DEEP FASCIAL SPACE INFECTIONS PART-2

ARJUN SHENOY

DEPT OF OMFS

• MASSETRIC SPACE

• LUDWIGS ANGINA

• PHARYNGEAL SPACE

• RETROPHARYNGEAL SPACE

• CAVERNOUS SINUS THROMBOSIS

• MEDIASTINITIS

• CONCLUSION

• REFERENCES

MASTICATORY SPACEMASSETRIC + PTERYGOID + TEMPORAL

MASTICATOR SPACE

• Massetric, pterygoid and temporal- well differentiated

• Communicate with each other

• Also with

• Buccal

• Submandibular

• Parapharyngeal

• MASTICATOR SPACE CONTENTS-

• Muscles of mastication

• Internal maxillary artery

• Mandibular nerve

SUBDIVISION

• MASSETRIC SPACE-

• Lateral- masseter

• Medial- mandibular ascending ramus

• PTERYGOID-

• Lateral-mandible

• Medially- pterygoid muscle

• Communication-

• Superiorly- superficial and deep temporal space

• Anteriorly- buccal space

• Posteriorly- lateral pharyngeal space

ORGIN

molar (commonly 3rd molar)Contaminated injectionsTemporocranial flaps - neurosurgeryNearby contiguous spacesCircumzygomatic wiring in traumaTMJ surgery

• Clinical hallmark- trismus

• Exception- immunocompromised

• Swelling – may not be prominent

• Infectious process deep to muscles -

• swelling less prominent

• contrast to buccal space infections

•

SICHER’S APPROACH

• Sicher suggested approach to all compartments – incision through pterygomandibular raphae

• Feasible in cadavers - not trismus

• Oral approach-compromise airway

• purulent oozing pus

• Difficult drain - loosening

I & D• MASSETRIC + PTERYGOID SPACE-

• Extra-oral – easier technically & prudent

• Sharp dissection - external angle of the mandible

• Allows dependent drainage of both spaces

SURGICAL INTERVENTION

• TEMPORAL SPACE –

• Intra-oral- sichers-incision

• Percutaneous-

• incision -slightly superior-zygomatic arch

LUDWIGS ANGINAWilhelm Frederick von Ludwig

DEFINITION

• Ludwigs angina is a firm , acute, toxic cellulitis of the submandibular and sublingual spaces bilaterally and of the submental space

• Three F’s

• Feared

• Not fluctuant

• Fatal

HISTORICAL PERSPECTIVE

• Wilhelm Frederick von Ludwig first described in 1836 a potentially fatal, rapidly spreading soft tissue infection of the neck and floor of the mouth

• Ludwig published his now-famous paper on

Ludwig's angina with no title in 1836.

• A colleague dubbed the condition "Angina Ludovici" (Ludwig's angina) a year later

• Pre-antibiotic era- 50% mortality

• 5%- use of penicillin

• observed frequently in compromised host

• Less than 1% of all OMFS admissions

• Untreated- mortality rate 100%

• Compound mandibular fracture

• Puncture wounds of oral floor

• Secondary infection of oral malignancies

• Submandibular gland sialadenitis

• Oral soft tissue lacerations

• Reported in new born

• Pseudo-ludwigs angina /phenomenon- non dental

CLINICAL FEATURES

• Bilateral infection of sublingual and submandibular spaces

• brawny edema,

• elevated tongue

• airway obstruction

• paucity of pus

MICROBIOLOGY

• Streptococci or mixed oral flora are commonly reported from cultures

• Contemporary- Ecoli ,pseudomonas and anaerobes bacteroides and peptostreptococcus

• Prevotello melaninogenicus, prevotella oralis, prevotella corrodens also isolated

DIFFERENTIAL DIAGNOSIS

• angioneurotic edema

• lingual carcinoma

• sub- lingual hematoma

• salivary gland abscess

• lymphadenitis

• cellulitis

• peritonsilar abscess

TREATMENT• Establisment and maintainance of an adequate

airway are the sine qua non of therapy

• Early diagnosis,maintainance of patent airway, intense empirical and intra-venous prolonged antibiotic therapy, extraction of affected teeth, hydration, early surgical drainage,

• Pencillinplus, metronidazole or clindamycin or imipenem

TRACHEOSTOMY• Death more likely to occur from airway obstruction than

sepsis

• Tracheostomy most routine during most of twentieth century

• Difficult to perform in late stage –massive neck oedema and tissue distortion

BLIND NASAL INTUBATION

• Swollen tongue and glottis oedema- time consuming , unsuccessful and fraught with danger especially if attempted by inexperienced anaesthesiologist.

• Danger of rupturing a bulging lateral pharyngeal or retropharengeal abscess

FIBRE-OPTIC ASSISTED INTUBATION

• Cervical soft tissue plain films + CT scan

• fiberoptic laryngeoscopy- premedicated +cooperative patient

• Tracheal intubation under deep inhalation anaesthesia may be successful obliviating the need for tracheostomy

SURGEONS PERSPECTIVE

• Sedative and narcotic agents- rapid respiratory deterioration

• Some authorities advocate high doses of antibiotic without surgery until fluctuance develops, in most surgeons experience prompt and deep surgical incision is required since fluctuance is uncommon and late

• Diffuse cellulitis of deep spaces – 70% cases require surgical intervention and drainage

• “A chance to cut is a chance to cure”

INCISION• Horizontal incision midway between the chin and the

hyoid bone - classic approach to the surgical drainage - ludwigs angina

• “cut-throat”incision unaesthetic and unnecessary

• Platysma and supra-hyoid fascia incised by this approach

• Fascia of submandibular gland also entered

• Mylohyoid muscle divided and sublingual space entered

• A closed clamp is inserted through the median raphae of mylohyoid muscle and advanced to the hyoid bone at the base of the tongue

NEEDLE ASPIRATION

• Needle aspiration of deep fascialspace infection has been attempted obliviating need for open drainage

• Ludwigs angina not amenable to this technique even if needle is CT guided

• may result in reinfection

• adequate drainage or premature closure of surgical

DRAIN PLACEMENT• Bilateral incision into the submandibular spaces with

blunt dissection to the midline suffices if a through and through drain or bilateral drains meeting in midline are placed combined with drainage of sublingual space

• Relieves intense pressure of oedematous tissue on the airway and provides specimen for culture

SCAR REVISION• Secondary revision of scarring may be necessary for

cosmetic or to repair the stenosis of whartons duct

• Disseminated intravascular coagulation-well recognized but fortunately uncommon sequelae of severe infection

PHARYNGEAL SPACE INFECTION

PHARYNGEAL SPACE• Lateral neck space shaped like a inverted cone

• Base at skull and apex at the hyoid bone

• Medial wall contiguous with carotid sheath ,lies deep to pharyngeal constrictor muscle

• Divided into anterior and posterior compartments

CAUSES

• Pharyngitis

• tonsillitis

• parotitis

• otitis

• mastoiditis

• dental infection

• Herpetic gingivostomatitis involving pericoronal tissue

CLINICAL FEATURES• Anterior compartment-

• Pain, fever,chills

• Medial bulging of the lateral pharengeal wall

• Deviation of palatal uvula from midline

• Dysphagia, swelling below angle of mandible

• Posterior compartment-

• Visible swelling with absence of trismus

• Respiratory obstruction

• Septic thrombosis of internal jugular vein

• Carotid artery haemorrhage - later stage

TREATMENT

• CT more useful than standard radiographs

• Therapy-antibiotic, surgical drainage, tracheostomy if indicated

• Surgical approach – oral - incision of the lateral wall

• External approach- exposure of carotid sheath-lateral tip

• of sternocleidomastoid- retraction of sternocleidomastoid

• Blunt dissection along posterior border of digastric muscle leads to lateral pharengeal space

• Combined intra-oral + extraoral approach – mucosal incision – lateral to pterygomandibular raphae , large curved clamp passed medial to medial pterygoid muscle in a posterior-inferior direction.

• Tip of clamp delivered through skin- cutaneous incision between the angle of the mandible and the sternocleidomastoid muscle

RETROPHARYNGEALSPACE INFECTION

RETROPHARYNGEAL SPACE

• Space lies behind the esophagus and pharynx and extends inferiorly to the upper mediastinum and superiorly – base of skull

• Orgin- nasal or pharyngeal infection in children

• Oesophageal trauma, foreign bodies, tuberculosis

• Symptoms-

• Dysphagia

• Dyspnea

• Nuchal rigidity

• Eosophageal regurgititation

• fever

• Visualization of pharynx- bulging of posterior wall – more prominent unilaterally

• Adherance of median raphae to prevertebral fascia

• Lateral soft tissue radiographs useful

• widening of retropharyngeal space

• >3-6mm adults >14mm children (2nd vertebra)

• Presence of gas in prevertebral soft tissue

• Loss of normal lordtic curvature of cervical spine

• CT- inferior extent + plain films

TREATMENT• Early cases 10-40% resolve with medical management

• Prompt surgical drainage – protocol

• Tracheostomy indicated

• Transoral approach- Extreme trendelenburg position and constant suction- under LA

CONTINUED

• Transoral- incision through midline of posterior pharyngeal mucosa-blunt dissection

• Exernal approach- dependent

• Incision- anterior border of STM

• Muscle+carotid sheath retracted medially

• Blunt finger dissection deeply

• Upto level of hypopharynx

• Deep drains placed + maintained

• Overall mortality rate – approx. 10%

CAVERNOUS SINUS THROMBOSIS

• Orgin- ascending rom maxillary teeth, upper teeth, nose or orbit

• Through valveless anterior and posterior fascial veins

• Extremely high mortality rate

INITIAL SIGNS• Proptosis

• Fever

• Obtunded state of consciousness

• Ophthalmoplegia

• Paresis of –

• occulomotor

• trochlear + abducens nerve

MEDIASTINITIS• Extension of infection from deep neck spaces into the

mediastinum

• C/F –

• Chestpain, fever

• Severe dyspnea

• Mediastinal widening

• IV drug abusers- greater risk

CONTINUED• Late complication

• Progressive septicemia-mediastinal abscess-pleural effusion-empyema-pericarditis

• Necrotizing mediastinitis- aerobic+anaerobic

• Treatment- extensive long term antibiotic therapy and surgical drainage of mediastinum

• Emergency neurosurgical intervention

CONCLUSION• Incidence and severity have diminished with advent of

antibiotic therapy

• To be alert to the potential seriousness of these infections-never to be dismissed as simple dental abscess

• Deep fascial infections must be recognized promptly and treated as an emergency

• Repeat diagnostic and therapeutic measures may be necessary until the very end point

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