SPREAD OF ORAL INFECTIONS IN FASCIAL SPACES

BHARATHREDDY

THE CONCEPT OF FASCIAL SPACES IS BASED ON ANATOMISTS KNOWLEDGE THAT ALL SPACES EXIST POTENTIALLY, UNTIL FASCIAE ARE SEPARATED BY PUS, BLOOD, DRAINS OR SURGEONS FINGER.

WHEN DENTAL INFECTIONS SPREAD DEEPLY INTO SOFT TISSUE RATHER THAN EXITING THROUGH ORAL OR CUTANEOUS ROUTES,FASCIAL SPACES MAY BECOME INVOLVED FOLLOWING PATH OF LEAST RESISTANCE.

Classification of facial spaces

According to topazian

ON FACE:

BUCCAL CANINE MASTICATOR MASSETER PTERYGOID ZYGOMATICO TEMPORAL

SUPRAHYOID:
SUBLINGUAL SUBMANDIBULAR SUBMAXILLARY SUBMENTAL PHARYNGOMAXILLARY PERITONSILLAR

INFRAHYOID:
ANTEROVISCERAL (PRETACHEAL)

SPACES OF TOTAL NECK:

RETROPHARYNGEAL DANGER SPACE SPACE OF CAROTID SHEATH

FASCIAL LAYER

SUPERFICIAL LAYER

DEEP LAYER

SUPERFICIAL OR ANTERIOR LAYER MIDDLE LAYER POSTERIOR LAYER

THESE DEVIDE, UNITE, BLEND AND FUSE TO FORM VARIOUS COMPARTMENTS OR SPACES

Previsceral fascia( sagittal section)

BUCCAL SPACE
BOUNDRIES
SUPERIORLY INFERIORLY ANTERIORLY POSTERIORLY MEDIALLY LATERALLY ZYGOMATIC ARCH LOWER BORDER OF MANDIBLE MODIOLUS OF MOUTH PTERYGOMANDIBULAR RAPHE BUCCINATOR MUSCLE AND BUCCOPHARYNGEAL FASCIA : SKIN OF CHEEK : : : : :

BUCCAL SPACE ABSCESS

CONTENTS

STENSENS DUCT MAXILLARY ARTERY BUCCAL FAT PAD

SOURCE OF INFECTION
MAXILLARY AND MANDIBULAR MOLAR REGION OR EVEN BICUSPID

IF CONFINED TO BUCCINATOR: INFECTION DRAINS INTRA ORALLY IN BUCCAL VESTIBULE CROSSES BUCCINATOR: INFECTION DRAIN DEEP INTO BUCCAL SPACE AND EXTRA ORAL DRAINAGE

CANINE SPACE
INFREQUENTLY INVOLVED IN ODONTOGENIC INFECTIONS

LEVATOR ANGULI ORIS OVERLIES THE APEX OF CUSPID ROOT . ORIGIN OF THE MUSCLE IS HIGH IN CANINE FOSSA WHEREAS ITS INSERTION IS THE ANGLE OF MOUTH AND ZYGOMATIC MUSCLE. IF CUSPID INFECTION PERFORATES THE LATERAL CORTEX OF MAXILLARY BONE SUPERIOR TO INSERTION OF MUSCLE POTENTIAL CANINE SPACE BECOME INVOLVED

MASTICATOR SPACES
CONSIST OF MESSETERIC PTERYGOID TEMPORAL THESE ARE WELL DIFFERENTIATED BUT COMMUNICATE WITH EACH OTHER AND WITH BUCCAL, SUBMANDIBULAR AND PARAPHARYNGEAL SPACES

SORCE OF INFECTION
THIRD MOLAR (PERICORONITIS, DENTAL CARIES INDUCED ABSCESS ETC)
INFECTION OF MAXILLARY CANINE USUALLY PRESENT AS LABIAL SULCUS SWELLING AND LESS COMMONLY AS PALATAL SWELLING

ALSO BY CONTAMINATED MANDIBULAR BLOCK INJECTIONS OR DIRECT TRAUMA HERE, CLINICALLY THE HALLMARK OF INFECTION IS TRISMUS

SUBLINGUAL SPACE
BILATERAL V SHAPED SPACE

BOUNDRIES:
SUPERIORLY : SUBLINGUAL MUCOUS MEMBRANE INFERIORLY : MYLOHYOID MUSCLE POSTERIORLY : HYOID BONE ANTERIORLY : LINGUAL SURFACE OF MANDIBLE LATERALLY : LINGUAL SURFACE OF MANDIBLE MEDIALLY : GENIOGLOSSUS, GENIOHYOID,

COMMUNICATIONS
ANTERIORLY SPACE : SUBMENTAL

POSTERIORLY : SUBMANDIBULAR SPACE

SOURCE OF INFECTION
PREMOLARS PERIODONTAL INFECTION OF INCISORS LINGUAL INJECTIONS INFECTION OF WHARTSONS DUCT SIALIDINITIS

MPORTANT CLINICAL FEATURES

RAISED TONGUE WHITE DISCOLORATION OF FLOOR OF MOUTH BRAWNY ERYTHEMATOUS TENDER SWELLING OF FLOOR OF MAOUTH OPEN MOUTH DRIBBLING OF SALIVA WHITE COLLAR APPEARANCE DYSPHAGIA DYSPNOEA OTHER FEATURES OF TOXEMIA

NO EXTRA ORAL DRAINAGE, ONLY INTRA ORAL DRAINAGE D/D: CELLULITIS WITH INFECTED SIALOLITH

SUBMANDIBULAR SPACE
SEPARATED FROM OVERLYING SUBLINGUAL SPACE BY MYLOHYOID MUSCLE

BOUNDRIES
LATERALLY : SUBMANDIBULAR SKIN,SUPERFICIAL FASCIA,PLATYSMA, LOWER BORDER OF MANDIBLE : MYLOHYOID, HYPOGLOSSUS. STYLOGLOSSUS INFERIORLY OF : ANTERIOR AND POSTERIOR BELLY DIGASTRIC

MEDIALLY

SUBMANDIBULAR SPACE INFECTION

CONTENTS
SUBMANDIBULAR SALIVARY GLAND AND LYMPH NODES FACIAL ARTERY WHARTSONS DUCT

LINGUAL NERVE
HYPOGLOSSAL NERVE

SOURCE OF INFECTION
MANDIBULAR SECOND AND THIRD MOLAR SOMETIMES EVEN FIRST MOLAR SECONDARY TO ADJOINING SPACESSUBLINGUAL OR SUBMENTAL
D/D: ACUTE SIALADENITIS SUBMANDIBULAR LYMPHADENITIS

SUBMENTAL SPACE
BOUNDRIES
SUPERIORLY BORDER OF INFERIORLY MUSCLE : INFERIOR MANDIBLE : MYLOHYOID

POSTERIORLY : MYLOHYOID MUSCLE LATERALLY : ANTERIOR BELLY

SOURCE OF INFECTION
MANDIBULAR INCISORS OR FROM SUBMANDIBULAR SPACE

Presentation
The patient presents with a swollen face and occasionally swollen neck. Toothache or facial pain may or may not be a feature. There is often general malaise and possibly rigors with fever. Patients may complain of trismus (inability to open the mouth fully), pain or difficulty in swallowing, drooling, sore throat and a hoarse voice.

Examination
Specific attention should be paid to the location of swelling, size, flactuance, any possible pointing and coexistent lymph node enlargement.

Good oral examination should include

presence of halitosis, evidence of intraoral pus draining any tongue elevation, any sublingual or submandibular swelling, swelling in the mandibular or maxillary sulci, palatal swelling especially of the soft palate or uvula, general dental state patency of salivary outlets (parotid, submandibular and sublingual), nature of saliva produced (clear, thick, pus?).

Suspect teeth should be tapped with a metallic object to elicit any tenderness to percussion. Swelling should be palpated bimanually if possible with a finger of one hand intraorally and and the second hand extraorally (pushing towards the oral site). The neck should be evaluated for swelling, lymphadenopathy and possible tracheal deviation.

Teeth can contribute by:

Aetiology of major facial infections

Potential route of spread of pulpal infection

(1) Decay (caries) reaching the dental pulp=pulpitis, this in turn spreads to supporting bone resulting in (2) periapical abscess which in turn may spread subperiosteally. (2) Periapical abscess may occur in seemingly intact but devitalised teeth (trauma, cracks or decay under fillings). (3) Periapical and periodontal abscess may form as a result of chronic gingivitis and supporting bone and soft tissue loss (periodontal disease) - note again the tooth may be entirely intact clinically and radiographically.

(4) Erupting teeth (especially partially impacted lower third molars) can result in inflammation and infection of the gum flap preventing eruption (operculum) with swelling pus etc. around the crown (pericoronitis). (5) Retained roots supragingival or subgingival.

JAWS
(1)Can develop cysts or tumours that can range from odontogenic (=dental origin) to either primary or secondary malignancy. Most are derived from the dental apparatus and although benign can nevertheless continuously grow and become secondarily infected on breaching the surrounding bone. (2)Osteomyelitis although rare can be the result of chronic infection as mentioned before. (3) Osteoradionecrosis occurs readily in irradiated jaws subjected to further trauma (such as extractions).

(4) Rarer are tuberculosis, Actinomycosis and syphilitic osteomyelitis. (5) Most jaw fractures in the tooth bearing segments are by definition compound to the oral cavity and can easily be infected by the oral microbes. (6) Extraction sites again are comparable to compound fractures and it is surprising that infection is so relatively rare.

Major salivary glands

(1) May be the subject of either viral or bacterial infections often superimposed on obstruction of ducts (stone, stricture, etc). (2) Tumours rarely also become secondarily infected.

Paranasal sinuses
(1)May be primarily infected, obstruct and result in facial swelling. (2)May become infected secondary to infected teeth protruding into the maxillary sinus (upper premolar and molar teeth often do). (3)Tumours or cysts may become infected. (4)Fractures such as the orbital floor are by definition compound to the outside and may result in orbital

Investigations
In many cases careful history and examination will make diagnosis clear, however certain investigation will still be necessary.

Plain X rays
(1)The OPG (orthopantomogram) is invaluable in displaying the teeth, whole of mandible, tooth bearing segment of the maxilla as well as parts of the maxillary sinuses. Use for any suspected fractures of the mandible, periapical abscesses and bony cysts and tumours. Will show impacted third molars ('wisdom teeth'). (2)Occipito-mental 15 and 30 degrees (Waters view) will show both maxillary sinuses (effusion?), orbital floor and most fractures of the maxilla.

(3) Mandibular occlusal views and lateral oblique views may demonstrate stones in the submandibular gland. (4) 'Puffed cheek' view may demonstrate stones in the parotid duct.
Sialography:
Can be used for suspected gland obstruction however CT sialogram is the gold standard.

Ultrasound
Useful in confirming collections as well as a guide to aspiration. Will also show stones in salivary ducts and glands.

CT scan
With axial and coronal views will demonstrate exact extent of the swelling, potential airway compromise and is invaluable to both the surgeon and anaesthetist. However patients unwell enough to potentially obstruct their airway should be taken straight to theatre rather than risk an emergency in the radiology dept.

Microbiology of any pus or discharge. The usual blood tests.

INFRATEMPORAL AND MASTICATOR SPACE SUPERIORLY

BUCCALY MESSETRIC SPACE POTENTIAL SPREAD OF INFECTION FROM LOWER THIRD MOLAR

POSTERO INFERIORLY PTERYGOMANDIBULAR SPACE

ANTERIORLY,BUCCALY BUCCAL SPACE

INFERIORLY SUBMANDIBULAR SPACE LUDWIGS ANGINA

PTERYGOMANDIBULAR SPACE

PTERYGOID SPLEXUS EMISSERY VEINS CAVERNOUS SINUS THROMBOSIS

LATERAL PHARYNGEAL SPACE RETROPHARYNGEAL SPACE MEDIASTINUM CAROTID SHEATH DANGER SPACE 4

NOTE : DANGER SPACE 4 IS THE SPACE BETWEEN PREVERTIBRAL AND ALAR FASCIA

EVOLUTIVE STAGES OF ODONTOGENIC INFECTION

AN INITIAL PERIOD OF PERIAPICAL CONTAMINATION BY BACTERIA GENERALLY ORIGINATING FROM ROOT CANAL CLINICAL PERIOD WITH SIGNS AND SYMPTOMS ACUTE APICAL PERIODONTITIS, DEVELOMENT OF A PERIAPICAL ABSCESS PERIOSTEUM RUPTURES AND INFECTION GAINS ECCESSTO SURROUNDING SOFT TISSUES PRODUCING CELLULITIS ( PHLEGMON ) FINAL RESOLUTION PERIOD AND GENERATION OF REPAIR TISSUE.

CELLULITIS(PHLEGMON)
TYPES 1. SEROUS CIRCUMSCRIBED ACUTE CELLULITIS AFFECTING SINGLE
ANATOMIC SPACE

2. SUPPURATIVE CIRCUMSCRIBED ACUTE CELLULITIS WITH PLURULENT

SUPPURATION

3. DIFFUSE ACUTE CELLULITIS

LUDWIIGS ANGINA PERIPHARYNGEAL CELLULITIS NECROTIZING FASCIITIS

4. CHRONIC CELLULITIS

CLINICAL MANIFESTATIONS
SHARP PULSATILE PAIN REDENING AND WARMTH OF SKIN AND MUCOSA POORLY DELIMITED SWELLING THAT ERASES THE SKIN FOLDS AND SULCI LOSS OF FUNCTION FEVER

LUDWIGS ANGINA
FIRST DESCRIPTION IN 1836 BY DR.VON LUDWIG ANGINA: CHOAKING SENSATION DEFINITION ARCHER: ITS A BILATERAL,ACUTE,RAPIDLY SPREADING, SEPTIC,INFLAMMATORY,INDURATED ,WOODEN HARD CELLULITIS OF FLOOR OF MOUTH

 THOMA: ITS A GANGRENOUS CELLULITIS OF LOOSE ALVEOLAR TISSUE WHICH ORIGINATES IN SUBMANDIBULAR SPACE AND SPREADS RAPIDLY TOWARDS FLOOR OF MOUTH KILLEY-KEY-SEWARD: ITS A CLINICAL DIAGNOSIS AND IS THE NAME GIVEN TO BRAWNY CELLULITIS OCCURING BILATERALLY AT SUBMANDIBULAR REGION WHICH ALSO INVOLVE SUBLINGUAL SPACE

SPREAD OF INFECTION
ACCORDING TO KRUGER,TOPAZIAN,LUDWIG THIRD MOLARS SUBMANDIBULAR SPACE SUBLINGUAL

CONTRALATERAL SUBMANDIBULAR AND SUBMENTAL SPACE INVOLVEMENT LASKIN SUBLINGUAL SPACE SPREADS BILATERALLY SUBMANDIBULAR AND SUBMENTAL SPACE

BACKWARD SPREAD TO SUBSTANCE OF TONGUE INFECTION REACHES EPIGLOTTIS SWELLING AROUND LARYNGEAL INLET MICROORGANISM INVOLVED ARE MOJORITILY STREPTOCOCCUS HEMOLYTICUS

ETIOLOGY PERODONTAL, PERICORONAL OR PERIAPICAL ABSCESS OF MANDIBULAR MOLARS NON ODONTOGENIC CAUSES (PSEUDO LUDWIG) COMPOUND FRACTURE OF MANDIBLE NEEDLE INJURY TO FLOOR OF MOUTH FISH BONE INJURY SIALIDINITIS

LUDWIGS ANGINA

SIGNS AND SYMPTOMS

MASSIVE,FIRM,HARD BOARD LIKE,BRAWNY NON PITTING SWELLING OF NECK EXTENDING DOWN TO CLAVICLE OPEN MOUTH DRIBBLING OF SALIVA RAISED FLOOR OF MAOTH SHINY MUCOSA WHITE COLLAR APPEARANCE STIFF TONGUE TOUCHING PALATE DYSPHAGIA, DYSPNOEA EDEMA OF GLOTTIS

 AIRWAY OBSTRUCTION OTHER FEATURES OF TOXEMIA

SEQUELE
IT CAN CAUSE MEDIASTINITIS LEADING TO ASPIRATION PNEUMONIA AND DEATH DUE TO RESPIRATORY PARALYSIS IT CAN INVOLVE PTERYGOID COMPARTMENT AND VIA PTERYGOID PLEXUS CAN CAUSE CAVERNUS SINUS THROMBOSIS IT CAN CAUSE SEPTICEMIA OR BACTEREMIA BECAUSE OF HEMATOLOGICAL SPREAD

GENERAL MANAGEMENT

 PROPER HISTORY TAKING AND EXAMINATION AND INVESTIGATIONS ANTIBIOTIC ANALGESIC THERAPY ANTIINFLAMMATORY DRUGS FLUID BALANCE AND AIRWAY ESTABLISHMENT WHERE REQUIRED REMOVAL OF FOCUS OF INFECTION ESTABLISHMENT OF DRAINAGE ADEQUATE MEDICAL CONSULTATION AND REFFERAL

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