present with fever, sore throat and dysphagia

50. COMPLICATIONS Spontaneous rupture and aspiration, contiguous spread to pterygomaxillary space . SURGICAL MANAGEMENT If the patient is not seen until the pus is formed or if the antibiotic therapy fails , the abscess must be drained . But since peritonsillar abscess often tends to recur , tonsillectomy should be performed 6–8 weeks after formation of the abscess .

51. LIFE THREATEMNING COMPLICATIONS RELATED TO LOWER JAW - lugwigs angina -descending deep cellulitis of neck, resulting in mediastinitis -carotid sheath invasion RELATED TO UPPER JAW -Cavernous sinus thrombosis, brain abscess, dural meningitis & osteomyelitis of skull - retrobulbar cellulitis with possibility of blindness

52. CONCLUSION Infection of orofacial region & neck have one of the most common disease in human being Despite great advancement in the healthcare , these infection remains a major problem These infection range from periapical abscess to superficial & deep abscess of neck Early recoginition and prompt appropriate treatment is absolutely essential

53. REFRENCE Neelima anil malik ; text book of oral & maxillofacial surgery:5th edition S M Bhalaji;textbook of oral & maxillofacial surgery; 3rd edition