Oral and Maxillofacial Infections By Dave Telles, DDS Diplomate of the American Board of Oral and Maxillofacial Surgeons

management of odontogenic infections eight steps : 1. Determine the severity of infection. 2. Evaluate host defenses. 3. Decide on the setting of care. 4. Treat surgically. 5. Support medically. 6. Choose and prescribe antibiotic therapy. 7. Administer the antibiotic properly. 8. Evaluate the patient frequently.

Question What is the difference between cellulitis and abscess? Is there a difference in type of infection in the head and neck region?

Oral and Maxillofacial Infection – Fascial Spaces In 1930s Grodinsky and Holyoke established the modern understanding of fascial layers Infections spread primarily by HYDROSTATIC pressure w/ the flow of infected fluid guided by the resistance of certain tissues (fascia, muscles, bone) Established 5 spaces of the H + N region

Oral and Maxillofacial Infection – Fascial Spaces Space # 1: lies superficial to the superficial fascia – SubQ sp Space #2: group of spaces surrounding the strap muscles Superficial to the sternothyroid-thyrohyoid division of the middle layer of the DCF Space # 3: potential anatomic space lying superficial to the visceral division of the MDCF Contents: Pretracheal, Retropharyngeal, Lateral Pharyngeal sp Space #3a: contains the Carotid Sheath Space #4: potential spaces that lies btwn the alar and pre- vertebral divisions of the PDCF “the danger space” Space #5: Prevertebral sp Space # 5a: enclosed by the prevertebral fascia – post. To the transverse process of the vertebrae Surrounds the scelene and postural muscles

Oral and Maxillofacial Infection – Fascial Spaces Superficial Layer of dense CT that courses deep the SQ tissue Muscles of facial expression lie deep below the mouth and superficial above Deep cervical fascia Anterior layer Investing Parotidomasseteric Temporal Middle Sternohyoid-omohyoid Sternothyroid-thyroid Visceral Division * Buccopharyngeal Pretracheal Retropharyngeal Posterior Alar Prevertebral

Oral and Maxillofacial Infection – Fascial Spaces Anterior layer – contains the investing, Parotidomasseteric, Temporal Forms the superficial border of the submandibular space to form the capsule At the ramus splits and surrounds the masseter and parotid posteriorly Covers the superficial layer of the temporalis Above the zygomatic arch – divides ~ 2cm above and houses the temporal fat pad 2cm above the sternum divides and forms the suprasternal space of burns

Oral and Maxillofacial Infection – Fascial Spaces Middle layer of the DCF Sternohyoid Sternothyroid-thyrohyoid Visceral*** Important in deep neck spaces Contains the retropharyngeal, lateral pharyngeal and pretracheal spaces] …all lie superficial to the middle layer

Oral and Maxillofacial Infection – Fascial Spaces Posterior Alar Passes through the transverse process of the vertebrae post to the retropharyngeal fascia Extends from bases of skull to diaphragm Fuses w/ the retropharyngeal fascia at lvls btwn C6-T4 forming the bottom of the RP space Infections may rupture this fascia and enter the danger space #4 Prevertebral Surrounds the vertebra and attach postural muscles of the neck and back Infection of the vertebrae may enter this space i.e. Osteomyelitis related to TB Usually not caused by OMF infection

Oral and Maxillofacial Infection – Fascial Spaces Carotid Sheath Origin at superior mediastinum Passes through pre-tracheal space in an upward and posterior direction Above the hyoid lies @ the junction of the lateral and Retropharyngeal spaces

Light blue: Superficial Y: alar Purp: middle Red: Anterior

Vestibular/Palatal Space Simple! Localized swelling of vestibular or palatal space adjacent to the tooth Possible spread into other adjacent spaces Peritonsilar sp Masticator Space Canine Space Buccal Space Pterygomandibular/masseteric space When there is a palatal swelling always consider – infection vs. neoplasia – ask about duration of swelling

(Sub)Masseteric Space Borders Anterior: Buccal Space Posterior: Parotid gland Superior: Zygomatic Arch Inferior: Inferior border of the mandible Superficial/Medial: Ascending ramus of the mandible Deep/Lateral: Masseter muscle Causes Lower 3rd molars, fracture angle of the mandible Contents: Masseteric artery and vein Neighboring sp: Buccal, Pterygomand., Superficial Temp, Parotid One of the 3 spaces of the Masticator space, commonly associated with Trismus

Canine/Infraorbital Space Borders Superior- Quadratus Labii superioris Inferior- Oral mucosa Posterior- Buccal Sp. Anterior- Nasal Cartilages Lateral (Deep)- Levator anguli oris, Maxilla Medial (superficial) - Quadratus Labii superioris, Contents Angular artery and vein, infraorbital nerve Causes of infection Upper canine and pre-molars Can spread to cavernous sinus via angular vein (non-valves)  leading to Cavernous Sinus Thrombosis **********

Canine Space PICTURE

Cavernous Sinus Thrombosis

Cavernous Sinus Thrombosis CS Anteriorly bordered by the SOF and receives tributary from the ophthalmic vein (from a combination of the superior and inferior ophthalmic veins) Posterior communication via the Pterygoid plexus Via the Posterior facial (retromandibular) and external jugular veins “Valveless veins” of the face and anterior skull base allow blood flow in either direction An Ascending Thrombophlebitis can occur anteriorly or posteriorly CNs III, IV, V1, VI Dx: via clinical presentation and confirmed with CT w/ contrast showing a filling void on the affected side of the cavernous sinus, CN deficits Diplopia, visual disturbance vascular congestion in the periorbital/scleral/retinal veins Ptosis dilated pupils absent corneal reflex supraorbital sensory deficits

Buccal Space Borders Contents Causes of infection Superior- Maxilla/infraorbital space Inferior- Mandible Posterior- Masseter and Pterygomandibular sp. Anterior- corner of mouth Lateral- subQ tissue and skin Medial- buccinator Contents Parotid Duct Anterior facial artery/vein Transverse facial artery Buccal fat pad Causes of infection Upper pre-molars/molars and lower pre-molars Neighboring spaces: Infratemporal, Pterygomand., Infratemporal

Sublingual Space- BORDERS: CONTENTS: CAUSES OF INFECTION: Superior- mucosa of the floor of the mouth Inferior- mylohyoid muscle Posterior- submandibular space and hyoid bone Anterior- lingual surface of the mandible Lateral- medial surface of the mandible Medial- muscles of the tongue CONTENTS: The sublingual space contains the sublingual gland, the Wharton’s duct, the lingual nerve and the sublingual artery and vein. CAUSES OF INFECTION: Broken down and carious mandibular premolars and molars are the most common etiological factor leading to infection of the sublingual space, direct trauma to the sublingual space can also cause infection ****Commonly pt has pain on protrusion of tongue and possibly Trismus

Superficial Temporal Space- BORDERS: Superior- superior temporal lines Inferior- zygomatic arch Lateral- superficial temporal fascia Medial- temporalis muscle Anterior- posterior surface of the lateral orbital rim Posterior- fusion of temporal fascia with pericranium CONTENTS: The superficial temporal space contains temporal fat pad and the temporal branch of the facial nerve.  CAUSES OF INFECTION: The most likely causes of spread of infection to the superficial temporal space are carious and broken down maxillary and mandibular molars. ***Temporal tenderness, possible periorbital edema

Deep Temporal Space- BORDERS: CONTENTS: CAUSES OF INFECTION: Lateral- temporalis muscle Medial- squamous temporal bone, skull base Inferior- lateral pterygoid muscle Superior and Posterior- attachment of the temporalis muscle to the cranium at the temporal crest Anterior- posterior wall of the maxillary sinus and the posterior surface of the orbit CONTENTS: The deep temporal space contains the pterygoid plexus, the internal maxillary artery and vein and the mandibular division of the trigeminal nerve  CAUSES OF INFECTION: The deep temporal space is most commonly involved when infection spreads from infected and necrotic maxillary molars.

Infratemporal Space- BORDERS: CONTENTS: CAUSES OF INFECTION: Medial- Lateral pterygoid plate Superior- base of the skull Lateral- continuous with the deep temporal space CONTENTS: The infratemporal space is continuous with the deep temporal space and contains the pterygoid plexus, the internal maxillary artery and vein and the mandibular division of the trigeminal nerve. CAUSES OF INFECTION: The most likely cause of spread of infection to this space is a infected maxillary third molar. ***One of the 3 spaces of the masticator space – pain/swelling on maxillary tuberosity

Space of The Body of the MANDIBLE Potential cleavage plane between the fascia and the bone. Limited anteriorly by superfical investing fascia and the attachment of the anterior belly of the digastric Limited posteriorly by investing fascia and the attachment of the medial pterygoid to the jaw Inferiorly closed by the continuity of the fascial layers Superiorly closed by the attachment of fascial layers to the inferior border of the body of the mandible. Formed by the attachment of the superficial layer of fascia to both the outer and inner surfaces of the body of the mandible attachment to the outer surface is at the lower border of the mandible attachment to the inner surface can be elevated from the mandible up to the origin of the mylohyoid muscle Clinical: An infection here may remain localized or may spread to the masticator space.

Pterygomandibular Space Borders: Lateral-Mandibular Ramus Medial-Medial Pterygoid Anterior-Pterygomandibular Raphe Posterior-Parotid Gland Superior-Lateral Pterygoid Inferior-Pterygomasseteric Sling CONTENTS Mandibular division of trigeminal nerve(lingual, IAN, mylohyoid, and auriculotemporal) IAN neurovascular bundle   Infection Spread is typically from sublingual and submandibular spaces with little or no swelling but significant trismus ***One of the 3 sp of the masticator spaces, TRISMUS!!

Submandibular Space Borders: CONTENTS CAUSES OF INFECTION: Lateral-mandible Medial and Posterior-Digastric muscles Superior-Mylohyoid Inferior-Superficial Fascia, platysma, and skin Anterior-Anterior belly of digastric CONTENTS Submandibular gland, Facial artery and vein, and lymph nodes CAUSES OF INFECTION: Perforation of lingual cortex of mandible typically in the 3rd molar region, but can arise from 2nd molar. Communicates posteriorly with pterygomandibular space.

Ludwigs Angina Condition exhibiting bilateral swelling of the submental, sublingual, and submandibular spaces. Characterized by extreme hardness of the floor of the mouth, "brawny", "indurated" swelling (no give or fluctuation due to pus formation) of the neck centering about the floor of the mouth and by the ensuing elevation of the mucosa of the mouth and tongue. Interstitial spaces are filled with fluid. The infection here may eventually extend to the lateral pharyngeal space and then may enter the retropharyngeal space and even descend to the mediastinum. Death from Ludwig's angina occurs as a result of suffocation due to edema of the mouth, tongue, and the glottis, from mediastinitis due to spread, or from septicemia or pneumonia Problem with the patient opening the mouth: Trismus Extraction of a lower molar tooth and subsequent infection precedes Ludwig's angina in a majority of cases. The roots of the second and third molar teeth reach downward to the level of the attachment of the mylohyoid muscle, and usually below it, while most of those of the first molar teeth, and usually all of those anterior to this, are located above this level

Ludwig’s Angina

LATERAL PHARYNGEAL SPACE Borders: Posterior to pterygomandibular space Superior-Base of skull Inferior-Hyoid bone Lateral-Medial Pterygoid Medial-Superior constrictor Anterior-Pterygomandibular Raphe Extends posteromedially to prevertebral fascia Divided into 2 compartments by the styloid process Anterior-primarily muscles Posterior-Contains carotid sheath and cranial nerves IX through XII CONTENTS Carotid, Internal jugular vein, Vagus nerve, and Cervical Sympathetic chain   Infection spreads from pterygomandibular space and can cause trismus, lateral swelling of the neck, and swelling of the lateral pharyngeal wall toward midline. May also cause erosion of the carotid, thrombosis of the internal jugular and interference with CN IX through XII.

Retropharyngeal Space Area of loose connective tissue lying posterior to the pharynx and anterior to the alar layer of the prevertebral fascia Largest interfascial space in the neck which permits movement of the pharynx, esophagus, larynx, and trachea during swallowing Borders Anterior: Superior and middle Pharyngeal Constrictor Muscles Posterior: Alar Fascia Superior: Skull Base Inferior: Fusion of the Alar and prevertebral Fascia at C6 – T4 Superficial/Medial: Deep/lateral: Carotid Sheath and lateral pharyngeal space Passes downward and is continuous with the (Retro)Visceral (retroesophageal) space (which begins below the pharynx) and opens inferiorly into the posterior mediastinum Closed superiorly by the base of the skull, superficial layer of fascia of the masticator space, submandibular space and laterally by the carotid sheath Contents retropharyngeal lymph nodes which drain the adenoids, nasal cavities, nasopharynx, and posterior ethmoid sinuses

Retropharyngeal Space Clinical importance Key to an understanding downward spread of infections of the head and neck: Commonly regarded as a route through which infections of the mouth and throat reach the mediastinum. It can break through the posterior wall of the space through the alar fascia, and can enter Danger Space 4, between the two lamellae of the prevertebral layer of fascia (extends from the base of the skull to the level of the diaphragm). Fatal hemorrhage could potentially result from an extension of a retropharyngeal abscess to the deep vessels of the neck Majority of cases arising from the internal carotid artery rather than from the jugular vein: the vein is more often occluded by the infectious process than it is eroded to the point of hemorrhage. A sudden enlargement of a retropharyngeal mass may indicate erosion of a large vessel and that in such a case aspiration of the mass before its incision may prevent fatal hemorrhage

Pretracheal Space Borders Ant: Sternothyroid-thyrohyoid fascia Post: Restropharyngeal Space Sup: Thyroid Cartilage Inf: Superior Mediastinum Superficial/medial: sternothyroid-thyrohyoid fascia Deep/lateral: Visceral fascia over trachea and thyroid gland

Other Spaces Prevertebral Danger Space 4 Potential pocket existing between the "prevertebral" fascia and the vertebral bodies. Danger Space 4 An area of delicate loose connective tissue that lies between the alar and prevertebral fascia Extends from the base of the skull to the mediastinum Infection can communicate from posterior wall of the oropharynx and oral cavity to the thorax by traveling from the Retropharyngeal Space, and passing downward to the Retrovisceral space (which begins below the pharynx). It can then pierce thru the weak alar fascia - into Danger Space #4 "Dangerous" because an infection can easily travel to the thoracic cage and mediastinum, i.e., mediastinitis. Abscess in the mediastinum could go anteriorly to the pericardial area and could affect the manubrium, sternum, etc..

Microbio Oral cavity has dense, diverse microbiota consisting of protozoa, yeast, virus and > 20 genera of bacteria Composed primarily of aerobic and anaerobic GP cocci and anaerobic GN rods Most odontogenic infections are caused by mixed aerobic/anaerobic organisms (~ 60%)