SPACE INFECTIONS-TYPES, DIAGNSOSIS AND MANAGEMENT

Space infections pose a threat to patients life if not dealt with it on an emergency basis

1. SPACE INFECTIONS

2. CONTENTS INTRODUCTION HOST DEFENSE AND INFECTION MICROBIOLOGY AND ANTIBIOTIC THERAPY FASCIAE OF HEAD AND NECK CLASSIFICATION OF SPACES MAXILLARY SPACES MANDIBULAR SPACES SECONDARY SPACES COMPLICATIONS OVERALL MANAGEMENT STAGES OF INFECTION CONCLUSION

3. INTRODUCTION Fascial spaces are potential spaces between the layers of fascia- Shapiro Represent major pathways for spread of infections When infections spread deeply into soft tissue- involvement following path of least resistance

4. INFECTIONS AND HOST DEFENSE In establishing presence of an infection, interaction occurs among three factors: Host Environment Microorganism Infection occurs when either host is immunocompromised or when pathogenecity and number of microbes invading host is more

5. SPREAD OF OROFACIAL INFECTION FACTORS INFLUENCING SPREAD GENERAL FACTORS: Host resistance Virulence of microorganism Medically compromised LOCAL FACTORS: - Intact anatomical barriers Alveolar bone Periosteum Adjacent muscles and fascia.

6. ANATOMICAL CONSIDERATIONS MUSCLE ATTACHMENTS- Posteriors- Buccinator - midroot level Anteriors –Intrinsic lip muscles & risorius - at apex In maxilla- infection above attachment of muscle enters extra oral space In mandible- infection below attachment of muscle enters extra oral space

7. PREDISPOSING FACTORS Dental caries or periodontal infections Lowered body resistance Trauma Primary signs & symptoms of these infections: Redness Raised temperature Edema overlying tissue Tenderness Loss of function Lymphadenopathy

8. MICROBIOLOGY –SPACE INFECTION Aerobic bacteria (5%) Gram positive cocci (85%)– Streptococcus species( 90% ) S.Milleri S.Sanguis S.Salivarius S.Mutans Staphylococcus species (6 %) Anaerobic bacteria (25%) Gram positive cocci (30%)- Peptococcus species 33% Pepto Streptococcus species 33% Gram negative bacilli (50%) – Prevotella species, Porphyromonas species (75%), Fusobacterium -20% Mixed bacteria (70%) Micro-organisms and Odontogenic infections 2009 ADJ

9. Indications for antibiotics: Toxic signs and symptoms, febrile condition or trismus . Poorly localized extensive abscesses, diffuse cellulitis Abscesses in systemically compromised patients Deep fascial space infections Pericoronitis , Osteomyelitis , Fractures Soft tissue wounds Selection of antibiotics: Identification of causative organism Antibiotic sensitivity Bactericidal drugs preferred Antibiotics of the narrowest spectrum preferred The least toxic antibiotic should be selected Cost of antibiotics Oral and maxillofacial infections, 4 th Edition- Topazian , Goldberg & Hupp

10. COMMON ANTIBIOTICS β - lactams - Penicillins , Cephalosporins , Monobactams , Carbapenems Macrolides - Erythromycin, Clindamycin , Azithromycin , Clarithromycin , Aminoglycosides Nitromidazoles - Metronidazole Quinolones - Ciprofloxacin, Moxifloxacin

11. STAGES OF INFECTIONS Stage I – Inoculation- caused by early spread Stage II – Cellulitis - inflammatory process Stage III – Abscess- necrosis predominates Stage IV – Resolution- occurs after spontaneous or therapeutic drainage

12. STAGES OF INFECTION CHARACTERISTIC INOCULATION CELLULITIS ABSCESS Duration 0-3 days 3-7 days More than 5 days Pain Mild- moderate Severe & generalized Moderate – severe and localized Size Small Large Small Localization Diffuse Diffuse Circumscribed Palpation Soft, doughy, mildly tender Hard, exquisitely tender Fluctuant, tender Appearance Normal color Reddened Peripherally reddened Skin Quality Normal Thickened Centrally undermined, shiny Surface temperature Slightly heated Hot Moderately heated Loss of function Minimal or none Severe Moderately severe Tissue fluid Edema Serosanguinous , flecks of pus Pus Levels of malaise Mild Severe Moderate- severe Severity Mild Severe Moderate- severe Percutaneous bacteria Aerobic Mixed Anaerobic

13. LAYERS OF NECK

14. SUPERFICIAL FASCIA Ensheathes - 1. Platysma 2. Muscles of facial expression Dense connective tissue

15. SUPERFICIAL LAYER OF DEEP CERVICAL FASCIA Superficial Layer of the Deep Cervical Fascia Muscles Sternocleidomastoid Trapezius Glands Submandibular Parotid Spaces Posterior Triangle Suprasternal space Of Burns

16. MIDDLE LAYER OF DEEP CERVICAL FASCIA Muscular Division Infrahyoid Strap Muscles Visceral Division Pharynx, Larynx, Thyroid Esophagus, Trachea Buccopharyngeal Fascia The deep neck spaces viz. retropharyngeal, lateral pharyngeal & pretracheal lie superficial side of visceral division

17. DEEP LAYER OF DEEP CERVICAL FASCIA Arises from spinous processes and ligamentum nuchae . Splits into two layers at the transverse processes: Alar layer Superior border – skull base Inferior border – upper mediastinum at T1-T2 Prevertebral layer Superior border – skull base Inferior border – coccyx Envelopes vertebral bodies and deep muscles of the neck. Extends laterally as the axillary sheath.

18. CLASSIFICATION OF FASCIAL SPACES BASED ON CLINICAL SIGNIFICANCE - TOPAZIAN FASCIAL SPACES FACE SUPRAHYOID INFRAHYOID TOTAL NECK Buccal Canine Masticatory Parotid Sublingual Submandibular Pharyngomaxillary Anterovisceral ( Pretracheal ) Retro pharyngeal Carotid sheath space

19. MAXILLARY MANDIBULAR DIRECT (Primary spaces) INDIRECT (Secondary spaces) CLASSIFICATION OF FASCIAL SPACES BASED ON MODE OF INVOLVEMENT Masseteric Pterygomandibular Superficial & Deep Temporal Lateral Pharyngeal Retropharyngeal Prevertebral & Parotid Spaces Canine Buccal Infratemporal Submental Buccal Submandibular Sublingual FASCIAL SPACES

20. CLASSIFICATION OF FASCIAL SPACES ACCORDING TO GRODINSKY AND HOLYOKE (1938) Space 1 – Superficial to superficial fascia Space 2 – Group of spaces surrounding cervical strap muscle lying superficial to sternothyroid-thyrohyoid division of middle layer of deep cervical fascia. Space 3 – Space lying superficial to visceral division of middle layer of deep cervical fascia Space 3A – Carotid sheath space or viscerovascular space (Lincoln’s High way) Space 4 – Space lies between alar & prevertebral division of posterior layer of deep cervical fascia (Danger space) Space 4A – Posterior triangle space posterior to carotid sheath Space 5 - Prevertebral space Space 5A- Space enclosed by Prevertebral fascia

21. BUCCAL SPACES ANTERIOR POSTERIOR SUPERIOR INFERIOR MEDIAL LATERAL Modiolus of Mouth Pterygomandibular Raphe , Masseter Maxilla, infraorbital space Lower Border Of Mandible Buccinator Muscle, Buccopharyngeal Fascia Skin Of Cheek CONTENTS: Buccal pad of fat, Stenson’s duct , Anterior and transverse facial artery LIKELY SOURCE OF INFECTION: Maxillary & mandibular premolars and molars

22. BUCCAL SPACES- COMMUNICATIONS Submasseteric Space Pterygomandibular Space Superficial Temporal Space Infratemporal space Lateral Pharyngeal Space

23. BUCCAL SPACES CLINICAL FEATURES: Vestibular abscess Extra oral swelling TREATMENT: Antibiotic prophylaxis Intra oral horizontal vestibular incision through oral mucosa of cheek in the premolar, molar region.

24. CANINE SPACE ANTERIOR POSTERIOR SUPERIOR INFERIOR MEDIAL LATERAL Nasal cartilages Buccal space Quadratis labii superioris Oral mucosa Quadratis labii superioris Levator anguli oris CONTENTS : Angular artery and vein, Infraorbital nerve. LIKELY SOURCE OF INFECTION : Maxillary canine or first premolar

25. CANINE SPACE CLINICAL FEATURES : Swelling lateral to the nose Obliteration of the nasolabial fold, Swelling of the upper lip, Edema occurs in the upper and lower lid that may close the eye TREATMENT: Antibiotic prophylaxis Mucosa of buccal vestibule in incisor and canine region

26. SUB MANDIBULAR SPACE ANTERIOR POSTERIOR SUPERIOR INFERIOR LATERAL MEDIAL Anterior belly of digastric Posterior belly Of digastric , Stylohyoid , Stylopharyngus Inferior & medial surface of mandible Digastric tendon Platysma , Investing fascia Mylohyoid , Hypoglossus , Superior Constrictor CONTENTS: Submandibular gland, Facial artery & vein LIKELY SOURCE OF INFECTION : Mandibular molars

27. CLINICAL FEATURES : Induration and erythema Obliteration of the mandibular line & extending to the level of hyoid bone No trismus SUB MANDIBULAR SPACE

28. SUMBANDIBULAR SPACE I & D through Extra-oral incision. Incision – 2 stab incisions given over dependent part below lower border of mandible Curved hemostat inserted & blunt dissection through subcutaneous fat Drain is placed & dressing is given

29. SUBMANDIBULAR SPACE- COMMUNICATION Submental space Lateral pharyngeal space Sublingual space Contralateral spaces

30. SUB LINGUAL SPACE ANTERIOR POSTERIOR SUPERIOR INFERIOR MEDIAL LATERAL Lingual surface of mandible Submandibular space Oral mucosa Mylohyoid muscle Muscles of tongue Lingual Surface of mandible CONTENTS : Sublingual glands, Wharton’s duct, Lingual nerve, Sublingual artery & vein LIKELY SOURCE OF INFECTION : Mandibular premolars & molars

31. SUB LINGUAL SPACE CLINICAL FEATURES : Elevation of tongue Edema and induration of floor of mouth Tongue cannot be extended beyond vermilion border of upper lip COMMUNICATIONS: Infection through buccopharyngeal gap into lateral pharyngeal space Infection along posterior border of mylohyoid into submandibular space

32. SUB LINGUAL SPACE TREATMENT :- Antibiotic prophylaxis Incision made Intraorally over lingual sulcus at the base of the alveolar process Haemostat passed beneath sublingual gland in an antero posterior direction and drain is placed.

33. SUB MENTAL SPACE ANTERIOR POSTERIOR SUPERIOR INFERIOR SUPERFICIAL DEEP Inferior border of mandible Fascia between Hyoid and inferior border of mandible Mylohyoid Investing fascia Investing Fascia Anterior bellies of digastric CONTENTS : Anterior Jugular veins, Lymph Nodes LIKELY SOURCE OF INFECTION : Lower anteriors

34. SUB MENTAL SPACE CLINICAL FEATURES : Limited to point of chin & to region immediately below it Fullness of submental space Limitation of swelling to hyoid bone TREATMENT : Transverse incision in skin below symphysis of the mandible and blunt dissection in upward and backward Drain & dressings are placed .

35. MASTICATORY SPACE These are secondary spaces, well differentiated and communicate with each other

36. PTERYGOMANDIBULAR SPACE ANTERIOR POSTERIOR SUPERIOR INFERIOR MEDIAL LATERAL Buccal space Deep lobe Of Parotid gland Lateral Pterygoid Inferior border of mandible Medial pterygoid muscle Ascending Ramus of mandible CONTENTS : Mandibular division of trigeminal nerve, inferior alveolar artery & vein LIKELY SOURCE OF INFECTION : Lower third molars

37. PTERYGOMANDIBULAR SPACE CLINICAL FEATURES : No external swelling, trismus Dysphagia Medial displacement of lateral wall of pharynx Uvula displaced to opposite side INCISION AND DRAINAGE: Intraorally : Sicher’s incision along the pterygomandibualr raphe Extraorally : In cases of severe trismus , incision is placed behind the angle of the mandible

38. SUBMASSETRIC SPACE ANTERIOR POSTERIOR SUPERIOR INFERIOR MEDIAL LATERAL Buccal space Parotid gland Zygomatic arch Inferior border of mandible Ascending ramus of mandible Masseter muscle CONTENTS : Massetric artery & vein LIKELY SOURCE OF INFECTION: Lower 3 rd molar

39. SUBMASSETRIC SPACE CLINICAL FEATURES: Mild swelling over angle of mandible Deep seated severe throbbing pain Trismus Tenderness over the mandibular ramus Ear lobes are obscured

40. TREATMENT: Intra oral Vertical incision along external oblique line Haemostat is passed Drain is placed Extra oral Incision beneath angle of mandible Blunt dissection through masseter muscle fibres Drainage with plastic or rubber catheter to withstand muscle contraction . SUBMASSETRIC SPACE

41. SUPERFICIAL TEMPORAL SPACES ANTERIOR POSTERIOR INFERIOR MEDIAL LATERAL Posterior surface of lateral orbital rim Fusion of temporalis fascia with pericranium Zygomatic arch Lateral surface of temporalis muscle Temporal Fascia CONTENTS: Temporal fat pad, temporal branch of facial Nerve LIKELY SOURCE OF INFECTION: Upper & Lower molars

42. DEEP TEMPORAL SPACES ANTERIOR SUPERIOR INFERIOR MEDIAL LATERAL Posterior wall of maxillary sinus, Pterygomaxillary fissure, posterior surface of orbit Attachment of temporalis to cranium Lateral pterygoid muscle Temporal bone Temporalis muscle CONTENTS: Pterygoid plexus, inferior maxillary artery & vein, mandibular division of trigeminal nerve LIKELY SOURCE OF INFECTION: Upper molars

43. SUPERFICIAL & DEEP TEMPORAL SPACES CLINICAL FEATURES : Characteristic dumbell shaped swelling (Superficial) Mild swelling over temporal region (Deep) TREATMENT: Intraoral- vertical incision made medial to upper extent of anterior border of the ramus Haemostat  P assed superiorly along lateral aspect of the coronoid (Superficial) Passed supero -medially (Deep) Extra oral incision- slightly superior to zygomatic arch Drain is placed, dressing is given

44. INFRATEMPORAL SPACE ANTERIOR POSTERIOR SUPERIOR INFERIOR MEDIAL LATERAL Maxillary tuberosity Mandibular condyle Infratemporal crest of sphenoid Lateral pterygoid muscle Lateral pterygoid plate Temporalis Tendon, Coronoid process CONTENTS: Pterygoid plexus, internal maxillary artery and vein , mandibular division of trigeminal nerve

45. INFRATEMPORAL SPACE CLINICAL FEATURES: Marked Trismus Swelling of face in front of ear, over TMJ, behind zygomatic process Eye is closed and proptosed

46. TREATMENT: INTRAORAL Incision is made into buccolabial fold lateral to maxillary third molar- Kruger Curved hemostat is inserted behind maxillary tuberosity Vertical incision made medial to upper extent of the anterior border of the ramus - Laskin Curved hemostat is passed superiorly into infratemporal region, drain is inserted EXTRAORAL Horizontal incision above the zygomatic arch Curved hemostat is directed in inferior and medial direction to enter infratemporal space Insertion of drain. INFRATEMPORAL SPACE

47. PREVERTEBRAL SPACE Formed by deep cervical fascia Extends from skull base to coccyx Fascia attaches to transverse process of cervical vertebra dividing it into anterior and posterior compartments Anterior compartment : Vertebral bodies. Spinal cord. Vertebral arteries. Phrenic nerve. Prevertebral and scalene muscles Posterior compartment : -Posterior vertebral elements. Paraspinous muscles.

48. PERITONSILLAR SPACE INFECTION (QUINCY) Clinical evaluation: 3-7 days H/o pharyngitis Severe sore throat, dysphagia , Odyonophagia and referred otalgia . The speech is muffled and classically described as hot potato voice. Trismus is not present Needle aspiration instead of open incision and drainage - JOMS,Vol 51,2009

49. LATERAL PHARYNGEAL SPACE Inverted pyramid shape with base at base of skull and apex at hyoid bone Medial- pharyngeal constrictor Lateral- medial pterygoid muscle & deep cervical fascia Anterior- palatal musculature, buccinator , superior constrictor, stylohyoid and posterior belly of digastric Posterior- carotid sheath, retropharyngeal space

50. LATERAL PHARYNGEAL SPACE Infection spreads from peritonsillar infection, sublingual, submandibular & retropharyngeal space infections May encircle airway by spreading from one side to another Patients head may tilt to unaffected side to position upper airway over deviated trachea and lungs

51. LATERAL PHARYNGEAL SPACE CLINICAL FEATURES: Firm swelling with surrounding erythema lateral and anterior to sternocleidomastoid muscle Difficulty in flexing and turning of neck Trismus , Dysphagia , Dyspnoea TREATMENT: Hospitalization with IV antibiotics Airway protection Surgical approach always through neck not through oral cavity Incision is made at the level of hyoid bone across the sternocleidomastoid muscle

52. RETROPHARYNGEAL SPACE Extends from base of skull to retropharyngeal fascia (between 4 th and 6 th thoracic vertebra) Lateral border- lateral pharyngeal space and carotid sheath Separated in midline by septum Contains areolar tissue, lymph nodes draining Waldeyer’s ring Infections impinge directly on airway, involve danger space

53. RETROPHARYNGEAL SPACE CLINICAL FEATURES: Dysphagia Cervical lymphadenopathy . Slight neck rigidity Noisy breathing due to laryngeal edema. Neck tilts towards involved side. Hyperextended complete inability to flex the neck.

54. RETROPHARYNGEAL SPACE- COMMUNICATION Posterior- pre-vertebral space Lateral- carotid artery ( haemorrhage , pseudoaneurysm , thrombosis) and jugular vein (thrombosis) Anterior-compression and compromise of the airway Inferior- mediastinum resulting in mediastinitis

55. DANGER SPACE Entire length of neck Anterior border - alar layer of deep fascia Posterior border - prevertebral layer Extends from skull base to diaphragm Contains loose areolar tissue Infection may enter mediastinum & compress major vessels, lower airway and upper digestive tract 71% mediastinitis cases- infection from retropharyngel space through danger space: Mediastinitis following cervical suppuration, Pearse , 1938

56. CAROTID SPACE Encloses common & internal carotid arteries, internal jugular vein and vagus nerve Named “Lincoln’s Highway” by Mosher in 1929 Extends from jugular foramen & carotid canal to mediastinum Infection eroding this space may cause- Expanding hematoma in neck Bleeding episodes( herald bleeds) Horner’s syndrome- miosis , ptosis and anhidrosis

57. MEDIASTINUM Extension of infection from deep neck spaces into the mediastinum is clinically seen as chest pain severe dyspnea Unremitting fever, Radiographic demonstration of mediastinal widening.

58. LUDWIG’S ANGINA Ludwig’s angina is a firm, acute , rapidly progressing polymicrobial toxic cellulitis of the submandibular and sublingual spaces bilaterally and of the submental space resulting in life threatening airway compromise. Wilhelm Friedrich von Ludwig 1. Rapidly spreading gangrenous cellulitis . 2. Originates in the region of submandibular gland but never involves one single space 3. Arises from extension by continuity and not by lymphatics 4. Produces gangrene with serosanguinous , putrid infiltration but very little or no frank pus.

59. Polymicrobial - predominantly oral flora Organisms isolated - Streptococcus viridans and Staphylococcus aureus Anaerobes - bacteroides , peptostreptococci , and peptococci . Other gram-positive bacteria- Fusobacterium nucleatum , Aerobacter aeruginosa,spirochetes , and Veillonella , Candida, Eubacteria , and Clostridium species. Gram-negative organisms Neisseria species, Escherichia coli,Pseudomonas species, Haemophilus influenzae , and Klebsiella species LUDWIG’S ANGINA- BACTERIOLOGY Ludwig’s Angina: Diagnosis and Treatment, David M. Lemonick

60. Clinical features : Toxic, ill, dehydrated Difficulty in deglutition Firm, brawny swelling Mouth slightly open, Hot potato voice Respiratory difficulties, cyanosis, increased respiratory rate, stridor Increased salivation, stiffness of tongue, Elevation of floor of mouth LUDWIG’S ANGINA

61. LUDWIG’S ANGINA SPREAD ACCORDING TO KRUGER,TOPAZIAN,LUDWIG THIRD MOLARS - SUBMANDIBULAR SPACE - SUBLINGUAL SPACE - CONTRALATERAL SUBMANDIBULAR AND SUBMENTAL SPACE INVOLVEMENT ACCORDING TO LASKIN SUBLINGUAL SPACE - SPREADS BILATERALLY - SUBMANDIBULAR AND SUBMENTAL SPACE - BACKWARD SPREAD TO SUBSTANCE OF TONGUE - INFECTION REACHES EPIGLOTTIS - SWELLING AROUND LARYNGEAL INLET

62. PRINCIPLES OF MANAGEMENT OF LUDWIG’S ANGINA Hospitalization Securing the airway Anaesthetic implications Early I.V. antibiotics & hydration External surgical exploration with division of mylohyoid muscle and drainage Medical supportive therapy Review and re-evaluation in the post op period

63. LUDWIG’S ANGINA MANAGEMENT Early diagnosis and hospitalization Maintenance of airway: i } cricothyrotomy / laryngotomy ii} Nasoendotracheal intubation using fibre optic laryngoscope. Anaesthesia : LA into superficial tissue of neck or if intubated then G.A. I.V. analgesics Removal of cause: Extraction of offending tooth which facilitates evacuation of pus

64. LUDWIG’S ANGINA MANAGEMENT Bilateral incision, Midline incision Blunt dissection Initially no pus, but later on profuse pus drains out Drain placement

65. LUDWIG’S ANGINA MANAGEMENT Antibiotic therapy: Penicillin– 2-4MU i.v . 4hourly, then penicillin V- 500mg orally slowly. Amoxicillin- 500mg TID orally Cloxacillin-500mg TID orally Erythromycin-600mg 6-8hourly Clindamycin-600mg i.v . 300-400mg orally TID Cephalosporin Treatment of dehydration: excess oral fluid intake or i.v . fluid infusion

66. LUDWIG’S ANGINA RISKS   Posteriorly into larynx causing suffocation, death   Spread of infection to mediastinum   Septicaemia and septic shock   Venous and cavernous sinus thrombosis, carotid sheath erosion   Brain abscess and meningitis.   Aspiration pneumonia   Pericarditis .   Death

67. COMPLICATIONS OF SPACE INFECTION Scar formation Sinus tract formation Cavernous sinus thrombosis Necrotising fascitis

68. CAVERNOUS SINUS ANATOMY Large venous space situated in the middle cranial fossa Interior divided into number of caverns by trabeculae ANTERIOR POSTERIOR MEDIAL LATERAL SUPERIOR INFERIOR Medial end of superior orbital fissure Apex of petrous temporal bone Pitutary above and sphenoid below Temporal lobe and uncus Optic chiasma Endosteal dura mater, greater wing of sphenoid

69. CONTENTS

70. DANGEROUS AREA OF FACE The cavernous communicate with dangerous area of face through 2 routes: Superior opthalmic vein Deep facial veins , pterygoid plexus of vein , emissary vein.

71. SPREAD OF INFECTION TO CAVERNOUS SINUS Infection of upper lip, vestibule of nose and eyelids  A ngular, supraorbital and supratrochlear veins to ophthalmic veins Intranasal surgeries on septum, turbinates or ethmoid / sphenoid sinus infection  E thmoidal veins Surgeries on tonsil, peritonsillar abscess, osteomyelitis of maxilla, dental extraction and deep cervical abscess  spread through pterygoid plexus or by direct extension to the internal jugular vein.

72. CAVERNOUS SINUS THROMBOSIS- DIAGNOSIS  Eagleton’s criteria for Cavernous Sinus Thrombosis: 1. Sepsis 2. Early obstructive signs 3. Ocular nerve paralysis 4. Surrounding soft tissue abscesses 5. Symptoms of a complicated disease

73. CAVERNOUS SINUS THROMBOSIS Characterized by multiple cranial neuropathies Clinical feature - General feature of infection Exopthalmos & tender eye ball Oedema of eyelid & chemosis of conjuctiva Oculomotor feature – External opthalmoplegia Ptosis Slight exopthalmos Dilated pupil with loss of accomdation reflex

74. TREATMENT Septic cavernous sinus thrombosis – Early and aggressive antibiotic administration. Broad-spectrum coverage for gram-positive, gram-negative, and anaerobic organisms Antibiotic therapy should include a penicillinase -resistant penicillin plus a third generation cephalosporin. Vancomycin may be added for MRSA. IV antibiotics are recommended for a minimum of 3-4 weeks Corticosteroid therapy

75. DIAGNOSTIC IMAGING OF FASCIAL & NECK SPACES Plain film- AP & Lateral view MRI CT Ultrasound

76. PRINCIPLES OF INCISION AND DRAINAGE Incise healthy skin and mucosa when possible Incision placed at site of maximum fluctuance Incision in esthetically acceptable area Incision should be in dependent position Dissect bluntly with closed surgical clamp or finger, through deeper tissues Clean wound margins daily under sterile conditions Place a drain and stabilize it with sutures

77. GENERAL MANAGEMENT 1. Determine severity Assess history of onset and progression perform physical examination of area: - Determine character and size of swelling - Establish presence of trismus 2. Evaluate host defenses : -Diseases that compromise the host - Medications that may compromise the host 3. Relieve pressure - Remove the cause of infection - Drain pus by performing incision and drainage

78. GENERAL MANAGEMENT 4. Select antibiotic Determine: - Most likely causative organisms based on history - Host defense status - Allergy history - Prescribe drug properly (route, dose and dosage interval, and duration) - Culture & sensitivity 5. Administration of steroids to reduce edema 6. Follow up Monitor frequently Out-patient follow up in 2-3 days Decreased swelling, discharge, airway edema, malaise in 2-3 day

79. CONCLUSION Thorough knowledge of anatomy is necessary to diagnose and manage the space infections. To be alert to the potential seriousness of these infections-never to be dismissed as simple dental abscess In severe cases the systemic management of the patient is also very important Incidence and severity have diminished with advent of antibiotic therapy Deep fascial infections must be recognized promptly and treated as an emergency Repeat diagnostic and therapeutic measures may be necessary until the very end

80. REFERENCES Oral &Maxillofacial Infections- Topazian Oral & Maxillofacial Surgery- Laskin Vol.I&II Killey & kay’s -Outline Of Oral Surgery- Peter Banks Text book of oral and maxillofacial surgery – Neelima Malik Head & neck Imaging – Peter.M.Som Principles of oral and maxillofacial surgery – Peterson Contemporary management of deep neck space infections- Paul Gidley Otolaryngol Head Neck Surg 1997:116:16-22 Predicting deep neck space abscess using CT – Joseph American Journal Of Otolaryngology – 27(2006)244-277 Infections of the neck leading to descending necrotizing mediastinitis – role of multi detector row CT - Antonio European Journal Of Radiology 65 (2008) 389-394