dr. mohit bindal senior lecturer department of omfsdental.subharti.org/lectures_bds/space...
TRANSCRIPT
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%)–
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%)
70
5
25
MICRO ORGANISMS
MIXED
AEROBIC
ANAEROBIC
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
Canine
Masticatory
Parotid
Sublingual
Submandibular
Pharyngomaxillary
Anterovisceral
(Pretracheal)
Retro
pharyngeal
Carotid sheath
space
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
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
Mouth
Pterygomandib
ular Raphe,
Masseter
Maxilla,
infraorbital
space
Lower Border
Of Mandible
Buccinator
Muscle,
Buccopharyng
eal 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
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
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
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
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
CLINICAL FEATURES : Induration and erythema Obliteration of the mandibular line & extending to the level of hyoid bone No trismus
SUB MANDIBULAR SPACE
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
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
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
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
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
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
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
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 3rd molar
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
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
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
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
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 Passed superiorly along lateral aspect of the coronoid (Superficial)
Passed supero-medially (Deep)
Extra oral incision- slightly superior to zygomatic arch
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
INFRATEMPORAL SPACE CLINICAL FEATURES:
Marked Trismus
Swelling of face in front of ear, over TMJ, behind zygomatic process
Eye is closed and proptosed
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
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.
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
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
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
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 SCM muscle
RETROPHARYNGEAL SPACE Extends from base of skull to retropharyngeal fascia (between 4th and
6th 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
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.
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
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
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
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.
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.
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
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
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
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
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
LUDWIG’S ANGINA MANAGEMENT
Bilateral incision, Midline incision Blunt dissection
Initially no pus, but later on profuse pus drains out Drain placement
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
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
COMPLICATIONS OF SPACE INFECTION
Scar formation
Sinus tract formation
Cavernous sinus thrombosis
Necrotising fascitis
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
CONTENTS
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.
SPREAD OF INFECTION TO CAVERNOUS SINUS 1. Infection of upper lip, vestibule of nose and eyelids Angular,
supraorbital and supratrochlear veins to ophthalmic veins
2. Intranasal surgeries on septum, turbinates or ethmoid / sphenoid sinus
infection Ethmoidal veins
3. 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.
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
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 exophthalmos,Dilated pupil with loss of accomdation reflex
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 ( adrenal insufficiency due to cranial nerve
dysfunction or pituitary necrosis)
DIAGNOSTIC IMAGING OF FASCIAL & NECK SPACES
•Plain film- AP & Lateral view
•MRI
•CT
•Ultrasound
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
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
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
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
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