OS Sheet #5 bY Aseel Hattar

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aseel hattar
5/3/2012
oral surgery #5
dr.hazm


Last lec. We started talking about facial spaces infection we started with the primary involvement spaces. today we'll talk about the secondary spaces; (the spaces nearer to the airway).

Secondary spaces: **

1)submasseteric space :
Localized related to the muscle, laterally to the ramus of the mandible.
It's boundaries : sup. à zygomatic arch
Inf. à buccal pad of fat or the Inferior border of mandible Ant.  Parotidomasseteric fascia
Post. parotid med. ramus
lat. masseter
(I think it’s the E in the pic below).
* acommon story that happens that a pt comes with a recurrent pericoronitis in the lower wisdom (infection ), then the infection might spread and it might go to the submand. Space and it might invade and spread behind the masseter .
{the infections in the submassetric space could happen from any other causes rather than the pericoronitis }.

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*the most characteristic sign of those pt's is trismus bcz of the reflex spasm of the masseter due to the abscess and sever
Clenching ex. : last year there was a pt ,they took a CT scan for his parotid and they found a swelling in the area ,then they took a panoramic x-ray and they found infection in the wisdom area and a cystic lesion invading the posterior aspect of the masseter. as soon as they extract the wisdom , there was a pus drainage for 24 h. .

*so we can simply diagnose the condition by taking a panoramic x-ray to find the cause or by CTscan to find the localization of the pus underneath the masseter .

2) Pterygomandibular Space:
(the place that we inject the needle to give the inferior alveolar block (ID) ).
It's boundaries : sup lateral pterygoid m.
Inf Pterygomasseteric sling
Ant Pterygomandibular raphae
Post  parotid
Med  medial pterygoid
Lat  ramus
(I think it’s the F in the pic )




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*it's the exact space of the injection ,so one of the possible causes of this infection is the needle injection due to contamination .

3) temporal space:
just lateral to the temporalis m. underneath the temporalis fascia.(between the m. & its fascia).

**Now the cervical facial spaces

1) Lateral Pharyngeal Space:
Located laterally to the sup. Constrictor .
- as u can imagin we have the oropharynx ,lateral wall , posterior wall .
Lat wall is the lateral pharyngeal space The
The Post wall is the retropharengeal space

*infections within ptyrygomand. Space can go posteriorly and reach the lateral pharyngeal space .

It's boundaries : post prevertbral facsia .vertebral column
Antpterygomandibular raphe
Lat med.ptrygoid m.
Medsup.constrector
Sup base of the skull ,spheniod bone .
*if u go medially there is retropharyngeal space
Inf hyoid bone

S&s of the infections :

1) sever trismus
2) swelling of the neck ,even its located more to the lateral side of the oropharynx ,there will be swelling intraorally and sometimes it pushes the content of the neck laterally.
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Complications:
There is artries ,veins within the lat. Pharyngeal spaces like the carotid artery ,jugular veins ,it might have erosions , thrombosis and it might affect the cranial N. IX, XII ,so its life threatening infection and its not common .

2) retropharyngeal space:
** there is direct connection between retropharyngeal space and the mediastinum ,so the infection can go down the neck reaching the mediastinum causing mediastinatitis , and this is a very dangerous complication .
Involvement of prevertebral space. -


**we don’t really get the common infections only from the streptococcal or anaerobic bac. But there is the actinomycosis ; its an endogenous flora (from the normal flora not from outside )
But sometimes it becomes active and cause infection ,and it has a typical appearance (sulfer containing pus ) ,it need antibiotic for 6 monthes and its one of the aggressive infections that might affect the area as well as the necrotizing faciaitis .

Necrotizing faciaitis :uncommon infection of the head and neck ,its due to mix bacterial infection , and its charectarized by a very rapid spreading of infection causing necrosis of skin ,underlying facsia ,connective tissue and it can kill the pt within few hours .
It has a predisposing factors like immune problems,and the only manegment is resection .

Manegment of the facial infections :
Always start with taking history trying to reach the diagnosis ,we need to do all the investigations .
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Important aspect of investigations is the radiological investigation &always start with the simplest one ; periapical ,panoramic ,then go for ultrasound and CTscan .

-whats the difference between ultrasound and CTscan ??
There is a difference in the aggresivness .
CTscan  x-ray machine
Ultrasound  waves of ultrasound ,it helps to know if there is fluids .

**so if there is swelling and we'r not sure to drain it or it's only cellulites we do ultrasound and if there is fluids we drain it .

And to be sure we go for more aggressive investigations like CTscan or MRI .
-whats the difference between MRI &CTscan ??
MRIfor soft tissue

Another option is the cone beam ,it’s the standerd for dentistry ,it’s a 3d image .

**whats the difference between cellulites and abscess ??
Cellulites  generalized , streptococcus , no pus ,no drainge but decompression .
Abscess  anaerobs , localized pus containing cavity and needs drainage. it
-the pt starts with a periapical infection  mild cellulites  it goes bigger  develops to a redness of skin  abscess .
(abscess at a later stage ).

In normal cases if there is a pt with swelling we go through the investigation ((skin color,duration ,redness )those are the signs of abscess (collection of pus )) . but if its generalized swelling

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with no sever changes in the color of the skin ;usually its
cellulites and we can go for antibiotic manegment and removal of the cause and usually the pt usually improves.

Treatment :
--Once diagnosis is established, the same principles of manegment of any emergency pt (ABC's ) is done.

--securing the airway is the most significant factor that reduce the mortality rate in sever infections .
Ex: tracyostomy ,needle injection technique.
-needle injection technique :aspiration for the lateral pharyngeal space ,ptrygomand. Space to avoid the rupture of the pus in the oropharynx .

--giving fluids is very important bcz with infections there is high fever and therefore high metabolic rate and there is load on the cardiovascular system. and therefore losing a lot of fluids and over load might lead to further complications ,so usually we secure an IV line and make sure he's taking a proper antipyretics.

-- In case of respiratory distress or embarrassment, intubation should be strongly considered.

--Fiberoptic intubation or surgical airway, "cric" or "trach" may be necessary if edema has distorted the anatomy

((Always think of removal of the cause ,but try to reach the proper diagnosis before that .))

--For odontogenic infections: endodontic treatment, or extraction of the offending dentition Should be done
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concurrently with establishment of drainage of the involved space(s).

--Antimicrobial aid

Q: can we do extraction if there is infection ???
In mild dentoalveolar infections we give the pt antibiotic first bcz the L.A won't work if there is infection, but in sever cases we go through G.A bcz its dangerous and we cant wait .

--we prepare the site of the operation,usually we do aspiration either therapeutic or to obtain a sample for culture and sensitivity .

--if the abscess size is small the aspiration is enough ,we don’t need an incision .

-- incision (1-2 cm) skin, or mucous if there is fistula or collection intraorally ,and sometimes intraorally won't be reachable like in submand. Space or submental or the spaces mentioned earlier .

--by blunt dissection we try to insert our instrument inside the cavity and then break the septa or the adhesions within the abscess to allow the pus to come out(Use shortest and most direct route to the space)
and we insert a tube or drain ;it allows 1) patent pathway for the pus to come out from the area 2)prevent recollection 3) and prevent closure of the layers of the soft tissues .
then we close around it .
((Placement of a drain, secured to the stoma of incision
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with nylon, silk, or chromic suture.))


**why we do blunt dissection ?
Inorder not to damage any vital structures
Ex:
1)submand.space 
It has arteries ,marginal mand.nerve that can be injured if we go in a sharp way.
2)in the lateral pharyngeal space  there is the carotid artery, jugular vein ,so if u go sharply u may kill the pt.

**in submand. Abscess try to reach the border of the body of mand. ,bcz the abscess starts from the roots (inner surface of the body of the mand .) so we touch the bone expand then go back ,inorder not to leave any puss behind .


Incisions we can use according to the facial space infections:
1)temporal space 2cm on the scalp
2)sub mand &sub lingual  can have it through the retromand. Approach .

*retromand. approuch  it’s common ,its an insicion in the submand area . &u need to avoid the lower border of the mand. By at least 2 cm to avoid the marginal mand. Nerve (if its damaged it causes weakness of the lower lip of the affected side ) and then u go up through the layers .
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3) we can go to a lower level for lateral pharyngeal space anterior to the sternocledomastoid.


((the most common one is the sub mand. Or the sub mental ))

**penroze drain :
we insert it from one side and pull it out from the other side (see the pic below),it has perforations to allow the pus to come out and to prevent recollection ,bcz the tissues can close very early .
-usually the pus come out within 48-72 h. if we remove the causative factor ,then we can remove the drain and close the skin .
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Antimicrobial treatment
Generally speaking , dental infections can be treated by penicillins (they are wide spectrum covers gram +ve,-ve, and a good deal of anaerobs ).
*For sever infections we can give amoxicillin or penicillin with metronedazol which can cover a wider spectrum.
*also agumntin or amoclan is a good modification of penicillin .
*clindamycin  for allergic pt's .

**always start with broad spectrum ;its very safe & have minimal side effects .
(narrow spectrum can cause side effect like psudomambranous colitis ).

* In mild infection we don’t need to do culture and sensitivity ;usually empirical antibiotics are enough .

*if the pt is medically compromised or he didn’t respond to the antibiotic or if there is a suspection of a rare
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Bac. Like (klebsilla in diabetic pt or TB in HIV pts ) then we need a culture and sensitivity .

**the grps in general
( penicillins,cephalosporins , erythromycin , clindamycin, Metronidazole ,aminoglycosides)

--now the dr is talking about his pt's (pic's)
1) this is the pt I showed u last lec. :
(pregnant woman, limited mouth opening ,we tried the aspiration from outside ,she didn’t need extra oral insicion .


2)pt with a huge submand. Space infection and we took a CTscan and it showed a collection of pus (frank abscess ). She required insicion and drainage extraorally to allow the pus to come out .

--2 cm from the lower border of the mand. ,we mark our insicion with a marker ,try to aspirate first and then starting the insicion 2-3 cm .

**what are the layers that we go through it ??
1)skin 2)superfacial facia 3)platsma 4) deep facia.

--then we go up and we reach the sub mand. Space .

--as we enterd the submand. Space there was a pus mixed with blood ,then we did the blunt dissection to break the septa within the abscess then we inserted a drain and kept the wound open ,then it was removed after 3 days ,and ofcourse we removed the causative
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factor by extracting the tooth first .

Q: in the pic u draw 2 marks ,the first 1st for the site of the insicion the 2nd for what ???
Its for the marginal mand. N. that gives the motor supply for the lower lip m. , that’s why we go underneath ,trying to elevate the skin with the nerve together inorder not to injure the N. .

Q:how would u mange a diabetic pt who represented with sever submental space infection ???

1)simple examination .but bcz its submental its hard to diagnose
2) CBC
3)random bloog suger (bcz he's not fasting )
70-140 mg/dl normal
**even if we don’t know if he's a diabetic pt ,we should suspect that he's diabetic and there is immune problem that cause this infection ,bcz the diabetis is a strong predisposing factor for spreading of infections .
4)take a panoramic x-ray so we can see one of the possible causes of this infection, like a previous trauma of the lower incisors loss of vitality  spread of infection  reach the submental space .
also we can take periapical x –ray ,then we put a surgical plan .
5)now we'll go for the surgery and remove the causative factor ,so we decide if the tooth needs only RCT or its not restorable and needs extraction .
6) then we do insicion and drainge extraorally bcz its more reachable .
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**pt with uncontrolled diabities and there is a facial space infection we must admit him to the hospital ,then they can control the sugar level by short acting insulin or by other ways .


Q: how we could manage a buccal space?
1st we make sure its an infection not a swelling only by :
1)s&s
(s&s of infection :1-fever 2-pain 3-redness4-loss of function 5-malaise )

2)aspiration ,but its not always easy so we cant depend on that.
3)CTscan

Note : if we extract a tooth and the pus came out from the socket ,there is no need to do insicion and drainage






GOD bless u







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