Management of Complex orofacial Infections Flashcards
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:
(3)
– Soft tissue/fascial spaces – More common
– Osseous structures (Osteomyelitis) – Less common
– Vital structures – Orbits, CNS, thoracic cavity, etc
Spread of Oro-Facial Infections
(3)
- 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.
Understanding anatomical boundaries can help Dentists/Oral and Maxillofacial
Surgeons manage complex Head and Neck infections by predicting their spread.
Boundaries of Facial Space:
(5)
- 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?
(8)
– Need I & D?
– Need hospitalization?
- Rapidly progressing infection
- Difficulty breathing
- Difficulty swallowing
- Fascial space involvement
- Elevated temperature(>101F)
- Trismus(<10mm)
- Toxic appearance
- Compromised host defenses
Space infections that can arise from a maxillary odontogenic infection
(4)
- Canine/infraorbital space
- Buccal space
- Infratemporal space
- Temporal space
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.
Microbiologic Considerations
* Identification of bacteria
(4)
– Representative specimen collected
- Aspiration
- Swab
– Examine specimen
– Aerobic and anaerobic culturettes
– Submit for culture and sensitivity
Gram staining
(2)
– Early diagnosis
– Guides antibiotic therapy
Common Mandibular Space Infections
(4)
Sub lingual space
Submandibular space
Submental space
Buccal Space
Secondary Space Infections
(4)
- Masticator (Sub-masseteric) space
- Pterygomandibular space
- Lateral pharyngeal space
- Retropharyngeal Space
Common Progression Of Fascial Space Infections In The Head And Neck
Masticator Space Lateral Pharyngeal Space Retropharyngeal Space Danger Space
MEDIASTINITIS
Submandibular Space Submental Space Contralateral Submental Space Sublingual
Ludwigs Angina AIRWAY OBSTRUCTION
Canine Space Infraorbital Space Angular Vein CAVERNOUS SINUS THROMBOSIS
Assessment of a Patient with Complex Oro-Facial Infections
Determine the severity of the infection
(4)
- Complete history
- Clinical examination
- Determine the state of the patients host defense
- Advanced Radiography (C.T. Scan with contrast)
Clinical Examination - Danger Signs
(6)
Trismus
Difficult airway access
Inability to palpate inferior border of mandible
Visual changes
Malaise +/- Fever
Shortness of breath
Difficulty in swallowing with secretions
Trismus
Indicates involvement of muscles of mastication, Difficult airway access
Inability to palpate inferior border of the 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 embarrassment
Difficulty in swallowing with secretions
Indicates oro-pharyngeal involvement
Radiographic Examination
(4)
- Periapical
- Panorex
- Plain Films
- CT Scan with contrast
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 Scan with contrast helps us to evaluate the extent of the
complex oro-facial infection in the head and neck
region.
A rim enhancement around the area of infection is observed whenever we use a C.T. Scan along with a
contra
Laboratory Analysis
* CBC (Complete Blood Count) with differential count –
large outpouring of immature
granulocytes indicate severe infection.
Treatment of Complex Oro-Facial Infections
(2)
- 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
(6)
- 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 frequently
Serious Space Infections
(2)
Ludwigs Angina.
Cavernous Sinus Thrombosis.
Ludwigs Angina
(3)
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 is significantly narrowed causing
severe respiratory distress.
Due to this situation, intubation during general
anesthesia also becomes very challenging
Ludwig’s Angina –Management
(7)
– 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)
Cavernous Sinus Thrombosis
(3)
- 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
(6)
– 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
(4)
– Hospitalization.
– Neurosurgical consultation.
– Intensive antibiotic therapy.
– Heparin to prevent extension of thrombosis.
