Fascial Spaces Flashcards
There is evidence that the incidence of dental abscesses is related to ______________________.
socio-economic deprivation
Give an example of a serious and potentially life- threatening complication of dental sepsis
Spread of infection into fascial spaces of the neck
What is the most common cause of fascial space infection in adults?
odontogenic infections
What is the most common cause of fascial space infections in children?
tonsilitis
Aside from those of odontogenic origin, give other causes of fascial space infections
- salivary gland infection
- trauma
- post-operative infection
- complications related to congenital abnormalities of the neck such as infected thyroglossal duct cyst
What are the potential consequences of a spread of infections through the fascial spaces
- risk to airway
- systemic compromise
- cardiovascular collapse
Infections in the fascial spaces in the neck can spread to … (name areas)
- mediastinal or pleural cavities
- peri-orbital or orbital tissues
- carvenous sinus
How can infections in fascial spaces in the neck spread to the carvenous sinus?
they can travel through the facial vein
What is an abscess?
localised collection of pus
What is cellulitis?
inflammation of the subcutaneous tissues with no significant localisation of pus. It may later organise to form an abscess
Subcutaneous tissue- tissue in deepest layer of the skin
Define sepsis
The presence of systemic inflammatory response syndrome
- temperature: <36/>38
- pulse rate >90 per minute
- respiratory rate >20 per minute
- white cell count <4 or >12 x 10^9/L
- plus a confirmed infection
What is dysphagia?
subjective sensation of difficulty swallowing
What is dyspnoea?
subjective sensation of difficulty breathing
What is fascia?
fascia is loose connective tissue that lies beneath the skin, envelops the muscles and invests the internal organs
The vital structure of the neck are invested in _________ fascia
cervical
What are the layers of the cervical fascia?
- superficial layer
- deep layers
Briefly describe the location of the superficial cervical fascia
it lies just deep (beneath?) to the subcutaneous tissue and surrounds the whole neck. It invests the platysma muscle
What are the layers of the deep cervical fascia?
- investing layer of deep cervical fascia
- middle layer
- deep layer
What does the investing layer of the deep cervical fascia surround?
- the entire neck
- envelops sternocleidomastoid and trapezius muscles
What deep cervical fascia layer divides to form capsules of the submandibular and parotid salivary glands?
the investing layer
The middle layer is also known as …
the preveterbral layer
The middle layer extends from the base of the thoracic cavity to become continuous with the …
pericardium
The middle layer invests…
- pharynx
- larynx
- trachea
- oesophagus
- thyroid glands
- strap muscles
The deep layer surrounds…
- spine
- paravetebral muscles
Between the deep fascia layers, there are spaces which contain…
loose connective tissue
What are the fascial spaces above the hyoid bone?
- sub- masseteric space
- sub-lingual space
- sub-mandibular space
- parotid space
- pharyngeal space
- parapharyngeal space (lateral pharyngeal space)
What are the fascial spaces along the entire length of the neck?
- retropharyngeal space
- carotid space
- pre-vertebral space
- danger space
What are fascial spaces below the hyoid bone
visceral space
Where is the danger space located?
lies between the retropharyngeal and prevertebral spaces
Extends from the base of the skull to the diaphragm
State some symptoms of deep neck space infection
- pain aroudn causative tooth or teeth
- feeling generally unwell
- fever and rigors
- trismus
- dysphagia
- dyspnoea
- change in voice
How might a fascial space infection lead to a change in voice?
- Hot potato voice
- due to elevation of the tongue and floor of mouth in the oral cavity
What do symptoms of fascial space infections often indicate ?
actual or impending airway compromise
What is swinging pyrexia?
intermittent fever pattern
If there is an abscess associated with a fascial space infection, what clinical sign is often associated with this?
swinging pyrexia
When does septic shock occur?
occurs when a septic patient remains hypotensive despite aggresive attempts to restore the blood pressure
What is ludwigs angina?
defined by bilateral cellulitis of the submandibular and sublingual spaces, most often arising from a lower molar tooth
What fascial spaces does the mouth contain?
Sublingual
Submandibular
Submental
There is ready communication across the midline of fascial spaces in the oral cavity. True or false.
True
What are the clinical signs of ludwig angina ?
- firm swelling of FoM, resulting in elevation of the tongue
- submandibular and sublingual spaces become tense and tender
- accompanying:
- dysphagia
- trismus
- respitatory embarrassment
The cellulitis in ludwigs angina may spread an involve the…
lateral pharyngeal space
How are patients with ludwigs angina treated?
- (following urgent referral to hospital)
- urgent antibiotic therapy
- surgical drainage
- may require additional airway support
How should infections of deep neck space be investigated in the dental setting?
- check temperature
- check basic vital signs (pulse and respiratory rates)
- plain radiograph if patient can tolerate it
- in cases of trismus, OPT can be taken
- when referring, send imaging with patient to avoid un-necessary repeated radiation exposure
What investigations are carried out for deep neck space infections in the hospital?
- blood tests
- ultrasound and/or CT scan
- microbiological investigations
Briefly describe the sublingual space
it is bounded bythe submucosa of the floor of the mouth superiorly and the mylohyoid muscle inferiorly
Briefly describe the submandibular space
lies between the mylohyoid muscle, superficial fascia, platysma and skin.
Contains submandibular gland and lymph nodes
Briefly describe the submental space
lies between the mylohyoid muscle and the skin, just beneath the chin. Contains submental lymph nodes
Briefly describe the submasseteric space
bounded by the lateral border of the mandible and the medial aspect of the masseter
Describe the pharyngeal (lateral pharyngeal) space
extends from base of skull to hyoid bone level
contains internal carotid artery, internal jugular vein, cranial nerves IX to XIII and the sympathetic chain
Describe the position of the retropharyngeal space
this space lies behind thepharynx and oesophagus between the skull base and mediastinum
What are the signs and symptoms of an infection in the sublingual space
- swollen, red FoM
- little ot no extra-oral sign of swelling
- elevation of tongue may result in dysarthria, dysphagia and/or dyspnoea
What are the signs and symptoms of an infection in the submandibular space?
- painful red swelling of the neck immediately below the border of the mandible
- involvement of the muscles of mastication results in trismus
What are the signs and symptoms of infection in the submental space?
swelling and erythema of the chin
What are the signs and symptoms of infection in the submasseteric space?
pain and swelling over the angle of the mandible plus trismus
What are the signs and symptoms of infection in the parapharyngeal space?
- examination of the oropharynx reveals deviation of the uvulae to the opposite side by displaced tonsil and lateral pharyngeal surface
- there may be trismus
- swelling of lateral neck
- involvement of vital structures may include internal jugular vein thrombosis, horners syndrome and meningitis
What are the signs and symptoms of an infection in the retropharyngeal space?
- the patient will be unwell and complain of severe sore throat
- Dysphagia and limitation of neck movement
What is horners syndrome?
Caused by involvement of the sympathetic chain and is characterised by:
- ptosis (drooping eyelid), miosis (constricted pupil) and anhydrosis (lack of sweating affecting one side of the face)
Outline some suitable treatment options for a stable patient with localised swelling and minimal soft tissue involvement
- local treatment including pilp extirpation
- extraction of the tooth
*all with or without antibiotics
The acute odontogenic abscess in ludwigs angina is often polymicrobial in nature. Give examples of bacteria found in these abscesses
- they are often facultative anaerobes e.g. viridans sterptococci, steropococcus anginosus
- some can be strict anaerobes like prevotella and fuscobacterium species
How are septic patients treated ?
- treated aggressively with fluid resuscitation
- early and empirical administration of antibiotics
What are the requirements for the drainage of a neck space?
Under general anaesthetic in an operating theatre
What is the consequence of severe airway compromise resulting from a neck space infection?
- tracheostomy tube
- post operative admission into intensive care
What is the purpose of surgical exploration of affected spaces in ludwigs angina?
- although there is often no collection of pus, surgical exploration of the affected spaces is performed to decompress the neck
What adjuncts can be used following surgical intervention of neck space infections?
- surgical drains placed until infection is resolved
- corticosteroids (dexamathasone) may be given to reduce oedema
Antibiotic therapy can be used as a substitute for removal of the source of infection. True or false
false
What are the potential consequences of odontogenic infections spreading to neck fascial spaces ?
- sepsis
- life threatening airway compromise
What does an initial ABCD assessment of neck space infection comprise of?
- can the patient speak normally without drooling saliva
- is the patients breathing rate less than 20 per minute and effortless
- is the pulse rate less than 90 beats per minute
- is the patient fully conscious and coherent
