MINISTRY OF HEALTH OF UKRAINE Ukrainian medical stomatological academy

“Approved” On the meeting chair Of Propaedeutics Surgical Stomatology The Head of the Department prof. ovikov V.M. ______“ ____ ” ______20 ____

GUIDELINES Individual work of students During preparation for Practical classes

Educational discipline Surgical stomatology Module № 2 Inflammatory diseases in maxillofacial region. Odontogenous inflammatory diseases in Content module № 3 maxillofacial region Phlegmon of lateral pharyngeal and retropharyngeal Theme lesson spaces. Clinic, diagnostics, medical treatment. Course 3 Faculty Stomatological

Poltava 2018 1. Actuality of the topic. In practice of the doctor - stomatologist there are patients with a phlegmon of peripharyngeal region, or an abscess of this region. Less often - a phlegmon of . Timely recognition of these diseases will speed up the help to this patient, and to prevent serious complications which threaten life of the patient. 2. The objectives of the studies. To know about a course of operation of disclosing of abscess, phlegmon of forward peripharyngeal space. To know an etiology, clinical manifestation of abscess and phlegmon of peripharyngeal and retropharyngeal spaces, methods of examination and treatment of patients with the given pathology. To acquire skills of examination of patients with abscesses and phlegmons of peripharyngeal region. To make the diagnosis. To carry out differential diagnostics. To combine a treatment planning of the patient with a phlegmon and an abscess of peripharyngeal region. To fill in a case history of the inpatient.

3. Basic knowledge, skills, skills necessary for study topics (interdisciplinary integration). Name of previous These skills courses Physiopathology. Inflammatory processes. Anatomical pathology. Inflammatory processes. Microbiology. The infestant, microbic flora of an oral cavity. Operative surgery and Features of an anatomical structure of the upper and upperographical lower jaws and fat tissue spaces of the face. . Histology. Features of intraosteal frame of the upper and lower jaws, mild tissues fat spaces of the face. Propedeutics of a Methods of examination of the stomatologic patient surgical odontology.

4. Tasks for independent work in preparation for the classes. 4.1. A list of key terms, parameters, characteristics that must learn the student in preparation for the lesson:

Term Definition Anterolaterally the fascia covering the masticator space boundary Posteriorly boundary the parotid space Medially boundary superior constrictor muscle of the

2 Posteriorly boundary the prevertebral and visceral layers of the deep cervical fascia

4.2. Theoretical questions to lesson: 1. The causes infection forward peripharyngeal space. 1) What teeth can become the cause infection peripharyngeal space? 2) From what fat spaces can the infection contamination in peripharyngeal space will be distributed? 3. The causes of an abscess of peripharyngeal space. What kinds of traumas of a lateral wall of a pharynx result in a peripharyngeal abscess? 4. The causes of an inflammation of retropharyngeal space. Name oral and other routes of penetration of an infection contamination to retropharyngeal space. 5. Clinical manifestation a phlegmon of peripharyngeal space. 1) Describe complaints of the patient at the given pathology. 2) Name attributes of a phlegmon which are possible for revealing at survey and a palpation of the outward side. 3) Describe manifestation a phlegmon of peripharyngeal space in an oral cavity. 6. Clinical manifestation an abscess of peripharyngeal space. 1) Data of survey, interrogation and a palpation. 2) Signs of an abscess in an oral cavity. 7. Clinic of a retropharyngeal abscess. 1) Complaints and an anamnesis at a retropharyngeal abscess. 2) The data of survey of the patient through a mouth. 3) Name instruments which are expedient for applying to survey of a back wall of a pharynx. 8. Treatment of a phlegmon of peripharyngeal and retropharyngeal spaces. 1) Course of operation of dissecting of a phlegmon of peripharyngeal space. 2) A course of operation of dissecting of an abscess of peripharyngeal space. 3) A course of operation of dissecting of a retropharyngeal abscess. 9. Diffusion of a phlegmon of peripharyngeal space. In what spaces pus from peripharyngeal space can be distributed? 10. Medicamental treatment of the patient. What medicamental agents are expedient for applying the patient with this pathology?

4.3. Practical works (tasks) are performed in class: − To take possession of technique of realization observation of the patients with phlegmon of lateral pharyngeal and retropharyngeal spaces. − To make a treatment planning of phlegmon of lateral pharyngeal and retropharyngeal spaces.

3 − To acquire technique of carrying out observation of patient with phlegmon of lateral pharyngeal and retropharyngeal spaces. − To make the plan of examine of the patient with phlegmon of lateral pharyngeal and retropharyngeal spaces. − To make the plan of local treatment of patients with phlegmon of lateral pharyngeal and retropharyngeal spaces.

5. Theme contents. 1. Lateral Pharyngeal space () pharyngeomaxillary space, pterygopharyngeal space). The lateral pharyngeal space is a lateral neck space. It has the shape of an inverted cone with its base at the skull and its apex at the hyoid bone. Boundaries Anterolaterally: This space is bounded by the fascia covering the masticator space. Posteriorly: By the parotid space. Medially: By the superior constrictor muscle of the pharynx. Posteriorly: By the prevertebral and visceral layers of the deep cervical fascia. The upper limit of the lateral pharyngeal space is a line on the base of the skull along the sphenoid bone, from the root of the medial pterygoid to the sphenoid spine behind. Inferiorly: The lateral pharyngeal space is bounded by the attachement of the capsule of the submandibular gland to the sheath of the stylohyoid muscle and posterior belly of digastric muscle. Contents: The lateral pharyngeal space contains deep cervical lymph nodes, facial and ascending pharyngeal arteries, carotid sheath (internal carotid artery, internal jugular vein and vagus nerve), glossopharyngeal, accessory and hypoglossal nerves and cervical sympathetic trunk.

Pathologic Development: Infection of the lateral pharyngeal space may result from: 1. The pharynx peritonsillar suppuration may erode through the superior pharyngeal constrictor muscle to enter the lateral pharyngeal space. 2. Dental Infections: Abscess, may develop in this space from an acute infection around the mandibular molar or from extension of infection from a mandibular nerve block injection. 3. Infections of the parotid space, or space of the body of the mandible.

4 Signs & Symptoms: 1. Because of the depth of the abscess and thickness of the overlying fascia, external fluctuation is seldom encountered. 2. External swelling: Firm, tender and indurate swelling may be observed beneath the angle of the mandible. 3. Internal swelling: Swelling of the lateral wall of the pharynx and medial displacement of the tonsils, tonsillar pillars and the uvula. 4. The patient complains of difficulty of swallowing (dysphagia). 5. Trismus that occurs sometimes is so severe that the patient is unable to open his mouth. This causes a delay in diagnosis and treatment. 6. Excruciating pain radiating to the ear, face or neck. Probably the greatest danger of infections in this area is their tendency to involve the carotid bundle. This bundle is the core of the soft structures of the neck. When the infection travels in this space many complications may result. These include phlebitis, sepsis, tongue paresis, and arterial erosion. Acute suppuration of the mediastinum is a well recognized complication of descending neck infection. Treatment: The treatment consists of antibiotics, surgical drainage and tracheostomy. Incision and drainage may be carried out extra-or intra-orally.

Extraoral Incision: The incision is made along the anterior border of the sternocleidomastoid muscle, extending from the angle of the mandible approximately 2 cm. long. To gain entrance to the lateral pharyngeal space, the fascia behind the submandibular gland is opened by a blunt hemostat. The hemostat is introduced medially behind the mandible. For complete evacuation of pus, the hemostat can be introduced superiorly and posteriorly. A drain is inserted.

Intra-oral Incision: Vertical incision is made in the retromolar triangle lateral and parallel to the pterygomandibular fold. The posterior part of the buccal space is opened and the tendon of the temporal muscle is exposed. A curved hemostat is introduced medial to the medial pterygoid muscle to evacuate the pus present in the lateral pharyngeal space. A drain is then inserted.

2. The Retropharyngeal Space The retropharyngeal space occurs between the posterior wall of the pharynx and the prevertebral fascia. The loose areolar connective tissue which exists here not only permits pharyngeal movement but allows infection to travel inferiorly to the posterior mediastinum as far as the diaphragm and superiorly to the base of the skull. Adequate drainage of the retropharyngeal and lateral pharyngeal spaces are together considered as parapharyngeal space.

5 Differential Diagnosis of Facial Swelling: 1. Facial edema associated with acute dental infections. 2. Angioneurotic edema due to allergy, hereditary or psychoneurotic forces, in this condition the facial swelling is due to liberation of histamine or histamine-like substance. 3. Emphysema: Caused by incorporation of air in tissue spaces. 4. Lymphangioma: Which commonly affects the lips, sometimes the condition is caused by blocking of lymph vessels due to trauma and fibrosis, causing stasis of lymph in lymph vessels (lymphangiaectasis). 5. Tumors and cysts of the oral cavity and jaws e.g. lipoma, ranula and dermoid cyst. 6. Salivary gland affections: As mucous retention phenomenon, epidemic parotitis, sialolithiasis etc. 7. Trauma from prolonged surgical intervention and retraction is followed by facial edema; traumatic injuries causing fractures of facial bones are associated with facial swelling hematoma and ecchymosis. 8. Specific infections affecting the facial tissues as actinomycosis which causes indurated facial swelling characterized with multiple sinuses with yellowish discharge containing sulphar granules.

6. Materials for self control: А. Assignments for self control (tables, charts, drawings, graphs): Main tasks Recommendations Keys 1. Anatomical borders of Name outward, peripharyngeal and retropharyngeal intrinsic, forward spaces. and back borders of peripharyngeal and retropharyngeal spaces.

B. Self-control tests: 1. Than circumscribed from back Overhead floor of bottom of cavity of mouth? A. Internal surface of body of lower jaw B. The inferior edge of a body of the mandible; C. bottom of cavity of mouth; D. Foundation of tongue. E. Region deep to the body of the mandible and above the mylohyoid muscle.

2. The phlegmon of Overhead floor of bottom of cavity of mouth educes at disease: 6 A. The upper and inferior incisors; B. The upper and lower canines; C. The lower premolar; D. The lower frontals choose, premolar and molar.

3. Operative access of dissection of a phlegmon of Overhead floor of bottom of cavity of mouth: A. Submandibular incision; B. In region of an angle of a mandible; C. Collarshape cut with the partial cutting fibers of mylohyoid muscle; D. From side of cavity of mouth.

4. Than circumscribed from back Lower floor of bottom of cavity of mouth? A. The inferior edge of a body of the mandible; B. Mylohyoid muscle; C. The inferior surface of the big wing of the basic bone; D. Muscles, incipient from the styloid process of temporal bone and back belly of digastric muscles. E. Region deep to the body of the mandible and above the mylohyoid muscle.

5. The phlegmon of Lower floor of bottom of cavity of mouth educes at disease: A. The lower premolar; B. The lower molar. C. The upper and lower canines D. The lower incisors.

6. Operative access of dissection of phlegmon Lower floor of bottom of cavity of mouth: A. Submandibular incision; B. In region of an angle of a mandible; C. Incision on the floor of the mouth; D. From the side of skin covers cut in a submandibulars regions on the right and on the left or transverse section parallel to the overhead neck fold.

C. Tasks for self-control:. 1. The patient complains of a pain in region of a mandible at the left, labored opening of a mouth, a body temperature. Locus morby - asymmetry of the face owing to an edema of tissues of auriculo-masticatory region at the left, circumscribed opening of a mouth up to 1,5 cm between incisors, infiltratio retromolaris regions at the left, it decayed semi retention 28 teeth.

7 Question. What manifestative attributes at the patient are at a lesion of peripharyngeal space? What preliminary diagnosis? The answer. Circumscribed opening of a mouth, an infiltration retromolaris regions. The diagnosis - retromolaris a periostitis. 2. Patient С. is disturbed with a pain in earlier cured 16 teeth. Thus it marks periodically intumescence mild tissues in submandibular regions on the right. Three days ago the pain in teeth has amplified, has appeared a tumescence, the body temperature has increased up to 38°С, there was a pain at a swallowing, general delicacy. In submandibular regions the morbid infiltrate on the right is marked, the skin above it bloodshots. In an oral cavity - the crown of 16 teeth decayed, the percussion is morbid, the mucosa of the sublingual platen is hydropic. Question. Make the preliminary diagnosis. Whether there are at the patient attributes of a lesion of peripharyngeal space? The answer. At the patient a phlegmon dextral submandibular spaces. This phlegmon can be distributed in peripharyngeal space. Attributes which specify a lesion of peripharyngeal space - a pain at a swallowing. 3. Patient G. has addressed with complaints to a whining pain in a mandible at the left, a sharp pain at a swallowing, delicacy, a headache. There is a small tumescence of mild tissues under an angle of a mandible at the left. The skin has not changed color, the palpation is moderately morbid. Opening of a mouth circumscribed up to 1,5 see. In an oral cavity - roots of 27 and 28 teeth. Pterygoid-gnathic складка it is hydropic and infiltratio, at pressing - it is sharply morbid. The tumescence is distributed to the forward palatal handle. Question. Differentiated from a phlegmon of peripharyngeal space. The answer. At the patient a phlegmon of Pterygoid-gnathic space. Similar attributes with a phlegmon of peripharyngeal space are present at the given patient: - Circumscribed opening a mouth; - A tumescence under an angle of a mandible; - A sharp pain at a swallowing. The patient does not have such attributes of a phlegmon of peripharyngeal space: - Moving to the able-bodied side lateral pharynxes and a soft palate; - A morbid infiltrate under an angle of a mandible. 4. For the patient diagnosed a phlegmon of auriculo-masticatory region. Question. Specify possible routes of diffusion of pyoinflammatory process. Whether probably diffusion of a phlegmon of the given localization on peripharyngeal space? The answer. Inflammatory process from this region can will be distributed in Pterygoid -gnathic space, peripharyngeal space, an alary fossa and region of a neck. 5. In maxillofacial abjointing to the patient have carried out dissecting a phlegmon of peripharyngeal space. Question. What regions next to struck spaces are necessary for dissecting simultaneously to avoid diffusion of an infection contamination? 8 The answer. Simultaneously with dissecting a phlegmon of peripharyngeal space it is necessary to pass in pterygoid-gnathic space with a dissecting away of a part of a medial alary muscle, and in with a dissecting away of a part of a maxillary-sublingual muscle. 6. What phlegmons of regions can be distributed in peripharyngeal space? The answer. From submandibular, pterygoidmaxillary, a sublingual, alary fossa, auriculo-masticatory and pastmaxillary regions.

7. Bibliography. Basic: 1. Contemporary Oral and Maxillofacial Surgery//Larry J. Peterson, Edvard Ellis III, James R.Hupp, Myron Tucker/ 2003, MOSBY, – 776 p. 2. Hupp JR, Williams TP, Vallerand WP: The 5 minute clinical consult for dental professionals PDA, Baltimore, 2002, Williams & Wilkins Additional: 1. http://www.revistachirurgia.ro/pdfs/2014-3-355.pdf 2. http://www.uptodate.com/contents/retropharyngeal-infections-in-children 3.

Methodical recommendations is prepared by docent Rezvina Ye.Yu.

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