fascial space infections

FASCIAL SPACE INFECTIONS

Dr. Smijal GMMDS 2016

CONTENTS

• Introduction• Definition and classification-Fascial space infections• Various fascial space infections in head and neck • Conclusion• References

INTRODUCTION• Oral cavity consists of more than 500 bacterial taxa, several fungal

species, few protozoal genera and many viruses as normal residents• Occurrence of infectious disease is determined by the interaction of

host, the organism and the environment• In healthy state there is a balance among these factors and when the

balance is lost disease occurs

• An oral infection can originate in the dental pulp and extend through the root canals of the tooth into the periapical tissues or

• It may originate in the superficial periodontal tissues and subsequently disperse through the bone.

• Later it may perforate the outer cortical bone and spread in various tissue spaces or discharge onto a free mucous membrane

• Fascial spaces are fascia lined areas that can be eroded or distended by purulent exudate. These areas are potential spaces that do not exist in healthy people but become filled during infections

FASCIAL SPACESDefinition –

The fascial spaces in head and neck are the potential spaces between the various layers of fascia normally filled with loose connective tissue and bounded by anatomical barriers, usually of bone, muscle or fascial layers.

( Moore-1975)

Shapiro defined fascial spaces as potential spaces between layer of fascia. Its filled with loose connective tissues and various anatomical structures

Compartments Neurovascular structuresClefts Loose areolar connective tissue

• Routes by which an infection can spread are• Lymphatic system• Blood stream• Through tissues

• Local changes:• Pain• Swelling• Restriction of movement• Surface erythema• Pus formation

• Systemic changes• Toxic appearance• Fever • Lymphadenopathy • Malaise • Increased white blood cell count

• Most odontogenic infections arise as a sequel of pulp necrosis caused by caries, trauma, periodontitis, etc.

• They range from periapical abscesses to superficial and deep infections in neck.

• Some resolve with little consequence and some lead to severe infections of head and neck region.

NATURAL HISTORY OF PROGRESSION OF ODONTOGENIC INFECTION• Once bacteria has reached periapical tissue an active lesion is

established• Infection will spread equally in all directions, but preferentially along

the lines of least resistance • Spread through cancellous bone until it encounters a cortical plate• If thin cortical plate, infection erodes through bone and enters soft

tissue• It appears in predictable locations

Location of infection from a specific tooth is determined by• The thickness of bone overlying the apex of the tooth• The relationship of the site of perforation of bone to muscle

attachments of the maxilla and mandible

1vestibular abscess2buccal space3 palatal abscess4sublingual space5submandibular space6maxillary sinus

Cervical Fascia described under :- a) Superficial fascia b) Deep fascia

SUPERFICIAL FASCIA: • Layer of dense CT that courses deep to the SC tissue

throughout the body• SC space is defined as tissues lying superficial to superficial

fascia• Also known as tela subcutanea or hypodermisDEEP FASCIA:• Formed by dense, organized connective tissue• “Invests” deep structures such as muscles• Creates compartments that contain / direct spread of infection• Limits outward expansion of muscles so that veins are

compressed moving blood toward heart (musculovenous pump)

• Superficial fascia• Deep cervical fascia

• Anterior layer/ Superficial/ Investing layer

• Investing fascia• Parotideomasseteric• Temporal

• Middle layer• Sternohyoid-omohyoid

division• Sternothyroid-

thyrohyoiddivision• Visceral division

• Buccopharyngeal • Petracheal • Retropharyngeal

• Posterior layer• Alar division• Prevertebral division

• Abscesses located either superficial to or within the tissue space immediately deep to the superficial cervical fascia are treated by simple incision and drainage

• Superiorly attaches to:• Superior nuchal line of occipital bone(a)• Spinous processes of cervical vertebrae and nuchal

ligament (b)• Mastoid processes of temporal bones ©• Zygomatic arches (d)• Inferior border of mandible (e)• Hyoid bone (f)

• Inferiorly attaches to:• Manubrium (g)• Clavicles (h)• Acromion (i)

• Just above sternum this layer splits around the anterior and posterior surfaces of manubrium forming the Suprasternal space

• Completely surround the neck• Forms floor of submandibular space• Envelopes

• Sternocleidomastoid• Trapezius• Submandibular• Parotid

ANTERIOR LAYER

• Middle layer divided into three divisions. The first two are sternohyoid-omohyoid and the sternothyroid-thyrohyoid divisions

• Surround the corresponding strap muscles of the neck between the hyoid bone and the clavicle

• Primary surgical significance of these layers is that they must be divided in the mid line in a surgical approach to the trachea or thyroid gland

• Not directly involved in head and neck infections because they do not lie on the major routes that an orofacial infection may follow to the mediastinum or chest wall

MIDDLE LAYER

Visceral layer of deep cervical fascia

• Lies deep to the infrahyoid muscles, following their origin behind the sternum, and splits to enclose the thyroid, trachea, pharynx, and oesophagus

• Attached superiorly to cricoid cartilage (e), thyroid cartilage(d), and hyoid bone(f)

• Attached posteriorly to prevertebral fascia• Is referred to pretracheal anteriorly (a) and

retrovisceral (c) posteriorly

POSTERIOR LAYER

Vertebral layer of Deep cervical fascia

• Forms a tubular sheath for the vertebral column and the muscles associated with it extending from the base of the skull to T3 vertebrae

• Begins from cervical spinous processes (a) and the ligamentum nuchae(b)

• Covers the floor of the posterior triangle of the neck

• Attaches to the transverse processes (c) and divides into two layers/ laminae as it passes behind the esophagus

Alar fascia• Anterior subdivision of prevertebral fascia that

bridges between the transverse processes (a)• It blends with the (retro) Visceral fascia( posterior

fascia of the esophagus) at the level of T2 vertebral body. This seals inferiorly the (retro)pharyngeal space

• It runs from base of skull to the superior mediastinum

• Infections of the retropharyngeal space may rupture the alar fascia, thus entering the danger space, which is continuous with the posterior mediastinunm

Carotid sheath• Formed by all three layers of deep

fascia• Contains carotid artery, internal

jugular vein and the vagus nerve• Lincon’s Highway:- A viscerovascular

space coined by mosher- is the carotid sheath from the jugular foramen & carotid canal at the base of the skull to the middle mediastinum

Danger space• Immediately posterior to the retropharyngeal space and immediately

anterior to the prevertebral space• Spread within the danger space tends to occur rapidly because of the

loose areolar tissue that occupies this region. This spread can lead to mediastinitis, empyema, and sepsis

CLASSIFICATION OF FASCIAL SPACES

• Hollinshead’s classification(1958)Infrahyoid spaces -1.Visceral compartment

A) Pretracheal / previsceralB) Retrovisceral

2. Visceral space3. Other space

I. Cavity within carotid sheathII. Space between 2 layers of prevertebral fascia

SPACES OF HEAD AND NECKGrodinsky and Holyoke in 1938 described

Space 1: superficial to the platysma as well as between the latter and the deep fascia.

Space 2: lies in the anterior triangle between the superficial layer of deep fascia and the deep surface of the sternothyroid sheath, thus including the sternohyoid-omohyoid fascia with its contents and the sternothyroidthyrohyoid muscles with the anterior portion of their sheaths.

We have designated as space 2A the corresponding space in the posterior triangle between the superficial layer of the deep fascia and the posterior belly of the omohyoid muscle with its sheath (

Space 3: between the visceral fascia and the sternothyroid-thyrohyoid layer anteriorly, the carotid sheath laterally, and the alar fascia posteriorly.

Space 3a: Lincoln’s highway

• Space 4: also known as danger space, lies between alar & prevertebral fascia.

• Space 4a: posterior triangle of neck

• Space 5: prevertebral space.

• Space 5a: fascia enclosed by prevertebral fascia

BASED ON MODE OF INVOLVEMENT

1. Direct Involvement. (Primary Spaces)• Maxillary Spaces – Canine, buccal infratemporal• Mandibular Spaces – Submental, Submandibular,

Sublingual, Buccal2. Indirect involvement (Secondary Spaces)

• Masseteric• Pterygomandibular• Superficial and deep temporal• Lateral and retro pharyngeal• Prevertebral, parotid, carotid sheath,peritonsillar and danger

spaces.

• Based on clinical significance- (TOPAZIAN)

Face- Buccal, canine, parotid, masticatory.

Suprahyoid- Sublingual, submental, submandibular,

lateral pharyngeal, peritonsillar.

Infrahyoid- Pretracheal.

Spaces of total neck- Retropharyngeal, space of carotid

sheath.

Based on aetiology

General classification• Odontogenic• Traumatic• Implant surgery• Reconstructive surgery• Infection arising from contaminated needle puncture• Others (including from factors such as infected antrum,

salivary gland afflictions)• Secondary to oral malignancies

On the basis of causative organisms• Bacterial infection• Odontogenic• Non odontogenic

• Tonsillar infection• Nasal infection• Furuncle overlying skin

Buccal space

BOUNDARIES:-

• ANTERIORLY-Corner of mouth • POSTERIORLY-Masseter muscle, Pterygomandibular space• SUPERFICIAL- skin and Subcutaneous tissue

• DEEP- Buccinator muscle • SUPERIORILY- Maxilla, Infraorbital space• INFERIORLY- Lower border of mandible.

The buccal space occupies the portion of subcutaneous space between the fascial skin and buccinator muscle.

• CONTENTS OF BUCCAL SPACE:-• Buccal pad of fat• Stensons (Parotid duct)• Anterior and transverse facial artery and vein.

MUSCLE RELATED – Buccinator muscle

Neighboring spaces- Infraorbital, pterygomandibular, infratemporal space

BUCCAL SPACE INFECTION-Cause Infection from maxillary

premolars, molars andmandibular premolars if the roots are localized

above the buccinator muscle insertion (upper jaw) or below insertion (lower jaw)

infection spread into the soft tissues of the cheek → along anatomical planes toward the infratemporal or pterygopalatine fossa (pterygomandibular raphe!)

Relation of root with buccinator muscle

Clinical features:Dome shaped swelling on the anterior aspect of cheek extending anteroposteriorly from corner of mouth to angle of mandible and superoinferiorly from level of zygomatic arch to inferior border of mandible.

TREATMENTIncision & Drainage: Incision-Horizontal incision

through oral mucosa of cheek in the premolar, molar region.

Extra oral – below the lower border of mandible

Canine space / Infraorbital space

Boundaries –Anteriorly –Oribicularis orisPosteriorly- Buccal space Superficially – Quadratus labi superioris Deep- Lavator anguli oris, anterior

surface of maxillaMedially – Levator labi superioris alaque

nasiLaterally – Zygomaticus major, Superiorly – Quadratus labi superioris Inferiorly - caninus muscle

• Contents – Angular artery and vein, Infraorbital nerve

• Neighboring spaces – Buccal space

CANINE SPACE INFECTIONETIOLOGY:

• Maxillary canine, rarely from maxillary first premolar.• Rarely from nasal & upper lip infections.

Clinical Features-Swelling of cheek, lower eyelid & upper lip.Drooping of angle of mouth.Nasolabial fold obliterated.Edema of lower eyelid

TREATMENT:- Incision & Drainage: incision – through mucosa of buccal vestibule: of

lateral incisor & canine.

Drainage – A curved mosquito forceps is inserted superior to caninus muscle, pus is evacuated and drain is secured.

Complication- Cavernous sinus thrombosis

PALATAL ABSCESS

Involvement: palatal roots of posterior teeth, abscesses from palatal pocket - cause infection.

Boundaries: inferiorly:- bounded by cortical plates of hard palatesuperiorly: overlying periosteium. laterally: alveolar process of maxilla & teeth

Clinical features: i) well defined circumscribed fluctuant swelling, confined to one side of palateii) offending tooth is tender on percussion.

Incision & Drainage. incision- through the mucosa down to the bone, care should be taken as to avoid cutting of greater palatine nerves & blood vessels.

The submucosal portion of the hard palate contains neurovascular bundle, minor salivary glands a lymfoid tissue

the rich innervation of thePeriosteumpainful

the course of the palatineArterybleeding

Infratemporal SpaceBoundaries-• Superiorly: infratemporal surface of

greater wing of sphenoid.• Inferiorly: lateral pterygoid muscle.• Laterally: temporalis tendon ,ramus of

mandible• Medially: lateral pterygoid plate,muscle

& medial pterygoid plate• Posteriorly: parotid gland• Anteriorly: infratemporal surface of

maxilla & posterior surface of zygomatic bone.

Contents-• Pterygoid plexus of veins.• Internal maxillary artery.• Mandibular nerve & its branches.Etiology-• Infected buccal roots of maxillary 3rd molars and 2nd molars• Infected needles or contaminated LA solution in the area of

tuberosity• Spread from other space infections• infection may ascend into the cavernous sinus (through

venous plexus in the ovale and spinosum foramen), orbita, temporal fossa, pterygopalatine fossa

Infratemporal space

Clinical features:

Extraoral: trismus, bulging of temporalis muscle, swelling of the face on affected side in front of the ear, eye is often closed

Intraoral: swelling in the tuberosity area, elevated temp: upto 104 F

TREATMENTIncision & Drainage

• Intraoral approach: no trismus opposite to 2nd & 3rd molar

• Extraoral approach: in severe casesincision made at upper & posterior edge of temporalis muscle. A sinus forceps is directed upwards and medially

• If failure in mouth openingtemporalis myotomy / excision of coronoid process.

Submandibular SpaceBoundaries-• Superiorly: mylohyoid muscle, inferior border of mandible.• Inferior: anterior & posterior belly of digastric.• Laterally: deep cervical fascia, platysma, superficial fascia & skin.• Medially: hyoglossus,styloglossus,mylohyoid muscle.• Posteriorly: to hyoid bone.• Anteriorly: submental space.Contents-• Submandibular salivary gland.• Proximal portion of Wharton’s duct.• Lingual & hypoglossal nerves.• Branches of facial artery- palatine,tonsillar,glandular,submental.

Submandibular Space Infection

Etiology-• Infected mandibular 2nd & 3rd molars.• From submental,sublingual spaces.• infecting mandibular lymphnodes & salivary glands• Involvement from middle 3rd of tongue, posterior part of

sublingual space, submental space, maxillary teeth, cheek, maxillary sinus and palate.

Clinical features

Extraoral: firm swelling in submandibular region some degree of tenderness redness of overlying skin Intraoral: teeth sensitive on percussion mobility of teeth dysphagia moderate trismus

TREATMENTIncision & drainage

Incision made of 1.5 to 2 cm below border of mandiblesinus forceps inserted superior & posteriorly on lingual side of mandible below mylohyoid – pus- drained & sutured

Submental SpaceBoundaries-Roof: mylohyoid muscle.Inferior: deep cervical fascia, platysma, superficial fascia & skin.Laterally: anterior belly of digastric.Posteriorly: submandibular space.

• MUSCLE RELATED – mentalis muscle

• CONTENTS – submental lymph nodes and anterior jugular vein.

SUBMENTAL SPACE INFECTION

ETIOLOGY:-• From lower anteriors.• Secondarily due to infection from submental lymph

nodes which drain lower lip, skin overlying chin, anterior part of floor of the mouth, tip of the tongue & sublingual tissues.

• Symphysis fracture.

Clinical features:

Extra oral: distinct , firm swelling in midline beneath chin, skin is taunt.

Intra oral: non-vital/ fractured teeth discomfort on swallowing mobility & tenderness on percussion in offending tooth

Incision & drainage:

Transverse incision symphysis of mandible kelly’s forceps/sinus forcepsupward & backward directiondrained & sutured

Sublingual SpaceBoundaries-• Superiorly: mucosa of floor of mouth.• Inferior: mylohyoid muscle. • Posteriorly: body of hyoid bone.• Anteriorly & laterally: inner aspect of mandibular body.• Medially: geniohyoid,styloglossus,genioglossus muscle.Contents-• Deep part of Submandibular gland.• Wharton’s duct.• Sublingual gland.• Lingual & hypoglossal nerves.• Terminal branches of lingual artery.

SUBLINGUAL SPACE INFECTION

Involvement:Infection spreads from mandibular incisors, canine,

premolars sometimes first molar, perforates lingual cortical plate & passes into sublingual space

Clinical features

Extraoral: little or no swelling enlarged & tenderness of lymphnodes discomfort & pain on deglutition speech affectedIntraoral: pain on affected side of floor of mouth

floor of mouth raised tongue pushed superiorly airway obstructed


Intraorally: incision made close to lingual cortical plate, sinus forceps inserted, pus drained & sutured

Extraoral: incision done in case were both submental & sublingual spaces are affected , incision made at submental region

Ludwig´s angina = the right and left submandibular, sublingual and submental spaces are infected

A fulminant infection can spread rapidly to pharyngeal and retropharyngeal space

Submandibular space

Submental space

Sublingual space

• The original description of the disease was given by Wilhelm Friedrich von Ludwig.

1. Rapidly spreading gangrenous cellulitis.

2. Originates in the region of submandibular gland but never involves one single space and

3. Arises from extension by continuity and not by lymphatics

4. Produces gangrene with serosanguinous, putrid infiltration but very little or no frank pus.

Ludwig’s Angina

Etiology

Odontogenic- acute dentoalveolar abscess, periodontal, pericoronal- mandibular 2nd & 3rd teeth

Iatrogenic- contaminated needleTrauma- mandibular fractures, punctured woundsOsteomyelitisSubmandibular & sublingual sialadenitisSecondary infections of oral malignancies

CLINICAL FEATURES

Patient looks toxic, difficulty in swallowing, impaired speech, marked pyrexia

Extraoral- severe tenderness, firm brawny swelling in submandibular & submental region, muscle spasm- trismus, airway obstruction , dilatation of alae nasi, cyanosis, death

Intraorally- raises the floor of mouth, tongue maybe raised, difficulty in swallowing,drooling of saliva

TREATMENT• Establishment & maintenance of adequate airway• Extraction of affected teeth, prolonged I.V antibiotics,

hydration, incision & drainage• Antibiotic regime-penicillin, metronidazole or clindamycin.• Tracheostomy

Incision for surgical drainage of Ludwig’s Angina

Classic method – Not used nowadaysBilateral through and though drainage of spaces

COMPLICATIONS • Death due to airway compromise• septicemia• mediastinitis• carotid blow out

Masticatory spaceThere are 5 masticatory spaces .1. Superficial temporal space2. Infratemporal space3. Deep temporal space 4. Submassetric space5. Pterygomandibular space

SubMasseteric SpaceBoundaries-Superiorly: zygomatic arch.Inferiorly: inferior border of

mandible.Laterally: medial surface of

masseter muscle.Medially: lateral surface of

ramus of mandible.Posteriorly: parotid gland & its

fascia.Anteriorly: buccal space &

buccopharyngeal fascia.

CONTENTS -• Masseteric artery and vein

Neighboring spaces-• Buccal, pterygomandibular,

superficial temporal, parotid space

SUBMASSETERIC SPACE INFECTION

• ETIOLOGY:-• Pericoronitis related to vertical or distoangular

impaction of third molars- Fracture of angle of mandible

Clinical features

External facial swelling is moderate

Tenderness over angle of mandible

Limited mouth opening

Pyrexia & malaise.

Necrosis of muscle

TREATMENTIncision & drainageIntraoral approach- incision done at lower part of

ramussinus forcepsdownward &backwarddrain inserted and secured

Extraoral approach- approach-incision is placed behind angle of mandiblehilton’s methodrubber drain inserted & secured

Pterygomandibular SpaceBoundaries-• Superiorly: lower head of lateral pterygoid

muscle.• Laterally: medial surface of ramus.• Medially: medial pterygoid muscle.• Posteriorly: deep part of parotid.• Anteriorly: pterygomandibular raphe.Contents-• Inferior alveolar neurovascular bundle.• Lingual & auriculotemporal nerves.• Mylohyoid nerve & vessels.

Etiology-• Infected mandibular 3rd molars(mesioangular/horizontal)• Pericoronitis.• Infected needles or contaminated LA solution.Clinical Features-• Absence of extra-oral swelling.• Severe trismus.• Difficulty in swallowing.• Anterior bulging of half of soft palate & tonsillar pillars with deviation of

uvula to unaffected side.

Spread of Infection-• Superiorly to infratemporal space.• Medially to lateral pharyngeal space.• To submandibular space.

TREATMENT:

Intraoral- vertical incision(1.5cm) made on anterior & medial aspect oframus of mandiblesinus forceps opened & closed & with drawnPus drained & sutured.

Extraoral- incision made at angle of mandiblesinus forceps Pus drained & sutured

Temporal Spaces• Superficial temporal-Laterally: temporalis fascia.Medially: temporalis muscle.• Deep temporal-Laterally: temporalis

muscle.Medially: temporal bone &

greater wing of sphenoid.

Temporal space infectionClinical featuresPain , trismus, swelling may/ may not

be present

Incision & drainage

Extraoral- incision at temporal region, haemostat inserted above & below temporalis muscle

Lateral Pharyngeal SpaceBoundaries-Shape of an inverted cone or pyramid, the

base is at sphenoid bone and the apex at hyoid bone.

Anteriorly: pterygomandibular raphe. Posteriorly: extends to prevertebral fascia.Laterally: fascia covering medial pterygoid

muscle, parotid & mandible.Medially: buccopharyngeal fascia on lateral

surface of superior constrictor muscle.Styloid process divides the space into

anterior muscular and posterior vascular compartment.

Contents-

Anterior compartment: loose areolar connective tissue, lymph nodes and facial artery

Posterior compartment: carotid sheath(carotid artery,internal jugular vein,vagus nerve), cranial nerves IX through XII.

LATERAL PHARYNGEAL SPACE INFECTION

Clinical features

Extraoral-brawny induration of face

Intraoral- marked trismus, lateral pharyngeal wall maybe swollen, dysphagia


Extraoral- incision made at ant: border of sternocleidomastoid Muscle extending to the middle of sub-mandibular glandhemostat inserted into mandible until cavity is reached

Intraoral approach

Incision made at pterygomandibular rapheforceps insertedpus drained

Retropharyngeal SpacePosteromedial to lateral pharyngeal space and anterior to

the prevertebral space .

Boundaries-Anterior: posterior pharyngeal wall. Posterior: prevertebral fascia. Superior: skull base.Inferior: mediastinum.Laterally: lateral pharyngeal space.

.

RETROPHARYNGEAL SPACE INFECTIONInvolvement- lateral pharyngeal space

Clinical features

Infection of throatSnoring, chocking , dyspnoeaSwelling in lower portion of pharynx


Suprahyoid portion Infrahyoid portion

spaces is approached through lateral pharyngeal space

Peritonsillar space infection

Clinical evaluation:• Pharyngitis .• Severe sore throat, dysphagia, and

referred otalgia.• The speech is muffled and classically

described as hot potato voice.• Trismus is not present

Treatment • According to recent literature,needle aspiration is done instead

of incision and drainage .• (JOMS,Vol 51,2009

PAROTID SPACE BOUNDARIES:-• superiorly zygomatic arch• Inferiorly lower border of mandible• Anteriorly posterior border of the mandible• Posteriorly Retromandibular region

• Space formed by splitting of the superficial layer surrounding the parotid gland and lies posterior to the masticator space.

• CONTENTS:• Parotid gland• Parotid lymph nodes• Facial nerve.• Retromandibular vein• External carotid artery

PAROTID SPACE INFECTIONClinical featuresSevere painSwelling at masseter musclePus escapes from stenson’s duct


Extraoral approach- retromandibular incision done at posterior border of mandible extending to lobule of sinus forceps inserted & various parts of gland accomplished

Rubber drain is inserted & secured with suture

DRAINAGE OF FASCIAL SPACES• Canine, Sublingual and Vestibular abscesses intraorally.

• Masseteric, Pterygomandibular, Buccal and Lateral

Pharyngeal space abscesses combination of intraoral and

extraoral drainage.

• Temporal, Submandibular, Submental, Retropharyngeal and

Parotid space abscesses extraoral incision and drainage.

Differences between cellulitis and abscess

Characteristics Cellulitis Abscess

Duration. Acute phase Chronic phase

Pain Severe and generalised Localised

Size Large. Small

Localization Diffuse borders Well-demarcated

Palpation Doughy / indurated Fluctuant

Presence of pus No Yes

Degree of seriousness Greater Less

Bacteria. Aerobic Anaerobic/mixed

DIRECTION OF SPREAD OF INFECTION• Infection from any tooth will spread along the path of

least resistance. It can perforate either the buccal cortical plate or lingual / palatal cortical plate depending upon which is thinner

LIFE THREATENING COMPLICATIONS OF OROFACIAL INFECTIONS

Complications of space infection

• Osteomyelitis• Mediastenitis• Meningitis • Brain abscess• Cavernous sinus thrombosis• Ludwig’s angina

BRAIN ABSCESSEtiologyArises from bacteremia – odontogenic infectionsProduces- inflammation, edema and septic thrombosisClinical featuresHeadacheHemiplegia PapilloedemaAphasiaConvulsionsAbducens palsy

Treatment

1) IV chloramphenicol2) Surgery to provide drainage

CAVERNOUS SINUS THROMBOPHLEBITIS

• Occur as a result of superior spread of odontogenic infection via a hematogenous route

• Formation of thrombus in cavernous sinus/ communicating branches

• Unusual occurrence, rarely the result of an infected tooth

• Serious, life threatening infection

• 2 routes• External route (Anteriorly)- infection enters- face & lipsuperior

or inferior ophthalmic veinsuperior orbital fissurecavernous sinus

• Internal route (Posteriorly)- pterygoid plexusemissary veincavernous sinus

Microbiology streptococci & staphylococci & gram –ve bacteria

Clinical featuresSwelling of face, eyesPain in the eyeEdema of conjunctivaPulsating exophthalmos

Treatment

Antibiotic therapyNeurosurgical consultation AnticoagulantsSurgical drainage

CONCLUSION• A clinician must have a working knowledge of all

information regarding signs, symptoms & history ,with results from clinical examination & tests to obtain diagnosis. A methodical & disciplined approach, along with a good measure of patience will help establish an accurate diagnosis & resulting in a good treatment

References • Textbook of oral & maxillofacial surgery : Neelima Malik.• Oral & maxillofacial Infections : Topazian• Textbook of oral & maxillofacial surgery : Laskin• Manuel Grodixsky And Edward A. Holyoke:THE FASCIAK AND FASCIAL

SPACES OF THE HEAD, NECK AND ADJACENT REGIONS• Newman, Takei, Klokkevold & Carranza: Carranza’s Clinical

Periodontology: 11th Edition

fascial space infections

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