Transcript Oral and Maxillofacial Infections

ORAL AND MAXILLOFACIAL
INFECTIONS
By Dave Telles, DDS
Diplomate of the American Board of Oral and
Maxillofacial Surgeons
MANAGEMENT OF ODONTOGENIC INFECTIONS
eight steps :
 1. Determine the severity of infection.
 2. Evaluate host defenses.
 3. Decide on the setting of care.
 4. Treat surgically.
 5. Support medically.
 6. Choose and prescribe antibiotic therapy.
 7. Administer the antibiotic properly.
 8. Evaluate the patient frequently.
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QUESTION
What is the difference between cellulitis and
abscess?
 Is there a difference in type of infection in the
head and neck region?
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ORAL AND MAXILLOFACIAL INFECTION –
FASCIAL SPACES
In 1930s Grodinsky and Holyoke established the
modern understanding of fascial layers
 Infections spread primarily by HYDROSTATIC
pressure w/ the flow of infected fluid guided by
the resistance of certain tissues (fascia, muscles,
bone)
 Established 5 spaces of the H + N region
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ORAL AND MAXILLOFACIAL INFECTION –
FASCIAL SPACES
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Space # 1: lies superficial to the superficial fascia – SubQ
sp
Space #2: group of spaces surrounding the strap muscles
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Space # 3: potential anatomic space lying superficial to the
visceral division of the MDCF
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Contents: Pretracheal, Retropharyngeal, Lateral Pharyngeal
sp
Space #3a: contains the Carotid Sheath
Space #4: potential spaces that lies btwn the alar and prevertebral divisions of the PDCF
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Superficial to the sternothyroid-thyrohyoid division of the
middle layer of the DCF
“the danger space”
Space #5: Prevertebral sp
Space # 5a: enclosed by the prevertebral fascia – post. To
the transverse process of the vertebrae
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Surrounds the scelene and postural muscles
ORAL AND MAXILLOFACIAL INFECTION –
FASCIAL SPACES
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Superficial
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Layer of dense CT that courses deep the SQ tissue
Muscles of facial expression lie deep below the mouth and
superficial above
Deep cervical fascia
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Anterior layer
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Middle
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Investing
Parotidomasseteric
Temporal
Sternohyoid-omohyoid
Sternothyroid-thyroid
Visceral Division *
 Buccopharyngeal
 Pretracheal
 Retropharyngeal
Posterior
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Alar
Prevertebral
ORAL AND MAXILLOFACIAL INFECTION –
FASCIAL SPACES
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Anterior layer – contains the investing,
Parotidomasseteric, Temporal
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Forms the superficial border of the submandibular
space to form the capsule
At the ramus splits and surrounds the masseter and
parotid posteriorly
Covers the superficial layer of the temporalis
Above the zygomatic arch – divides ~ 2cm above and
houses the temporal fat pad
2cm above the sternum divides and forms the
suprasternal space of burns
ORAL AND MAXILLOFACIAL INFECTION –
FASCIAL SPACES
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Middle layer of the DCF
Sternohyoid
 Sternothyroid-thyrohyoid
 Visceral***
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Important in deep neck spaces
 Contains the retropharyngeal, lateral
pharyngeal and pretracheal spaces]
…all lie superficial to the middle
layer
ORAL AND MAXILLOFACIAL INFECTION –
FASCIAL SPACES
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Posterior
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Alar
Passes through the transverse process of the vertebrae post
to the retropharyngeal fascia
 Extends from bases of skull to diaphragm
 Fuses w/ the retropharyngeal fascia at lvls btwn C6-T4
forming the bottom of the RP space
 Infections may rupture this fascia and enter the danger
space #4
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Prevertebral
Surrounds the vertebra and attach postural muscles of the
neck and back
 Infection of the vertebrae may enter this space i.e.
Osteomyelitis related to TB
 Usually not caused by OMF infection
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ORAL AND MAXILLOFACIAL INFECTION –
FASCIAL SPACES
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Carotid Sheath
Origin at superior mediastinum
 Passes through pre-tracheal space in an upward and
posterior direction
 Above the hyoid lies @ the junction of the lateral and
Retropharyngeal spaces
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Light blue: Superficial
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Y: alar
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Purp: middle
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Red: Anterior
VESTIBULAR/PALATAL SPACE
Simple!
 Localized swelling of vestibular or palatal space
adjacent to the tooth
 Possible spread into other adjacent spaces
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Peritonsilar sp
Masticator Space
Canine Space
Buccal Space
Pterygomandibular/masseteric space
When there is a palatal swelling always consider
– infection vs. neoplasia – ask about duration of
swelling
(SUB)MASSETERIC SPACE
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Borders
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Causes
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Masseteric artery and vein
Neighboring sp:
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Lower 3rd molars, fracture angle of the mandible
Contents:
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Anterior: Buccal Space
Posterior: Parotid gland
Superior: Zygomatic Arch
Inferior: Inferior border of the mandible
Superficial/Medial: Ascending ramus of the mandible
Deep/Lateral: Masseter muscle
Buccal, Pterygomand., Superficial Temp, Parotid
One of the 3 spaces of the Masticator space,
commonly associated with Trismus
CANINE/INFRAORBITAL SPACE
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Borders
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Contents
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Superior- Quadratus Labii superioris
Inferior- Oral mucosa
Posterior- Buccal Sp.
Anterior- Nasal Cartilages
Lateral (Deep)- Levator anguli oris, Maxilla
Medial (superficial) - Quadratus Labii superioris,
Angular artery and vein, infraorbital nerve
Causes of infection
Upper canine and pre-molars
 Can spread to cavernous sinus via angular vein (nonvalves)  leading to Cavernous Sinus Thrombosis
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CANINE SPACE
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PICTURE
CAVERNOUS SINUS THROMBOSIS
CAVERNOUS SINUS THROMBOSIS
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CS
Anteriorly bordered by the SOF and receives tributary from the
ophthalmic vein (from a combination of the superior and inferior
ophthalmic veins)
 Posterior communication via the Pterygoid plexus
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“Valveless veins” of the face and anterior skull base allow blood flow
in either direction
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Via the Posterior facial (retromandibular) and external jugular veins
An Ascending Thrombophlebitis can occur anteriorly or posteriorly
CNs III, IV, V1, VI
Dx: via clinical presentation and confirmed with CT w/
contrast showing a filling void on the affected side of the
cavernous sinus, CN deficits
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Diplopia, visual disturbance
vascular congestion in the periorbital/scleral/retinal veins
Ptosis
dilated pupils
absent corneal reflex
supraorbital sensory deficits
BUCCAL SPACE
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Borders
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Contents
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Superior- Maxilla/infraorbital space
Inferior- Mandible
Posterior- Masseter and Pterygomandibular sp.
Anterior- corner of mouth
Lateral- subQ tissue and skin
Medial- buccinator
Parotid Duct
Anterior facial artery/vein
Transverse facial artery
Buccal fat pad
Causes of infection
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Upper pre-molars/molars and lower pre-molars
Neighboring spaces: Infratemporal, Pterygomand.,
Infratemporal
SUBLINGUAL SPACE
BORDERS:
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CONTENTS:
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The sublingual space contains the sublingual gland, the Wharton’s
duct, the lingual nerve and the sublingual artery and vein.
CAUSES OF INFECTION:
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Superior- mucosa of the floor of the mouth
Inferior- mylohyoid muscle
Posterior- submandibular space and hyoid bone
Anterior- lingual surface of the mandible
Lateral- medial surface of the mandible
Medial- muscles of the tongue
Broken down and carious mandibular premolars and molars are the
most common etiological factor leading to infection of the sublingual
space, direct trauma to the sublingual space can also cause infection
****Commonly pt has pain on protrusion of tongue and
possibly Trismus
SUPERFICIAL TEMPORAL SPACE
BORDERS:
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CONTENTS:
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The superficial temporal space contains temporal fat pad
and the temporal branch of the facial nerve.
CAUSES OF INFECTION:
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Superior- superior temporal lines
Inferior- zygomatic arch
Lateral- superficial temporal fascia
Medial- temporalis muscle
Anterior- posterior surface of the lateral orbital rim
Posterior- fusion of temporal fascia with pericranium
The most likely causes of spread of infection to the
superficial temporal space are carious and broken down
maxillary and mandibular molars.
***Temporal tenderness, possible periorbital edema
DEEP TEMPORAL SPACE
BORDERS:
Lateral- temporalis muscle
Medial- squamous temporal bone, skull base
Inferior- lateral pterygoid muscle
Superior and Posterior- attachment of the temporalis
muscle to the cranium at the temporal crest
 Anterior- posterior wall of the maxillary sinus and the
posterior surface of the orbit
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CONTENTS:
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The deep temporal space contains the pterygoid plexus, the
internal maxillary artery and vein and the mandibular
division of the trigeminal nerve
CAUSES OF INFECTION:
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The deep temporal space is most commonly involved when
infection spreads from infected and necrotic maxillary
molars.
INFRATEMPORAL SPACE
BORDERS:
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CONTENTS:
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The infratemporal space is continuous with the deep
temporal space and contains the pterygoid plexus, the
internal maxillary artery and vein and the mandibular
division of the trigeminal nerve.
CAUSES OF INFECTION:
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Medial- Lateral pterygoid plate
Superior- base of the skull
Lateral- continuous with the deep temporal space
The most likely cause of spread of infection to this space is
a infected maxillary third molar.
***One of the 3 spaces of the masticator space –
pain/swelling on maxillary tuberosity
SPACE OF THE BODY OF THE MANDIBLE
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Potential cleavage plane between the fascia and the bone.
Limited anteriorly by superfical investing fascia and the
attachment of the anterior belly of the digastric
Limited posteriorly by investing fascia and the attachment
of the medial pterygoid to the jaw
Inferiorly closed by the continuity of the fascial layers
Superiorly closed by the attachment of fascial layers to the
inferior border of the body of the mandible.
Formed by the attachment of the superficial layer of fascia
to both the outer and inner surfaces of the body of the
mandible
attachment to the outer surface is at the lower border of the
mandible
 attachment to the inner surface can be elevated from the
mandible up to the origin of the mylohyoid muscle
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Clinical: An infection here may remain localized or
may spread to the masticator space.
PTERYGOMANDIBULAR SPACE
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Borders:
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Lateral-Mandibular Ramus
Medial-Medial Pterygoid
Anterior-Pterygomandibular Raphe
Posterior-Parotid Gland
Superior-Lateral Pterygoid
Inferior-Pterygomasseteric Sling
CONTENTS
Mandibular division of trigeminal nerve(lingual, IAN,
mylohyoid, and auriculotemporal)
 IAN neurovascular bundle
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Infection
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Spread is typically from sublingual and submandibular spaces
with little or no swelling but significant trismus
***One of the 3 sp of the masticator spaces, TRISMUS!!
SUBMANDIBULAR SPACE
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Borders:
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CONTENTS
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Lateral-mandible
Medial and Posterior-Digastric muscles
Superior-Mylohyoid
Inferior-Superficial Fascia, platysma, and skin
Anterior-Anterior belly of digastric
Submandibular gland, Facial artery and vein, and lymph
nodes
CAUSES OF INFECTION:
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Perforation of lingual cortex of mandible typically in the 3rd
molar region, but can arise from 2nd molar. Communicates
posteriorly with pterygomandibular space.
LUDWIGS ANGINA
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Condition exhibiting bilateral swelling of the submental, sublingual,
and submandibular spaces.
Characterized by extreme hardness of the floor of the mouth,
"brawny", "indurated" swelling (no give or fluctuation due to pus
formation) of the neck centering about the floor of the mouth and by
the ensuing elevation of the mucosa of the mouth and tongue.
Interstitial spaces are filled with fluid.
The infection here may eventually extend to the lateral pharyngeal
space and then may enter the retropharyngeal space and even
descend to the mediastinum.
Death from Ludwig's angina occurs as a result of suffocation due to
edema of the mouth, tongue, and the glottis, from mediastinitis due to
spread, or from septicemia or pneumonia
Problem with the patient opening the mouth: Trismus
Extraction of a lower molar tooth and subsequent infection precedes
Ludwig's angina in a majority of cases.
The roots of the second and third molar teeth reach downward to the
level of the attachment of the mylohyoid muscle, and usually below it,
while most of those of the first molar teeth, and usually all of those
anterior to this, are located above this level
LUDWIG’S ANGINA
LATERAL PHARYNGEAL SPACE
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Borders:
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Divided into 2 compartments by the styloid process
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Posterior to pterygomandibular space
Superior-Base of skull
Inferior-Hyoid bone
Lateral-Medial Pterygoid
Medial-Superior constrictor
Anterior-Pterygomandibular Raphe
Extends posteromedially to prevertebral fascia
Anterior-primarily muscles
Posterior-Contains carotid sheath and cranial nerves IX through XII
CONTENTS
Carotid, Internal jugular vein, Vagus nerve, and Cervical Sympathetic chain
Infection spreads from pterygomandibular space and can cause trismus, lateral
swelling of the neck, and swelling of the lateral pharyngeal wall toward
midline. May also cause erosion of the carotid, thrombosis of the internal
jugular and interference with CN IX through XII.
RETROPHARYNGEAL SPACE
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Area of loose connective tissue lying posterior to the pharynx and anterior to
the alar layer of the prevertebral fascia
Largest interfascial space in the neck which permits movement of the
pharynx, esophagus, larynx, and trachea during swallowing
Borders
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Anterior: Superior and middle Pharyngeal Constrictor Muscles
Posterior: Alar Fascia
Superior: Skull Base
Inferior: Fusion of the Alar and prevertebral Fascia at C6 – T4
Superficial/Medial:
Deep/lateral: Carotid Sheath and lateral pharyngeal space
Passes downward and is continuous with the (Retro)Visceral
(retroesophageal) space (which begins below the pharynx) and opens inferiorly
into the posterior mediastinum
Closed superiorly by the base of the skull, superficial layer of fascia of the
masticator space, submandibular space and laterally by the carotid sheath
Contents
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retropharyngeal lymph nodes which drain the adenoids, nasal cavities, nasopharynx,
and posterior ethmoid sinuses
RETROPHARYNGEAL SPACE
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Clinical importance
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Key to an understanding downward spread of infections of the
head and neck: Commonly regarded as a route through which
infections of the mouth and throat reach the mediastinum. It
can break through the posterior wall of the space through the
alar fascia, and can enter Danger Space 4, between the two
lamellae of the prevertebral layer of fascia (extends from the
base of the skull to the level of the diaphragm).
Fatal hemorrhage could potentially result from an extension of
a retropharyngeal abscess to the deep vessels of the neck
Majority of cases arising from the internal carotid artery
rather than from the jugular vein: the vein is more often
occluded by the infectious process than it is eroded to the point
of hemorrhage.
A sudden enlargement of a retropharyngeal mass may
indicate erosion of a large vessel and that in such a case
aspiration of the mass before its incision may prevent fatal
hemorrhage
PRETRACHEAL SPACE
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Borders
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Ant: Sternothyroid-thyrohyoid fascia
Post: Restropharyngeal Space
Sup: Thyroid Cartilage
Inf: Superior Mediastinum
Superficial/medial: sternothyroid-thyrohyoid fascia
Deep/lateral: Visceral fascia over trachea and thyroid
gland
OTHER SPACES
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Prevertebral
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Potential pocket existing between the "prevertebral" fascia
and the vertebral bodies.
Danger Space 4
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An area of delicate loose connective tissue that lies
between the alar and prevertebral fascia Extends from the
base of the skull to the mediastinum
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Infection can communicate from posterior wall of the
oropharynx and oral cavity to the thorax by traveling from the
Retropharyngeal Space, and passing downward to the
Retrovisceral space (which begins below the pharynx). It can
then pierce thru the weak alar fascia - into Danger Space #4
"Dangerous" because an infection can easily travel to the
thoracic cage and mediastinum, i.e., mediastinitis. Abscess in
the mediastinum could go anteriorly to the pericardial area and
could affect the manubrium, sternum, etc..
MICROBIO
Oral cavity has dense, diverse microbiota
consisting of protozoa, yeast, virus and > 20
genera of bacteria
 Composed primarily of aerobic and anaerobic GP
cocci and anaerobic GN rods
 Most odontogenic infections are caused by mixed
aerobic/anaerobic organisms (~ 60%)
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