Fascial Space Infection Part - 2 retropharyngeal space, ludwigs angina, pharyngeal space, cavernous sinus thrombosis, mediastinitis

1. DEEP FASCIAL SPACE
INFECTIONS
PART-2
ARJUN SHENOY
DEPT OF OMFS

2. • MASSETRIC SPACE
• LUDWIGS ANGINA
• PHARYNGEAL SPACE
• RETROPHARYNGEAL SPACE
• CAVERNOUS SINUS THROMBOSIS
• MEDIASTINITIS
• CONCLUSION
• REFERENCES

3. MASTICATORY SPACE
MASSETRIC + PTERYGOID + TEMPORAL

4. MASTICATOR SPACE
• Massetric, pterygoid and temporal- well differentiated
• Communicate with each other
• Also with
• Buccal
• Submandibular
• Parapharyngeal
• MASTICATOR SPACE CONTENTS-
• Muscles of mastication
• Internal maxillary artery
• Mandibular nerve

6. SUBDIVISION
• MASSETRIC SPACE-
• Lateral- masseter
• Medial- mandibular ascending ramus
• PTERYGOID-
• Lateral-mandible
• Medially- pterygoid muscle
• Communication-
• Superiorly- superficial and deep temporal space
• Anteriorly- buccal space
• Posteriorly- lateral pharyngeal space

7. ORGIN
molar (commonly 3rd molar)
Contaminated injections
Temporocranial flaps - neurosurgery
Nearby contiguous spaces
Circumzygomatic wiring in trauma
TMJ surgery
• Clinical hallmark- trismus
• Exception- immunocompromised
• Swelling – may not be prominent

8. • Infectious process deep to muscles -
• swelling less prominent
• contrast to buccal space infections
•

9. SICHER’S APPROACH
• Sicher suggested approach to all compartments –
incision through pterygomandibular raphae
• Feasible in cadavers - not trismus
• Oral approach-compromise airway
• purulent oozing pus
• Difficult drain - loosening

10. I & D
• MASSETRIC + PTERYGOID SPACE-
• Extra-oral – easier technically & prudent
• Sharp dissection - external angle of the mandible
• Allows dependent drainage of both spaces

11. SURGICAL INTERVENTION
• TEMPORAL SPACE –
• Intra-oral- sichers-incision
• Percutaneous-
• incision -slightly superior-zygomatic arch

12. LUDWIGS ANGINA
Wilhelm Frederick von Ludwig

13. DEFINITION
• Ludwigs angina is a firm , acute, toxic cellulitis of the
submandibular and sublingual spaces bilaterally and of
the submental space
• Three F’s
• Feared
• Not fluctuant
• Fatal

14. HISTORICAL PERSPECTIVE
• Wilhelm Frederick von Ludwig first described in 1836 a
potentially fatal, rapidly spreading soft tissue infection
of the neck and floor of the mouth

15. • Ludwig published his now-famous paper on
Ludwig's angina with no title in 1836.
• A colleague dubbed the condition "Angina Ludovici"
(Ludwig's angina) a year later
• Pre-antibiotic era- 50% mortality
• 5%- use of penicillin
• observed frequently in compromised host
• Less than 1% of all OMFS admissions
• Untreated- mortality rate 100%

16. • Compound mandibular fracture
• Puncture wounds of oral floor
• Secondary infection of oral malignancies
• Submandibular gland sialadenitis
• Oral soft tissue lacerations
• Reported in new born
• Pseudo-ludwigs angina /phenomenon- non dental

18. CLINICAL FEATURES
• Bilateral infection of sublingual and submandibular spaces
• brawny edema,
• elevated tongue
• airway obstruction
• paucity of pus

19. MICROBIOLOGY
• Streptococci or mixed oral flora are commonly
reported from cultures
• Contemporary- Ecoli ,pseudomonas and anaerobes
bacteroides and peptostreptococcus
• Prevotello melaninogenicus, prevotella oralis, prevotella
corrodens also isolated

20. DIFFERENTIAL DIAGNOSIS
• angioneurotic edema
• lingual carcinoma
• sub- lingual hematoma
• salivary gland abscess
• lymphadenitis
• cellulitis
• peritonsilar abscess

21. TREATMENT
• Establisment and maintainance of an adequate airway
are the sine qua non of therapy
• Early diagnosis,maintainance of patent airway, intense
empirical and intra-venous prolonged antibiotic
therapy, extraction of affected teeth, hydration, early
surgical drainage,
• Pencillinplus, metronidazole or clindamycin or
imipenem

22. TRACHEOSTOMY
• Death more likely to occur from airway obstruction than
sepsis
• Tracheostomy most routine during most of twentieth century
• Difficult to perform in late stage –massive neck oedema and
tissue distortion

23. BLIND NASAL INTUBATION
• Swollen tongue and glottis oedema- time consuming , unsuccessful
and fraught with danger especially if attempted by inexperienced
anaesthesiologist.
• Danger of rupturing a bulging lateral pharyngeal or
retropharengeal abscess

24. FIBRE-OPTIC ASSISTED
INTUBATION
• Cervical soft tissue plain films + CT scan
• fiberoptic laryngeoscopy- premedicated +cooperative
patient
• Tracheal intubation under deep inhalation anaesthesia
may be successful obliviating the need for
tracheostomy

26. SURGEONS PERSPECTIVE
• Sedative and narcotic agents- rapid respiratory deterioration
• Some authorities advocate high doses of antibiotic without
surgery until fluctuance develops, in most surgeons
experience prompt and deep surgical incision is required
since fluctuance is uncommon and late
• Diffuse cellulitis of deep spaces – 70% cases require surgical
intervention and drainage
• “A chance to cut is a chance to cure”

27. INCISION
• Horizontal incision midway between the chin and the hyoid
bone - classic approach to the surgical drainage - ludwigs
angina
• “cut-throat”incision unaesthetic and unnecessary

28. • Platysma and supra-hyoid fascia incised by this approach
• Fascia of submandibular gland also entered
• Mylohyoid muscle divided and sublingual space entered
• A closed clamp is inserted through the median raphae of
mylohyoid muscle and advanced to the hyoid bone at the
base of the tongue

29. NEEDLE ASPIRATION
• Needle aspiration of deep fascialspace infection has
been attempted obliviating need for open drainage
• Ludwigs angina not amenable to this technique even if
needle is CT guided
• may result in reinfection
• adequate drainage or premature closure of surgical

30. DRAIN PLACEMENT
• Bilateral incision into the submandibular spaces with
blunt dissection to the midline suffices if a through and
through drain or bilateral drains meeting in midline are
placed combined with drainage of sublingual space
• Relieves intense pressure of oedematous tissue on the
airway and provides specimen for culture

31. SCAR REVISION
• Secondary revision of scarring may be necessary for
cosmetic or to repair the stenosis of whartons duct
• Disseminated intravascular coagulation-well recognized but
fortunately uncommon sequelae of severe infection

32. PHARYNGEAL SPACE
INFECTION

33. PHARYNGEAL SPACE
• Lateral neck space shaped like a inverted cone
• Base at skull and apex at the hyoid bone
• Medial wall contiguous with carotid sheath ,lies deep to
pharyngeal constrictor muscle
• Divided into anterior and posterior compartments

34. CAUSES
• Pharyngitis
• tonsillitis
• parotitis
• otitis
• mastoiditis
• dental infection
• Herpetic gingivostomatitis involving pericoronal tissue

35. CLINICAL FEATURES
• Anterior compartment-
• Pain, fever,chills
• Medial bulging of the lateral pharengeal wall
• Deviation of palatal uvula from midline
• Dysphagia, swelling below angle of mandible
• Posterior compartment-
• Visible swelling with absence of trismus
• Respiratory obstruction
• Septic thrombosis of internal jugular vein
• Carotid artery haemorrhage - later stage

36. TREATMENT
• CT more useful than standard radiographs
• Therapy-antibiotic, surgical drainage, tracheostomy if
indicated
• Surgical approach – oral - incision of the lateral wall
• External approach- exposure of carotid sheath-lateral tip
• of sternocleidomastoid- retraction of sternocleidomastoid

37. • Blunt dissection along posterior border of digastric muscle
leads to lateral pharengeal space
• Combined intra-oral + extraoral approach – mucosal incision
– lateral to pterygomandibular raphae , large curved clamp
passed medial to medial pterygoid muscle in a posterior-inferior
direction.
• Tip of clamp delivered through skin- cutaneous incision
between the angle of the mandible and the
sternocleidomastoid muscle

38. RETROPHARYNGEAL
SPACE INFECTION

39. RETROPHARYNGEAL
SPACE
• Space lies behind the esophagus and pharynx and extends
inferiorly to the upper mediastinum and superiorly – base of skull
• Orgin- nasal or pharyngeal infection in children
• Oesophageal trauma, foreign bodies, tuberculosis
• Symptoms-
• Dysphagia
• Dyspnea
• Nuchal rigidity
• Eosophageal regurgititation
• fever

40. • Visualization of pharynx- bulging of posterior wall – more
prominent unilaterally
• Adherance of median raphae to prevertebral fascia
• Lateral soft tissue radiographs useful
• widening of retropharyngeal space
• >3-6mm adults >14mm children (2nd vertebra)
• Presence of gas in prevertebral soft tissue
• Loss of normal lordtic curvature of cervical spine
• CT- inferior extent + plain films

41. TREATMENT
• Early cases 10-40% resolve with medical management
• Prompt surgical drainage – protocol
• Tracheostomy indicated
• Transoral approach- Extreme trendelenburg position and
constant suction- under LA

42. CONTINUED
• Transoral- incision through midline of posterior pharyngeal
mucosa-blunt dissection
• Exernal approach- dependent
• Incision- anterior border of STM
• Muscle+carotid sheath retracted medially
• Blunt finger dissection deeply
• Upto level of hypopharynx
• Deep drains placed + maintained
• Overall mortality rate – approx. 10%

43. CAVERNOUS SINUS
THROMBOSIS
• Orgin- ascending rom maxillary teeth, upper teeth,
nose or orbit
• Through valveless anterior and posterior fascial veins
• Extremely high mortality rate

44. INITIAL SIGNS
• Proptosis
• Fever
• Obtunded state of consciousness
• Ophthalmoplegia
• Paresis of –
• occulomotor
• trochlear + abducens nerve

45. MEDIASTINITIS
• Extension of infection from deep neck spaces into the
mediastinum
• C/F –
• Chestpain, fever
• Severe dyspnea
• Mediastinal widening
• IV drug abusers- greater risk

46. CONTINUED
• Late complication
• Progressive septicemia-mediastinal abscess-pleural
effusion-empyema-pericarditis
• Necrotizing mediastinitis- aerobic+anaerobic
• Treatment- extensive long term antibiotic therapy and
surgical drainage of mediastinum
• Emergency neurosurgical intervention

47. CONCLUSION
• Incidence and severity have diminished with advent of
antibiotic therapy
• To be alert to the potential seriousness of these infections-never
to be dismissed as simple dental abscess
• Deep fascial infections must be recognized promptly and
treated as an emergency
• Repeat diagnostic and therapeutic measures may be
necessary until the very end point

48. REFERENCES
• R.G Topazian , Oral & Maxillofacial Infections 4th edition
• Journal of Oral and Maxillofacial Surgery, Volume 72, Issue 9,
Supplement, September 2014, Pages e83-e84
• The Journal of Emergency Medicine, Volume 43, Issue 4,
October 2012, Pages 605-611
• Journal of Plastic, Reconstructive & Aesthetic Surgery,
Volume 60, Issue 4, April 2007, Pages 372-378
• Journal of Infection, Volume 50, Issue 1, January 2005, Pages
34-40
• Emergency Medicine Clinics of North America, Volume 18,
Issue 3, 1 August 2000, Pages 481-519