Primary spaces of space infection

PRIMARY SPACES OF SPACE INFECTION

BY MANMOY SAHA(INTERN)

CONTENTS INTRODUCTION POTENTIAL SPACES PRIMARY MAXILLARY SPACES -CANINE SPACE -BUCCAL SPACE -INFRA TEMPORAL SPACE PRIMARY MANDIBULAR SPACES -SUBMENTAL SPACE -BUCCAL SPACE -SUBMANDIBULAR SPACE -SUBLINGUAL SPACE

INTRODUCTION Infections of orofacial and neck regions

range from periapical abscess to superficial and deep neck infections

The infections spread by following the path of least resistance through connective tissue and fascial planes

The infection spread to such an extent ,distant from the site of origin causing considerable morbidity and occasional death

PATHWAYS OF ODONTOGENIC INFECTIONS

Invasion of dental pulp by bacteria after decay of tooth

-> Inflammation, edema, lack of collateral blood supply

-> venous congestion or avascular necrosis

->Reservoir for bacterial growth ->periodic egress of bacteria into

surrounding alveolar bone

SPREAD OF OROFACIAL INFECTIONS ROUTES OF SPREAD By direct continuity through the tissues

By lymphatics to the regional lymph nodes and eventually into blood stream

Which may lead to secondary areas of cellulitis or tissue space abscess

By the blood stream

If the infection remains confined to the peri-apical areas, chronic periapical infections develop , which leads to sufficient destructions of bone-> osteomyelitis

MAXILLA Swelling or fistula in the posterior part of hard palate

it is related to palatal roots of molars

Maxillary incisor and cuspid roots lie closer to thin labial plate of bone than to thicker palatal bone

Infection from maxillary bicuspids may extend into connective tissue of buccal vestibule spread superiorly causing cellulitis of eyelids

Infection from molars may exit from alveolar bone buccally, palatally or posteriorly

Superior spread -> infratemporal space, maxillary sinus

Posteriorly->masticator and pharyngeal space

MANDIBLE

Infection of mandibular incisors and cuspids shows bulging in labial sulcus

If infection spreads from bone deeper to origin of mentalis muscle->submental space

Infection from mandibular 3rd molar involve buccal vestibule, buccal space, masticator space, parapharyngeal spaces

CLASSIFICATION OF FASCIAL SPACES BASED ON THE MODE OF INVOLVEMENT: Direct involvement:- Primary maxillary spaces- canine

space, buccal space, infra temporal space Primary mandibular spaces-

submental space buccal space, submandibular space, sublingual space Indirect involvement- Secondary fascial spaces- masseteric

spaces

Pterygomandibular space Superficial temporal space Deep temporal space Lateral pharyngeal space Retropharyngeal space Prevertebral space Parotid space Based on clinical significance Face - Buccal , canine, masticatory, parotid Suprahyoid- sublingual, submandibular,

pharyngomaxillary, peritonsillar Infrahyoid- anterovisceral(pre tracheal) Spaces of total neck: retropharyngeal , space of

carotid sheath

The teeth which frequently give rise to abscess in this area are maxillary canines, premolars and sometimes mesiobuccal root of 1st molar

CANINE SPACE( INFRA-ORBITAL SPACE)

Boundaries:-

Anteriorly- orbicularis oris

Posteriorly- buccinator Superiorly-levator labii

superioris, zygomaticus minor

Inferiorly- caninus muscle

Medially- anterolateral surface of maxilla

CLINICAL FEATURES:-

Swelling of cheek and upper lip

Obliteration of nasolabial fold

Drooping of the angle of mouth

edema of lower eyelid

Redness and marked tenderness of facial tissues

Intraoral- offending tooth is mobile and tender on percussion

INCISION & DRAINAGE:-

A curved mosquito forcep is inserted superior to the attachment of caninus muscle & the infra-orbital space is entered

Pus is evacuated and a drain is inserted & secured to one of the margins with suture

It is the potential space between buccinator & masseter muscle Maxillary & Mandibular premolars and molars area involved. Location of the root tip to the level of origin of buccinator muscle determines the spread of infection either intraorally into the vestibule or deep into the buccal space

Boundaries:- Anteromedially- buccinator

muscle

Posteromedially- masseter overlying the anterior border of ramus of mandible

Laterally- forward extension of deep fascia from the capsule of parotid gland & platysma muscle

Inferiorly- deep fascia to the mandible & depressor anguli oris

Superiorly- zygomatic process of maxilla & zygomaticus major and minor

CLINICAL FEATURES:-

Gum boil is seen in the vestibule(when the pus accumulates on oral side of the muscle)

If the pus accumulates lateral to the muscle extraoral swelling is seen extending from lower border of mandible to the infra orbital margin

and from anterior margin of masseter muscle to the corner of the mouth


Horizontal incision through the oral mucosa of the cheek in the premolar molar region

If the pus is lateral to the muscle then the muscle is penetrated with curved mosquito forceps to enter the buccal space

Drain is placed secured with suture

It is also called “retrozygomatic space”

The space is continuous with upper part of pterygomandibular space anteriorly, it is separated from it by lateral pterygoid muscle posteriorly

The infratemporal fossa forms the upper extremity of pterygomandibular space

Involvement- Infections of the

infratemporal space occurs from the infections of buccal roots maxillary 2nd and 3rd molars

Local anesthesia injections with contaminated needles in the area of tuberosity

Spread from other spaces infection

Spread of infection

Pus can extend upwards to involve the temporal space or inferiorly perforate the lateral pterygoid muscle to involve the pterygomandibular space

It can spread through pterygoid plexus of veins upwards into cavernous sinus

From infratemporal fossa to middle cranial fossa

Boundaries:-

Laterally- ramus of mandible and temporalis muscle

Medially-medial pterygoid plateand lateral pterygoid muscle

superiorly - infratemporal surface of greater wing of sphenoid

Inferiorly- lateral pterygoid muscle

Anteriorly- infratemporal surface of maxilla

Posteriorly -parotid gland

CLINICAL FEATURES:-

Extraoral- trismus

Bulging of temporalis muscle

Marked swelling of the face on the affected side in front of the ear overlying area of tmj

Intra oral –swelling in tuberosity area with elevation of temp 104F


Intraoral approach- incision is given in buccal vestibule opposite 2nd and 3rd molar exploration is carried out medial to coronoid process and temporalis muscle upwards backwards with sinus forcep ,space is entered and drained

Extra oral approach- incision is made at upper and posterior edge of temporalis muscle within hairline.

Sinus forcep directed upward medially

Pus is evacuated

Infections originating from 6 anterior mandibular teeth then perforate cortical plate below the origin of mentalis muscle labially ,mylohyoid lingually

It can also affected from lower incisors , lower lip, skin overlying the chin, anterior part of floor of mouth,

tip of tongue and sublingual tissues

BOUNDARIES:-

Lateral- lower border of mandible and anterior bellies of digastric

Superior:- mylohyoid muscle Inferior:- suprahyoid portion of the investing

layer of deep cervical fascia

CLINICAL FEATURES:- Extraoral findings- distinct,

firm swelling in midline beneath the chin

Skin over the swelling is board like taut

Intraoral findings- the anterior teeth are either non-vital fractured or carious .

The offending tooth may exhibit tenderness to percussion may show mobility

Spread: of infection-

Posteriorly- to involve submandibular space

It may discharge on the face in the submental region


A transverse incision is made in the skin below the symphysis of the mandible.

Blunt dissection is carried out by inserting a kelly’s forcep through this incision ,upward ,backward

Then corrugated rubber drain is inserted in the abscess cavity and sutured

The space lies between the anterior and posterior bellies of digastric muscle.

Upper part lies beneath the inferior border of mandible and lower part lies deep to the investing layer of deep cervical fascia

INVOLVEMENT

Infections originating from mandibular molars, pus perforates the lingual cortical plate of mandible passes directly into the submandibular space

Infection from submental space

Infection from posterior part of sublingual space

Infections from middle third of the tongue, posterior part of floor of mouth, maxilary teeth, cheek, maxillary sinus, palate

BOUNDARIES:- Anteromedially:- floor is

formed by mylohyoid muscle

Posteromedially:- floor is formed by hyoglossus muscle

superolaterally :- medial surface of mandible

Anterosuperiorly:- anterior belly of digastric

Posterosuperiorly:- posterior belly of digastric

CLINICAL FEATURES:-

Extra oral:- firm swelling in the submandibular region, below inferior border of mandible

Redness of overlying skin

Intra oral:- teeth are sensitive to percussion

Teeth are mobile

Dysphagia

Moderate trismus


There is no major anatomic barriers so infection can extend into submental space

There is no anatomical barrier so infection can spread easily across the midline involve submandibular space on other side

It communicates with sublingual space around posterior border of mylohyoid muscle

It can also spread into parapharyngeal space

An incision of about 1.5 to 2 cm length is made 2cm below the lower border of mandible

Skin and subcutaneous tissues are incised

Sinus forcep is inserted through the incision superiorly and posteriorly on the lingual side of mandible below the mylohyoid to release pus from submandibular space


Space is a “V” shaped trough lying lateral to muscles of tongue including hyouglossus, genioglossus, geniohyoid

Involvement:- mandibular incisors, canines, premolars , sometimes molars

It is a paired space but the 2 sides communicates anteriorly, with submandibular space around the posterior border of mylohyoid muscle

BOUNDARIES:- Inferiorly- mylohyoid muscle

Laterally:- medial side of the mandible above mylohyoid muscle

Medially:- hyoglossus, genioglossus & geniohyoid muscles

Posteriorly:- hyoid bone

Laterally and inferiorly:- mylohyoid muscle and lingual side of mandible

CLINICAL FEATURES:-

Extraorally: there is little or no swelling.

The lymph nodes may be tender & enlarged

Pain and discomfort on deglutition

Intraorally: firm, painful swelling seen in the floor of the mouth

Floor of the mouth is raised

Tongue pushed superiorly will cause airway obstruction


Infection crosses the midline and effect the space on the opposite

Infection from posterior inferior part of the space spread into submandibular space-> pterygomandibular and parapharyngeal space

Infection spread via lymphatics to the submandibular or submental lymph node

INCISION & DRAINAGE:- Inraorally:- incision is made

close to the lingual cortical plate, lateral to sublingual plica (whartons duct, sublingual artery,veins & lingual nerve)

Sinus forceps is then inserted and openeed to evacuate the pus

Extraorally:- when both submental and sublingual space contains pus they can be drained by placing incision in submental region

MANAGEMENT OF OROFACIAL INFECTIONS Antibiotic therapy:-

Use of penicillin G (2 to 4 million units, IV 4 to 6 hrs)and

metronidazole(400 mg 8 hourly orally or IV)

Oral clindamycin

Amoxicillin-clavulanic acid(augmentin)

1st and 2nd generation cephalosporins are useful in orofacial infections

In compromised patients- clindamycin alone 300 to 600 mg 8 hourly IV)

Or in combination with gentamycin ( 80 mg IM) can be given

SURGICAL THERAPY

Hilton’s method of incision and drainage

The method of opening an abscess ensures that no blood vessels or nerve is damaged

Incision helps to get rid of toxic purulent material

To allow better perfusion of blood containing antibiotic and defensive elements

To increase oxygenation of infected area

HILTON’S METHOD OF INCISION AND DRAINAGE

Topical anesthesia:- achieved with the help of ethyl chloride spray

Stab incision:- it is made over the point of maximum fluctuation in the most dependent area through skin and subcutaneous tissue

Deepening of surgical site is achieved with sinus forceps

Closed forceps are pushed through deep fascia move towards the pus collection

Abscess cavity is entered and forceps is opened in a direction parallel to vital structures

Pus flow along side of beaks

Explore the entire cavity for additional loculi

Placement of drain:- A corrugated rubber drain is inserted into depth of abscess cavity & external part secured with suture

Drain is left for 24 hrs

Dressing:- applied over the site of incision taken extraorally without pressure

INVOLVEMENT OF MULTIPLE PRIMARY SPACES LUDWIG’S ANGINA It is a firm, massive, brawny cellulitis and acute, toxic stage involving

simultaneously submandibular, sublingual, submental space bilaterally

It means “suffocation or choking sensation” Clinical features:- There is pyrexia, anorexia , chills, malaise

Severe muscle spasm may lead to trismus with restricted mouth opening and also jaw movements

Tongue movements may be reduced

Air obstruction

Fatal death may occur in untreated case of Ludwig’s angina within 10 to 24 hours due to asphyxia

TREATMENT OF LUDWIG’S ANGINA Early diagnosis

Maintenance of the patient airway

Intense and prolonged antibiotic therapy

Extraction of offending teeth

Surgical drainage or decompression of fascial spaces

THANK YOU

Healthcare

Primary spaces of space infection