Management of Complex Orofacial Infections Flashcards
spread of odontogenic infections may involve:
- soft tissue/fascial spaces- more common
- osseous structures (osteomyelitis)- less common
- vital structures- orbits, CNS, thoracic cavity
generally infections follow the path of:
least resistance
what is the spread of oro facial infections dictated by
anatomic location of teeth, position of muscle attachments, bone density
infective processes can spread by:
disruption of intervening fascial planes
what are fascial spaces
potential spaces between the fascia and underlying organs/tissues
when do fascial spaces not exist
in a healthy state
fascial spaces can distended by:
fluid or infective process
infective process can be spread from one area to the adjoining ones by:
disruption of intervening fascial plane or around perforating blood vessels and nerves
what are the spaces involved in odontogenic infections
- primary maxillary spaces: canine, buccal, infratemporal
- primary mandibular spaces: submental, buccal, submandibular, sublingual
- secondary fascial spaces: masseteric, pterygomandibular, superficial and deep temporal, lateral pharyngeal, retropharyngeal, prevertebral
what are the boundaries of facial space
- fascial layers or planes
- muscles
- bone
- skin
- mucous membranes
what is considered in determining whether to be treated by dentist or a oral and maxillofacial surgeon
- rapidly progressing infection
- difficulty breathing
- difficulty swallowing
- fascial space involvement
- elevated temperature- greater than 101F
- trismus (less than 10mm)
- toxic appearance
- compromised host defense
what types of drains are available
- penrose drain
- corrugated drain
- glove drain
space infections that can arise from a maxillary odontogenic infection
- canine/infraorbital space
- buccal space
- infratemporal space
- temporal space
infection spreads to the canine/infraorbital space through:
the root apices of the maxillary teeth usually the canine
I and D of the canine/infraorbital space achieved through ____ approach
intra oral
direct surgical access in I and D of the canine/infraorbital space is achieved via:
incision in the depth of the maxillary labial vestibule adjacent to the tooth causing the infection
buccal space infection presents as:
dome shaped swelling
where is the buccal space
between the buccinator muscle and overlying skin and the superficial fascia
the buccal space may become involved via:
upper jaw or lower jaw molars
buccal space I and D is achieved through ___ approach
intra oral
temporal space infection I and D achieved through ______ approach
extra oral
how are the bacteria in I and D identified
- representative specimen collected: aspiration, swab
- examine specimen
- aerobic and anaerobic culturettes
- submit for culture and sensitivity
what is the purpose of gram staining
- early dx
- guides AB therapy
what are the common mandibular space infections
- sublingual space
- submandibular space
- submental space
- buccal space
where is the submandibular space
between the mylohyoid muscle and skin and superficial fascia- primarily 2nd and 3rd molars infect it
what are secondary space infections
- masticator (sub masseteric) space
- pterygomandibular space
- lateral pharyngeal space
- retropharyngeal space
what is the common progression of the masticator space
masticator space -> lateral pharyngeal space -> retropharyngeal space -> danger space -> mediastinitis
what is the common progression of the submandibular space
submandibular space -> submental space -> contralateral submental space -> sublingual ludwig’s angina ->airway obstruction
what is the common progression of the canine space
canine space -> infraorbital space -> angular vein -> cavernous sinus thrombosis
what needs to be done in the assessment of a patient with complex oro-facial infections
- determine the severity of the infection
- complete history
- clinical exam
- determine the state of the patients host defense
- advances radiography - CT scan with contrast
what are the danger signs in the clinical exam
- trismus
- inability to palpate inferior border of mandible
- visual changes
- malaise with or without fever
- shortness of breath
- difficulty in swallowing with secretions
what does trismus indicate
involvement of muscles of mastication, difficulty airway access
what does the inability to palpate inferior border of mandible indicate
spread to the submandibular space
what do visual changes indicate
ocular involvement
what does malaise with or without fever indicate
advanced disease with systemic response
what does shortness of breath indicate
airway embarassment
what does difficulty in swallowing with secretions indicate
oro pharyngeal involvement
what radiographs should be ordered
- PA
- pano
- plain films
- CT scan with contrast
how does the CT scan with contrast help
- clearly delineates the position and size of the infection process as well as its relationship with the adjacent anatomic structures
- useful to evaluate any changes to the patients upper airway (due to edema) as it occurs in more advanced infections of the head and neck
what is a rim enhancement used for
- around the area of infection whenever a CT scan is used with contrast
what is ordered in the lab analysis and what does it tell us
CBC with differential - large outpouring of immature granulocytes indicate severe infection
maxillofacial infections are:
surgical problems
how are complex orofascial infections treated
- treat the cause of infection - etiology
- treat the infection surgically - I and D
- send the purulent discharge for culture and sensitivity
- support the patient medically - infectious disease consult
- choose and prescribe the appropriate antibiotic - culture and sensitivity - IV antibiotics
- re eval frequently
what are the serious space infections
- ludwigs angina
- cavernous sinus thrombosis
what is ludwigs angina
- a fulminating, bilateral sublingual, submndibular, submental and cervical infection or cellulitis displacing the tongue with potential airway obstruction
- life threatening
what is the etiology of ludwigs angina
related to PA abscess related to the lower molar teeth
what is the management of ludwigs angina
- pt hospitalized immediately
- CT scan with contrast
- consultative services- infectious diseases and respiratory therapy
- blood and tissue culture and sensitivity test specifically for anaerobes
- IV antibiotic therapy
- extensive surgical drainage
- close monitoring- airway
what is cavernous sinus thrombosis
serious condition that is recognized by the appearance of marked edema and congestion of the eyelids and conjunctiva as a result of impaired venous drainage
cavernous sinus thrombosis starts as:
unilateral and rapidly becomes bilateral
is ludwigs angina or cavernous sinus thrombosis more common
ludwigs angina
what is the etiology of cavernous sinus thrombosis
- hematogenous spread of infection from the jaw to the cavernous sinus may occur anteriorly via the inferior or superior opthalamic vein or posteriorly via emissary veins from the pterygoid plexus
- direct extension through the opening of the cranial bones
what are the signs and symptoms of cavernous sinus thrombosis
- ocular pain
- high fluctuating fever, chills and sweating
- periorbital and conjunctival edema, starting unilaterally and progressing to bilateral as a result of thrombophlebitis
- pulsating exophathalmos and retinal hemorrhage
- opthalmoplegia, paralysis, dialted pupils and loss of corneal reflexes
- other cranial nerve involvement - trigeminal nerve
what is the management of cavernous sinus thrombosis
- hospitalization
- neurosurgical consult
- intensive AB therapy
- heparin to prevent extension of thrombosis
