management complex odontogenic infections Flashcards
Spread of Odontogenic Infections
* Odontogenic infection can spread from? to? can be?
- Odontogenic infection can spread from their original sites to remote areas in the head and neck and can on occasions be life threatening.
Spread of odontogenic infections may involve what tissues/strucutures:
– Soft tissue/fascial spaces – More common
– Osseous structures (Osteomyelitis) – Less common
– Vital structures – Orbits, CNS, thoracic cavity, etc
Spread of Oro-Facial Infections
* Generally, infections follow?
* This is dictated by?
* Infective processes can spread by disruption of ?
Spread of Oro-Facial Infections
* Generally, infections follow the path of least resistance.
* This is dictated by anatomic location of teeth, position of muscle attachments, bone density, etc.
* Infective processes can spread by disruption of intervening fascial planes.
Fascial Spaces
- Potential spaces between the fascia and underlying organs/tissues.
- In a healthy state, these spaces do not exist. However, these spaces can be distended by fluid or infective process.
- Thus infective process can spread from one area to the adjoining ones by disruption of intervening fascial planes or around perforating blood vessels and nerves
primary maxillary spaces for infection
- canine
- buccal
- infratemporal
primary man spaces for infection
- submental
- buccal
- sabman
- sublingial
secndary fascal spaces
- masserteric
- pterygoman
- superficial and deep temp
- lat pharyngeal
- retropharyngeal
- prevert
Boundaries of Facial Space
* Understanding anatomical boundaries can help?
Boundaries of Facial Space
* Understanding anatomical boundaries can help Dentists/Oral and Maxillofacial
Surgeons manage complex Head and Neck infections by predicting their spread
Boundaries of Facial Space components:
- Fascial layers or planes
- Muscles
- Bone
- Skin
- Mucous membrane
Determine whether to be treated by dentist or a Oral and Maxillofacial
surgeon
– Who should treat?
* Rapidly progressing infection
* Difficulty breathing
* Difficulty swallowing
* Fascial space involvement
* Elevated temperature(>101F)
* Trismus(<10mm)
* Toxic appearance
* Compromised host defenses
– Need I & D?
– Need hospitalization?
Types of Drain available
Space infections that can arise from a maxillary odontogenic infection
- Canine/infraorbital space
- Buccal space
- Infratemporal space
- Temporal space
Canine/Infraorbital Space Infection
Infection spreads to the Canine/infraorbital space through the root apices of the maxillary teeth, usually
the canine
Canine/Infraorbital Space Infection I and D approach
Incision and Drainage achieved through Intra-oral approach
Direct surgical access is achieved via incision in the depth of the maxillary labial vestibule adjacent to the tooth causing the infection.
Gravity Dependent Drainage
Buccal Space Infection
shape
“Dome” shaped swelling
Buccal Space Infection
could be due to man or max tooth
buccal space I and D apprroach
Incision and Drainage achieved through Intra-oral approach
Direct surgical access is achieved via incision through the depth of the buccal sulcus adjacent to the tooth causing the infection.
Infra -Temporal Space Infection
Temporal Space Infection – Incision and Drainage approach
extraoral
microbio considerations
Identification of bacteria?
– Representative specimen collected
- culture? submit for?
* Gram staining?
– Representative specimen collected via Aspiration or Swab
– Examine specimen
– Aerobic and anaerobic culturettes
– Submit for culture and sensitivity
* Gram staining
– Early diagnosis
– Guides antibiotic therapy
Common Mandibular Space Infections
Sub lingual space
Submandibular space
Submental space
Buccal Space
Sublingual Space Infection
above mylohyoid, commonly PM and 1st M (apices above mylohyoid line)
Sublingual Space Infection I and D
Submandibular Space Infection
below mylohyoid, 2nd/3rd molars
subman infection I and D
extraoral
key sign of subman infection
no palpation of inf cortex
subman space btwn which mm?
mylohyoid and platysma
Submental Space Infection
also below mylohyoid, anterior teeth
submental I and D approach
extraoral, gravity dependent drain
Secondary Space Infections
- Masticator (Sub-masseteric) space
- Pterygomandibular space
- Lateral pharyngeal space
- Retropharyngeal Space
how can we examine secondary infection sites?
CT scan
Sub-Masseteric Space Infection/ I and D approach
Extraoral with gravity dependent drian
Pterygomandibular Space Infection
spread from subman space to medial side of man beneath the medial pteryogid
Pterygomandibular Space Infection common sign
trismus
Retropharyngeal Space Infection
can compromise airway
mediastinitis spread path
ludwigs spread path
cavernous thrombosis spread path
Assessment of a Patient with Complex Oro-Facial Infections
Determine the severity of?
- Determine the state of the patients?
- imaging?
Determine the severity of the infection
- Complete history
- Clinical examination
- Determine the state of the patients host defense
- Advanced Radiography (C.T. Scan with contrast)
danger signs of clinical exam
- trismus
- no palpation inferior border
- visual changes
- malaise/fever
- SOB
- difficulty swallowing
trismus with infection
Indicates involvement of muscles of mastication, Difficult airway access
Inability to palpate inferior border of mandible
Indicates spread to the submandibular space
Visual changes
\
Indicates ocular involvement
Malaise +/- Fever
Indicates advanced disease with systemic response
Shortness of breath
Indicates airway embarrassmen
Difficulty in swallowing with secretions
Indicates oro-pharyngeal involvement
Radiographic Examination options
- Periapical
- Panorex
- Plain Films
* CT Scan with contrast
C.T. Scan with contrast use
C.T. Scan with contrast helps as follows,
-It clearly delineates the position and size of the infection process as well as its relationship with the adjacent
anatomic structures.
-It is also useful to evaluate any changes to the patient’s upper airway(due to edema) as it occurs in more advanced
infections of the head and neck.
CT contrast will exhibit what around infection
CBC use with infections
CBC (Complete Blood Count) with differential count – large outpouring of immature
granulocytes indicate severe infection
Treatment of Complex Oro-Facial Infections
* Maxillofacial infections are what problems?
* Medical therapy is used?
- Maxillofacial infections are surgical problems.
- Medical therapy is used adjunctively. Alone, it will not suffice, and only delays
necessary treatment
Treatment of Complex Oro-Facial Infections
* Treat the?
* sx?
* Send the purulent discharge for?
* Support the patient?
* Choose and prescribe the appropriate?
* Re-evaluate?
- Treat the cause of infection (Etiology)
- Treat the infection surgically (Incision and drainage)
- Send the purulent discharge for Culture and Sensitivity
- Support the patient medically (Infectious disease consultation)
- Choose and prescribe the appropriate Antibiotic (Culture and sensitivity) I.V Antibiotics
- Re-evaluate the patient frequent
Serious Space Infections
Ludwigs Angina.
Cavernous Sinus Thrombosis
Ludwigs Angina
- Ludwig’s Angina is a fulminating, bilateral sublingual, submandibular, submental and cervical infection or cellulitis displacing the tongue with potential airway obstruction.
- Life-threatening condition
- Aetiology: Usually related to periapical abscess related to the lower molar teeth
Ludwig’s Angina – C.T Scan examination
Airway?
Airway is significantly narrowed causing severe respiratory distress.
Due to this situation, intubation during general anesthesia also becomes very challenging
Ludwig’s Angina –Management
– Patient must be?
– C. T. Scan?
– Consultative services?
– Blood and tissue culture?
– IV?
– Extensive?
– Close monitoring?
– Patient must be hospitalized immediately
– C. T. Scan with Contrast
– Consultative services e.g. infectious diseases and respiratory therapy
– Blood and tissue culture and sensitivity test specially for anaerobes
– Intravenous antibiotic therapy
– Extensive surgical drainage
– Close monitoring (Airway
Ludwigs Angina – Incision and Drainage
Cavernous Sinus Thrombosis:
* Serious condition that is recognised by the appearance of? as a result of?
* uni or bilateral?
* more or less common than ludwigs?
- Serious condition that is recognised by the appearance of marked oedema and congestion of the eyelids and conjunctiva as a result of impaired venous drainage.
- This start as a unilateral and rapidly becoming bilateral.
- This condition is not as common as Ludwig’s Angina
Cavernous Sinus Thrombosis - Aetiology
- Hematogenous spread of infection from the jaw to the cavernous sinus may occur anteriorly via the inferior or superior opthalmic vein or posteriorly via emissary veins from the pterygoid plexus. Direct extension through the
opening in the cranial bones.
Cavernous Sinus Thrombosis
Signs & Symptoms
– Ocular?
– fever?
– Periorbital and conjunctival?
– exopthalmamus/retina?
– pupils?
– Other cranial nerves?
– Ocular pain.
– High fluctuating fever, chills, and sweating.
– Periorbital and conjunctival oedema, starting unilaterally and progressing to bilateral as a result of thrombophlebitis.
– Pulsating exophthalmos and retinal haemorrhage
– Ophthalmoplegia, paralysis, dilated pupils and loss of corneal reflexes
– Other cranial nerve involvement e.g. trigeminal nerve
Cavernous Sinus Thrombosis - Management
– Hospital?
– consult with?
– Abx?
– Rx for thrombosis?
– Hospitalization.
– Neurosurgical consultation.
– Intensive antibiotic therapy.
– Heparin to prevent extension of thrombosis
