Space Infection Dr. Amit T. Suryawanshi Oral and Maxillofacial Surgeo Pune, India Contact details : Email ID - [email protected] Mobile No - 9405622455
May 24, 2015
Space Infection
Dr. Amit T. SuryawanshiOral and Maxillofacial Surgeon
Pune, India
Contact details :Email ID - [email protected]
Mobile No - 9405622455
Contents • Introduction• History • Anatomy of fascia• Host defense and infection• Microbiology and antibiotic therapy• Stages of infection• Definition of fascial spaces• Classification of fascial spaces• Anatomy of fascial spaces• Diagnosis of Space infection• Complications • Controversies• Recent advances • Conclusion • Reference
Introduction
Space infections of head and neck are very common in
Oral and maxillofacial practice. Although most of the
infections can be managed successfully with minimal or
no complication, some can produce serious morbidity or
even death. Depending on the virulence of
microorganisms and host resistance, bacterial infections
have the potential to spread beyond the bony confines of
jaw bones into surrounding soft tissues.
They flow following the path of least resistance , into loose areolar connective tissue of fascia surrounding the muscles. This tissue is destroyed by hyaluronidases and collagenases produced by bacteria, thus opening the potential SPACES surrounding the muscles. Thus such innocuous periapical infections have a potential to develop into life-threatening deep fascial infections.
Early extraction of offending tooth and incision and drainage tend to shorten the usual course of infection and minimize the chances of further complications.
In new era of antibiotics, incidence of death due to infection is reduced but due to developing drug resistance, there is outbreak of new range of infections requiring invention of newer antibiotics.
For accomplishment of proper management,maxillofacial surgeon must understandphysiologic and anatomic factors that influencethe spread and localization of dental infections.
HistoryBurns (1811) first described fascial space as ananatomical entity and gave their clinical significance.
In 1836 Wilhelm Frederick von Ludwig described hisobservations concerning repeated occurrences ofinflammation of throat. Hence most severe orofacialInfection at that time was named as Ludwigs angina.
Greek author Parker(1879) gave vivid descriptions ofinfections which produced inflammation oral cavity,tonsil and larynx.
The term “ Quinsy “ was given by Muckleston in1928.
In 1929 Mosher called Viscerovascular space as “Lincoln highway”
Space of the body of mandible is describedby Coller & Iglesias. (1935)
Anatomy of fascia
Functions of the fascia
• Acts as a musculovenous pump-• Limits outward expansion of muscles as they
contract.• Contraction of muscles compresses the
intramuscular veins (push the blood towards the heart).
• Determine the direction of spread of infection
Infections and Host defense
• In establishing presence of an infection, interaction occurs among three factors.
1. Host2. Environment 3. Microorganism
In state of Homeostasis , balance exists among these three and disease occurs when imbalance exists.
Infection occurs whenhost is immunocompromisedor when pathogenesityand number of microbesInvading host is more.
Host vs Microbe relationship
Stages of infectionInfections generally pass through these 4 stages before theyundergo complete resolution.
• Stage I – InoculationTime between exposure of microorganism and the first set ofsymptoms . During 1-3 days, Swelling is soft, mildly tender,doughy in consistency
• Stage II – cellulitisChronic stage-fistulous/sinus tract or osteomyelitis During 3-7 days, centre of lesion begins to soften
Stage III –After day 5 underlying abcess underminesskin or mucosa making it compressible.
Stage IV - Finally there is resolution of abcess thatmay be spontaneous or after surgical drainage. Duringresolution phase, the involved region is firm onpalpation due to process of removing tissueand bacterial debris.
Differences between cellulitis and abscessCharacteristics Cellulitis Abscess
Duration. Acute phase Chronic phase
Pain Severe and generalised Localised
Size Large. Small
Localization Diffuse borders Well-demarcated
Palpation Doughy / indurated Fluctuant
Presence of pus No Yes
Degree of seriousness Greater Less
Bacteria. Aerobic Anaerobic/mixed
Microbiology –Space infection Aerobic bacteria (25%)Gram positive cocci (85%)– Streptococcus species( 90% ) -
• S.Milleri• S.sanguis• S.Salivarius• S.Mutans
Staphylococcus species (6 %)
Anaerobic bacteria (75%)Gram positive cocci (30%)– Peptococcus species 33%Pepto Streptococcus species 33%Gram pasitive bacilli (50%) – Prevotella species, Porphyromonas species (75%)Fusobacterium -20%
Ref – Micro-organisms and Odontogenic infections 2009 ADJ
Staphylococcus causes –osteomyelitis and abscess Streptococcus causes- cellulitis
• In an abscess, common causative organisms are anaerobic (Higher percentage) & Aerobic.
• Fusobacterium + strep. Milleri – cause aggressive infections. Eg.,.mediastinum.infections.
Fascial spaces
Definition -The fascial spaces in head and neck are thepotential spaces between the various layers offascia normally filled with loose connectiveTissue and bounded by anatomical barriers, usuallyof bone, muscle or fascial layers.
(Ref – Moore-1975)
CLASSIFICATION OF FASCIAL SPACESGRODINSKY AND HOLYOKE (1938)
Space 1 – Superficial to superficial fasciaSpace 2 – Group of spaces surrounding cervical strap muscles
lying superficial to sternothyroid-thyrohyoid division of middle layer of deep cervical fascia.
Space 3 – Space lying superficial to visceral division of middle layer of deep cervical fascia
Space 3A – Carotid sheath space or viscerovascular space (Lincoln’s High way)
Space 4 – Space lies between alar & prevertebral division of posterior layer of deep cervical fascia (Danger
space)Space 4A – Posterior triangle space posterior to carotid sheathSpace 5 - Prevertebral space Space 5A- Space enclosed by Prevertibral fascia.
• Hollinshead’s classification(1958)Infrahyoid spaces -1.Visceral compartment
A) Pretracheal / previsceralB) Retrovisceral
2. Visceral space3. Other space
I. Cavity within carotid sheathII. Space between 2 layers of prevertebral fascia
BASED ON MODE OF INVOLVEMENT1. Direct Involvement. (Primary Spaces)»Maxillary Spaces – Canine, buccal infratemporal»Mandibular Spaces – Submental,
Submandibular, Sublingual, Buccal2. Indirect involvement (Secondary Spaces)»Masseteric»Pterygomandibular»Superficial and deep temporal»Lateral and retro pharyngeal»Prevertebral, parotid, carotid
sheath,peritonsillar and danger spaces.
Surgical anatomy of deep facial spaces of head and neck
BOUNDARIES:-
• ANTERIORLY - Corner of mouth • POSTERIORLY-
Masseter muscle, Pterygomandibular space• SUPERFICIAL- skin and Subcutaneous tissue
• DEEP- Buccinator muscle • SUPERIORILY - Maxilla, Infraorbital space
• INFERIORLY - Lower border of mandible.
Buccal spaceThe buccal space occupies the portion of subcutaneous space between the fascial skin and buccinator muscle.
Cause Infection from maxillary premolars, molars andmandibular premolars
Relation of root with buccinator muscle
Buccal space
Clinical features:Dome shaped swelling on the anterior aspect of cheek extending anteroposteriorly from corner of mouth to angle of mandible and superoinferiorly from level of zygomatic arch to inferior border of mandible.
• CONTENTS OF BUCCAL SPACE:-• Buccal pad of fat• Stensons (Parotid duct)• Anterior and transverse facial artery and vein.
MUSCLE RELATED – Buccinator muscle
Neighboring spaces- Infraorbital, pterygomandibular, infratemporal space
TREATMENT:- (I & D)
• Antibiotic prophylaxis.• Intra oral horizontal vestibular
incision.• Extra oral (2 stab) incisions
below the lower border of the mandible with No. 11 blade.
• Drainage – Hemostat is passed from anterior incision and taken out from the posterior incision then the rubber drain is inserted and secured with pins and dressing is done.
Boundaries –
Anteriorly – Nasal cartilage Posteriorly- Buccal space Superficially – Quadratus labi superioris Deep- Lavator anguli oris, anterior
surface of maxillaMedially – Levator labi superioris alaque
nasiLaterally – Zygomaticus major, Superiorly – Quadratus labi superioris Inferiorly - Oral mucosa ,Orbicularis oris
Canine space / Infraorbital space
ETIOLOGY -
• Maxillary canine, rarely from maxillary first premolar.
• Rarely from nasal & upper lip infections.
Canine space / Infraorbital space• Clinical features:
• Swelling lateral to the nose over cheek.
• Obliteration of the nasolabial fold,
• Swelling of the upper lip, • Oedema occurs in lower
eyelid leading to closure of eye.
• Contents – Angular artery and vein, Infraorbital nerve
• Neighboring spaces – Buccal space
TREATMENT:-
• Antibiotic prophylaxis • Incision is made intraorally high in the
maxillary labial vestibule.• Small hemostat is inserted through levator
anguli oris into abcess cavity.• Drainage with drain secured.
Submandibular spaceBOUNDARIES:-ANTERIORLY – Anterior bellly of digastric musclePOSTERIORLY – Posterior bellly of digastric
muscle, stylohyoid, stylopharyngeous muscle.
LATERALLY -skin, superficial fascia, platysma
SUPERFICIAL- Platysma, Investing fasciaDEEP- Myelohyoid, Hyoglossus, superior
constrictor
INFERIORILY -Anterior & posteriorbellies of the diagastric
SUPERIORILY -Inferior medial aspect of mandible & mylohyoid muscle
Cause -• Infection from Mandibular molars.• From sublingual space• Infections from middle third of the tongue,
posterior part of floor of the mouth.• From submental space / submental lymph
nodes• Infection from the submandibular gland
Clinical Evaluation:Swelling begins at lower border of mandible extends to the level of hyoid bone in a shape of inverted cone.
No trismus.
Contents -• Superficial lobe of submandibular salivary gland
& submandibular lymph nodes, facial artery & vein
Neighboring spaces –Submental, sublingual, lateral pharyngeal, buccaland submandibular space of other side.
• I & D through Extra-oral incision.
• Incision – 2 stab incisions are given over the dependent part below the lower border of mandible in the neck (shadow) of the mandible
• Curved hemostat is inserted & Blunt dissection through subcutaneous fat not to damage facial A, anterior facial vein and the facial nerve
• Drainage – Drain is placed & dressing is given
TREATMENT
• BOUNDARIES:-
• ANTERIORLY - Lingual surface of mandible
• POSTERIORLY - Submandibular space
• INFERRIORLY - Mylohyoid muscle• SUPERIORIL -oral mucosa• MEDIALLY- - geniohyoid,
genioglossus & styloglossus • LATERALLY - lingual aspect of
mandible
Sublingual space
CAUSE
• Mandibular premolars and molars, trauma
Sublingual spaceClinical evaluation: •Swelling in anterior part of floor of the mouth on the affected side displacing tongue medially and superiorly.
•Interferes with swallowing and is extremely painful.
•Elevation of tongue to palate causes airway compromise.
• CONTENTS:-
• Sublingual artery and vein• Lingual nerve.• Deep part of submandibular salivary gland and its duct
anteriorily.• Sublingual salivary gland
Neighboring spaces –
Submandibular, Lateral pharyngeal, visceral(trachea, esophagus)
TREATMENT:-
• Antibiotic prophylaxis
• Incision is made Intraorally over lingual sulcus at the base of the alveolar process.
• Haemostat is passed beneath sublingual gland in an antero posterior dissection and drain is placed.
• When infection crosses midline, same incision is made bilaterally, hemostat is passed through floor of mouth from one side to other & drain is placed
BOUNDARIES:-ANTERIORLY – Inferior border of mandiblePOSTERIORLY – Hyoid bone
• LATERALLY – Anterior bellies of the digastric m.
• SUPERIORILY – Mylohyoid muscle• INFERIORILY – skin, investing fascia• SUPERFICIAL – Investing fascia• DEEP – Anterior bellies of digastric
Submental space
ETIOLOGY:-• From lower anteriors.• Secondarily due to infection from submental
lymph nodes which drain lower lip, skin overlying chin, anterior part of floor of the mouth, tip of the tongue & sublingual tissues.
• Symphysis fracture.
Submental space
Clinical evaluation:
Swelling is limited to the point of the chin & to the region immediately below it
• MUSCLE RELATED – mentalis muscle
• CONTENTS – submental lymph nodes and anterior jugular vein.
• TREATMENT:-
Extraoral Incisions are made bilaterally (two stab incisions) through skin, subcutaneous tissue and platysma muscle at most inferior aspect of swelling.
Drain & dressings are placed.
Ludwig’s Angina
• The original description of the disease was given by Wilhelm
Friedrich von Ludwig.
1. Rapidly spreading gangrenous cellulitis.
2. Originates in the region of submandibular gland but never
involves one single space and
3. Arises from extension by continuity and not by lymphatics.
4. Produces gangrene with serosanguinous, putrid infiltration
but very little or no frank pus.
Ludwig’s Angina
Ludwig’s AnginaLudwig’s angina is acute, aggressiveand rapidly spreading cellulitis ofthe submandibular and sublingualspaces bilaterally and of thesubmental space.
Clinical evaluation:Bilateral swelling below chinextending inferiorly at the level ofhyoid bone.Fever, chills. - Airway compromise occur quickly
and with little fore warning.
- Drooling, dysphagia and neck stiffness are common.
- Anteriorly protruding tongue is present - Trismus is usually absent.
Principles of Management of Ludwig’s Angina
• Hospitalization.• Securing the airway.• Antibiotics & hydration.• External surgical exploration with bilateral through
and through drainage of the submandibular spaces with simultaneous exploration of the submental and sublingual spaces.
• Medical supportive therapy• Review and re-evaluation in the post op period
Incision for surgical drainage of Ludwig’s Angina
Classic method – Not used nowadays Bilateral through and though drainage of spaces
- Ref – Laskin Vol. 2 pg no. 249
There are 5 masticatory spaces .1. Superficial temporal space2. Infratemporal space3. Deep temporal space 4. Submassetric space5. Pterygomandibular space
Masticatory space
Boundaries – • Superiorly & Laterally Temporal fascia• Inferiorly – Zygomatic arch • Medially Lateral surface Temporalis muscle
Superficial temporal space
cause
• Infection from maxillary and mandibular molars.
Superficial temporal spaceClinical evaluation:
•swelling above & below the zygomatic arch causing a dumbell shaped appearance
• Severe pain & trismus
• Contents- Temporal fat pad, temporal branch of the facial nerve.
• Neighboring spaces – Buccal , Deep temporal.
TREATMENT:-Intraorally vertical incision made medial to the upper extent of the anterior border of the mandibular ramus.
• Haemostat passed superiorily along the lateral aspect of the coronoid process to enter superficial temp. space
• Intra oral approach good
• Extra-oral incision horizontal incision
• Haemostat is passed medially to enter superficial temporal space.
• Drainage drain is placed, dressing is given.
Deep Temporal space
Boundaries -• Laterally medial surface of temporalis m.• Medially Temporal bone• Below the level of zygomatic arch both the
spaces communicate with each other and with the infratemporal space.
Cause
• Infection from maxillary molars
Clinical features
Mild swelling over temporalRegion.
Difficult to diagnose.
• Contents – Pterygoid plexus, Internal maxillary artery and vein.
• Neighboring Spaces – Buccal, superficial temporal, inferior petrosal sinus
TREATMENT:-• Intraorally vertical incision made medial to the
upper extent of the anterior border of the mandibular ramus.
• Haemostat passed supero-medially to enter deep temporal space.
• Through blunt dissection deep temporal space is approached through temporalis muscle
• Drainage drain is placed, dressing is given.
Boundaries –
• Anteriorly, -Infratemporal surface of the maxilla• Posteriorly,- the articular tubercle of the temporal
bone, mandibular condyle • Superiorly, - Greater wing of the sphenoid below
the infratemporal crest• Inferiorly, - Medial pterygoid muscle• Medially - lateral pterygoid plate• Laterally, - Ramus of mandible
Infratemporal space
Cause
• Infection from maxillary molars
Infratemporal space
• Clinical features :• Marked Trismus• swelling of face in front of ear, over TMJ & zygomatic
arch• Eye is closed and proptosed
• Contents – Pterygoid plexus, Internal maxillary artery and vein.
• Neighboring Spaces – Buccal, superficial temporal, inferior petrosal sinus
TREATMENT:-• Intraoral and extraoral approach • Intraorally, incision is made into buccolabial fold
lateral to maxillary third molar. (Kruger)• Curved hemostat is inserted behind max.
tuberosity superomedially within the cavity and drain is inserted.
• Intraorally vertical incision made medial to the upper extent of the anterior border of the mandibular ramus.(Laskin)
• Curved hemostat is passed superiorly into infratemporal region and drain is inserted.
• Extraoral approach in presence of severe trismus.It consists of horizontal incision above the zygomatic arch and then curved hemostat is directed in inferior and medial direction to enter infratemporal space followed by insertion of drain.
SUBMASSETERIC SPACE
• BOUNDARIES:Anteriorily Buccal space Posteriorily parotid fascia and retromandibular portion of the
parotid glandLaterally masseter muscleMedially lateral surface of the mandibular ramusSuperiorily zygomatic archInferiorly – Inferior border of mandible
ETIOLOGY:-• – Periocoronal infection, periapical infection with
mandibular third molars (linguoversion with root buccally placed)
- Fracture of angle of mandible
CLINICAL FEATURES:-
– Swelling over the angle of mandile from the level of the zygomatic arch to inferior border of mandible , anteriorily to anterior border of masseter and posteriorly to posterior border of mandible.– Deep seated severe throbbing pain– Trismus– Tenderness over the mandibular
ramus,.
•
CONTENTS -• Masseteric artery and vein
Neighboring spaces-• Buccal, pterygomandibular, superficial
temporal, parotid space
TREATMENT:-• Incision Intra oral approach - vertical incision along the
external oblique line of the mandible starting at the level of the occlusal plane and extending downward and forward in buccal sulcus opposite 2nd molar.
Haemostat is passed along lateral aspect of ramus beneathmasseter muscle to enter submasseteric space. drainage isdone.
• Incision Extra oral incision - beneath angle of mandible.• Blunt dissection through masseter muscle fibres.
– Drainage with plastic or rubber catheter to withstand muscle contraction.
Pterygomandibular space
• BOUNDARIES:
– Anterior Buccal space– Posterior deep portion of
parotid gland– Laterally medial surface of
ramus of mandible– Medially Lateral aspect of the
medial pterygoid m.– Superiorly lateral pterygoid
muscle– Inferiorly – Inferior border of
mandible
ETIOLOGY-
Infection from impacted mandibular molars , from contaminated needle during I.A.N.B
CLINICAL FEATURES:
– Trismus, Dysphagia, Dyspnoea– No external evidence of swelling – Anterior bulging of half the soft palate and the anterior
tonsillar pillar with deviation of uvula to the unaffected side.– If Peritonsillar abscess (Less trismus, no dental involvement)
• CONTENTS:– Mandibular division of trigeminal nerve – Inferior alveolar artery and vein
• Neighboring spaces -– Deep temporal spaces– Lateral pharyngeal space– Buccal space– Submasseteric space– Parotid space
TREATMENT: I & D
• If trismus is severe. -Extraoral mandibular nerve block or G.A. is given
• Incision intra oral incision in the mucosal area between medial aspect of ramus and the pterygomandibular raphae.
• Blunt dissection using hemostat.• Drainage.
• Extra oral incision is made below the angle of mandible.
Lateral pharyngeal space infections
• It lies immediately posterior and lateral to the pharynx
• Anatomically the lateral pharyngeal space may be thought of as an inverted pyramid shape-the base of the pyramid being the skull base and the apex the hyoid bone.
• BOUNDARIES:-
– Superiorly Base of skull– Inferiorly Hyoid bone– Medially superior pharyngeal
constrictor– Laterally medial pterygoid m.,
capsule of parotid gland– Posteriorly carotid sheath
,styohyoid, styloglossus, & stylopharyngeus.
This is a cone – shaped space
• ETIOLOGY:- Spread from – Sublingual spaces– Submandibular spaces– Pterygomandibular spaces– Lateral spread from tonsillar abscess, pharyngitis,
parotitis, otitis, mastoiditis – Abcess from the region of 38,48– Surgical displacement of roots of 38,48 into this space
•
• CONTENTS:– Anterior compartment: • Ascending pharyngeal A.• Loose areolar connective tissue.
– Posterior compartments:- • Cervical sympathetic trunk• Carotid sheath with its contents
Neighboring spaces -Pterygomandibular, submandibular, sublingual,
peritonsillar, retropharyngeal space.
Lateral pharyngeal space infection
• Firm swelling with surrounding erythema lateral and anterior to sternocleidomastoid muscle.
• Difficulty in flexing and turning of neck.
• Trismus secondary pterygoid muscle involvement.
• Dysphagia.• Dyspnoea.
Clinical evaluation
Management
• Hospitalization with I.v. antibiotics.• Airway protection.• Rapid surgical drainage.• Surgical approach always through neck not through
oral cavity.• Incision is made at the level of hyoid bone across the
sternocleidomastoid muscle.
Complications
• Suppurative jugular venous thrombosis.• Patient will have shaking chills, high fever.• Tenderness at the mandibular angle and along
sternocleidomastoid muscle.
Peritonsillar space infection
Clinical evaluation:• pharyngitis .• Severe sore throat, dysphagia,
and referred otalgia.• The speech is muffled and
classically described as hot potato voice.
• Trismus is not present• According to recent
literature,needle aspiration is done instead of incision and drainage .
• (JOMS,Vol 51,2009)
BOUNDARIES:-• superiorly zygomatic arch• Inferiorly lower border of mandible• Anteriorly posterior border of the mandible• Posteriorly Retromandibular region
– Space formed by splitting of the superficial layer surrounding the parotid gland and lies posterior to the masticator space.
• CONTENTS:– Parotid gland– Parotid lymph nodes– Facial n.– Retromandibular vein– External carotid artery
Parotid space infection
• ETIOLOGY:– From extension of infection from submasseteric,
pterygomandibular, lateral pharyngeal spaces,– Blood-borne infection, retrograde infections through the
stensons duct.
Parotid space infection
.
Clinical evaluation:
The symptoms of parotitis include pain and induration over the involved gland.
Purulent marked swelling of the angle of the jaw without associated trismus or pharyngeal swelling.
Secretions may sometimes be expressed after massage from the parotid depth.
Very characteristic pitting edema of the gland is pathognomic for parotid gland abscess.
Drainage of parotid space infection
Deep neck infections
• All involve only posterior side of neck.a)Retropharyngeal spaceb)Danger space c) Prevertebral space d)Visceral vascular space (within the carotid
sheath)
Retropharyngeal spaceRetropharyngeal space is the potential space sandwiched between alar and prevertebral layers of deep layer of the deep investing fascia.
Extension Base of the skull
Mediastinum
Two compartments:
Suprahyoid
1. Lymph nodes and fat.
Infrahyoid
1. Only fat
Sagittal section of retropharyngeal space
Most dangerous of all types of deep neck infections (Danger space)
Clinical Evaluation
• Children less than 4 yrs commonly affected.• Sore throat, dysphagia,• Hot potato voice.
Clinical features•Refusal to take food.•Cervical lymphadenopathy.•Slight neck rigidity.•Noisy breathing due to laryngeal edema.
Late Clinical features -•Neck tilts towards involved side.•Hyperextended complete inability to flex the neck.•Respiratory embarrassment may occur if abscess is not ruptured or drained.
Diagnosis of the soft tissue radiograph for retropharyngeal space infection
Step I:• Look at the prevertebral or
retropharyngeal soft tissue shadow.
• In the area of 2nd and 3rd CV, shadow should be less than 7mm in width.
• In the area of 6 cervical vertebra soft tissue shadow is behind the trachea and includes the thickness of esophagus making it approx. Children – 14mm wideadults – 22mm wide
Step III. - Finally, the lateral radiograph will show the curve of the cervical spine- Loss of the curve is a strong indication of retropharyngeal space infection.- Tipping of the head forward in sniffing position to maintain an open airway.
Management of Retropharyngeal space infection
Prevertebral space• Is formed by the deep cervical fascia.• It extends from skull base to coccyx• Facia attaches to the transverse process of the cervical vertebra
dividing this space into anterior and posterior compartments.
Anterior compartment contains:-Vertebral bodies.-Spinal cord.-Vertebral arteries.-Phrenic nerve.-Prevertebral and scalene muscles
Posterior compartment contains:
-Posterior vertebral elements.
-Paraspinous muscles.
Diagnostic Imaging for Space infections
Plain film. MRI
Plain Film
• Diagnostic imaging starts with a plain film study of pharyngeal or cervical airways.
• Views taken– AP view– Lateral view
• Plain film findings:- In the AP view the normal cervical airway should
appear symmetrical over the middle third of the cervical spine.
- Lateral view – In the adult the width of the prevertebral soft tissue should not exceed 7mm at the C3 level and 20mm at C7 level.
AP view
Lateral view
MRI
Complications of space infection
• Osteomyelitis• Mediastenitis• Brain abcess• Meningitis • Cavernous sinus thrombosis• Scar formation• Sinus tract formation
Signs & symptoms of toxicity
• Dyspnoea• Dysphagia• Paleness• Tachypnoea• Tachycardia• Fever• Lethargy
• level of consciousness• Evidence of meningeal
irritation(severe headache)
• Eyelid edema & abnormal eye signs
CNS symptoms
Who should be hospitalized ???
Controversies • Does the Investing Layer of the Deep Cervical Fascia
Exist? - Nash, Lance M.Sc November 2005
Journal of American society of anesthesiologists
The placement of the superficial cervical plexus blockhas been the subject of controversy. Although theinvesting cervical fascia has been considered as animpenetrable barrier, clinically, authors went on a trial andfound that the placement of the block deep or superficial tothe fascia provides the same effective anaesthesia.
• Conclusion of study: This study provides anatomical evidence to indicate that the so-called investing cervical fascia does not exist in the anterior triangle of the neck. Here the author’s findings strongly suggest that deep potential spaces in the neck are directly continuous with the subcutaneous tissue.
Controversies
• Surgical vs ultrasound-guided drainage of deep neck space abscesses: a randomized controlled trial: surgical vs ultrasound drainage
-Vincent L Biron, George KurienJournal of Otolaryngology - Head and Neck Surgery 2013,
• Introduction -Deep neck space abscesses are relatively common head and neck surgery emergencies and can result in significant morbidity . Traditionally, surgical incision and drainage (I&D) with antibiotics has been the mainstay of treatment. Some reports have suggested that ultrasound-guided drainage is a less invasive and effective alternative in selected cases.
Controversies
Results• Seventeen patients were recruited .They found a
significant difference in mean Length of hospital stay between patients who underwent USD (3 days) vs I&D (5 days).They identified significant cost savings (41%) in comparison to I&D.
• ConclusionsUltrasound drainage of deep neck space abscesses in a certain cases is effective, cost saving & safe as it is less invasive. Still this remains a controversial topic whether to follow Incision and drainage or ultrasound drainage.
Recent advances
Effective antibiotics for severe infections causedby resistant bacteria are needed urgently. Thespeed with which bacteria develop resistance toantibiotics, in contrast with the slow developmentof new drugs, has led some experts to developnewer antibiotics.
FDA approved newer antibiotics Compound name (Brand name )
Targeted Microorganisms
Quinupristin/ dalfopristin (1999) (Synercid)
methicillin-susceptible S. aureus and Streptococcus pyogenes
Moxifloxacin (1999 )(Avelox)
G+ and G-, including multi-drug resistant Streptococcus pneumoniae
Linezolid (2000)(Zyvox)
G+; including MRSA
Cefditoren pivoxil (2001)(Spectracef)
methicillin-susceptible S. aureus and Streptococcus pyogenes
Daptomycin (2003 )(Cubicin)
G+, including MRSA
Tigecycline (2005 )( Tigacil)
G+ and G-
Dalbavancin (2004 ) G+ (including VRE and MRSA)
Compound name (Brand name )
Targeted Microorganisms
Faropenem (2005)(medoxomil )
G+ and G-
Telavancin (2007) G+ (including MRSA)
Ceftobiprole (2007) G+ and G-
Oritavancin (2011) G+ (including MRSA)
Iclaprim (2012) G+ (including MRSA)
Conclusion
We being Oral & maxillofacial surgeons mustunderstand anatomy of fascial spaces, spread ofinfection and proper management for theprevention of further complications and bettermentof health of the patient.
References.Books -• Oral &maxillofacial Infections-Topazian• Oral & Maxillofacial Surgery-Laskin Vol. II
Articles –1. Does the Investing Layer of the Deep Cervical Fascia Exist?
- Nash, Lance M.Sc November 2005 Journal of American society of anesthetist
2. Surgical vs ultrasound-guided drainage of deep neck space abscesses: a randomized controlled trial: surgical vs ultrasound drainage-Vincent L Biron, George Kurien Journal of Otolaryngology - Head and Neck Surgery 2013,
Head and Neck space infections (Dissertation ) University of sydney.
Websites - http://www.upd8.org.uk
References.
Thank you