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RETROSPECTIVE STUDY

Received: 12 October 2008 / Accepted: 05 February 2010© Association of Oral and Maxillofacial Surgeons of India 2009

A retrospective study of 256 patientswith space infection

Manisha Gupta1 · Virendra Singh2

1 Senior Lecturer2 Associate Professor

Dept. of Oral and Maxillofacial SurgeryPostgraduate Institute of Medical Sciences,Haryana

Address for correspondence:

Manisha GuptaDept. of Oral and Maxillofacial SurgeryITS Dental College and HospitalDelhi-Merrut Road, Ghaziabad, IndiaPh: +91-9899978166E-mail: manishaa_h@yahoo.co.in

AbstractAim The purpose of this study was to retrospectively evaluate a series of patientswith space infection.Patients and methods In this study 256 patients with space infection over aperiod of two years were treated with intravenous antibiotic and prompt incisionand drainage followed by culture and sensitivity tests in some cases. Datacollection included demographic, anatomic treatment and complicationinformation.Results The sample consisted of 256 patients with a mean age of 28 years. 7patients were immunocompromised and 20 female patients were pregnant out of84 female patients who were included in the study. Caries followed by implantfailure were identified to be the most frequent cause for space infection. Trismusand dysphagia were present in over 70% of the cases. The vestibular masticator,perimandibular (submandibular, submental and/or sublingual) and parapharyngeal,submaxillary spaces were involved. Abscess was found in 76% of the cases. All thepatients were drained under local anesthesia or conscious sedation except onepatient who was drained under GA. Three deaths occurred.Conclusion This study indicated that prompt incision and drainage along withintravenous antibiotic under local anesthesia or conscious sedation was themainstay of treatment of severe space infection. Patients were relieved of theirsigns and symptoms by third day, however trismus may persist for 5–7 days.

Keywords Odontogenic space infection · Incision and Drainage · Spaces

Introduction

Spaces as defined by SHAPHIRO are thepotential spaces between the layers of fascia,normally filled with loose connective tissueand various anatomical structures like veins,arteries, glands, lymphnodes etc [1,2]. Spaceinfections have varied etiology and occur invarious spaces based on the cause ofinfection in its anatomical vicinity. When leftuntreated, space infections spread andinvolve not just one space but also itsadjacent space and sometimes develop intolife threatening infections leading to death[3]. Studying past space infections and theircourse of treatment will help us deal withfuture space infections effectively. Thespecific aim of this study was (a) to evaluatethe effect of incision and drainage i.e. howpromptly it achieves best result (b) toevaluate the effect of removing the etiology

at the same time. It was found that in someinstitutions, prompt incision and drainagewas not done and the patients were kept onIntravenous antibiotic for long time.

Patients and methodsStudy design/Sample

In this study 256 patients wereretrospectively evaluated with severeodontogenic space infection. Patients wereincluded in this study based on the followingcriteria: severe space infection which wasdetermined on the basis of suggestive signand symptoms. Informed consent wasobtained. The criteria for hospital admissionwas: Odontogenic infection causing swellingin one or more of the deep fascial spaces ofhead and neck impending threat to theairway or vital structure, fever greater than

101° F, need for a general anesthesia or theneed for in-patient control of concomitantsystemic disease. All the medicallycompromised patients and pregnant femalesand infections due to non-odontogeniccauses were also included. Previouslypublished nomenclature and description ofthe deep fascial spaces were used for thepurpose of this study.

Treatment methods

All the patients were subjected to the sametreatment protocol (Fig. 1) [7]. The patientswere prepared for surgery as soon aspossible after appropriate premedicalworkup. Premedical workup included casehistory taking, physical examination,complete hematological work up, urineanalysis, appropriate imaging studies like

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History and physical examination

Fig. 1 Stepwise protocol for the management of space infection

Medicallycompromised Non compromised

Appropriate lab investigations

Incision and Drainage

Copious irrigation with saline andH2O2

Removal of etiology

Maintenance of patency withcorrugated rubber drain

Antiseptic dressing

Spaces again explored to dainresidual pus

Irrigation

Physiotherapy

Intra Oral Peri-Apical (IOPA) radiograph,Orthopantamogram (OPG) and medicalopinion. Skin and mucosa were preparedwith antiseptic solution. Incision anddrainage had been performed for allanatomic spaces that were infected due tocellulitis or abscess. Specimen for cultureand sensitivity tests had been harvested byeither aspiration or by swap sampling ofopen surgical wound [4]. All spaces thatwere opened were copiously irrigated withsaline and hydrogen peroxide and weremaintained with rubber-corrugated drains.The odontogenic or nonodontogenicetiology had been removed during the sameappointment. The following day the spaceswere explored, any residual pus drained,wound irrigated and dressing had beendone. Physical therapy had been advised.If patient had severe trismus patient hadbeen adviced spoon exercise and they weresent for physiotherapy.

Data collection

Data was analyzed retrospectively and thedemographic variables like age, gender,and pre-admission variables such as thepresence of immuno-compromised state(diabetes, HIV, hepatitis B, chronic renalfailure) were noted. Preoperative clinicalvariables included causative teeth,nonodontogenic cause, sign and symptomsassociated with severe infection. Theanatomic variables included deep fascialspaces involved by cellulitis or abscessand number of spaces affected. Thetreatment variables included the anatomicspace drained and presence or absence ofpus at the time of drainage. Stage ofinfection was recorded as abscess if therehad been presence of pus, and if not, stageof infection was recorded as cellulitis. Allthe patients were drained under localanesthesia or conscious sedation exceptone who had been drained under generalanesthesia. The complications recordedwere post drainage trismus, further spreadof infection, trigeminal nerve deficit anddeath.

Results

256 patients (172 male, 84 female) whoseage had ranged between 1½ to 75 years.7 patients were immunocompromised, 40patients were diabetic, 2 patients werechronic renal failure, 20 patients werepregnant. In this study, it was observedthat maximum number of patient were

lesser than 30 years of age and infectionwas mainly due to either erupting 3rdmolar or carious 2nd or 1st molar (Fig.2). Of the 256 patients 86 patients hadsubmandibular space infection, 75 patientof vestibular space infection, 4 patienthad necrotising fasciitis and in 2 patientinfection spreaded to mediastinum. Themost commonly space infected wasvestibular followed by submandibularand buccal space infection. Some patientshad infection in more than one space thushaving multiple space infection creating

an over lap which is showing the pie chart(Fig. 3). Most of the patients wererelieved of sign and symptoms ofinfection by third day. Out of 20 immuno-compromised patients, 3 patients losttheir l ife because complicatonsprecipitated by their medical state. Onepatient died of septic shock. 76% casesyielded pus. One patient who was drainedunder GA was mentally challenged withLudwig angina with further spread. 3deaths occurred and all three wereimmuno-compromised.

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Discussion

Space infection ranges from superficial todeep neck infection and they follow the pathof least resistance through connective tissueand along fascial plane [5]. Space infectionare often accompanied by systemic changeslike fever, nausea, chills, andlymphadenopathy [6]. So there is a needfor early recognition and referral. If thesespace infections are not recognized early,they can cause considerable morbidity andeven death.

The present study was undertaken toretrospectively analyse the patient withsevere space infection to know the mostcommon etiology, to standardize a protocolfor management of space infection. Spaceinfection like submandibular, submassetric,mediastinal, lateral pharyngeal space wasdrained extra-orally while infection likevestibular, pterygomandibular, buccalinfection were drained intra-orally.

In all the patient, same standardizedprotocol was followed starting fromhistory clinical examination, labinvestigation, ultrasound if necessary, I.V.antibiotic, incision and drainage extra-orally or intra-orally, copious irrigationwith saline and hydrogen peroxide, drainto maintain the patency of opening. Labinvestigation like complete haemotologywere done in each patient while specificinvestigation like ELISA, Hepatitis Bsurface Ag, serum creatinine were done inimmuno compromised patient. During labinvestigation, it was found that bloodsugar level rises upto 200 mg% or beyond200 mg% in severe infection and asdisease was controlled, blood sugar cameto normal level [8]. As most of patientswith severe space infection are oftendehydrated, the type of intravenous fluidto be adminstered had been selecteddepending upon the stage of infection. Asper the stage of infection Dextrose NormalSaline (DNS) had been avoided in thepatient, and were given Ringerlactatesolution (RL) to keep the balance of serumelectrolytes.All the pregnant women whowere treated were in their second trimesterand were treated after getting fittness fortreatment from their gynecologist.

All patients had recovered well exceptcases with submassetric space infectionwhere trimus was found to be acomplication which had persisted for 2–3days and in some cases lasted upto 5–7days. Trismus patients were advisedphysiotherapy for mouth opening. Likeevery surgical procedure incision and

drainage also has some disadvantages likein cases of extra-orally drainage it leaves ascar. But prompt treatment, a course ofantibiotics and follow-up has producedgood results. It is a painful procedurebecause if carried out under localanesthesia. Sometime, the patient alsocomplaint of numbness of lower lip whichmay persist for sometime. Despite thedisadvantages, immediate treatment withincision and drainage may lead to septicshock and death. So timely recognition ofspace infection is very important.

Conclusion

Space infections occur due to spread ofinfection form anatomical locations in thevicinity of the space [8]. In case ofimmunocompromised patients andpregnant women a course of prophylacticantibiotics will help reduce the risk ofspread of infection. In this study it is shownthat one the most effective treatmentprotocols is for immediate treatment withincision and drainage for medically healthypatients. A more extensive study with asample of varied age group would help uscome to a conclusive decision for thetreatment protocol for space infections.

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Fig. 2 Etiology of infections

Fig. 3 Type of infections

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