Deep space infections of the neck and floor of mouth

Dr David Maritz

Introduction

• Penicillin 1940’s

• Odontogenic infections

• Deep anatomic fascial space

• Threaten vital structures

Introduction

• Most important:• Submandibular• Lateral Pharyngeal• Retropharyngeal / Danger / Prevertebral

• Clinical examination underestimate extent in 70%

Potential pathways of extension of deep fascial space infections of the head and neck

Fascial spaces around the mouth and face

Figure 69-4 Natural progression of dental infection. The pathways by which such infections may travel are: 1, postzygomatic (from canine fossa in cuspid and bicuspid region; pterygomaxillary fossa communicates from rear); 2, vestibular; 3, facial; 4, submandibular; 5, sublingual; 6, palatal; 7, antral; 8, pterygomandibular; 9,

parapharyngeal; 10, masseteric. (Redrawn from Rose LF, Hendler BH, Amsterdam JT: Temporomandibular disorders and odontic infections. Consultant 22:125, 1982.)

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Clinical examination of odontogenic infections

Stages of infection

• 4 stages

• Inoculation

Cellulitis

Abscess

Rupture

• Spreading odontogenic infection

Trismus

• Inability to open mouth widely

• Inflammation muscles of mastication

• Masticator space / Pterygomandibular space

• Difficult intubation

Airway / Physical evaluation

• Pharyngeal swelling – difficulty swallowing

• Difficulty sleeping supine

• Sniffing position – Retropharyngeal space

• Head deviated to opposite side – Lateral pharyngeal space

• Muffled voice – Epiglottitis

• Distant quality to voice – Retropharyngeal / Lateral Pharyngeal

• Elevated tongue – Sublingual space

Intraoral examination

• Caries• Swellings of oral vestibule• Periodontal disease• Tooth mobility• Pericoronitis• Swellings• Position of uvula

Radiographic evaluation

• Rapid CT scanners

• Contrast enhanced CT

• Postero-anterior / lateral soft tissue x-rays of neck

• Dental panoramic view (Orthopantomogram)

Lateral radiograph of the neck

Figure 69-5 Periapical abscesses (arrows) as seen on Panorex film.

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Culture and sensitivity testing

• Penicillin resistance 30 – 50%

1. Submandibular Space

Introduction

• ‘’Ludwigs angina’’

• ‘’Angina maligna’’

• ‘’Morbus strangulatorius’’

• ‘’Garotillo’’

Early appearance of patient who has Ludwig’s angina with characteristic submandibular ‘’woody’’ swelling

Anatomy and pathogenesis

• Sublingual and submylohyoid spaces

• Odontogenic ( periapical abscesses of mandibular molars – 2nd / 3rd)

• Communicate freely:• Entire submandibular space• Buccopharyngeal gap – lateral pharyngeal space – retropharyngeal space

Anatomic relationships in submandibular infections

Routes of spread of odontogenic orofacial infections along planes of least resistance

Clinical manifestations

• Mouth pain / stiff neck / drooling / dysphagia

• No trismus

• Woody inflammation

• No lymph node involvement

• Protruding tongue

Ludwig's Angina

• Involvement submandibular spaces bilaterally and submental space in midline

• Rapid spread to lateral pharyngeal / retropharyngeal space

• Rapidly obstruct upper airway

Early Ludwig's angina

Early Ludwig's angina

Submandibular space abscess and Cellulitis

Potential complications

• Airway compromise

• Spread into the lateral pharyngeal space and beyond

Figure 69-6 Extensive spread of infection of odontogenic origin involving masseteric, sublingual, submental, and submandibular spaces with extension to mediastinum. A, Preoperative. B, Postoperative. Note drainage from mediastinum. (From Guernsey LH: Practical problem solving in oral surgery. In Cohen DW [ed]: Continuing

Dental Education, vol 2, suppl 10. Philadelphia, University of Pennsylvania School of Dental Medicine, 1979.)

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Figure 69-6 Extensive spread of infection of odontogenic origin involving masseteric, sublingual, submental, and submandibular spaces with extension to mediastinum. A, Preoperative. B, Postoperative. Note drainage from mediastinum. (From Guernsey LH: Practical problem solving in oral surgery. In Cohen DW [ed]: Continuing

Dental Education, vol 2, suppl 10. Philadelphia, University of Pennsylvania School of Dental Medicine, 1979.)

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© 2007 Elsevier

Therapeutic considerations

• Mixed infection – synergistic interaction

• Immunocompromised

• MRSA

• Candida / Aspergillus

2. Lateral Pharyngeal Space

Potential pathways of extension of deep fascial space infections of the head and neck

Anatomy and pathogenesis

• Anterior / muscular compartment

• Posterior / neurovascular compartment• Carotid sheath• 9 to 12 cranial nerves• Sympathetic trunk

• Peritonsillar abscesses

Clinical manifestations

• Anterior compartment• Dysphagia• Trismus• pain

• Posterior compartment• No trismus• Neurologic / vascular• Edema epiglottis / larynx

Abscess of lateral Pharyngeal space

Potential complications

• NB: Posterior compartment

• Laryngeal edema

• Vagal nerve

• Horner's syndrome

• Cranial nerve palsies

• Suppurative jugular thrombophlebitis (lemierre syndrome)

• Carotid artery erosion

Lemierre’s Syndrome

• Septic thrombophlebitis of internal jugular vein

• Septic emboli – lung / liver abscesses / septic arthritis

• Fusobacterium necrophorum

Jugular venous thrombosis

Therapeutic considerations

• Suppurative

• Posterior more conservative

• Anterior more aggressive treatment

3. Retropharyngeal / Prevertebral / Danger Space

Introduction

• Caudal extension of infection

• Considered together

Anatomy and pathogenesis

• Between pharynx-esophagus and spine

• Delineated by fascial planes: 3 layers of deep cervical fascia

Retropharyngeal space

• Base skull to C7 / T1

• Mediastinal spread

• Pleural / pericardial spread

• Deep cervical chain of nodes in children

• Other causes eg: oesophageal instrumentation, foreign bodies….

Retropharyngeal abscess

Retropharyngeal space

Danger space

• Base skull to diaphragm

• Contiguous spread from adjacent spaces

Prevertebral space

• Between prevertebral fascia and vertebral bodies

• Base skull to coccyx

• Contiguous with psoas muscle sheath

• Haematogenous spread NB• Local instrumentation• Contiguous spread

• Different microbiology

Clinical manifestations

Retropharyngeal danger space

• Sore throat / dysphagia / stiff neck

• Upper airways obstruction

• Head tilt contralateral side

• Pleuritic chest pain

• Bulging posterior oropharynx

Lateral radiograph of the neck

Prevertebral space

• Spinal cord compression

• Epidural abscess

Potential complications

• Laryngeal inflammation

• Rupture with aspiration

• Descending necrotizing mediastinitis

• Pyothorax / pericardial involvement

• Spinal epidural collections

• Psoas muscle infection

Therapeutic considerations

• Retropharyngeal / danger space:• Adequate anaerobic / oral gram + cover• Surgery if indicated

• Prevertebral:• Surgical drainage• NB gram + / MRSA / gram - rods

4. Buccal space

• Subcutaneous space

• Connects to: infraorbital space, periorbital tissues, superficial temporal space

• Hemophilus influenzae Cellulitis:• Children• Recent URTI / sinusitis

Buccal Cellulitis (Hib)

5. Infraorbital space

• Lower lid / periorbital swelling

• Point medially (inner canthus) or laterally (lateral canthus)

• Septic thrombophlebitis angular vein → cavernous sinus

6. Orbital space

• Preseptal Cellulitis

• Subperiosteal abscess (orbital wall)

• Orbital Cellulitis / abscess → optic nerve damage / cavernous sinus thrombosis

7. Vestibular space

• Diffuse facial swelling

• Elevation of the oral vestibule

• Potential space between oral mucosa and muscles facial expression

• Draining sinus

8. Subperiosteal space

• Dental infection

• Perforates cortical layer but not periosteum

• Eg: mandibular subperiosteal infection

9. Submental space

• Secondary spread from submandibular space

10. Masticator space

• Severe trismus

• Surrounding muscles of mastication

Masticator space infection with trismus

Masticator space abscess

11. Temporal space

• Trismus (infratemporal fossa – part of masticator space)

• Cavernous sinus thrombosis

Deep temporal space infection with spread to parotid space

Treatment

The admission decision

• Airway issues

• High fever

• Dehydration

• Need for I+D

• Inpatient control systemic disease

• Immune compromise

Airway security

• Protect against aspiration

• ETT ruptures abscess

• Trismus / Swelling

• Maintain airway reflexes during intubation

Surgical treatment

• Gravity dependent surgical drainage

• Antibiotics secondary

• Tooth extraction

Antibiotic therapy

• Predominately anaerobic nature

• Initially: aerobic streptococci ( penicillin )

• Later: anaerobic bacteria ( penicillin resistant )

• Synergistic interaction

Complications

Mediastinitis

• Airway security

• Contrast CT

• Open thoracotomy

• Broad spectrum antibiotics

Cavernous sinus thrombosis

• Ascending septic thrombophlebitis

• Anterior route – angular vein (infraorbital space)

• Posterior route – facial vein (buccal space)

• Congestion retinal veins

• CN 6 paresis → ophthalmoplegia / blindness

• Severe orbital / periorbital / infraorbital swelling

Cavernous Sinus Thrombosis

• Treatment:

• Tooth extraction root canal• Drainage deep spaces• High dose IV antibiotics• Anticoagulation

Summary

• Preventative dental care

• Effective antibiotics