Professional Documents
Culture Documents
Overview
Introduction.
Microbiology
Aetiology
Assessment
Investigations
Spread of infection
Fascial spaces
Treatment
Conclusion
Introduction
Introduction
Severe
Rapidly progressive
Prolonged morbidity
Long term complications
Potentially endanger life.
Introduction
Accurate diagnosis
Early aggressive medical
treatment
And in most cases urgent
decisive surgical management.
Introduction
GP
Dental surgeon
Radiologist
Oral and maxillo-facial surgeon / Plastic surgeon
ENT surgeon
Anaesthetist
Infectious diseases specialist
Intensivist.
Ophthalmology
Neurosurgery
Mycrobiology
Most originate in :
The jaws
Teeth
Surrounding periodontal soft
tissues
Paranasal sinuses
Major salivary glands
The jaws:
(1) Can develop cysts or tumours
(2) Osteomyelitis
(3) Osteoradionecrosis occurs readily in irradiated
jaws.
(4) Rarer are tuberculosis, actinomycosis and
syphilitic osteomyelitis.
(5) Fractures / Extraction sites
Paranasal sinuses
(1) Primarily infected, obstruct
(2) Infected secondary to infected teeth protruding
into the maxillary sinus (upper premolar and molar teeth often
do).
(3) Tumours or cysts
(4) Fractures such as the orbital floor are by definition
compound to the outside and may result in orbital cellulitis.
Assessment
History
Presentation:
Onset
Duration
Rapidity
Previous treatment
Medically compromised
Physical exam
Assessment
History
Assessment
Presentation
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
Pain or difficulty in swallowing.
Drooling.
Sore throat
Boarse voice.
Assessment
Presentation
Assessment
Physical Examination
Vital Signs
Temperature- systemic
involvement >101 F
Blood Pressure- mild elevation
Pulse- >100
Increased Respiratory Ratenormal 14-16
Assessment
Physical Examination
General appearance
Palpate the area of
swelling:
-Location of swelling,
-Size
-Fluctuance
-Pointing
-Lymph node
enlargement.
Intra-oral exam
Assessment
Physical Examination
Good oral examination should include:
Halitosis
Intraoral pus draining and where, 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?).
Assessment
Physical Examination
Investigations
Plain X rays
Ultrasound
CT scan
MRI
Investigations
Plain X rays:
The OPG
(orthopantomogram)
Displaying the teeth
Whole of mandible
Tooth bearing segment of the
maxilla
Parts of the maxillary
sinuses.
Suspected fractures of the
mandible
Periapical abscesses
Bony cysts and tumours
Impacted third molars
('wisdom teeth').
Investigations
Plain X rays:
Occipito-mental 15 and 30 degrees
(Waters view)
Both maxillary sinuses (effusion?)
Orbital floor and most fractures of the maxilla.
Investigations
Plain X rays:
gland.
Sialography:
Can be used for suspected gland
obstruction however CT sialogram is the
gold standard
Investigations
Ultrasound:
Confirming collections
Guide to aspiration.
Stones in salivary ducts and glands.
Investigations
CT scan:
Investigations
MRI
Advantages
Better soft tissue detail
Imaging in multiple planes
No artifact by dental fillings
Disadvantages
Increased cost
Increased exam time
Dependent on patient
cooperation
Availability
Spread of Infections
Spread of Infections
Spread of Infections
Spread of Infections
Orbital floor can be perforated by pus from the sinus
Spread of Infections
Parotid gland
mandible
Parotid space
Masseteric space
Spread of Infections
Spread of Infections
Mandibular Infections
Potential pathways of
spread
Sublingual space
Submental space
Submandibular space
Masticator space
Lateral pharyngeal space
Retropharyngeal space
Spread of Infections
Maxillary Infections
Potential pathways of
extension
Canine space
Buccal space
Temporal space
Infratemporal space
Spread of Infections
Space infections
MASTICATOR
Masseteric and
pterygoid
Usual site of
origen
Clinical features
pain
trismus
Swelling
Dysphagia
Dyspnea
Molars (especially +
3rd)
+++
May not be
evident (deep)
Temporal
Post. Maxillary
molars
Face, orbit
( late)
BUCCAL
Bicuspids, molars
CANINE
Maxillary canines, ++
incisors
Cheek
(market)
Upper lip, canine fosa
INFRATEMPORAL
Post. Maxillary
molars
Face, orbit
( late)
SUBMENTAL
PAROTID
SUBMANDIBULAR
Mandibular
incisors
Masseteric
spaces
2nd, 3rd
mandibular
molars
++
+++
Chin
( firm)
Angle of jaw
(marked)
Submandibular ( brawny)
SUBLINGUAL
Spread of Infections
Masticator Space Infection
Masseteric,
Pterygomandibular
Temporal spaces
Spread of Infections
Masticator Space Infection
Masseteric,
Pterygomandibular
Temporal spaces
Spread of Infections
Temporal Space Infection
Spread of Infections
Space infections
MASTICATOR
Masseteric and
pterygoid
Usual site of
origen
Clinical features
pain
trismus
Swelling
Dysphagia
Dyspnea
Molars (especially +
3rd)
+++
May not be
evident (deep)
Temporal
Post. Maxillary
molars
Face, orbit
( late)
BUCCAL
Bicuspids, molars
CANINE
Maxillary canines, ++
incisors
Cheek
(market)
Upper lip, canine fosa
INFRATEMPORAL
Post. Maxillary
molars
Face, orbit
( late)
SUBMENTAL
PAROTID
SUBMANDIBULAR
Mandibular
incisors
Masseteric
spaces
2nd, 3rd
mandibular
molars
++
+++
Chin
( firm)
Angle of jaw
(marked)
Submandibular ( brawny)
SUBLINGUAL
Spread of Infections
Buccal Space Infection
Spread of Infections
Space infections
MASTICATOR
Masseteric and
pterygoid
Usual site of
origen
Clinical features
pain
trismus
Swelling
Dysphagia
Dyspnea
Molars (especially +
3rd)
+++
May not be
evident (deep)
Temporal
Post. Maxillary
molars
Face, orbit
( late)
BUCCAL
Bicuspids, molars
CANINE
Maxillary canines, ++
incisors
Cheek
(market)
Upper lip, canine fosa
INFRATEMPORAL
Post. Maxillary
molars
Face, orbit
( late)
SUBMENTAL
PAROTID
SUBMANDIBULAR
Mandibular
incisors
Masseteric
spaces
2nd, 3rd
mandibular
molars
++
+++
Chin
( firm)
Angle of jaw
(marked)
Submandibular ( brawny)
SUBLINGUAL
Spread of Infections
Canine Space Infection
Spread of Infections
Space infections
MASTICATOR
Masseteric and
pterygoid
Usual site of
origen
Clinical features
pain
trismus
Swelling
Dysphagia
Dyspnea
Molars (especially +
3rd)
+++
May not be
evident (deep)
Temporal
Post. Maxillary
molars
Face, orbit
( late)
BUCCAL
Bicuspids, molars
CANINE
Maxillary canines, ++
incisors
Cheek
(market)
Upper lip, canine fosa
INFRATEMPORAL
Post. Maxillary
molars
Face, orbit
( late)
SUBMENTAL
PAROTID
SUBMANDIBULAR
Mandibular
incisors
Masseteric
spaces
2nd, 3rd
mandibular
molars
++
+++
Chin
( firm)
Angle of jaw
(marked)
Submandibular ( brawny)
SUBLINGUAL
Spread of Infections
Temporal Space Infection
Spread of Infections
Space infections
MASTICATOR
Masseteric and
pterygoid
Usual site of
origen
Clinical features
pain
trismus
Swelling
Dysphagia
Dyspnea
Molars (especially +
3rd)
+++
May not be
evident (deep)
Temporal
Post. Maxillary
molars
Face, orbit
( late)
BUCCAL
bicuspids, molars
CANINE
Maxillary canines, ++
incisors
Cheek
(market)
Upper lip, canine fosa
INFRATEMPORAL
Post. Maxillary
molars
Face, orbit
( late)
SUBMENTAL
PAROTID
SUBMANDIBULAR
Mandibular
incisors
Masseteric
spaces
2nd, 3rd
mandibular
molars
++
+++
Chin
( firm)
Angle of jaw
(marked)
Submandibular ( brawny)
SUBLINGUAL
Spread of Infections
Submental Space Infection
Spread of Infections
Submental Space Infection
Spread of Infections
Space infections
MASTICATOR
Masseteric and
pterygoid
Usual site of
origen
Clinical features
pain
trismus
Swelling
Dysphagia
Dyspnea
Molars (especially +
3rd)
+++
May not be
evident (deep)
Temporal
Post. Maxillary
molars
Face, orbit
( late)
BUCCAL
bicuspids, molars
CANINE
Maxillary canines, ++
incisors
Cheek
(market)
Upper lip, canine fosa
INFRATEMPORAL
Post. Maxillary
molars
Face, orbit
( late)
SUBMENTAL
PAROTID
SUBMANDIBULAR
Mandibular
incisors
Masseteric
spaces
2nd, 3rd
mandibular
molars
++
+++
Chin
( firm)
Angle of jaw
(marked)
Submandibular ( brawny)
SUBLINGUAL
Spread of Infections
Submandibular Space Infection
Spread of Infections
Space infections
MASTICATOR
Masseteric and
pterygoid
Usual site of
origen
Clinical features
pain
trismus
Swelling
Dysphagia
Dyspnea
Molars (especially +
3rd)
+++
May not be
evident (deep)
Temporal
Post. Maxillary
molars
Face, orbit
( late)
BUCCAL
bicuspids, molars
CANINE
Maxillary canines, ++
incisors
Cheek
(market)
Upper lip, canine fosa
INFRATEMPORAL
Post. Maxillary
molars
Face, orbit
( late)
SUBMENTAL
PAROTID
SUBMANDIBULAR
Mandibular
incisors
Masseteric
spaces
2nd, 3rd
mandibular
molars
++
+++
Chin
( firm)
Angle of jaw
(marked)
Submandibular ( brawny)
SUBLINGUAL
Spread of Infections
Sublingual Space Infection
Spread of Infections
Ludwigs Angina
Celllulitis not abscess. Bilateral submandibular, sublingual, submental
spaces
Treat aggressively, potential airway compromise
Dysphagia, dyspnea, trismus.
Spread of Infections
Space infections
Clinical features
pain
trismus
Swelling
Dysphagia
Dyspnea
LATERAL PHARYNGEAL
Anterior
Mandibular
incisors
Posterior
RETROPHARYNGEAL
PRETRACHEAL
Floor of mouth
(tender)
+ if bilat.
+ if bilat.
+++
Angle of jaw
Masticator spaces
Post. pharynx
+++
Lateral pharybgeal +
space, distant via
lymphatics
Post pharynx
(Midline)
Retropharyngeal
space, anterior
esophagus
hipopharynx
+++
Spread of Infections
Space infections
Clinical features
pain
trismus
Swelling
Dysphagia
Dyspnea
LATERAL PHARYNGEAL
Anterior
Mandibular
incisors
Posterior
RETROPHARYNGEAL
Masticator spaces
PRETRACHEAL
Floor of mouth
(tender)
+ if bilat.
+ if bilat.
Angle of jaw
Post. pharynx
+++
Lateral pharyngeal +
space, distant via
lymphatics
Post pharynx
(Midline)
Retropharyngeal
space, anterior
esophagus
hipopharynx
+++
Spread of Infections
Lateral Pharyngeal Space
Retropharyngeal Space
Spread of Infections
Acute Orbital Cellulitis
Treatment
Medical support
Antibiotic therapy
Surgical treatment
Treatment
Medical support
Airway maintenance
Rehydration
Analgesia
Nutrition
Treatment
Antibiotic Therapy
Antibiotics alone will not cure most deep facial infection.
Polymicrobial infections : Aerobic Strep, anaerobes
Ampicillin/sulbactam with metronidazole
Beta-Lactam resistance in 17-47% of isolates
Alternatives
Third generation cephalosporins
Clindamycin
Culture and sensitivity
Treatment
Compromised host
One of the following an aminoglycoside)
Cefotaxime, 2 g IV Q 6h or
Ceftizoxime, 4 g IV Q 6h or
Ticarcillin-clavulanate 3 g IV Q 4h or
Piperacillin-tazobactam, 3 g IV Q 4h or
Imipenem-cilastatin, 500 mg IV Q 6h or
Meropenem, 1 g IV Q 8h.
Treatment
Surgical treatment
Removal of the cause and drainage of
accumulated pus will prevent worsening and
recurrence.
In early cases the surgical treatment may be as
simple as root canal treatment of the tooth suspected
or alternatively simple tooth extraction by the
patients dentist followed by oral antibiotics.
Treatment
Surgical treatment
More advanced cases need urgent admission for
intravenous antibiotics followed by urgent surgery to
remove the cause as well as achieve incision and
drainage of tissue spaces involved.
These cases may need expert fiberoptic
endotracheal intubation with prolonged (few days)
intubation and occasionally emergency surgical
airway access such as cricothyrotomy or
tracheostomy may be needed.
These cases will need ICU postoperatively until the
safety of airway is assured.
Treatment
Surgical treatment
Surgically most cases can be approached
transorally.
One should avoid the temptation to cut through
facial skin for reasons of facial nerve preservation as
well as to avoid the ugly puckered scar that
invariably results.
Treatment
Surgical treatment
Submandibular and submental spaces full of pus
need to be drained trancutanously via neck
incisions with drains insertion.
The patient should be on triple IV antibiotics
covering aerobic Strep species as well as
anaerobes as well as Gram-ve organisms.
Treatment
Treatment
Facial nerve
Facial vessels
Parotid gland
Stenon duct
Treatment
Treatment
Vestibular abscess
Upper vestibular abscess
vessels.
mentonian nerve
Treatment
Lingual abscess
Treatment
Palatine abscess
Treatment
1.
1. 1. Masseteric space
1.Masseteric space
. 2. Pterygomandibular space
Treatment
1.
1.Ludwings angina
Treatment
1.
1.Submental space
1. Submaxilary abscess
2. Parotid abscess
Treatment
1.
1.Submental space
1.Paramandibular
space
Treatment
1.
1.Temporal space
Treatment
1.
1.Superficial
temporal space
1.Deep temporal
space
1.External
view of
intraoral
incision
Conclusion
Early diagnosis, prompt antibiotic treatment , together
with early removal of the cause should prevent most
complications and result in early recovery
Thank you