DMART Space Infections 08.06.14

Fascial Space

Infections

David D. Martinez, DMD MDBaylor OMFS

August 6th 2014

Fascial Spaces

These areas are potential spaces that do not exist in healthy people but become filled with

purulent exudate during infections.

Contemporary Oral and Maxillofacial Surgery, 4th Edition

Fascial Space Infections

• Usually caused by odontogenic infection eroding through cortical bone.

• Usually erode through thinnest bone.• Space invaded determined by muscle

attachment.

Today’s Outline

1. General Information2. Fascial Space Infections

– Infections associated with any tooth– Infections associated with Maxillary teeth– Infections associated with Mandibular teeth– Infections associated with deep fascial spaces of

the neck (secondary fascial spaces)3. Management of Fascial Space Infections

Anatomy Overview

General Information

• Indigenous bacteria usually causative of infection– Staph – Skin– Normal Oral Flora – Odontogenic Infections

• Aerobic Gram Positive Cocci• Anaerobic Gram Positive Cocci• Anaerobic Gram Negative Rods

• Only Aerobic Infections 5-7%• Only Anaerobic Infections 33-35%• MIXED Infections 60%

General Information

• Anaerobic 75%

– Gram-positive cocci 30%• Streptococcus 33%• Peptostreptococcus 65%

– Gram-negative cocci (Veillonella) 4%

– Gram-positive rods 14%• Eubacterium• Lactobacillus• Actinomyces• Clostridia

– Gram-negative rods 50%• Bacteroides 75%

-Porphymonas ginivalis -Prevotella intermedia

• Fusobacterium 25%

– Miscellaneous 6%

• Aerobic 25% Gram-positive cocci 85%

Streptococcus 90% Group D Streptococcus 2% Staphylococcus 6% Eikenella 2%

Gram-negative cocci (Neisseria) 2%

Gram-positive rods (Corynebacterium) 3%

Gram-negative rods (Haemophilus) 6%

Misc 4%

Progression of Infection

• Inoculation– First 3 days, normal color and feel– Presence of edema– Mild malaise and pain

• Cellulitic Process– Days 3-7, hot, red, firm, extremely tender– Serosanguineous tissue fluid– Severe malaise and pain, show cardinal signs of

inflammation

Progression of Infection

• Abscess– > 5 days, fluctuant to palpation– Pus pocket, yellowish color with red periphery– Moderate to severe malaise and pain

• Resolution– After spontaneous or surgical drainage

Aerobic Gram (+) => Anaerobic Gram ( - ) => increase in Beta-lactamase

Cellulitis vs. Abscess

• Cellulitis– Acute Onset– Severe, Generalized Pain– Large area with diffuse

borders– Doughy to indurated on

palpation– Little or No Pus– More Serious– Aerobic Bacteria

• Abscess– Chronic Process– Localized Pain– Small area with well

circumscribed borders– Fluctuance on palpation– Presence of Pus– Less Serious– Anaerobic Bacteria

Today’s Outline

1. General Information2. Fascial Space Infections



1. Fascial Space Infections– Infections associated with any tooth

• Vestibular• Buccal

Space Buccal

Ant. Border

Corner of mouth

Post. Border

Masseter, pterygo-mand sp.

Sup. Border

Maxilla, infraorb. sp.

Inf. Border

Mandible, skin

Medial/ Deep

Subcut- aneous

Lateral/ Superficial

Buccinat.

Likely causes

Mx can. Mx molar Md can.

Contents Parotid d. Ant. Fac a/v, trans fac a/v, buccal fat

Neigh-boring spaces

Infraorb, Pterygom, Infratemp

Approach for I&D

Intra (sm) Extra (lg)

- Potential space between skin laterally and

Buccinator medially.- Usually caused by Maxillary molar infection

but can be caused by Mandibular molar- Clinically, does not extend past inferior

border of mandible- I&D: subperiosteal dissection through

extraction site or through vestibular mucosa

Buccal

1. Fascial Space Infections– Infections associated with Maxillary teeth

• Infraorbial/Canine• Infratemporal/Deep temporal• Cavernous sinus thrombosis

Space Infra-orbital

Ant. Border

Nasal cartillage

Post. Border

Buccal space

Sup. Border

Quad. Labii sup.

Inf. Border

Oral mucosa

Medial/ Deep

Quad labii sup.


Lev ang oris, maxilla

Likely causes

Mx cuspid

Contents Angular a/v, infraorbial n

Neigh-boring spaces

Buccal

Approach for I&D

Intraoral

1) Potential space between levator anguli oris and levator labii superioris muscles

2) Causes loss of nasolabial angle facially

3) Drainage may occur inferior to medial canthus of eye

4) I&D: High in vestibule

Infraorbital

Space Infra- temporal / Deep temporal

Ant. Border

Maxilla

Post. Border

Middle Cranial Fossa

Sup. Border

Base of skull

Inf. Border

Lateral Pterygoid

Medial/ Deep

Lateral pterygoidplate


Continuous with deep temporal space

Likely causes

Mx molars

Contents Pterygoid plx, mx a/v, V3

Neigh-boring spaces

Buccal Sup.Temp Inf. Petr sinus

Approach for I&D

Intraoral Extraoral

1) Posterior to maxilla, below skull base2) Caused by maxillary third molar infections3) Contents include maxillary artery and

pterygoid plexus (infection may track to dural sinuses)

4) Rare in isolation5) I&D: Vertical incision

medial to anterior ramus, superior dissection along medial coronoid

Infratemporal/Deep Temoral

Cavernous Sinus Thrombosis

- Life threatening infection caused by retrograde flow of odontogenic infection through valve-less veins in head.

- Vascular inflammation caused by bacteria stimulate clotting pathways.- Occurs anteriorly through inferior or superior ophthalmic veins and posteriorly through

emissary veins and pterygoid plexus.- Lateral Rectus (CNVI) Palsy: Impaired extraocular movements laterally.- Treatment is immediate antibiotic therapy and removal of infection whenever possible.

1. Fascial Space Infections– Infections associated with Mandibular teeth

• Submandibular• Sublingual • Submental• Pterygomandibular• Submasseteric

Submental

- Infections from mandibular incisors erode through

lingual plate apical to mentalis muscle

- Isolated submental space infections uncommon,

usually caused by spread of submandibular space

infection.

- Discrete swelling noted in central submandibular

region

- I&D: Extraoral transverse incison.

Space Sub-mental

Ant. Border

Inf border of md.

Post. Border

Hyoid

Sup. Border

Mylohyoid

Inf. Border

Inv. fascia

Medial/ Deep

Inv fascia


Ant bellies digastric

Likely causes

Md inc, symphysis frxr

Contents Ant. Jug v, lymph nodes

Neigh-boring spaces

Submandibular

Approach for I&D

Extraoral

Space Submandibular

Ant. Border

Ant belly digastric,

Post. Border

Post belly digastric, stylohy, stylophar.

Sup. Border

Inf/Med mandible

Inf. Border

Digastric tendon

Medial/ Deep

Mylohyoid, hyoglossus, sup const mm


Platysma

Likely causes

Md molars

Contents Submand gl, facial a/v, lymph nodes

Neigh-boring spaces

Subling, Subment, Buccal, Lat phary

Approach for I&D

Extraoral

Submandibular - Can be progress rapidly into deeper spaces. - May cause elevation, swelling, induration and displacement of the tongue. - Extraoral swelling usually obvious, inferior border of mandible not visible. - Associated with trismus, drooling, dysphagia, dyspnea. - I&D: extraoral incision parallel to inferior border 1-2 cm below to avoid structures.

Space Sub-lingual

Ant. Border

Lingual mandible

Post. Border

Submand space

Sup. Border

Oral mucosa

Inf. Border

Mylohyoid

Medial/ Superfical

Tongue muscles

Lateral/ Deep

Lingual mandible

Likely causes

Md bicusp Md molar direct trauma

Contents Sublng gl, whartons lingual n. sublng a/v

Neigh-boring spaces

Submand, Lat phar, Viscera

Approach for I&D

Intra/Extr

Sublingual

- Intraoral swelling leads to tongue elevation.- Extraoral swellings uncommon- Progressively becomes bilateral- Posterior border of space communicates with

submandibular space leading to larger infections- I&D: anterior/posterior incision near lingual cortex

avoiding Wharton’s, Lingual a/n

Ludwig’s Angina

- Bilateral cellulitis of Submaxillary space (comprised of submental, sublingual and submandibular spaces).

- May cause respiratory distress and airway obstruction, often times rapidly from epiglottis edema.

- Severe swelling, tongue elevation and board like induration noted.

- May cause severe anxiety, furthering respiratory distress.

Space Pterygo-mandibular

Ant. Border

Buccal space

Post. Border

Parotid gland

Sup. Border

Lateral pteryg m.

Inf. Border

Inf border mandible

Medial/ Deep

Medial Pterygoid


Asc ramus mandible

Likely causes

Md 3rds, Md angle frxr

Contents V3, Inf alv. a/v

Neigh-boring spaces

Buccal, Lat phar, Masseteric, Temp.

Approach for I&D

Intraoral Intra/Extr

Pterygomandibular

- Site of inferior alveolar nerve block. May be caused by needle tract infection.- Little or no facial swelling is involved- Intraoral swelling seen on anterior tonsillar pillar on affected side + deviation of uvula contralaterally- Significant trismus usually noticed- I&D: Intraoral vertical incision lateral to raphe, disect along

medial surface of ramus. Beware lingual nerve.

Space Sub-masse-teric

Ant. Border

Buccal space

Post. Border

Parotid gland

Sup. Border

Zygomatic arch

Inf. Border

Inf border mandible

Medial/ Deep

Asc ramus mandible


Masseter

Likely causes

Md 3rds Md angle frxr

Contents Masseteric a/v

Neigh-boring spaces

Buccal Pterygomandular, Temporal

Approach for I&D


(Sub)Masseteric

- Commonly results from spread of buccal space infection or pericoronitis of mandibular third molars.

- Moderate to severe trismus due to inflammation of masseter muscle

- Mandibular angle fracture may cause infection- CT/MRI often helpful in identification- Submassetric + Pterygomanidbular + Temporal

Spaces = Masticator Space- I&D: Extraoral posterior to mandibular angle

1. Fascial Space Infections– Infections associated with deep fascial spaces of

the neck• Lateral pharyngeal• Retropharyngeal• Danger

Space Lateral Phar-yngeal

Ant. Border

Pterygomand raphe

Post. Border

Carotid sh., scalene fascia, parotid

Sup. Border

Skull base

Inf. Border

Hyoid bone

Medial/ Deep

Phary Const, retrophar space


Medial pterygoid,

Likely causes

Md 3rds, tonsillar infxn

Contents Carotid a, Int Jug v, Vagus n, Cervical SNS chain

Neigh-boring spaces

Pterygom Submand Sublingual Retrophar

Approach for I&D

Intra Intra/Extr

Lateral Pharyngeal Space

- Pterygomandibular, submandibular or sublingual space infections may spread first into this space.

- Primary clinical findings include trismus, dysphagia and fever.

- Lateral swelling of the neck usually seen between angle of mandible and sternocleidomastoid.

- Complications include internal jugular thrombosis, erosion of carotid artery and compression of CN IX,X,XII.

Space Lateral Phar-yngeal

Ant. Border

Sup/Mid Constrictor mm.

Post. Border

Carotid sheath, scalene fascia

Sup. Border

Skull base

Inf. Border

Hyoid bone

Medial/ Deep



Medial pterygoid

Likely causes


Contents Carotid a Int Jug v Vagus n Cerv SNS chain

Neigh-boring spaces


Approach for I&D

Intra Intra/Extr

Lateral Pharyngeal I&D

- Intraorally, vertical incision medial to raphe, dissect along medial side of medial pterygoid m. - Intraoral drainage is risky

- Extraorally, incise anterior and inferior to the angle of the mandible, dissect superiorly and medially along the deep surface of the medial pterygoid m.

- Also extraorally anterior to SCM

Space Retropharyngeal

Ant. Border


Post. Border

Alar fascia

Sup. Border

Skull base

Inf. Border

Alar/pre-vert fascia near C6-T4

Medial/ Deep

Midline


Carotid sheat, lateral pharyng sp.

Likely causes

Spread from primary space

Contents Potential space

Neigh-boring spaces

Lateral pharyngeal, danger space

Approach for I&D

Retropharyngeal Space

- Essentially a potential space between prevertebral (posterior) and viseral (anterior) fascial compontents.

- Infections may track down through superior mediastinum space causing mediastinitis.

Mediastinitis can lead to compression of the heart and lungs, interfere with

neurologic control of heart and lungs via CN X compression, spread to lungs,

trachea and abdominal cavity.

Danger Space (Space 4): Immediately posterior to retropharyngeal space

separated by thin Alar fascia. Infections from Danger space may track inferiorly

into posterior mediastinum.

Space Retropharyngeal

Ant. Border


Post. Border

Alar fascia

Sup. Border

Skull base

Inf. Border

Alar/pre-vert fascia near C6-T4

Medial/ Deep

Midline



Likely causes


Contents Potential space

Neigh-boring spaces

Lateral pharyngeal, danger space

Approach for I&D

Retropharyngeal Incision & Drainage

• Intraorally through vertical incision in the mucosa of the pharyngeal wall lateral to midline (+/- through lat pharyngeal), caution with pus aspiration

• Extraorally with incision parallel to SCM along ant border, below hyoid. Retract carotid sheath, finger dissection

Space Buccal Infra-orbital

Infratemporal/ Deep Temporal

Sub-mental

Submandibular

Sub-lingual

Pterygo-mandibular

Sub-masse-teric

Lateral Phar-yngeal

Retropharyngeal

Pre tracheal

Ant. Border

Corner of mouth

Nasal cartillage

Maxilla Inf border of md.

Ant belly digastric,

Lingual mandible

Buccal space

Buccal space



Sterno-thyroid fascia

Post. Border

Masseter, pterygo-mand sp.

Buccal space

Middle Cranial Fossa

Hyoid Post belly digastric, stylohy, stylophar.

Submand space

Parotid gland

Parotid gland

Carotid sheath, scalene fascia

Alar fascia Retrophar space

Sup. Border

Maxilla, infraorb

Quad. Labii sup.

Base of skull Mylohyoid Inf/Med mandible

Oral mucosa

Lateral pteryg m.

Zygomatic arch

Skull base Skull base Thyroid cartillage

Inf. Border

Mandible, skin

Oral mucosa

Lateral pterygoid

Inv. fascia Digastric tendon

Mylohyoid Inf border mandible

Inf border mandible

Hyoid bone Alar/pre-vert fascia

Superior media-stinum

Medial/ Deep

Subcut- aneous

Quad labii sup.

Lateral pterygoidplate

Inv fascia Mylohyoid, hyoglossus, sup const mm

Tongue muscles

Medial Pterygoid

Asc ramus mandible


Midline Sterno-thyroid fascia


Buccinat. Lev ang oris, maxilla

Continuous with deep temporal space

Ant bellies digastric

Platysma Lingual mandible

Asc ramus mandible

Masseter Medial pterygoid


Viseral fascia

Likely causes

Mx can. Mx molar Md can.

Mx cuspid Mx molars Md inc, symphysis frxr

Md molars Md bicusp Md molar direct trauma

Md 3rds, Md angle frxr

Md 3rds Md angle frxr



Spread form primary or retropharyngeal space

Contents Parotid d. Ant. Fac a/v, trans fac a/v, buccal fat

Angular a/v, infraorbial n

Pterygoid plx, mx a/v, V3

Ant. Jug v, lymph nodes

Submand gl, facial a/v, lymph nodes

Sublng gl, whartons lingual n. sublng a/v

V3, Inf alv. a/v

Masseteric a/v

Carotid a Int Jug v Vagus n Cerv SNS chain

Potential space

Potential space

Neigh-boring spaces

Infraorb, Pterygom, Infratemp

Buccal Buccal Sup.Temp Inf. Petr sinus

Submandibular

Subling, Subment, Buccal, Lat phary

Submand, Lat phar, Viscera

Buccal, Lat phar, Masseteric, Temp.

Buccal Pterygomandular, Temporal


Lateral pharyngeal

Retropharyngeal

Approach for I&D

Intra (sm) Extra (lg)

Intraoral Intraoral Extraoral

Extraoral Extraoral Intra/Extr Intraoral Intra/Extr


Intra Intra/Extr

Intra/Extra Intra/Extra

Today’s Outline

1. General Information 2. Fascial Space Infections



1) Determine Severity

2) Host Defenses

4) Treat Surgically

5) Medical Support

3) Setting of Care

7) Complete Follow Up

6) Antibiotic Regimen

Management of Fascial Space Infections

1Determine Severity of Infection

• History of present illness very important• Location

• Thorough clinical examination important• Rate of progression

• Onset of symptoms compared to current signs and symptoms.

• Potential for airway compromise• Evaluate for stridor/coarse airway sounds, posture (chin

elevation, forward lean)

2Evaluate Host Defenses

- Diabetes, steroid therapy, organ transplants, malignancy, chemotherapy, chronic renal disease, malnutrition, alcoholism, end stage AIDS.

- Febrile patients at risk for dehydration which may lead to increased cardiovascular and respiratory demands.

3Choose Setting of Care

- General Indications for hospital admission- Temperature elevation > 101F- Dehydration- Airway obstruction threat (moderate/high severity spaces)- Need for general anesthesia

- Inability to achieve adequate local anesthesia- Secure airway

4Treat Surgically

- Good communication with anesthesia team for airway management

- Early surgical intervention advocated- Consider needle decompression to reduce risk of abscess rupture

into airway (especially pterygomandibular, lateral pharyngeal, submandibular, sublingual). - Small incisions and blunt dissection- never close beaks in

wound- Make use of CT scans- Finger as a dissection tool- Culture & Sensitivity testing

- Communication with lab essential

Extraoral Sites for I&D of Deep Space Infections

Extraoral Sites for I&D of Deep Space Infections

A) Temporal

B) Submental Submandibular

C) Submandibular Masseteric

D) Lateral Pharyngeal Retropharyngeal

E) Retropharyngeal

5Support Medically

- Goal is to return patient to homeostasis- Fluid balance/electrolyte balance- Nutrition- Increased metabolic demands- Fever control- studies show initial temperature at

presentation correlated to length of hospital stay- Hydration - Ambulation- Utility of labs- WBC, Prealbumin, CRP

6Choose and Prescribe Antibiotic Properly

InpatientAmpicillin + sulbactamAmpicillin + metronidazoleClindamycinThird Generation Cephalosporin Moxifloxacin/Levofloxacin

OutpatientPCN, Amoxicillin, Augmentin - + 80% effectiveness Clindamycin- rapidly rising resistance Azithromycin Moxifloxacin- > 18 year old

7Evaluate the Patient Frequently

- Outpatient- Evaluate 2 days post op - May remove drain if symptoms improving

- Inpatient- Daily wound care, irrigation- Culture & Sensitivity - Ideal improvement within 48-72 hours

Treatment Failure

- Inadequate Surgery - Depressed host defenses - Foreign body - Antibiotic problems

Thank you for your attention

References

• Ghali, GE, Larsen PE, Waite, DP. Peterson’s Principles of Oral and Maxillofacial Surgery, 2nd Edition. BC Decker

• Hupp, James R.. Contemporary Oral and Maxillofacial Surgery, 5th Edition. Mosby, 032008.

• Langlais, Robert P.. Color Atlas of Common Oral Diseases, 3rd Edition. Lippincott Williams & Wilkins, 012003.

• Neville, Brad W.. Color Atlas of Clinical Oral Pathology, 2nd Edition. Williams & Wilkins, 011999

• Liebgott, Bernard. The Anatomical Basis of Dentistry, 2nd Edition. Mosby, 012001. 5.2.1.3

DMART Space Infections 08.06.14

Documents

Transcript of DMART Space Infections 08.06.14