Complex Odontogenic Infections Larry ). Peterson CHAPTEROUTLINE FASCIAL SPACE INFECTIONS Maxillary Spaces MANDIBULAR SPACES Secondary Fascial Spaces Cervical Fascial Spaces Management of Fascial Space Infections dontogenic infections are usually mild and easily and causes infection in the adjacent tissue. Whether or treated by antibiotic administration and local sur- not this becomes a vestibular or fascial space abscess is 0 gical treatment. Abscess formation in the bucco- determined primarily by the relationship of the muscle lingual vestibule is managed by simple intraoral incision attachment to the point at which the infection perfo- and drainage (I&D) procedures, occasionally including rates. Most odontogenic infections penetrate the bone dental extraction. (The principles of management of rou- in such a way that they become vestibular abscesses. tine odontogenic infections are discussed in Chapter 15.) On occasion they erode into fascial spaces directly, Some odontogenic infections are very serious and require which causes a fascial space infection (Fig. 16-1). Fascial management by clinicians who have extensive training spaces are fascia-lined areas that can be eroded or dis- and experience. Even after the advent of antibiotics and tended by purulent exudate. These areas are potential improved dental health, serious odontogenic infections spaces that do not exist in healthy people but become still sometimes result in death. These deaths occur when filled during infections. Some contain named neurovas- the infection reaches areas distant from the alveolar cular structures and are known as coinpnrtments; others, process. The purpose of this chapter is to present which are filled with loose areolar connective tissue, are overviews of fascial space infections of the head and neck known as clefts. caused by odontogenic infections and several of the more The spaces that are involved directly are known as the frequently seen unusual infections of the oral cavity. fnscinl spaces of priinow involvei?~ent.The principal maxil- lary primary spaces are the canine, buccal, and infratem- poral spaces (Box 16-1). The principal mandibular pri- FASCIAL SPACE INFECTIONS mary spaces are the submental, b~~ccal,submandibular, The erosion process of infections through bone into and sublingual spaces. Infections can extend beyond surrounding soft tissue is discussed in Chapter 15. As a these primary spaces into additional fascial spaces, or general rule infection erodes through the thinnest bone secondary spaces. 368 PART IV . Infections FIG. 16-1 As infection erodes through bone, it can express itself in a variety of places, depending on thickness of overlying bone and relationship of muscle attachments to site of perforation. This illus- tration notes six possible locations: vestibular abscess (7), buccal space (Z), palatal abscess (3), sublingual space (4), submandibular space (5), and maxillary sinus (6). (From Cummings CW et a/, editors: Otolaryngology: head and neck surgery, vol 3, St Louis, 1998, Mosby.) FIG. 16-2 Canine space infection in patient's right side resulted from infected canine tooth. The swelling of nasolabial and infraor- bital areas is demonstrated. Spaces Involved in Odontogenic Infections Primary hiaxillary This is the only tooth with a root sufficiently long to Canine allow erosion to occur through the alveolar bone supe- R Buccal rior to the muscles of facial expression. The infection U lnfratemporal erodes superior to the origin of the levator anguli oris Primary Mandibular Spaces muscle and below the origin of the levator labii superi- Submental oris muscle. When this space is infected, swelling of the a Buccal anterior face obliterates the nasolabial fold (Fig. 16-2). i Submandiibular Spontaneous drainage of infections of this space com- m SublinguaI monly occurs just inferior to the medial canthus of the ----1-7 I Secondary EUSLZUI >puce> eye. n Masseteric The buccal space is bounded by the overlying skin of a Pterygomandibular the face on the lateral aspect and the buccinator muscle BI Superficial and deep temporal on the medial aspect (Fig. 16-3). This space may become b~ Lateral pharyngeal infected from extensions of infection from either the w Retropharyngeal maxillary or mandibular teeth. The posterior maxillary BJ Prevertebral teeth, most commonly the molars, cause most buccal space infections. The buccal space becomes involved from the teeth when infection erodes through the bone superior to the attachment of the buccinator muscle. Maxillary Spaces Involvement of the buccal space usually results in The canine space is a thin potential space between the swelling below the zygomatic arch and above the inferior levator angulioris and the levator labii superioris mus- border of the mandible. Thus both the zygomatic arch cles. The canine space becomes involved primarily as and the inferior border of the mandible are palpable in the result of infections from the maxillary canine tooth. buccal space infections. Complex Odontogenic Infections CHAPTER 16 369 Buccal space FIG. 16-3 A, Buccal space lies between buccinator muscle and overlying skin and superficial fascia, This potential space may become involved via maxillary or mandibular molars (arrows). B, This buccal space infection was result of maxillary molar. Typical swelling of the cheek is demonstrated, which does not extend beyond inferior border of mandible. (From Cummings CW et a/, editors: Otolaryngology: head and neck surgery, vol3, St Louis, 1998, Mosby.) The infratemporal space lies posterior to the maxilla. It is bounded medially by the lateral plate of the pterygoid process of the sphenoid bone and superiorly by the base of the skull. Laterally, the infratemporal space is continu- Temporalis muscle ous with the deep temporal space. The infratemporal Superficial temporal space space is rarely infected, but when it is, the cause is usual- ly an infection of the maxillary third molar (Fig. 16-4). Maxillary odontogenic infections may also spread Deep temporal space superiorly to cause secondary periorbital or orbital celluli- tis or cavernous sinus thrombosis. Periorbital or orbital cellulitis rarely occurs as the result of odontogenic infec- tion, but when either does occur, the presentation is typi- cal: redness and swelling of the eyelids and involvement of both the vascular and neural components of the orbit. This is a serious infection and requires aggressive medical and surgical intervention from multiple specialists. Cavernous sinus thrombosis may also occur as the result of superior spread of odontogenic infection via a hematogenous route (Fig. 16-5). Bacteria may travel from the maxilla posteriorly via the pterygoid plexus and emis- sary veins or anteriorly via the angular vein and inferior or superior ophthalmic veins to the cavernous sinus. The veins of the face and orbit lack valves, which permits blood to flow in either direction. Thus bacteria can travel via the venous drainage system and contaminate the cavernous sinus, which results in thrombosis. Cavernous sinus thrombosis is an unusual occurrence that is the FIG. 16-4 Spaces of ramus of mandible are bounded by masjt.:er result of an infected tooth. Like orbital cellulitis, cavernous muscle,medial pterygoid muscle, temporalfascia, and skull. Tempo- sinus thrombosis is a serious, life-threatening infection ral space is divided into deep and superficial portions and by tern- that requires aggressive medical and surgical care. Cav- poralis muscle. (Redrawn from Cummings CW et a/, editors: Otolaryn- ernous sinus thrombosis has a high mortality even today. gology: head and neck surgery, vol3, St Louis, 1998, Mosby.) 370 PART IV lr~fectioris FIG. 16-5 Hematogenous spread of infection from jaw to cavernous sinus may occur anteri- orly via inferior or superior ophthalmic vein or posteriorly via emissary veins from pterygoid plexus. (From Cummings CWet al, editors: Otolaryngology: head and neck surgery, vol3, St Louis, 1998, Mosby.) FIG I6 Submental cpace lnfectlon appears as dlscrete swell~ngIn central area ul ~ub- mand~bularregion. Complex Odonto~yeiiiclnfectioris H CHAPTER 16 371 MANDIBULAR SPACES - " --- -- - -- - -- - -- - - The buccal space can be infected as an extension of Although most infections of the mandibular teeth infection from mandibular teeth, similar to the way in erode into the buccal vestibule, they may also spread which it is involved from the maxillary teeth (see Fig. into fascia1 spaces. The four primary mandibular spaces 16-3). The buccal space is most commonly infected from are (1) the submental, (2) the buccal, (3) the sublingual, maxillary teeth but can also be involved from the and (4) the submandibular spaces. mandibular teeth. The submental space lies between the anterior bellies of The sublingual and submandibular spaces have the the digastric muscle and between the mylohyoid muscle medial border of the mandible as their lateral boundary. and the overlying skin (Fig. 16-6). This space is primarily These two spaces are involved primarily by lingual perfo- infected by mandibular incisors, which are sufficiently ration of infection from the mandibular molars, although long to allow the infection to erode through the labial they may be involved by premolars, as well. The factor bone apical to the attachment of the mentalis muscle. The that determines whether the infection is submandibular infection is thus allowed to proceed under the inferior or sublingual is the attachment of the mylohyoid muscle border of the mandible and involve the submental space. on the