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

Clinical examination underestimate extent in 70% 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 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.) Downloaded from: Rosen's Emergency Medicine (on 15 January 2009 05:57 PM) © 2007 Elsevier

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. Downloaded from: Rosen's Emergency Medicine (on 15 January 2009 06:07 PM) © 2007 Elsevier

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.) Downloaded from: Rosen's Emergency Medicine (on 15 January 2009 06:09 PM) © 2007 Elsevier

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.) Downloaded from: Rosen's Emergency Medicine (on 15 January 2009 06:07 PM) © 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