arush space inf

8/10/2019 Arush Space Inf

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Man ag em en t of sp ace

infec t ions

Guided by - Dr. S.M KOTRASHETTI

Presenter - Dr. ARUSH SHAH


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CONTENTSFascial spaces

Anatomical boundaries

Stages of InfectionSigns and Symptoms

Primary and Secondaryspaces

Microbiology

Antibiotic therapy

Diagnostic radiology

Surgical Operative Protocol

Recent advances


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Fascial Spaces

Fascia

Fascial spaces

Fascial space infections


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FASCIAL SPACES

Fascial planes offer anatomic pathways for infection tospread from superficial to deep planes.

Antibiotic availability in fascial spaces is limited due topoor vascularity.

Fascial spaces are contiguous and infection readilyspreads from one space to another (open primary andsecondary spaces).


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Primary and secondaryspaces

Primary -

Secondary

Bacterial infection appears to spread by hydrostaticpressure , they follow the path of least resistance(looseareolar connective tissue around muscles enclosed byfascial layers)


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STAGES OF INFECTIONInnoculation Cellulitis Abcess

0-3 days 3-7 days >5days

Mild -moderate Severe and generalised Moderate -severe

Soft, mild, tender Hard ,tender Fluctuant ,tender

Aerobic Mixed Anerobic


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SIGNS AND SYMPTOMS

Pain

Swelling

Surface erythema

Pus formation

Trismus

LOCALLY


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SYSTEMIC SIGNS AND SYMPTOMS

Fever

Dehydration

Lymphadenopathy

Malaise

Toxic appearance

Elevated white blood cell count


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Submental space

Infection from- Anterior mandibular teeth

and from Submandibular space.

E/o- distinct firm swelling in midline benath the chin..skin over swellingis board like and taut..fluctuation may be present

I/o- anterior teeth either non vital, fractured or carious, TOP n mobilitymight be present..significant discomfort in swallowing

Clinical features:


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Clinical Features


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SUBLINGUAL SPACE

Infection from sub-lingual space canpass to Lateral Pharyngeal spacethrough Buccopharyngeal gap.

Sub-lingual and Sub-mandibular spacescontinuous at posterior border of

Mylohyoid muscle.


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Clinical Features

E/o..little or no swelling..enlarged lymphnodes..tender..pain n discomfort in

deglutition..affected speech

I/o..firm painful swelling in floor ofmouth..floor raised..tongue maybe pushed

superiorly which might lead to airwayobstruction..ability to protrude tongue beyond vermilion border is affected..


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BUCCAL SPACE

Sub-cutaneous space between facial skin andbuccinator muscle.

Both a primary mandibular and maxillary space


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Clinical Features:

Posteriorly, buccal space comminucates superficiallywith Sub-masseteric space.

Medially with Pterygomandibular spaceAlso with Infra-temporal space superior to lateral

pterygoid musclePosterior to pterygomandibular raphe, with Lateral

pharyngeal space

Via buccal pad of fat with Superficial temporal space


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SECONDARY MANDIBULARSPACES

Referred to as secondary spaces since they are infectedafter involvement of primary mandibular spaces

Failure to treat a primary space infection or a compromisedhost results in secondary space involvement

The secondary mandibular spaces include the masseteric,pterygomandibular, and temporal spaces


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SUB-MASSETERIC SPACE

A Boundaries- Anterior-Posterior-Superior-Inferior-

Lies between anterior layer of Deep cervical fascia

( parotidomasseteric fascia) and lateral surface of ascending ramusof mandible


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Communicates with Pterygomandibular space throughSigmoid notch.

Communicates with Superficial temporal space deep tozygomatic arch and above temporalis muscle.

Clinical Features:


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TEMPORAL SPACE

Located- posterior and superior to the masseteric andpterygomandibular spaces

Two components:1 Superficial temporal space: located between temporal

fascia and temporalis muscle2 Deep temporal space: located between the temporalis

muscle and the temporal bone

Continuous with the infratemporal space


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SUPERFICIAL TEMPORAL SPACE

Between Temporal fascia and temporalis muscle

Boundaries-

Anterior-

Posterior-

Inferior-


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Clinical featuresPain

Trismus

Swelling over temporal region may or may not bepresent


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INFRATEMPORAL SPACE

It is a portion of deep temporal space that lies inferior toinfratemporal crest of sphenoid bone.

Boundaries-Lateral-

Medial-

Inferior-

Superior and posterior-

Anterior-


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Clinical FeaturesE/o- marked trismus..bulging of temporalismuscle..marked swelling of face on affected side infront of ear overlying TMJ behind zygomatic process..

Eye- closed n proptosed..I/o-swelling in tuberosity area


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PTERYGOMANDIBULAR SPACE

Boundaries Anterior-Posterior-Superior-

Inferior-Medial-Lateral-


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Involved with pericoronitis of 3rd molar.

Infection can spread to Infra-temporal space by passingaround lateral pterygoid muscle.

Also to Lateral pharyngeal by passing around anteriorborder of medial pterygoid , following posterolateralsurface of buccinator and superior pharyngealconstrictor.

Needle track infections


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Clinical featuresSevere degree of trismus..no significant extraoralswelling..tenderness medial to ant border of mandramus..dysphagia..medial displacement of lat pharwall..redness and edema arnd 3 rd molar..uvuladisplaced to unaffected side..breathing difficulty..


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PRIMARY MAXILLARY SPACES

CANINE SPACE-

Boundaries-

Infection from


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AREAS OF SPREAD IN INFRAORBITALSPACE INFECTIONS


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BUCCAL SPACE

1. Posterior maxillary teeth are source of most buccal spaceinfections

2. Results when infection erodes through bone superior toattachment of buccinator muscle


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Etiology and microbiology

Cellulitis -

Abscess -

Aerobic and facultative AnaerobicViridans streptococci Prevotella species

Staphylococcus aureus Fusobaterium nucleatum

Streptococcus pyogens Viellonella species

Streptococcus pneumoniae Bacterioids speciesCornybacterium species Eubacterium species

Escherichia coli

Haemophilus influenzae


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Antibiotic therapy:Gram staining to detect the presence of Gram

positive and Gram negative organisms in thespecimen.

Aerobic culture for alpha hemolytic streptococci

Anaerobic culture transport with needle inserted intoa sterile rubber stopper or bent at 90degree to shut offair into the syringe or in and oxygen free gas container.

Empirical therapy- start with narrow spectrum antibitoticdepending on the possibility of organisms involved.

Combination of Broad spectrum antibiotics to be usedwhen the cause of infection is unknown.


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Identification of etiologic bacteria

1. Expected causes are alpha hemolytic streptococci andoral anaerobes

2. Cultures should be performed on all patientsundergoing incision and drainage and sensitivities

ordered if patient is not progressing well (possibleantibiotic resistance)

3. An aspirate of the abscess can be performed and sentfor culture and sensitivities if incision and drainage

delayed


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Selection of antibiotictherapy

1. Parenteral penicillin2. Metronidazole in combination with penicillin

can be used in severe infections

3.Clindamycin for penicillin-allergic patients

4. Cephalosporins (first-generationcephalosporins)

5. Antibiotics do not substitute for incision anddrainage in cases of significant odontogenicinfections

6. Causes for clinical failure include inadequatedrainage or antibiotic resistance


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DIAGNOSTIC IMAGING OF MAXILLOFACIAL ANDFASCIAL SPACE INFECTIONS

Plain film examination-OPG to identify source of infection

Computed tomography -short time required

Readily assess the

integrity of cortical bone

deep spaces involvement

MRI- vascularity of lesion

Ultrasonography - inability to penetrate osseous structuresSubmandibular region, Superficial lobe of parotid

E al ation of Ultrasonograph as a Diagnostic Tool in


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Objectives: The purpose of the study was to establish the role of ultrasonography indetermining the involvement of specific fascial spaces in maxillofacial region and thestage of infection, in indicating the appropriate time for surgical intervention and to

compare clinical and ultrasonographic findings.

Material and Methods: Twenty five patients with fascial space infection in maxillofacialregion were subjected to ultrasonographic examination following a detailed clinical andradiological examination. Ultrasonography guided needle aspiration was performed.Based on the findings, patients diagnosed with abscess were subjected to incision anddrainage and those with cellulitis were subjected to medical line of treatment.

Results: More than one fascial space was involved in all patients. On clinicalexamination 64 spaces were involved, of them 34 spaces had abscess formation and 30spaces were in the stage of cellulitis. On ultrasonography examination, 28 spaces werereported to have abscess formation and 36 spaces were diagnosed to be in the stage ofcellulitis. On comparative analysis of both clinical and ultrasonographic findings,ultrasonography was found to be sensitive in 65% of the cases and having specificity of80%. It was registered statistically significant (P < 0.001) agreement between these twomethods of assessment (kappa index = 0.814).

Conclusions: Ultrasonography is a quick, widely available, relatively inexpensive, andpainless procedure and can be repeated as often as necessary without risk to thepatient. Thus ultrasonography is a valuable diagnostic aid to the oral and maxillofacialsurgeon for early and accurate diagnosis of fascial space infection, their appropriatetreatment and to limit their further spread.

Evaluation of Ultrasonography as a Diagnostic Tool inMaxillofacial Space Infections


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Surgical operative protocol Admit

Antibiotics to be started

Fluid therapy

RBS

TLC


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Incision and drainage


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Incise in healthy skin/mucosa,at site of maximumfluctuance

Place incision in esthetically acceptable area

Place incision in dependable area

Dissect bluntly

Place a drain

Through & through drains

Do not leave drains for long periods

Clean wound margins daily


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DrainsTo collapse dead surgical space

To provide focused drainage of abscess

Vacuum assisted closure


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Adjuncts:Medical support of the patient

1. Rehydrate patient as dehydration may be present2. Treat conditions that predispose patient to infection

(DM)3. Correct electrolyte disturbances4. Oral pain, trismus, and swelling can be addressed by

appropriate analgesia and treatment of underlyinginfection


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Wound dressing:


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Pus assessment:Color

Quantity

Smell


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Recent advances:

USG guided aspiration of abscess


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Resistant strains:MRSA

Multiply resistant coagulase negative staphylococci


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Necrotising Fascitis:necrotizing fasciitis is a rapid, progressive liquefactionof the subcutaneous fat and connective tissue below arelatively normal looking skin surface.

The fascial planes disintegrate, and with the ensuingnecrosis come edema and the release of tissue fluid.Early in the development ofthe disease the veins thattraverse the liquefying subdermal fat become inflamedand start to thrombose, which gives the skin first a redand then a mottled color. Later the arterial supply isalso jeopardized and the skin becomes pale, whichleads to necrosis and wet gangrene.


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Clinical FeaturesThe area is acutely painful, and the surrounding tissues

are red (the signs depend on the specific mix ofbacteria), but on close inspection a central portion ofskin is pale and toxic . The skin subsequently developsa slightly mottled appearance as it becomes congested

through venous stasis. As the perfusion is further reduced through arterialfailure, the skin starts to blister.

Sensory perception is lost as nerves are destroyed andthe wound weeps fluid from the underlying liquefaction.Gross edema is a feature of the disease, and gas maybe present

Marked leucocytosis

i h d i di h i b


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With advancing disease the patient becomesprogressively unwell, with a general malaise andtachycardia.

Clinical inspection of the wound demonstrates that thesubcutaneous fat has no structural integrity and offerslittle resistance to theexploring finger.

The skin is widely undermined by the progressinginfection.


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Two treatments are recommended:

(1) surgery- Debridement(preserve underlying musclebut all necrotic tissue and overlying skin must beremoved.

Resected tissue sent for antibiotic sensitivity andculture.

More than one debridement may be necessary and it isconsidered prudent to make a second operativeinspection of the wound after 24 to 36 hours.

Antibiotics- IV Penicillin, Gentamycin, Metronidazole

R f


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ReferencesOral and maxillofacial infections Topazian-4 th edition

Killey and Kay outline of oral surgery volume one

Peterson s oral and maxillofacial surgery volume one

Fonseca oral and maxillofacial surgery volume 5

Oral and maxillofacial surgery Laskin vol 2

Bailey and love 25 th Edition

Schwartz -

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