Deep fascial space infection of oral and maxillofacial region of odontogenic orgin

1. DEEP FASCIAL
SPACE INFECTIONS
ARJUN SHENOY
DEPT OF OMFS

2. • HISTORY
• PRINCIPLES OF EXAMINATION
• CLASSIFICATION OF SPACES
• ANATOMICAL CONSIDERATIONS
• PATHWAYS OF SPREAD
• DIAGNOSTIC AIDS
• SPACES
• COMPLICATIONS
• CONCLUSION
• REFERENCES

3. “The concept of fascial spaces is based on the
anatomist’s knowledge that all “spaces” exist only
potentially, until fasciae are separated by pus,
blood, drains, or a surgeons finger”

4. INTRODUCTION
Shapiro defined fascial spaces as potential spaces
between the layers of the fascia
Filled by connective tissue

5. HISTORY
• 1938 landmark article - Grodinsky & Holyoke - modern
understanding

6. Injection dyed gelatin
Cadavers
Selective portals
HYPOTHESIS-
 spread hydrostatic pressure
Guided tissue resistance
• 1939- Ashbel Williams – 31cases Ludwigs angina (54%)
• 1979- Hough et al – (4%)

7. PRINCIPLES OF
EXAMINATION
Rapid initial assesment
Complete history Physical examination
Imaging and
laboratory data
Immediate
hospitalization with
aggressive
intervention
DATABASE

8. TOXICITY SIGNS
• Paleness
• Tachypnea
• Tachycardia
• Fever
• Shivering
• Lethargy
• diaphoresis
Decreased level of consciousness
Evidence of meningeal irritation-
1) Severe headache
2) Stiff neck
3) vomiting

9. PATHWAYS OF SPREAD

11. ANATOMICAL
CONSIDERATIONS
• MUSCLE ATTACHMENTS-
• Posteriors= Buccinator- midroot level
• Anteriors –intrinsic lip muscles & risorius

12. BUCCINATOR & ODONTOGENIC INFECTION
In maxilla Above the attachment
Root apex Extraoral
Below the
attachment
Intraoral swelling
(In Mandible it is vice versa)

13. MYLOHYOID & ODONTOGENIC INFECTIONS
Anteriors Posteriors
(Root apex below) (Root apex below)
Intraoral Extraoral
(Floor of the mouth) (submandibular)

14. Infection enters tissue spaces
Areolar connective tissue in tissue
spaces undergoes necrosis
Replaced by cellulitic fluid and then by pus
Vascular dilation, Transudation, and Exudation
draw fluid into the region, thus increasing
the hydrostatic pressure
pressure applied to the borders of the
space, the advancing front of the infection
may bypass the contiguous spaces

17. DIAGNOSTIC IMAGING
• ACCURATE DIAGNOSIS
• GUIDING DRAINAGE PROCEDURES
• EXTENT
• DETECTING COMPLICATION

18. PLAIN FILM
OPG
• Extent of pathology of
odontogenic orgin
• AP/LATERAL CERVICAL
• Lesser penetration c-spine
• Pharyngeal/ cervical
airway

19. COMPUTED TOMOGRAPHY
• Widely used - 5mm increments
• Contrast enchanced - 95% sensitivity
• Assess integrity cortical bone
• Short time –extent , epicentre
• Availability
• Relative low cost

20. ULTRASONOGRAPHY
• Superficial
• inability-osseous penetration
• Parotid /submandibular/ neck
• Differentiates solid / cystic

21. MAGNETIC RESONANCE IMAGING
• Not uncommon
• Coronal and saggital planes
• T1- anatomic detail
• T2- disease process sensitive
• Intravenous contrast agents- safer
• T1 + gadolinium

22. FASCIAL SPACES OF CLINICAL
FACE SIGNIFICANCE*
o Buccal
o Canine
o Masticator
 Massetric compartment
 Pterygoid compartment
 Zygomaticotemporal compartment
SUPRAHYOID
Sublingual
Submandibular
Lateral pharyngeal
Peritonsillar
* RICHARD G TOPAZIAN , ORAL & MAXILLOFACIAL INFECTION 4TH EDITION

23. CONTINUED
INFRAHYOID
 Anterovisceral (paratracheal)
SPACE OF TOTAL NECK
Retropharyngeal
Danger space
Space of carotid sheath
 RICHARD G TOPAZIAN , ORAL & MAXILLOFACIAL INFECTION 4TH EDITION

24. Based on mode of involvement
 DIRECT INVOLVEMENT (Primary spaces)
Maxillary spaces - canine, buccal, and infratemporal . .
Mandibular spaces - submental, buccal, submandibular, and
sublingual .
 INDIRECT INVOLVEMENT (Secondary spaces)
Masseteric,
Pterygomandibular,
Parotid,
Superficial and deep temporal,
Lateral pharyngeal,
Retropharyngeal and
Prevertebral spaces

25. ACCORDING TO THEIR RELATION
TO THE HYOID BONE
Most important anatomic structure - limits the spread of
infection-
Suprahyoid (above the hyoid)
Infrahyoid (below the hyoid)
Fascial spaces traversing the length of the neck

26. TRIVIA
• Diffusion- antibiotics- limited
• Grossly distorted anatomy
• Poor vascularity - thick walls
• Adequate open dependent drainage
• Spreads readily one to another
• Secondary-primary both to be drained

27. ANTIBIOTIC THERAPY
• EXCEPTIONS
• Well localized- easily drained –dentoalveolar abscess
• INCLUSION
• Poorly localized
• Extensive abscess
• Diffuse cellulitis
• Immunocompromised
• Systemic signs

28. INCISION AND DRAINAGE
• Incison- healthy skin/ mucosa- natural crease
• Site- max fluctuance- unaesthetic scar
• Dependent –
• Dissection- blunt- full extent
• Stabilize drain
• Remove on time

29. RECENT ADVANCES
• Two mini incisions, 4-5 mm each, far apart
• Abscess probed, pus drained.
• Abscess was irrigated -normal saline
•

30. • loop drain was passed through one incision, brought
out through the other, and tied to itself.

31. BUCCAL SPACE

32. BOUNDARIES
• Superiorly: zygomatic arch.
• Inferior: inferior border of mandible.
• Laterally: skin & subcutaneous tissue.
• Medially: buccinator muscle ,
• Posteriorly: anterior edge of
masseter.
• Anteriorly: posterior border of
zygomaticus major
& depressor anguli oris.

33. C/F
• Marked cheek swelling
• Diseased premolars/molars
• Fluctuance
• DD-complication of crohns
disease, H Influenzae

35. BUCCAL SPACE
• Contents-
• Buccal fat pad.
• Stenson’s duct.
• Facial artery.
• Communications
• Submasseteric Space
• Pterygomandibular Space
• Superficial Temporal Space
• infratemporal space
• Lateral Pharyngeal Space
• Carotid sinus

36. TREATMENT
• Intra-oral
• Attempts to direct- futile
• Drainage difficult
• Cutaneous
• Inferior to point of fluctuance
• Incision- stensons duct
• Blunt dissection- extreme borders

37. H INFLUENZAE
• Infants and children <3 yrs
• High fever 24 hours prior onset
• Otitis media - recent
• Augmentin/cephalosporin

38. SUBMENTAL SPACE

39. BOUNDARIES
• Boundaries:
• Ant - inferior border of mandible
• Post - hyoid bone
• Sup - mylohyoid bone
• Inf - skin and investing fascia
• Lat -investing fascia
• Med-Anterior belly of digastric.

40. Source of infection
incisors submandibular
• Intra-oral – non dependent
• Through mentalis –labialvestibule
• Percutaneous-
• horizontal incision-
• most inferior portion of the chin- natural skin crease

41. CANINE SPACE
• Infrequent
• Levator muscle – upper lip
• Perforates lateral cortex-
Potential canine space
True fascial space/muscular compartment??
Marked cellulitis of eyelids

43. • Drainage – intra-oral approach
• High maxillary vestibule- sharp blunt dissection
• Approach- extension of apicectomy- canine root
Percutaneous drainage
visible scar non dependent drainage

44. SUBMANDIBULAR + SUBLINGUAL SPACE
• Anatomically distinct
• Proximity + frequent dual involvement

45. SUBLINGUAL SPACE
• Sublingual space is defined superiorly by the mucosa of
the mouth floor and inferiorly by the mylohyoid muscle
• Boundaries:
• Ant – Lingual surface of mandible
• Post - Submandibular space
• Lat - Muscles of tongue
• Med - Lingual surface of mandible
• Sup - Oral mucosa
• Inf - Mylohyoid muscle

46. • CONTENT
• sublingual gland, submandibular duct, hilum of the
submandibular gland, lingual nerve, and sublingual
artery and vein.
• C/F - Brawny, erythematous, tender swelling of the floor
of the mouth, elevation of the tongue may be noted in
late cases.

47. TREATMENT
• Surgical drainage, antibiotics
• Definitive care of the primary dental infection
• INTRAORAL-
• by an incision through the mucosa parallel to
Wharton's duct bilaterally.

48. • blurring of the tracheal air shadow and symmetric
narrowing of the subglottic air shadow- characteristic
"church steeple" sign on anteroposterior films.

49. SUBMANDIBULAR SPACE
• Odontogenic infections of this space commonly are
caused by the second and third molar teeth
• Infection beginning in the mandibular molars is likely to
perforate the thin lingual plate of the mandible to enter
the submandibular space directly
• Influence of mylohyoid muscle attachment

50. BOUNDARIES
• Ant - Anterior belly of digastric muscle
• Post - Posterior belly of digastric muscle,
• Stylohyoid Stylopharyngeus muscle
• Med - Mylohyoid, hypoglosus, superior constricting muscles
• Lat - Platysma muscle, Investing fascia
• Sup - Inferior and medial surfaces of mandible
• Inf - Digastric tendon
• Contents - submandibular salivary gland and its lymph nodes,
• the facial artery,
• -the proximal portion of Wharton's duct,
• -lingual and hypoglossal nerves

51. TREATMENT
• Incision - through the skin below and parallel to the
mandible.
• Blunt dissection-avoid damage to the submandibular
gland, the facial artery, and the lingual nerve.
• Contralateral space - through and- through drain can
be placed into both sides
• Communication
• Sublingual space
• Submental space
• Lateral pharyngeal space
• Contralateral spaces

52. REFERENCES
• R.G Topazian , Oral & Maxillofacial Infections 4th edition
• Journal of Oral and Maxillofacial Surgery, Volume 72, Issue 9,
Supplement, September 2014, Pages e83-e84
• The Journal of Emergency Medicine, Volume 43, Issue 4,
October 2012, Pages 605-611
• Journal of Plastic, Reconstructive & Aesthetic Surgery,
Volume 60, Issue 4, April 2007, Pages 372-378
• Journal of Infection, Volume 50, Issue 1, January 2005, Pages
34-40
• Emergency Medicine Clinics of North America, Volume 18,
Issue 3, 1 August 2000, Pages 481-519