primary spaces of space infection
TRANSCRIPT
PRIMARY SPACES OF SPACE INFECTION
BY MANMOY SAHA(INTERN)
CONTENTS INTRODUCTION POTENTIAL SPACES PRIMARY MAXILLARY SPACES -CANINE SPACE -BUCCAL SPACE -INFRA TEMPORAL SPACE PRIMARY MANDIBULAR SPACES -SUBMENTAL SPACE -BUCCAL SPACE -SUBMANDIBULAR SPACE -SUBLINGUAL SPACE
INTRODUCTION Infections of orofacial and neck regions
range from periapical abscess to superficial and deep neck infections
The infections spread by following the path of least resistance through connective tissue and fascial planes
The infection spread to such an extent ,distant from the site of origin causing considerable morbidity and occasional death
PATHWAYS OF ODONTOGENIC INFECTIONS
Invasion of dental pulp by bacteria after decay of tooth
-> Inflammation, edema, lack of collateral blood supply
-> venous congestion or avascular necrosis
->Reservoir for bacterial growth ->periodic egress of bacteria into
surrounding alveolar bone
SPREAD OF OROFACIAL INFECTIONS ROUTES OF SPREAD By direct continuity through the tissues
By lymphatics to the regional lymph nodes and eventually into blood stream
Which may lead to secondary areas of cellulitis or tissue space abscess
By the blood stream
If the infection remains confined to the peri-apical areas, chronic periapical infections develop , which leads to sufficient destructions of bone-> osteomyelitis
MAXILLA Swelling or fistula in the posterior part of hard palate
it is related to palatal roots of molars
Maxillary incisor and cuspid roots lie closer to thin labial plate of bone than to thicker palatal bone
Infection from maxillary bicuspids may extend into connective tissue of buccal vestibule spread superiorly causing cellulitis of eyelids
Infection from molars may exit from alveolar bone buccally, palatally or posteriorly
Superior spread -> infratemporal space, maxillary sinus
Posteriorly->masticator and pharyngeal space
MANDIBLE
Infection of mandibular incisors and cuspids shows bulging in labial sulcus
If infection spreads from bone deeper to origin of mentalis muscle->submental space
Infection from mandibular 3rd molar involve buccal vestibule, buccal space, masticator space, parapharyngeal spaces
CLASSIFICATION OF FASCIAL SPACES BASED ON THE MODE OF INVOLVEMENT: Direct involvement:- Primary maxillary spaces- canine
space, buccal space, infra temporal space Primary mandibular spaces-
submental space buccal space, submandibular space, sublingual space Indirect involvement- Secondary fascial spaces- masseteric
spaces
Pterygomandibular space Superficial temporal space Deep temporal space Lateral pharyngeal space Retropharyngeal space Prevertebral space Parotid space Based on clinical significance Face - Buccal , canine, masticatory, parotid Suprahyoid- sublingual, submandibular,
pharyngomaxillary, peritonsillar Infrahyoid- anterovisceral(pre tracheal) Spaces of total neck: retropharyngeal , space of
carotid sheath
The teeth which frequently give rise to abscess in this area are maxillary canines, premolars and sometimes mesiobuccal root of 1st molar
CANINE SPACE( INFRA-ORBITAL SPACE)
Boundaries:-
Anteriorly- orbicularis oris
Posteriorly- buccinator Superiorly-levator labii
superioris, zygomaticus minor
Inferiorly- caninus muscle
Medially- anterolateral surface of maxilla
CLINICAL FEATURES:-
Swelling of cheek and upper lip
Obliteration of nasolabial fold
Drooping of the angle of mouth
edema of lower eyelid
Redness and marked tenderness of facial tissues
Intraoral- offending tooth is mobile and tender on percussion
INCISION & DRAINAGE:-
A curved mosquito forcep is inserted superior to the attachment of caninus muscle & the infra-orbital space is entered
Pus is evacuated and a drain is inserted & secured to one of the margins with suture
It is the potential space between buccinator & masseter muscle Maxillary & Mandibular premolars and molars area involved. Location of the root tip to the level of origin of buccinator muscle determines the spread of infection either intraorally into the vestibule or deep into the buccal space
Boundaries:- Anteromedially- buccinator
muscle
Posteromedially- masseter overlying the anterior border of ramus of mandible
Laterally- forward extension of deep fascia from the capsule of parotid gland & platysma muscle
Inferiorly- deep fascia to the mandible & depressor anguli oris
Superiorly- zygomatic process of maxilla & zygomaticus major and minor
CLINICAL FEATURES:-
Gum boil is seen in the vestibule(when the pus accumulates on oral side of the muscle)
If the pus accumulates lateral to the muscle extraoral swelling is seen extending from lower border of mandible to the infra orbital margin
and from anterior margin of masseter muscle to the corner of the mouth
INCISION & DRAINAGE:-
Horizontal incision through the oral mucosa of the cheek in the premolar molar region
If the pus is lateral to the muscle then the muscle is penetrated with curved mosquito forceps to enter the buccal space
Drain is placed secured with suture
It is also called “retrozygomatic space”
The space is continuous with upper part of pterygomandibular space anteriorly, it is separated from it by lateral pterygoid muscle posteriorly
The infratemporal fossa forms the upper extremity of pterygomandibular space
Involvement- Infections of the
infratemporal space occurs from the infections of buccal roots maxillary 2nd and 3rd molars
Local anesthesia injections with contaminated needles in the area of tuberosity
Spread from other spaces infection
Spread of infection
Pus can extend upwards to involve the temporal space or inferiorly perforate the lateral pterygoid muscle to involve the pterygomandibular space
It can spread through pterygoid plexus of veins upwards into cavernous sinus
From infratemporal fossa to middle cranial fossa
Boundaries:-
Laterally- ramus of mandible and temporalis muscle
Medially-medial pterygoid plateand lateral pterygoid muscle
superiorly - infratemporal surface of greater wing of sphenoid
Inferiorly- lateral pterygoid muscle
Anteriorly- infratemporal surface of maxilla
Posteriorly -parotid gland
CLINICAL FEATURES:-
Extraoral- trismus
Bulging of temporalis muscle
Marked swelling of the face on the affected side in front of the ear overlying area of tmj
Intra oral –swelling in tuberosity area with elevation of temp 104F
INCISION & DRAINAGE:-
Intraoral approach- incision is given in buccal vestibule opposite 2nd and 3rd molar exploration is carried out medial to coronoid process and temporalis muscle upwards backwards with sinus forcep ,space is entered and drained
Extra oral approach- incision is made at upper and posterior edge of temporalis muscle within hairline.
Sinus forcep directed upward medially
Pus is evacuated
Infections originating from 6 anterior mandibular teeth then perforate cortical plate below the origin of mentalis muscle labially ,mylohyoid lingually
It can also affected from lower incisors , lower lip, skin overlying the chin, anterior part of floor of mouth,
tip of tongue and sublingual tissues
BOUNDARIES:-
Lateral- lower border of mandible and anterior bellies of digastric
Superior:- mylohyoid muscle Inferior:- suprahyoid portion of the investing
layer of deep cervical fascia
CLINICAL FEATURES:- Extraoral findings- distinct,
firm swelling in midline beneath the chin
Skin over the swelling is board like taut
Intraoral findings- the anterior teeth are either non-vital fractured or carious .
The offending tooth may exhibit tenderness to percussion may show mobility
Spread: of infection-
Posteriorly- to involve submandibular space
It may discharge on the face in the submental region
INCISION & DRAINAGE:-
A transverse incision is made in the skin below the symphysis of the mandible.
Blunt dissection is carried out by inserting a kelly’s forcep through this incision ,upward ,backward
Then corrugated rubber drain is inserted in the abscess cavity and sutured
The space lies between the anterior and posterior bellies of digastric muscle.
Upper part lies beneath the inferior border of mandible and lower part lies deep to the investing layer of deep cervical fascia
INVOLVEMENT
Infections originating from mandibular molars, pus perforates the lingual cortical plate of mandible passes directly into the submandibular space
Infection from submental space
Infection from posterior part of sublingual space
Infections from middle third of the tongue, posterior part of floor of mouth, maxilary teeth, cheek, maxillary sinus, palate
BOUNDARIES:- Anteromedially:- floor is
formed by mylohyoid muscle
Posteromedially:- floor is formed by hyoglossus muscle
superolaterally :- medial surface of mandible
Anterosuperiorly:- anterior belly of digastric
Posterosuperiorly:- posterior belly of digastric
CLINICAL FEATURES:-
Extra oral:- firm swelling in the submandibular region, below inferior border of mandible
Redness of overlying skin
Intra oral:- teeth are sensitive to percussion
Teeth are mobile
Dysphagia
Moderate trismus
Spread: of infection-
There is no major anatomic barriers so infection can extend into submental space
There is no anatomical barrier so infection can spread easily across the midline involve submandibular space on other side
It communicates with sublingual space around posterior border of mylohyoid muscle
It can also spread into parapharyngeal space
An incision of about 1.5 to 2 cm length is made 2cm below the lower border of mandible
Skin and subcutaneous tissues are incised
Sinus forcep is inserted through the incision superiorly and posteriorly on the lingual side of mandible below the mylohyoid to release pus from submandibular space
INCISION & DRAINAGE:-
Space is a “V” shaped trough lying lateral to muscles of tongue including hyouglossus, genioglossus, geniohyoid
Involvement:- mandibular incisors, canines, premolars , sometimes molars
It is a paired space but the 2 sides communicates anteriorly, with submandibular space around the posterior border of mylohyoid muscle
BOUNDARIES:- Inferiorly- mylohyoid muscle
Laterally:- medial side of the mandible above mylohyoid muscle
Medially:- hyoglossus, genioglossus & geniohyoid muscles
Posteriorly:- hyoid bone
Laterally and inferiorly:- mylohyoid muscle and lingual side of mandible
CLINICAL FEATURES:-
Extraorally: there is little or no swelling.
The lymph nodes may be tender & enlarged
Pain and discomfort on deglutition
Intraorally: firm, painful swelling seen in the floor of the mouth
Floor of the mouth is raised
Tongue pushed superiorly will cause airway obstruction
Spread: of infection-
Infection crosses the midline and effect the space on the opposite
Infection from posterior inferior part of the space spread into submandibular space-> pterygomandibular and parapharyngeal space
Infection spread via lymphatics to the submandibular or submental lymph node
INCISION & DRAINAGE:- Inraorally:- incision is made
close to the lingual cortical plate, lateral to sublingual plica (whartons duct, sublingual artery,veins & lingual nerve)
Sinus forceps is then inserted and openeed to evacuate the pus
Extraorally:- when both submental and sublingual space contains pus they can be drained by placing incision in submental region
MANAGEMENT OF OROFACIAL INFECTIONS Antibiotic therapy:-
Use of penicillin G (2 to 4 million units, IV 4 to 6 hrs)and
metronidazole(400 mg 8 hourly orally or IV)
Oral clindamycin
Amoxicillin-clavulanic acid(augmentin)
1st and 2nd generation cephalosporins are useful in orofacial infections
In compromised patients- clindamycin alone 300 to 600 mg 8 hourly IV)
Or in combination with gentamycin ( 80 mg IM) can be given
SURGICAL THERAPY
Hilton’s method of incision and drainage
The method of opening an abscess ensures that no blood vessels or nerve is damaged
Incision helps to get rid of toxic purulent material
To allow better perfusion of blood containing antibiotic and defensive elements
To increase oxygenation of infected area
HILTON’S METHOD OF INCISION AND DRAINAGE
Topical anesthesia:- achieved with the help of ethyl chloride spray
Stab incision:- it is made over the point of maximum fluctuation in the most dependent area through skin and subcutaneous tissue
Deepening of surgical site is achieved with sinus forceps
Closed forceps are pushed through deep fascia move towards the pus collection
Abscess cavity is entered and forceps is opened in a direction parallel to vital structures
Pus flow along side of beaks
Explore the entire cavity for additional loculi
Placement of drain:- A corrugated rubber drain is inserted into depth of abscess cavity & external part secured with suture
Drain is left for 24 hrs
Dressing:- applied over the site of incision taken extraorally without pressure
INVOLVEMENT OF MULTIPLE PRIMARY SPACES LUDWIG’S ANGINA It is a firm, massive, brawny cellulitis and acute, toxic stage involving
simultaneously submandibular, sublingual, submental space bilaterally
It means “suffocation or choking sensation” Clinical features:- There is pyrexia, anorexia , chills, malaise
Severe muscle spasm may lead to trismus with restricted mouth opening and also jaw movements
Tongue movements may be reduced
Air obstruction
Fatal death may occur in untreated case of Ludwig’s angina within 10 to 24 hours due to asphyxia
TREATMENT OF LUDWIG’S ANGINA Early diagnosis
Maintenance of the patient airway
Intense and prolonged antibiotic therapy
Extraction of offending teeth
Surgical drainage or decompression of fascial spaces
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