Management of Complex orofacial Infections

Question 1

Odontogenic infection can spread from their original sites to remote areas in the

Answer 1

head and neck and can on occasions be life threatening.

Question 2

Spread of odontogenic infections may involve:
(3)

Answer 2

– Soft tissue/fascial spaces – More common
– Osseous structures (Osteomyelitis) – Less common
– Vital structures – Orbits, CNS, thoracic cavity, etc

Question 3

Spread of Oro-Facial Infections
(3)

Answer 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.

Question 4

Fascial Spaces

Answer 4

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.

Question 5

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)

Answer 5

• Fascial layers or planes
• Muscles
• Bone
• Skin
• Mucous membrane

Question 6

Determine whether to be treated by dentist or a Oral and Maxillofacial
surgeon
– Who should treat?
(8)
– Need I & D?
– Need hospitalization?

Answer 6

• Rapidly progressing infection
• Difficulty breathing
• Difficulty swallowing
• Fascial space involvement
• Elevated temperature(>101F)
• Trismus(<10mm)
• Toxic appearance
• Compromised host defenses

Question 7

Space infections that can arise from a maxillary odontogenic infection
(4)

Answer 7

• Canine/infraorbital space
• Buccal space
• Infratemporal space
• Temporal space

Question 8

Incision and Drainage achieved through Intra-oral approach

Answer 8

Direct surgical access is achieved via incision in the depth of the
maxillary labial vestibule adjacent to the tooth causing the infection.

Question 9

Microbiologic Considerations
* Identification of bacteria
(4)

Answer 9

– Representative specimen collected
- Aspiration
- Swab
– Examine specimen
– Aerobic and anaerobic culturettes
– Submit for culture and sensitivity

Question 10

Gram staining
(2)

Answer 10

– Early diagnosis
– Guides antibiotic therapy

Question 11

Common Mandibular Space Infections
(4)

Answer 11

 Sub lingual space
 Submandibular space
 Submental space
 Buccal Space

Question 12

Secondary Space Infections
(4)

Answer 12

• Masticator (Sub-masseteric) space
• Pterygomandibular space
• Lateral pharyngeal space
• Retropharyngeal Space

Question 13

Common Progression Of Fascial Space Infections In The Head And Neck

Answer 13

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

Question 14

Assessment of a Patient with Complex Oro-Facial Infections
Determine the severity of the infection
(4)

Answer 14

• Complete history
• Clinical examination
• Determine the state of the patients host defense
• Advanced Radiography (C.T. Scan with contrast)

Question 15

Clinical Examination - Danger Signs
(6)

Answer 15

Trismus
Difficult airway access
Inability to palpate inferior border of mandible
Visual changes
Malaise +/- Fever
Shortness of breath
Difficulty in swallowing with secretions

Question 16

Trismus

Answer 16

Indicates involvement of muscles of mastication, Difficult airway access

Question 17

Inability to palpate inferior border of the mandible

Answer 17

Indicates spread to the submandibular space

Question 18

Visual changes

Answer 18

Indicates ocular involvement

Question 19

Malaise +/- Fever

Answer 19

Indicates advanced disease with systemic response

Question 20

Shortness of breath

Answer 20

Indicates airway embarrassment

Question 21

Difficulty in swallowing with secretions

Answer 21

Indicates oro-pharyngeal involvement

Question 22

Radiographic Examination
(4)

Answer 22

• Periapical
• Panorex
• Plain Films
• CT Scan with contrast

Question 23

C.T. Scan with contrast helps as follows,

Answer 23

-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.

Question 24

CT Scan with contrast helps us to evaluate the extent of the

Answer 24

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

Question 25

Laboratory Analysis
* CBC (Complete Blood Count) with differential count –

Answer 25

large outpouring of immature
granulocytes indicate severe infection.

Question 26

Treatment of Complex Oro-Facial Infections
(2)

Answer 26

• Maxillofacial infections are surgical problems.
• Medical therapy is used adjunctively. Alone, it will not suffice, and only delays
  necessary treatment

Question 27

Treatment of Complex Oro-Facial Infections
(6)

Answer 27

• 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

Question 28

Serious Space Infections
(2)

Answer 28

 Ludwigs Angina.
 Cavernous Sinus Thrombosis.

Question 29

Ludwigs Angina
(3)

Answer 29

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.

Question 30

Ludwig’s Angina – C.T Scan examination

Answer 30

Airway is significantly narrowed causing
severe respiratory distress.
Due to this situation, intubation during general
anesthesia also becomes very challenging

Question 31

Ludwig’s Angina –Management
(7)

Answer 31

– 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)

Question 32

Cavernous Sinus Thrombosis
(3)

Answer 32

• 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

Question 33

Cavernous Sinus Thrombosis - Aetiology

Answer 33

• 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.

Question 34

Cavernous Sinus Thrombosis
Signs & Symptoms
(6)

Answer 34

– 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

Question 35

Cavernous Sinus Thrombosis - Management
(4)

Answer 35

– Hospitalization.
– Neurosurgical consultation.
– Intensive antibiotic therapy.
– Heparin to prevent extension of thrombosis.