DEEP FASCIAL SPACE INFECTIONS

ARJUN SHENOY

DEPT OF OMFS

• HISTORY

• PRINCIPLES OF EXAMINATION

• CLASSIFICATION OF SPACES

• ANATOMICAL CONSIDERATIONS

• PATHWAYS OF SPREAD

• DIAGNOSTIC AIDS

• SPACES

• COMPLICATIONS

• CONCLUSION

• REFERENCES

“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”

INTRODUCTION

Shapiro defined fascial spaces as potential spaces between the layers of the fascia

Filled by connective tissue

HISTORY

• 1938 landmark article - Grodinsky & Holyoke - modern understanding

Injection dyed gelatinCadaversSelective portals

HYPOTHESIS- spread hydrostatic pressureGuided tissue resistance

• 1939- Ashbel Williams – 31cases Ludwigs angina (54%)

• 1979- Hough et al – (4%)

PRINCIPLES OF EXAMINATION

Rapid initial assesment

Complete history Physical examination Imaging and laboratory data

Immediate hospitalization with

aggressive intervention

DATABASE

TOXICITY SIGNS

• Paleness

• Tachypnea

• Tachycardia

• Fever

• Shivering

• Lethargy

• diaphoresis

Decreased level of consciousness

Evidence of meningeal irritation-1) Severe headache2) Stiff neck3) vomiting

PATHWAYS OF SPREAD

ANATOMICAL CONSIDERATIONS

• MUSCLE ATTACHMENTS-

• Posteriors= Buccinator- midroot level

• Anteriors –intrinsic lip muscles & risorius

BUCCINATOR & ODONTOGENIC INFECTION

In maxilla Above the attachment

Root apex Extraoral

Below the

attachment

Intraoral swelling

(In Mandible it is vice versa)

MYLOHYOID & ODONTOGENIC INFECTIONS

Anteriors Posteriors

(Root apex below) (Root apex below)

Intraoral Extraoral

(Floor of the mouth) (submandibular)

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

DIAGNOSTIC IMAGING

• ACCURATE DIAGNOSIS

• GUIDING DRAINAGE PROCEDURES

• EXTENT

• DETECTING COMPLICATION

PLAIN FILM OPG

• Extent of pathology of

odontogenic orgin

• AP/LATERAL CERVICAL

• Lesser penetration c-spine

• Pharyngeal/ cervical

airway

COMPUTED TOMOGRAPHY

• Widely used - 5mm increments

• Contrast enchanced - 95% sensitivity

• Assess integrity cortical bone

• Short time –extent , epicentre

• Availability

• Relative low cost

ULTRASONOGRAPHY

• Superficial

• inability-osseous penetration

• Parotid /submandibular/ neck

• Differentiates solid / cystic

MAGNETIC RESONANCE IMAGING

• Not uncommon

• Coronal and saggital planes

• T1- anatomic detail

• T2- disease process sensitive

• Intravenous contrast agents- safer

• T1 + gadolinium

FASCIAL SPACES OF CLINICAL SIGNIFICANCE*FACE

o Buccalo Canineo Masticator Massetric compartment Pterygoid compartment Zygomaticotemporal compartment

SUPRAHYOIDSublingualSubmandibularLateral pharyngealPeritonsillar

* RICHARD G TOPAZIAN , ORAL & MAXILLOFACIAL INFECTION 4TH EDITION

CONTINUED

INFRAHYOID Anterovisceral (paratracheal)

SPACE OF TOTAL NECKRetropharyngealDanger spaceSpace of carotid sheath

RICHARD G TOPAZIAN , ORAL & MAXILLOFACIAL INFECTION 4TH EDITION

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

Based on mode of involvement

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

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

ANTIBIOTIC THERAPY• EXCEPTIONS

• Well localized- easily drained –dentoalveolar abscess

• INCLUSION

• Poorly localized

• Extensive abscess

• Diffuse cellulitis

• Immunocompromised

• Systemic signs

INCISION AND DRAINAGE

• Incison- healthy skin/ mucosa- natural crease

• Site- max fluctuance- unaesthetic scar

• Dependent –

• Dissection- blunt- full extent

• Stabilize drain

• Remove on time

RECENT ADVANCES

• Two mini incisions, 4-5 mm each, far apart

• Abscess probed, pus drained.

• Abscess was irrigated -normal saline

•

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

BUCCAL SPACE

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.

C/F

• Marked cheek swelling

• Diseased premolars/molars

• Fluctuance

• DD-complication of crohns

disease, H Influenzae

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

TREATMENT

• Intra-oral

• Attempts to direct- futile

• Drainage difficult

• Cutaneous

• Inferior to point of fluctuance

• Incision- stensons duct

• Blunt dissection- extreme borders

H INFLUENZAE

• Infants and children <3 yrs

• High fever 24 hours prior onset

• Otitis media - recent

• Augmentin/cephalosporin

SUBMENTAL SPACE

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.

Source of infection

incisors submandibular

• Intra-oral – non dependent

• Through mentalis –labialvestibule

• Percutaneous-

• horizontal incision-

• most inferior portion of the chin- natural skin crease

CANINE SPACE

• Infrequent

• Levator muscle – upper lip

• Perforates lateral cortex-

Potential canine space

True fascial space/muscular compartment??

Marked cellulitis of eyelids

• Drainage – intra-oral approach

• High maxillary vestibule- sharp blunt dissection

• Approach- extension of apicectomy- canine root

Percutaneous drainage

visible scar non dependent drainage

SUBMANDIBULAR + SUBLINGUAL SPACE

• Anatomically distinct

• Proximity + frequent dual involvement

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

• 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.

TREATMENT• Surgical drainage, antibiotics

• Definitive care of the primary dental infection

• INTRAORAL-

• by an incision through the mucosa parallel to Wharton's duct bilaterally.

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

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

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

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

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