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Space Infections

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Space Infections Dr. Mohit Bindal Senior Lecturer Department Of OMFS DR.MOHIT BINDAL, Subharti Dental College, SVSU 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 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 INFECTIONS AND HOST DEFENSE In establishing presence of an infection, interaction occurs among three factors: 1. Host 2. Environment 3. Microorganism Infection occurs when either host is immunocompromised or when pathogenecity and number of microbes invading host is more 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. 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 PREDISPOSING FACTORS 1. Dental caries or periodontal infections 2. Lowered body resistance 3. Trauma Primary signs & symptoms of these infections: - Redness - Raised temperature - Edema overlying tissue - Tenderness - Loss of function - Lymphadenopathy MICROBIOLOGY –SPACE INFECTION Aerobic bacteria (5%) . Gram positive cocci (85%)– MICRO ORGANISMS Streptococcus species( 90% ) • S.Milleri • S.Sanguis • S.Salivarius 25 MIXED • S.Mutans AEROBIC Staphylococcus species (6 %) 5 ANAEROBIC 70 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%) 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 COMMON ANTIBIOTICS β-lactams- Penicillins, Cephalosporins, Monobactams, Carbapenems Macrolides- Erythromycin, Clindamycin, Azithromycin, Clarithromycin, Aminoglycosides Nitromidazoles- Metronidazole Quinolones- Ciprofloxacin, Moxifloxacin 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 LAYERS OF NECK SUPERFICIAL FASCIA Ensheathes- 1. Platysma 2. Muscles of facial expression Dense connective tissue 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 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 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. CLASSIFICATION OF FASCIAL SPACES BASED ON CLINICAL SIGNIFICANCE - TOPAZIAN FASCIAL SPACES FACE SUPRAHYOID INFRAHYOID TOTAL NECK Buccal Sublingual Anterovisceral Retro (Pretracheal) pharyngeal Canine Submandibular Carotid sheath Masticatory Pharyngomaxillary space Parotid CLASSIFICATION OF FASCIAL SPACES BASED ON MODE OF INVOLVEMENT FASCIAL SPACES DIRECT (Primary spaces) INDIRECT (Secondary spaces) Masseteric Pterygomandibular MAXILLARY MANDIBULAR Superficial & Deep Canine Submental Temporal Buccal Buccal Lateral Pharyngeal Infratemporal Submandibular Retropharyngeal Sublingual Prevertebral & Parotid Spaces 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 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 BUCCAL SPACES ANTERIOR POSTERIOR SUPERIOR INFERIOR MEDIAL LATERAL Modiolus of Pterygomandib Maxilla, Lower Border Buccinator Skin Of Mouth ular Raphe, infraorbital Of Mandible Muscle, Cheek Masseter space Buccopharyng eal Fascia CONTENTS: Buccal pad of fat, Stenson’s duct , Anterior and transverse facial artery LIKELY SOURCE OF INFECTION: Maxillary & mandibular premolars and molars BUCCAL SPACES- COMMUNICATIONS Submasseteric Space Pterygomandibular Space Superficial Temporal Space Infratemporal space Lateral Pharyngeal Space 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. CANINE SPACE ANTERIOR POSTERIOR SUPERIOR INFERIOR MEDIAL LATERAL Nasal Buccal space Quadratis Oral mucosa Quadratis Levator anguli cartilages labii labii oris superioris superioris CONTENTS : Angular artery and vein, Infraorbital nerve. LIKELY SOURCE OF INFECTION : Maxillary canine or first premolar 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 SUB MANDIBULAR SPACE ANTERIOR POSTERIOR SUPERIOR INFERIOR LATERAL MEDIAL Anterior belly Posterior belly Inferior & Digastric Platysma, Mylohyoid, of digastric Of digastric, medial tendon Investing Hypoglossus, Stylohyoid, surface of fascia Superior Stylopharyngus mandible Constrictor CONTENTS: Submandibular gland, Facial artery & vein LIKELY SOURCE OF INFECTION : Mandibular molars SUB MANDIBULAR SPACE CLINICAL FEATURES : Induration and erythema Obliteration of the mandibular line & extending to the level of hyoid bone No trismus 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 SUBMANDIBULAR SPACE- COMMUNICATION . Submental space . Lateral pharyngeal space . Sublingual space . Contralateral spaces SUB LINGUAL SPACE ANTERIOR POSTERIOR SUPERIOR INFERIOR MEDIAL LATERAL Lingual Submandibular Oral mucosa Mylohyoid Muscles of Lingual surface of space muscle tongue Surface mandible of mandible CONTENTS : Sublingual glands, Wharton’s duct, Lingual nerve, Sublingual artery & vein LIKELY SOURCE OF INFECTION : Mandibular premolars & molars 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 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. SUB MENTAL SPACE ANTERIOR POSTERIOR SUPERIOR INFERIOR SUPERFICIAL DEEP Inferior Fascia between Mylohyoid Investing Investing Fascia Anterior border of Hyoid and fascia bellies of mandible inferior border digastric of mandible CONTENTS : Anterior Jugular veins, Lymph Nodes LIKELY SOURCE OF INFECTION : Lower anteriors 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 in upward and backward, Drain & dressings are placed. MASTICATORY SPACE These are secondary spaces, well differentiated and communicate with each other PTERYGOMANDIBULAR SPACE ANTERIOR POSTERIOR SUPERIOR INFERIOR MEDIAL LATERAL Buccal space Deep lobe Lateral Inferior Medial Ascending Of Parotid Pterygoid border of pterygoid Ramus of gland mandible muscle mandible CONTENTS : Mandibular division of trigeminal nerve, inferior alveolar artery & vein LIKELY SOURCE OF
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