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infections Flashcards

1
Q

how are fascial spaces classified

A

primary
- infection occurring by direct spread from oral cavity

secondary
- infection occurring by continued spread from another space

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2
Q

anatomy of sublingual space

A

between FOM oral mucosa and mylohyoid muscle
anteriorly and laterally: mandible
posteriorly: submand space

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3
Q

anat of submand space

A
  • continuous with sublingual space along the posterior free border of the mylohyoid muscle
  • anteriorly: anterior belly of digastric
  • posteriorly; posterior belly of digastric
  • superiorly: inferior surface of mandible and mylohyoid
  • inferiorly: digastric tendon and platysma
  • submand space is separated from parapharyngeal space by posterior belly of digastric
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4
Q

what is the most common reason for involvement of submental space

A

extension of a submandibular space

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5
Q

what is ludwigs angina

A

involvement of all perimandibular spaces
when infection form one submand space passes through the submental space to involve the contralateral submand space

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6
Q

anatomy of submental space

A
  • between mylohyoid muscle and superficial layer of deep cervical fascia
  • bounded laterally by the anterior digastric muscle
  • further inferiorly is hyoid bone
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7
Q

what does the masticator space comprises

A
  • submasseteric space (located deep to masseter)
  • pterygomandibular space (located between medial surface of ramus and superficial to the medial pterygoid)
  • superficial temporal space
  • deep temporal space (infratemporal space is the inferior portion of the deep temporal space)
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8
Q

most common etiology for pterygomandibular space involvement

A

direct spread from mandibular third molars into the space

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9
Q

anatomy of pterygomandibular space

A
  • medially: medial pterygoid
  • laterally: ascending ramus of mandible
  • superiorly: lateral pterygoid
  • anteriorly: buccal space
  • posteriorly: parotid gland
  • contents of pterygomandibular space: IAA and IAN, sphenomandibular ligament, CNV3
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10
Q

what is the common clinical presentation of a pterygomandibular space infection

A

trismus due to involvement of medial pterygoid, so i/o examination may be difficult for the reason stated above, but may be able to see marked erythema and oedema of the anterior tonsillar region and deviation of the uvula to the unaffected side

e/o swelling is minimal in an isolated pterygomandibular space infection

but if masticator space is involved (because there is direct communication from pterygomandibular to masticator space), then it will present as a swelling on either side of the ramus

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11
Q

what spaces first to be infected when mandibular third molar implicated

A

submasseteric space and pteryomandibular space

submasseteric space is sandwiched between masseter and lateral surface of ascending ramus

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12
Q

anatomy of submasseteric space

A
  • anteriorly and laterally: masseter
  • posteriorly: parotid gland
  • medially: mandible
  • superiorly: zygomatic arch
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13
Q

borders of the parapharyngeal space

A
  • inverted triangle in shape, located on both lateral aspects of the pharynx
  • extends from the sphenoid bone superiorly to the lvel of hyoid bone inferiorly
  • bordered by medial pterygoid muscle laterally
  • superior pharyngeal constrictor muscle medially and anteriorly
  • carotid sheath posteriorly
  • continuous with submand space anteriorly and retropharyngeal space posteriorly

can be divided into 2 compartments
- anterior compartment is associated with loose areolar CT and continuous with submand space
- posterior compartment borders the carotid sheath

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14
Q

clinical presentation of parapharyngeal space infection

A
  • trismus due to involvement of medial pterygoid
  • cellulitis or fluctuant swelling of the neck
  • difficulty palpating angle of mandible
  • i/o, pressure due to oedema on the superior constrictor muscle will result in bulging of the lateral pharyngeal wall to the midline
  • stridor
  • difficulty swallowing and speaking
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15
Q

why are parapharyngeal space infections dangerous

A

because can spread rapidly to retropharyngeal space
these infections can also directly cause thrombosis of the IJV, erosion of the wall of carotid artery and possible impingement on cranial nerves IX, X and XII (contents of carotid sheath)

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16
Q

borders of the retropharyngeal space

A
  • located behind the posterior pharyngeal wall
  • the space is created by the buccopharyngeal fascia anteriorly and the alar fascia posteriorly
  • extends from the base of skull superiorly to the level of T2, where the 2 layers of fascia fuse
17
Q

clinical presentation of retropharyngeal space infection

A
  • involvement of this space causes it to expand and press on anteriorly located oesophagus and trachea, causing difficulty swallowing and breathing
  • sore throat
  • raspy voice
18
Q

borders of the danger space

A
  • alar fascia anteriorly
  • prevertebral fascia posteriorly
  • superiorly is the base of skull
  • inferiorly is the diaphragm
19
Q

complications of deep space infections

A

1) descending medistinitis
2) ludwig angina
3) cavernous sinus thrombophlebitis
4) necrotizing fasciitis
5) septic shock

20
Q

clinical presentation of ludwig angina

A
  • firm induration of skin overlying submental and submandibular region
  • elevation of FOM and tongue
  • swelling bilaterally at inferior border of mandible to hyoid bone

signs and symptoms
- dysphagia, dysphonia, trismus
- feeling a lump in throat
- tongue sticking out
- tripod position (hands on knees, chest inclined forward to reduce work of breathing)

21
Q

mx of ludwigs angina

A
  • hospital admission since it is a medical emergency
  • establishment of airway security ASAP via endotracheal intubation or tracheostomy
  • incision and drainage
  • IV ab therapy - ampicillin and metronidazole most commonly used
22
Q

how can infection spread to cavernous sinus

A

1) canine space. can erode superiorly towards the orbit, then travel via the inferior opthalmic vein to the cavernous sinus

2) infratemporal space - odontogenic infections involving this space (commonly upper 3rd molar) spread from pterygoid plexus through the foramen ovale and into cavernous sinus

3) sinusitis.

23
Q

clinical presentation of cavernous sinus thrombosis

A
  • diplopia, inability to abduct eye (cant move laterally)
  • ptosis (drooping of upper eyelid)
  • exopthalmos (bulging eyes)
  • periorbital oedema
  • signs of sepsis - fever, tachycardia, hypotension, confusion, rigors
24
Q

complications of cavernous sinus thrombosis

A
  • can rapidly progress to meningitis (infection of brain)
  • unilateral blindness or decreased visual activity arising from prolonged cranial nerve dysfunction
25
what is necrotising fasciitis and how to manage
an aggressively spreading infection that follows the platysma muscle down the neck and onto the anterior chest wall can rapidly result in necrosis of large amounts of muscle, subcutaneous tissue and skin mx: aggressive debridement of affected soft tissues and broad spectrum IV AB
26
where are the 3 most likely areas that infection of a maxillary canine will spread
1) vestibular abscess - swelling of buccal vestibule/ mucosa at canine area 2) canine space/ infraorbital space - long root of maxillary canine erodes through alveolar bone superior to muscle attachment of levator anguli oris & levator labii superioris signs: - obliteration of nasolabial fold - upward displacement of lower eyelid 3) cavernous sinus: spread from canine space via superficial veins of face (inferior ophthalmic vein or infraorbital vein to common ophthalmic vein to cavernous sinus)
27
contents of cavernous sinus
cranial nerves: - maxillary and ophthalmic branches of trigeminal - trochlear (4) - oculomotor (3) - abducents (6) + internal carotid artery + venous drainage (superior and inferior ophthalmic veins)
28
what 2 common spaces for spread of infection from mandibular first molar and likely complication
1) vestibular abscess (most common) - can be buccal or lingual vestibule but buccal more common 2) sublingual/ submand space - elevation of FOM, trismus, swelling of face complication: LUDWIGS angina - aggressive and rapidly spreading cellulitis above level of hyoid bone, can spread from submental, sublingual or submand spaces present with - bull neck: swelling and tenderness of neck - woody tongue: elevation protrusion and posterior enlargement of tongue - dysphagia, dyspnea, dysarthria (difficulty speaking) - fever
29
contents of infratemporal space and what kind of infection is likely to spread here
- max artery - mandibular nerve - pterygoid venous plexus infratemporal space is secondary, spreads from buccal space first. and the buccal space might be affected from: infection of the maxillary posterior teeth (more common than infection of mandbular posterior teeth)
30
what spaces common for infection of: - mand premolars and 1st molar - mand 2nd and 3rd molars - mand 3rd molar
- mand premolars and 1st molar: sublingual space - mand 2nd and 3rd molars: submand space - mand 3rd molar: pterygomandibular space
31
symptoms of meningitis
- headache - fever - photophobia - altered mental status - stiff neck
32
ddx for one sided otalgia, facial swelling, pain on opening
we just need to think about the structures and how they could possibly be affected - salivary gland - bone: fracture - muscle: myalgia - TMD
33
similarities and differences between sinus and fistula
similartieis - both are abnormal openings of chronic nature - both can be associated with infections, pus formation - both can be caused by disease or trauma (resulting from infection, surgery, underlying conditions like crohns) - both potentially need surgical treatment differences - sinus is a blind ended tract leading from a deep tissue to a surface vs fistula is an abnormal passage connecting 2 epithelial lined surfaces like organs or tissues - sinus only got one opening but fistula has at least 2 openings - sinus may drain pus or serous fluid intermittently but for fistula, it is continuous/intermittent discharge
34
pathogenesis of osteomyelitis
inflammation causes thrombosis of vessels in the marrow, and then periosteal stripping by pus causes loss of periosteal blood supply, with consequent bone necrosis this encourages continuance of infection as well as bone resorption
35
for investigations of infection, what kind to do
break down into 2 kinds 1) radiographic - CT scan 2) lab - FBC - ESR, CRP (inflam marker) - culture and send to lab - possible to want to take hba1c also if the infection is very severe and we suspect patient is diabetic
36
in the cbct, what will abscess look like
rim enhancing collection if its cellulitis, wont have rim
37
what regional LNs are affected in infection
almost all cervicofacial infections drain to jugulodigastric LN in the upper part of the deep cervical chain mandibular infections tend to go first to submand & submental nodes facial infections drain to facial node which drains to the submand node which drains to the jugulodigastric anyway
38
how to differentiate infection and neoplasm using lymph nodes
infection: LN that are enlarged are firm/ rubbery in consistency, tender and usually mobile neoplasm: LN are hard, non tender and fixed
39
3 types of swelling and what are they caused by
1) swelling due to cellular infiltrate of inflammation - firmer - described as indurated 2) swelling due to oedema - relatively soft - move within tissues, accumulate at sites least constrained by fascia 3) swelling due to pus - described as fluctuance

OMS (18 decks)

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