Bleeding & Hemostasis PDF

Bleeding & Hemostasis Dr. Elif Özcan Department of Oral&Maxillofacial Surgery • Before the invasive procedures, patient should be classified regarding to the risk of hemorrhage. • Control of bleeding is the most important integral part of any surgical treatment procedure. • Care must be taken in e...

Bleeding & Hemostasis Dr. Elif Özcan Department of Oral&Maxillofacial Surgery • Before the invasive procedures, patient should be classified regarding to the risk of hemorrhage. • Control of bleeding is the most important integral part of any surgical treatment procedure. • Care must be taken in every step of the operation, from incision to suturation, and hemostasis should be achieved in every step. • First, the source of the bleeding must be identified. Remove the clot if necessary. • When faced with a postextraction hemorrhage the clinician should ensure that the area can be well visualized. This will allow the best opportunity to make the correct diagnosis, identifying the type of postextraction hemorrhage and the site of the hemorrhage, therefore enabling quick and effective management. • Stabilization of the mobile tissues contributes the hemostasis, so suturing these tissues will provide a better control. • Primary Hemorrhage This occurs during the surgery, as a result of injury like cutting or laceration of the artery or bleeding from bone.This also occurs when surgery is done in an infected area with a lot of granulation tissue.It can also occur after a very short period of time immediately after surgery.This type of bleeding is really normal and can be controlled easily. • Intermediate / Reactionary Hemorrhage This type of bleeding occurs within a few hours after surgery.This type of bleeding occurs as a result of failure of coagulation to occur (as in patients with systemic bleeding problems or those on anticoagulants). Patients who have unknowingly disturbed / dislodged the clot are also prone for this type of bleeding. +Insufficient hemostatic measures • Secondary Hemorrhage This occurs after 7 to 10 days after surgery. This is mainly due to partial division of blood vessel in combination with infection of the wound. This type of bleeding is not very frequently encountered after oral surgery procedures. Elevation of patient's blood pressure enough to overcome pressure external to blood vessel is another common reason for reactionary bleeding. • Local Treatment of Intermediate or Recurrent Hemorrhage and Secondary Hemorrhage: • One or a combination of the following methods may be used: • 1. If the sutures have become loose, the area should be anesthetized and suturation over the bleeding area. • • 2. Direct pressure may be applied over the bleeding area. This is accomplished by having the patient bite firmly on gauze pressure pads over the bleeding area. • 3. A vasoconstrictor, such as epinephrine poured on a sponge, can be applied directly to the bleeding area; this results in a constriction of the lumen of the vessel until a new clot can form. • • 4. The surgeon can also apply a local agent to speed up blood coagulation. All these agents are placed on gauze sponges and held over the bleeding areas, or placed into the sockets with pressure. Reasons of Bleeding • In healthy patients the postoperative bleeding is mainly due to local causes. • Local -Anatomical structures -Vascular tumors and malformations -Trauma • Iatrogenic Preop history Preop exams Anesthesia (Hypotensive Anesthesia-general/ Epinephrine-local) Incision-Suture Postop exams Instable wound Reasons of Bleeding • Systemic -Anticoagulant therapy Low/Intermediate/High Risk for Thromboembolism INR at the day of the procedure. *Mechanism of Hemostasis & Bleeding Tests 1. VASCULAR PHASE 2. PLATELET PHASE 3. COAGULATION PHASE 2. INR PT aPTT Bleeding time, Thrombin time, Platelet count -Coagulopathies Hemorrhagic Diatesis: Hemophilia A&B (Factor VII & IX) Von Villebrand ITP (Idiopathic thrombocytopenic purpura) Thrombocytopenia Ca++ deficiency Leukemia -High Blood Pressure Hypertension: Essential Secondary 14/9 --> «normal» of the patient -Diseases Related to the Collagen synthesis -Vit K deficiency -Liver disease -Chemotherapy/Radiotherapy Internal Hemorrhage • • • • • • • • We should obtain hemostasis in all wound depths. Pressure Cold compress (Min. 36 hours 5/5-10/10 minutes) Elevated head Elimination of the systemic problems Pressure bandage A removable drain may be placed. In the presence of hematoma, formation of ecchymosis may start within 3 days. Patient should be instructed. • Management: - Within a few hours: Aspiration/Exploration-if active - After Clotting: Minor: Cold compress for 36 hours, then warm compress (accelerates resorption). Extensive: Exploration may be needed. External Hemorrhage Capillary: Bleeding from a surface, continuous oozing, red Arterial: From a focus, pulsative, bright red Venous: ~Focus, continuous, darker color Intraosseous: Pooling, oozing, variable. originates either from nutrient canals in the alveolar region, central vessels, such as the inferior alveolar artery. **Veins-embolism: Compress first. • Vascular hemorrhage may cause the most distress to a patient given the excessive amount of blood flow. A large vessel may require ligation, whereas smaller vessels can be cauterized. If the vessel is not visible, a flap may to be raised to allow access and identification. • If, during operations involving the bony processes, an artery is severed, the bleeding can be controlled by taking a blunt instrument and crushing the surrounding bone into the point of bleeding. Capillary oozing from the bone either stops spontaneously or is usually controlled when the mucoperiosteal flaps are reapproximated and sutured back over the alveolar ridges. If bleeding is profuse, tightly pack the sockets with gauze for 5 to 10 minutes under pressure, remove the gauze and then place pieces of absorbable hemostatic gauze in each socket before suturing the soft tissues into place. • Capillary bleeding from soft tissues at the time of operation is • • • • best controlled by suturing if, for example, after a flap surgery there is still bleeding following the insertion of the usual number of sutures, additional sutures should be inserted in that area in which bleeding occurs. • • The anterior floor of mouth is a very vascular area. It is supplied by the sublingual branch of the lingual artery which anastomoses with the submental artery, a branch of the facial artery, and the incisive arteries which are branches of the inferior alveolar artery. As a result of trauma (either external or from the operator's instrument), the sublingual artery in the floor of the mouth may be severed. This vessel is extremely difficult, if not impossible, to ligate when severed by a puncture wound, and the consequences can be fatal if the wound remains untreated. Bi-manual pressure (one hand inside and one hand outside the mouth) will usually control this bleeding until an appropriate ligation can be performed in the neck** Autogenous block grafting Implant External Hemorrhage • Management: • Simple compress: First step in all types of bleeding. • Local hemostatic agents -Surgicel (Oxidised Regenerated Cellulose) -Spongostan (Gelatin sponge) -Gelfoam -Gelatamp (gelatin sponge+colloidal silver) -Ankaferd**** (herbal) ****SHOULD NOT BE INJECTED**** -~Local anesthesia - Celox: Chitosan (polymer from seashells) - Tranexamic acid 5%-Transamine: Local&Systemic • Suturation • Wet gauze -Simple suture: Resorbable/Nonresorbable • Electrocautery&Laser in bone: bone necrosis Ligation of Blood Vessels: In the event of arterial bleeding from the soft tissues, the vessel should be grasped with a hemostat and ligated by tying it directly or indirectly by the use of a circumferential suture around the soft tissue. -Clamp tie-direct -Stick tie-indirect -Ligation clips (Indirect vessel ligation) Palatal artery: Stick tie, closing and securing the vessel with the suture pressure, distal ligation, removed 1 week after, collateral circulation. Palatal pressure, great enough to stop the bleeding, should first be applied along the course of the vessel posterior to the point of bleeding and held firmly for at least 5 to 10 minutes. • Cauterization&Laser • Bone wax: exposed bone marrow • Management of systemic problems Oral and Dental Surgery - II Orofacial Infections - Part-I Asst. Prof. Ezgi YÜCEER ÇETİNER School of Dental Medicine Department of Oral and Maxillofacial Surgery [email protected] Course Content 1. Microbiology of Orofacial Infections 2. Pathophysiology of Oral Infections 3. Management of Odontogenic Maxillofacial Infections Orofacial Infections Part-I 27.10.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Learning Outcomes At the end of this course you will; Know the pathophysiology of odontogenic infections. Define microbiology of odontogenic infections. Explain how to manage orofacial infections. Orofacial Infections Part-I 27.10.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Resource • Hupp, J. R., Tucker, M. R., & Ellis, E. (2019). Contemporary Oral and maxillofacial surgery. 7th Ed., Elsevier. Chapter 16 Orofacial Infections Part-I 27.10.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Origin of Maxillofacial Infections • 1- Odontogenic Infections • 2-Non-odontogenic Infection • Salivary Gland Infections • Otitis media and tonsillitis • Jaw fractures • Dental caries • Periodontal Disease • Pericoronotis • Cutaneous infections Infected Odontogenic Cysts • Chemical irritations of mucosal and cutaneous layers • Non-sterile infiltration of local anesthetics • Specific bacterial infections • Paranasal sinusitis • • Remnant roots • Pulpal necrosis in devitalized teeth Management of Odontogenic Maxillofacial Infections 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. Microbiology of Odontogenic Infections  Odontogenic infections are primarily caused by normal oral bacterial flora, which include aerobic and anaerobic gram-positive cocci and anaerobic gram-negative rods.  Odontogenic infections are almost invariably polymicrobial, involving multiple bacteria.  Approximately 50% to 60% of all odontogenic infections involve a combination of both aerobic and anaerobic bacteria. Orofacial Infections Part-I 27.10.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Pathophysiology of Odontogenic Infections  The location of this erosion through bone largely depends upon the faciolingual location of the source of the infection, as well as the thickness of the cortical bone Orofacial Infections Part-I 27.10.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Pathophysiology of Odontogenic Infections  When infections reach the soft tissues, it generally manifests in four stages: inoculation (edema), cellulitis, abscess, and resolution.  The inoculation (edema) stage refers to the stage in which the invading bacteria begin to colonize and typically occurs in the first 3 days of onset of symptoms. This stage is characterized by diffuse, soft, doughy red swelling that is mildly tender.  The cellulitis stage occurs between days 3 and 5 and represents the intense inflammatory response elicited by the infecting mixed microbial flora. This stage is characterized by poorly defined diffuse firm red swelling that is exquisitely painful to palpation. As the infection evolves and anaerobes begin to predominate, liquefaction of tissues occurs with the formation of purulence, which is the hallmark of the abscess stage. As purulence is formed, the swelling and redness become better defined and localized, and the consistency changes from firm to fluctuant.  When an infection is drained, either spontaneously or via surgery, the host defense mechanism destroys the involved bacteria and healing begins to occur; this is the hallmark of the resolution stage. Orofacial Infections Part-I 27.10.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Pathophysiology of Odontogenic Infections Orofacial Infections Part-I 27.10.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Pathophysiology of Odontogenic Infections  In clinical practice, the most commonly encountered odontogenic infection is a vestibular space abscess of endodontic origin.  These infections may occasionally rupture and drain spontaneously, which results in temporary resolution, preventing spread to deeper potential spaces.  Spontaneously draining infections may continue to drain and form a fistula to the oral cavity or a sinus tract to skin, or reclose and result in the reforming of an abscess. Orofacial Infections Part-I 27.10.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Principle 1: Determine Severity of Infection • Determination of severity begins with a complete history, followed by physical examination, and any necessary ancillary testing (e.g., radiographic imaging studies, laboratory studies). Orofacial Infections Part-I 27.10.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Principle 1: Determine Severity of Infection • Physical examination must be performed in a comprehensive and organized fashion • It is recommended that the clinician begin from “big to small,” or “outside then inside.” • This begins with obtaining vital signs (temperature, blood pressure, heart rate, and respiratory rate). Orofacial Infections Part-I 27.10.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Principle 1: Determine Severity of Infection • Patient with left canine space infection with periorbital space extension, with malaise and characteristic “toxic appearance” indicating compromised host defenses. Orofacial Infections Part-I 27.10.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Principle 2: Evaluate State of Patient’s Host Defense Mechanisms  When the host defense mechanism is compromised, it must be compensated for by aggressively managing the infection with surgical treatment and, in most cases, adjunctive antibiotic therapy.  Two main categories of medical comorbidities that adversely affect the host defense system are inadequately controlled metabolic diseases and conditions that directly affect the immune system.  Poorly controlled diabetes mellitus  Severe alcoholism,  Hematologic cancers such as leukemia and lymphoma  HIV infections,  Chemotherapeutic agents for malignant conditions  Immunosuppressants and corticosteroids used for various indications (such as autoimmune diseases and organ transplantation) Orofacial Infections Part-I 27.10.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Principle 3: Determine Whether Patient Should Be Treated by General Dentist or Oral and Maxillofacial Surgeon  The decision should be based upon location, severity, surgical access, and status of host defenses Orofacial Infections Part-I 27.10.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Principle 4: Treat Infections Surgically One of the most common misconceptions about odontogenic infections is the role of antibiotics as the main treatment modality. It cannot be stressed enough that odontogenic infections are a surgically managed disease process and that antibiotics only serve an adjunctive role, if they are indicated at all. Robust evidence clearly shows that surgical management is significantly superior to antibiotic-only therapy in improving various clinical parameters, including body temperature, laboratory values, and hospital stay. Orofacial Infections Part-I 27.10.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Principle 4: Treat Infections Surgically Management of Odontogenic Infections eliminating the source of the infection: extraction, pulp extipation (with subsequent definitive root canal theraphy, and periodontal therapy establishing surgical drainage: incision and drainage mobilizing the host defense system Orofacial Infections Part-I 27.10.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Principle 4: Treat Infections Surgically Elimination of the Source:  The method of source control depends on the specific etiology (endodontic or periodontal), as well as the severity.  However, certain situations preclude adequate source control. An example is significant trismus that does not allow the clinician to properly access the offending tooth or teeth due to limited access to the oral cavity. In such instances, depending on the severity and location of the infection, the clinician may begin empirical antibiotic therapy or perform incision and drainage first to improve mandibular opening prior to eliminating the infection source. When an infection is deemed serious and aggressive, the patient must be treated under general anesthesia in a controlled operating room setting for immediate surgical management. Orofacial Infections Part-I 27.10.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Principle 4: Treat Infections Surgically Incision and Drainage:  Following source control, surgical drainage of the infection is the second component of surgical treatment.  Incision and drainage facilitates healing by two main mechanisms.  The first and most important mechanism is decreasing the bacterial load. Lowering the bacterial load with elimination of the source and drainage of the infection allows the host defense system (third component of management) to remove any residual infection.  The second mechanism of surgical drainage is decreasing the pressure of the infected tissues. When the hydrostatic pressure of the infected tissues is decompressed with surgical drainage, the local blood supply is improved, and this allows the host defense system, and adjunctive antibiotics, to better reach the infected area. Orofacial Infections Part-I 27.10.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Principle 4: Treat Infections Surgically  When the access is deemed insufficient, analgesia and anxiolysis may be used, because limited mandibular mouth opening with a vestibular space infection is almost invariably due to guarding from pain.  The next step in surgical treatment is to determine the need for microbiologic analysis and culture and sensitivity testing. Although not necessary on a routine basis, some situations warrant serious consideration for laboratory evaluation Orofacial Infections Part-I 27.10.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Principle 4: Treat Infections Surgically Orofacial Infections Part-I 27.10.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Principle 5: Support Patient Medically  Supportive measures include hydration, improved nutrition, pain control, adjunctive antibiotic therapy, and blood glucose control.  Most patients presenting with odontogenic infections are dehydrated and poorly nourished due to poor oral intake from pain and discomfort. Thorough surgical care (i.e., source control and incision and drainage) should always be supplemented with adequate pain control and encouragement of oral (or intravenous) hydration and improved nutritional intake.  For the acutely dehydrated patient, the clinician may elect to administer fluids intravenously to replenish lost intravascular volume.  The patient may present with other systemic illnesses that require special attention such as diabetes, hypertension, dysrhythmias, congestive heart failure, and autoimmune diseases with immunosuppressive therapy. Especially when multiple such comorbidities exist, expert consultation is frequently necessary from different specialists such as internal medicine and infectious diseases. Orofacial Infections Part-I 27.10.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Principle 6: Choose and Prescribe Appropriate Antibiotic • Although odontogenic infections must be managed with surgery, certain situations benefit from adjunctive antibiotic therapy. • The clinician should never assume antibiotics are required for appropriately managing odontogenic infections. • Inappropriate reliance on antibiotics not only poses the risk of increased antibiotic resistance and increased risk of antibiotic adverse effects (including opportunistic infections and more serious risks such as anaphylaxis), but it also may lead to inadequate surgical management. • It must be clearly understood that antibiotics should always be regarded as an adjunct to, not a substitution for, surgical management. Orofacial Infections Part-I 27.10.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Principle 6: Choose and Prescribe Appropriate Antibiotic Determine the Need for Antibiotic Administration: Three main factors should be considered when determining the appropriateness of adjunctive antibiotic use: (1) severity of the infection, (2) ability to render surgical treatment, and (3) patient host defense system. Use Empirical Antibiotic Therapy Routinely: Odontogenic infections are almost invariably caused by normal oral flora (predominantly facultative oral streptococci, anaerobic streptococci, and Prevotella and Fusobacterium species) and typically have a predictable bacterial composition. This predictability makes the routine use of culture and sensitivity testing unnecessary and impractical because the causative organisms are already known Use an Antibiotic With the Narrowest Spectrum: Broad-spectrum antibiotics can dramatically alter the normal bacterial flora of various organ systems such as the skin and the gastrointestinal (GI) tract, which could lead to untoward effects, such as the development of superinfections or opportunistic infections (e.g., fungal) that are usually controlled by the existing bacteria. Broad-spectrum antibiotics can also lead to the development of bacterial antibiotic resistance. Orofacial Infections Part-I 27.10.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Principle 6: Choose and Prescribe Appropriate Antibiotic Orofacial Infections Part-I 27.10.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Principle 6: Choose and Prescribe Appropriate Antibiotic Use the Antibiotic With the Lowest Incidence of Toxicity and Side Effects: As with any drug, antibiotics have adverse effects, which may vary from mild to severe. It is the clinician’s responsibility to be thoroughly aware of the adverse effects of commonly used antibiotics in order to weigh the risks and benefits of antibiotic usage. Use a Bactericidal Antibiotic Whenever Possible: Bactericidal antibiotics are preferred over bacteriostatic antibiotics because they lyse and kill bacteria and lessen the burden on the host defense system. Be Aware of the Cost of Antibiotics: Unnecessarily expensive drugs place a financial burden not only on the patient, but also on the health care system, and they should be used only when the clinical circumstances warrant it. Orofacial Infections Part-I 27.10.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Principle 7: Administer Antibiotic Properly • The proper dose, timing, and duration of administration of antibiotics are as important as proper antibiotic selection. • The goal is to achieve a high-enough plasma level to kill or halt the bacteria that are sensitive to the antibiotic while minimizing adverse side effects. • The clinician should refer to the manufacturer’s dosage recommendations based upon the indications. • Duration of administration can vary depending on the patient’s response to surgical treatment and antibiotic therapy, but the typical regimen consists of a 4- to 5-day course. Orofacial Infections Part-I 27.10.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Principle 8: Evaluate Patient Frequently • In most cases of uncomplicated odontogenic infections in immunocompetent patients, uneventful healing occurs within 1 week. • The typical follow-up period is 2 to 3 days after surgical treatment. At this time, an appropriately responding patient will have significant improvement of pain, intraoral swelling, and overall wellness. • If swelling and induration have decreased and there is no persistent drainage, any surgically placed drains should be removed, and the wound should be allowed to heal by secondary intention. • If the patient has persistent swelling, pain, drainage, and even constitutional symptoms, the clinician should carefully assess the cause of the inadequate clinical response. Orofacial Infections Part-I 27.10.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Principle 8: Evaluate Patient Frequently  As a general rule, inadequate surgical treatment (source control, drainage, or both) should be presumed the primary reason until proven otherwise. It is especially important to ascertain complete removal of the source of the infection.  Another reason for inadequate response is compromised host defenses. If a compromise is identified, it must be controlled (e.g., hydration, nutrition, glycemic control) and surgical measures aggressively performed. Adjunctive antibiotics are usually indicated when host defense is compromised, often for longer periods.  Another reason for failure is problems with antibiotic administration. Orofacial Infections Part-I 27.10.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner THANK YOU.. Orofacial Infections Part-1 27.10.2023 Dental Anesthesia and Pain Control © Asst. Prof. Ezgi Yüceer Çetiner Oral and Dental Surgery - II Orofacial Infections - Part-II Asst. Prof. Mustan Barış SİVRİ School of Dental Medicine Department of Oral and Maxillofacial Surgery [email protected] Course Content 1. Pathways of Orofacial Infection 2. Fascial Spaces 3. Spacies around the Maxilla Learning Outcomes At the end of this course you will; ✓Explain the pathways of odontogenic infections. ✓Define fascial spaces ✓Know fascial spaces around the maxilla Resource • Hupp, J. R., Tucker, M. R., & Ellis, E. (2019). Contemporary Oral and maxillofacial surgery. 7th Ed., Elsevier. Chapter 16 Pathways of Odontogenic Infection Pathways of Odontogenic Infection Odontogenic infections have two major origins: (a) Periodontal- due to bacterial inoculations into underlying tissues via deep periodontal pockets (b) Periapical-, more common, and occur subsequent to pulpal necrosis, reaching the periapical structures. Periapical Origin Pathways of Odontogenic Infection ❑ Once the periodontal or periapical tissues get inoculated with bacteria, the infection may spread equally in all directions but mostly follows the path of least resistance. ❑ It travels through the cancellous bone to reach the cortical plate. ❑ If the cortical plate is thin, infection easily perforates it to enter the surrounding soft tissue. ❑ At this stage, if an intervention such as an endodontic or periodontal procedure or dental extraction is done, the further spread may be arrested. ❑ Antimicrobials alone may not cure the condition as the focus of infection from necrotic pulp or periapical tissues still remains and may cause recurrence of the infection, if the therapy is stopped. ❑ When left untreated, the infection continues to spread depending principally on the thickness of bone and the type of muscle attachment. Buccinator muscle Buccinator muscle Vestibular Abscess Buccal Space Abscess ❑ Apart from these factors, the angulation of root apex is also important. For example, in periapical abscess with respect to maxillary lateral incisor, swelling is likely to occur on the hard palate rather than labial vestibule as its root apex is slightly palato-distally curved. What is Fascial Space? ❑The fascial spaces in the head and neck are the potential spaces between the various fascia normally filled with loose connective tissue and bounded by the anatomical barriers usually of bone, muscle, or fascial layers. ❑Facial planes offer anatomic highways for infection to spread superficially to deep planes. ❑Antibiotic availability in fascial spaces is limited due to poor vascularity. ❑An odontogenic infection follows the path of least resistance. ❑A periapical infection may perforate the nearest or the weakest cortex and travel along the soft tissue, initially as cellulitis and eventually resulting in abscess formation. ❑This abscess may drain spontaneously, extraorally or intraorally and may involve one or more anatomically potential spaces. When this happens, it is known as a space infection. What is Fascial Space? Fascial Space Infection 3. With any offending mandibular tooth ▪ Medullary space of mandibular body ▪ Submandibular ▪ Sublingual 1. With any tooth ▪ Submental ▪ Subcutaneous ▪ Masticator ▪ Vestibular ▪ Submasseteric ▪ Buccal ▪ Pterygomandibular 2. With any offending maxillary tooth ▪ Superficial temporal ▪ Buccal ▪ Maxillary along with other para nasal sinuses ▪ Deep temporal 4. Deep fascial spaces ▪ Infraorbital ▪ Lateral pharyngeal ▪ Infratemporal ▪ Retropharyngeal ▪ Temporal ▪ Pretracheal ▪ Danger (Alar space). ▪ Prevertebral Following are frequently affected anatomic spaces, Fascial Space Infection ❑Various Space Infections and Their Relative Severity: MILD—Vital structures and airway may be mildly threatened • Subperiosteal • Infraorbital • Buccal MODERATE—Airway may be compromised • Vestibular • Pterygomandibular • Osteomyelitis of the mandible • Superficial temporal HIGH—Vital structures or airway under direct threat • Lateral pharyngeal • Retropharyngeal • Danger space (Alar space) • Pretracheal • Cavernous sinus thrombosis • Intracranial infections (brain abscess) • Mediastinal • Prevertebral • Submandibular • Sublingual • Submental • Submasseteric • Infratemporal • Deep temporal • Masticator Fascial Space Infection Six possible locations are: ➢ the vestibular abscess (1), ➢ buccal space (2), ➢ palatal abscess (3), ➢ sublingual space (4), ➢ submandibular space (5), ➢ maxillary sinus (6). Space of the Head and Neck Space of the Head and Neck Space of the Head and Neck Space of the Head and Neck Spaces Around the Maxilla Canine Space/Infraorbital Space ❑ Source of Infection • From upper canine and premolars. • Skin infections of upper lip ❑ Contents • Angular artery and vein. • Infraorbital nerve. ❑ Clinical Features 1. Pain and tenderness. 2. Swelling in the anterior cheek region. 3. Obliteration of Nasolabial folds. 4. Edema of lower eyelid and upper lip. 5. Obliteration of labial vestibule. Canine Space/Infraorbital Space ❑ Boundaries • Anterior—Elevator muscles of upper lip (Orbicularis oris). • Posterior—Anterior surface of Maxilla. • Medial—Levator Labii Alaeque nasi. • Lateral—Zygomaticus major. Canine Space/Infraorbital Space Canine Space/Infraorbital Space ❑ Management ✓ Drainage of the space infection either intraorally or percutaneously is done; intraoral incision and drainage are preferred as these will not produce a facial scar. ✓ Drainage is made by making an in-depth incision of the maxillary vestibule near canine fossa. ✓ Sinus forceps is inserted superiorly, laterally, and medially for complete breakage of locules and drainage. ✓ Care is taken while using sinus forceps, so as to not damage the infraorbital nerve and its branches. ✓ Aggressive antibiotic therapy is mandatory to prevent the spread as it lies in the danger area of the face and also to prevent Cavernous sinus thrombosis from septic thrombi entering into angular vein. ✓ The involved tooth is either removed or subjected to root canal treatment with multiple dressings. ✓ Patient is advised good hydration and rest. Buccal Space ❑Source of infection • From maxillary premolar and molar teeth root apices above buccinator attachment. • From mandibular premolar and molar teeth root apices below the buccinator attachment. ❑Contents • Buccal pad of fat. • Stenson’s duct. • Facial artery. Buccal Space ❑Clinical Features 1. Pain and tenderness. 2. Diffuse swelling on the side of the cheek. 3. Obliteration of buccal vestibule. 4. Swelling of upper/lower lip ❑Boundaries • Medial: Buccinator muscle, buccopharyngeal fascia, and mucosa. • Lateral: Skin of cheek and subcutaneous tissue. • Anterior: Posterior border of zygomaticus major above and depressor anguli oris below. • Posterior: Edge of masseter muscle. • Superior: Zygomatic arch. • Inferior: Lower border of mandible. Buccal Space ❑ Management Temporal Pouches 1.Superficial Temporal Space 2.Deep Temporal Space Superficial Temporal Space ❑ Source of infection • From upper third molars and • Infection from other spaces ❑ Boundaries • Superior—superior temporal lines • Inferior—zygomatic arch • Lateral—superficial temporal fascia • Medial—temporalis muscle • Anterior—posterior surface of lateral orbital rim • Posterior—fusion of temporal fascia with pericranium ❑ Contents • Temporal fat pad. • Temporal branch of Facial nerve. ❑ Clinical Features 1. Pain and tenderness at the temporal region. 2. Swelling is present above and below zygomatic arch, leading to classical “Dumb bell” shaped appearance 3. Trismus may be present ❑ Management Surgical drainage is carried out through an incision made above the zygomatic arch; sinus forceps is inserted through the skin incision and passed through the superficial fascia and the temporal fascia. Superficial Temporal Space Deep Temporal Space ❑ Source of infection • Upper third molar and • Spread from other spaces. ❑ Boundaries • Superior—Attachment of temporal fascia to the cranium. • Inferior—Lateral pterygoid muscle. • Medial—Medial pterygoid plate and lower part of infratemporal fossa. • Lateral—Medial surface of the temporalis muscle. ❑ Contents • Branches of Internal maxillary artery. • Mandibular division of trigeminal nerve. ❑ Clinical Features 1. Pain. 2. Swelling at the infratemporal region and lateral aspect of the eye. 3. Obliteration of buccal sulcus at tuberosity area. 4. Trismus due to proximity of masticatory muscles. 5. Infection may extend to the infratemporal and pterygomandibular region. Deep Temporal Space ❑ Management • If the trismus is not severe, intraoral incision is given in the buccal sulcus at the second and third molar region. With the sinus forceps, the space is entered medial to coronoid process superiorly and the pus is drained. Corrugated rubber tube is placed and secured with a suture. • In case of severe trismus, extraoral incision is made above the zygomatic arch at the junction of frontal and temporal process of zygoma, sinus forceps is inserted and directed inferiorly and medially to enter the space and drain the pus. THANK YOU.. Oral and Dental Surgery - II Orofacial Infections - Part-III Asst. Prof. Ezgi YÜCEER ÇETİNER School of Dental Medicine Department of Oral and Maxillofacial Surgery [email protected] Course Content 1. Pathways of Orofacial Infection 2. Fascial Spaces 3. Spacies around the Mandible Orofacial Infections Part-III 10.11.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Learning Outcomes At the end of this course you will; Explain the pathways of odontogenic infections. Define fascial spaces Know fascial spaces around the mandible Orofacial Infections Part-III 10.11.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Resource • Hupp, J. R., Tucker, M. R., & Ellis, E. (2019). Contemporary Oral and maxillofacial surgery. 7th Ed., Elsevier. Chapter 16 Orofacial Infections Part-III 10.11.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Spaces Around the Mandible Orofacial Infections Part-III 10.11.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Perimandibular Spaces  Perimandibular spaces, as described by Grodinsky and Holyoke, include the submandibular, sublingual, and submental spaces.  These perimandibular spaces become involved when infections originating from the premolars and molars perforate the lingual cortex of the mandible.  If the infection perforates the mandible cephalad to the attachment of the mylohyoid muscle, the infection will enter the sublingual space.  If the infection perforates the lingual cortex inferior to the attachment of the mylohyoid muscle to the mandible, then it will enter the submandibular space. Orofacial Infections Part-III 10.11.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Submental Space • The submental space is affected often by infections originating from the mandibular incisor teeth. • However, commonly the submental space becomes involved as an extension of submandibular space infections. • This is due to the fact that the only anterior barrier of the submandibular space is the anterior belly of the digastric muscle, which is not a true barrier between the submandibular and submental spaces. • Furthermore, infections from one submandibular space may pass through the submental space to then involve the contralateral submandibular space. Orofacial Infections Part-III 10.11.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Submental Space Source of Infection • Infection from lower anterior teeth • Infected symphyseal or parasymphyseal fractures • Suppuration of submental lymph nodes Contents • Submental lymph nodes • Anterior jugular vein Orofacial Infections Part-III 10.11.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Submental Space  Boundaries • Lateral: Skin, superficial fascia, platysma, superficial layer of deep cervical fascia. • Medial: Mylohyoid, hyoglossus, and styloglossus. • Inferior: Anterior and posterior belly of digastric muscles. • Posterior: Hyoid bone. • Superior: Medial aspect of mandible and the attachment of mylohyoid muscle. Orofacial Infections Part-III 10.11.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Submental Space  Clinical Features 1. Pain and tenderness in the chin region 2. Firm swelling at the chin 3. Difficulty in swallowing 4. Tenderness of lower anterior teeth Orofacial Infections Part-III 10.11.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Submental Space  Management  Transcutaneous approach in the chin region is the most effective drainage; incision is made below the symphysis menti to produce dependent drainage.  Sinus forceps is inserted upward and backward to break the locules and the pus is drained.  A corrugated rubber drain is inserted and secured with a suture.  Intraoral approach is cumbersome as we need to pierce mentalis muscle to reach the submental space and also drainage against gravity is not possible. Orofacial Infections Part-III 10.11.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Sublingual Space • The sublingual space is a perimandibular space that is commonly the first deep fascial space involved in mandibular odontogenic infections. • The boundaries include the floor of the mouth submucosa and the mylohyoid muscle. • It is unusual to observe an isolated sublingual space infection without a synchronous submandibular space infection. • This is due to the fact that the sublingual space has no posterior boundary and freely communicates with the submandibular space. Orofacial Infections Part-III 10.11.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Sublingual Space • However, unlike a submandibular space abscess, in an isolated sublingual space abscess, by definition there should be no noticeable extraoral swelling because the infection is limited to a location that is cephalad to the mylohyoid muscle. • Clinical findings of isolated sublingual space involvement include tongue and floor of mouth elevation, with difficulty with speech or swallowing, especially in later stage infections or in bilateral sublingual space infections. Orofacial Infections Part-III 10.11.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Sublingual Space Source of infection • Periapical infection from mandibular teeth is situated above mylohyoid muscle. • Infection from sublingual gland. Contents • Lingual nerve and hypoglossal nerve. • Deep part submandibular gland and duct. Orofacial Infections Part-III 10.11.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Sublingual Space Clinical Features 1. Pain and discomfort during deglutition. 2. Due to edema, there is elevation and protrusion of the tongue. 3. In case of laryngeal edema, there may be breathlessness. 4. Speech may be affected. 5. Enlarged and tender submandibular nodes. Orofacial Infections Part-III 10.11.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Sublingual Space Boundaries • • • • • Orofacial Infections Part-III 10.11.2023 Anterior: Lingual aspect of mandible. Posterior: The body of hyoid bone. Superior: Mucosa of oral cavity. Inferior: Mylohyoid muscle. Medial:Geniohyoid,genioglossus,and styloglossus muscle. Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Sublingual Space  Management • An intraoral incision is made close to lingual cortical plate, near premolar region taking care of lingual nerve and the Wharton’s duct. Sinus forceps or a thin mosquito forceps is inserted and the pus is drained. • If an extraoral approach is planned, then incision is placed at the submandibular region, taking care of the facial artery and marginal mandibular nerve; a sinus forceps is inserted piercing the mylohyoid muscle to drain the pus and a corrugated rubber drain is inserted and secured with a suture, as this approach provides gravitydependent drainage. Orofacial Infections Part-III 10.11.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Submandibular Space • The submandibular space, as opposed to the sublingual space, almost always manifests with the clinical finding of visible extraoral swelling. • This edema results because, by definition, a submandibular space infection occurs caudal to the mylohyoid muscle, and therefore the SLDF and platysma muscle are the only barriers between the abscess cavity and the skin. • Clinically it is the SLDF that is surgically entered during an incision and drainage procedure and produces the release of purulence when present. Orofacial Infections Part-III 10.11.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Submandibular Space • As with the sublingual space, there is no posterior boundary of the submandibular space, and it communicates freely with the deeper fascial spaces of the neck (e.g., pterygomandibular and lateral pharyngeal spaces) that may result in significant morbidity when involved. • The submandibular space is triangular in configuration, formed by the inferior border of the mandible and the anterior and posterior bellies of the digastric muscles. Orofacial Infections Part-III 10.11.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Submandibular Space  Source of infection • Infection from the periapical region of molar teeth below mylohyoid muscle. • Septic fractures of the mandible body region. • Infections from submandibular salivary gland. • Infections from submental and sublingual. • Infection from other space.  Contents • Submandibular salivary gland. • Submandibular nodes. • Facial artery and vein. Orofacial Infections Part-III 10.11.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Submandibular Space  Boundaries • Laterally: Skin, superficial fascia, platysma, and superficial layer of deep cervical fascia. • Medially: Mylohyoid, hyoglossus, and styloglossus. • Inferiorly: Anterior and posterior belly of digastric muscles. • Posteriorly: Hyoid bone. • Superiorly: Medial aspect of mandible and the attachment of mylohyoid muscle. Orofacial Infections Part-III 10.11.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Submandibular Space  Clinical Features 1. Pain and tenderness. 2. Swelling is situated at the submandibular region, inferior to the lower of the mandible. 3. Swelling is firm to soft in consistency. 4. Submandibular nodes are palpable and tender. 5. Intraoral—the involved teeth are sensitive. 6. Mild trismus may be noticed. Orofacial Infections Part-III 10.11.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Submandibular Space  Management It is managed through an extraoral approach; incision is placed at the submandibular region in the most dependent area to facilitate gravitational drainage, taking care of the facial artery and marginal mandibular nerve; a sinus forceps is inserted superiorly, medially, and laterally piercing through the superficial fascia. A drain is inserted and secured with a suture to facilitate dependent drainage. Orofacial Infections Part-III 10.11.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Submandibular Space Orofacial Infections Part-III 10.11.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Ludwig’s Angina  Involvement of sublingual, submandibular, and submental spaces is known as Ludwig angina.  This is a term often used inappropriately by clinicians for any perimandibular space infection; but when it does exist, it has clinical significance because the airway may be compromised.  When a cellulitis or abscess involves all three of these spaces (actually, five spaces: two submandibular spaces, two sublingual spaces, and one submental space), the airway should be the primary consideration and be secured promptly (e.g., tracheal intubation of tracheostomy). Orofacial Infections Part-III 10.11.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Ludwig’s Angina  The clinical findings in Ludwig angına include firm induration of the skin in the submental and submandibular regions extraorally and elevation of the floor of the mouth and tongue intraorally (sublingual space) and possibly fluctuant swellings (abscess cavities) bilaterally from the inferior border of the mandible to the hyoid bone.  The inferior border of the mandible is often not palpable due to significant firm swelling.  Other clinical findings include dysphagia, dysphonia, trismus, floor of mouth, tongue elevation (causing inability to visualize and evaluate the posterior oropharynx), cervical immobility, globus sensation (feeling of a lump in throat) in the late stages, inability to handle oral secretions, head held in a forward “sniffing” position, a “hot potato” voice, and increased work of breathing due to upper airway obstruction.  In the early and mid-1900s, Ludwig angina was associated with high morbidity and mortality, and it was determined that securing the airway as early as possible, with early surgical intervention in the form of incision and drainage, significantly reduced patient morbidity. Orofacial Infections Part-III 10.11.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Ludwig’s Angina Masticator Space The masticator spaces comprise the following four spaces: • Submasseteric space. • Pterygomandibular space. • Temporal space. • Infratemporal space. Orofacial Infections Part-III 10.11.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Submasseteric Space  Source of infection • Infection from buccally placed lower third molar. • Septic foci from infected angle fracture. • Infection from other space.  Boundaries • Anterior: Facial extension of parotidomasseteric fascia. • Posterior: Parotid fascia and deep portion of parotid gland. • Superiorly: Level of zygomatic arch. • Lateral: Medial surface of the Masseter muscle. • Medial: Lateral surface of the ramus.. Orofacial Infections Part-III 10.11.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Submasseteric Space Clinical Features 1. Pain and tenderness at angle mandible. 2. Moderate size swelling at the angle region. 3. Firm consistency swelling. 4. Severe trismus. Orofacial Infections Part-III 10.11.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Submasseteric Space  Management • The drainage of the infection is done through two approaches. In intraoral approach, incision is placed at the retromolar area along the anterior border of the ramus of mandible. The sinus forceps is inserted through the incision laterally between the mandibular ramus and the masseter muscle to explore the submasseteric space. The disadvantage of intraoral technique is that incision and drainage is not gravity dependent. • In extraoral approach, the incision is placed on the skin at the angle and inferior border of the mandible; sinus forceps is inserted directing superiorly piercing the subcutaneous tissue and masseter muscle. Abscess drained corrugated rubber tube is placed and secured with a suture. Precautions are taken not to damage the marginal mandibular nerve. Orofacial Infections Part-III 10.11.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Pterygomandibular Space  Source of infection • From lower third molar. • Contaminated needle used during inferior alveolar nerve block. • Septic fractures of the mandibular angle. • Infection from other spaces (Superficial temporal) .  Contents • Inferior Alveolar nerve and artery. • Lingual Nerve. • Long Buccal Nerve. • Nerve to Mylohyoid. Orofacial Infections Part-III  Boundaries • Lateral: Medial surface of mandible. • Medial: Lateral aspect of medial pterygoid muscle. • Anterior: Pterygomandibular raphe. • Posterior: Deep part of parotid gland. • Superior: Lateral pterygoid muscle and infratemporal surface of greater wing of sphenoid bone. 10.11.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Pterygomandibular Space  Clinical Features 1. Pain at the retromolar region. 2. Dysphagia. 3. Trismus. 4. No obvious swelling extraorally. 5. Swelling near anterior tonsillar pillar. 6. Deviation of Uvula. Orofacial Infections Part-III 10.11.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Pterygomandibular Space  Management • Generally, incision and drainage are done through intraoral approach; however, in case of severe trismus, extraoral approach may be indicated. Drainage is done either under general anesthesia or by giving mandibular nerve block. Intraoral Approach • A vertical incision of 1.5 cm is made at the anterior and medial aspect of the mandible, sinus forceps is inserted into the abscess cavity, and pus is evacuated. Corrugated rubber drain is inserted and sutured to the margins of the incision to prevent dislodgement. Extraoral Approach • In case of severe trismus, this approach is advised, an incision of 1.5 cm is made on the skin, toward the inner aspect of the angle region. Sinus forceps is inserted toward the medial aspect of the mandible directing superiorly close to the bone. Pus is evacuated and rubber drain is inserted and sutured to the margins of the incision. Orofacial Infections Part-III 10.11.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Pterygomandibular Space Management Orofacial Infections Part-III 10.11.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner THANK YOU.. Orofacial Infections Part-III 10.11.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Oral and Dental Surgery - II Orofacial Infections - Part-IV Asst. Prof. Mustan Barış SİVRİ School of Dental Medicine Department of Oral and Maxillofacial Surgery [email protected] Course Content 1. Spaces of Neck 2. Sequelae of Space Infections Learning Outcomes At the end of this course you will; ✓Define spaces of neck ✓Know sequelae of space infections Resource • Hupp, J. R., Tucker, M. R., & Ellis, E. (2019). Contemporary Oral and maxillofacial surgery. 7th Ed., Elsevier. Chapter 16 Spaces of Neck Parapharyngeal Space ❑ The spaces around the pharynx form a ‘Ring’ and a pathway for spread of infections from the orofacial region to the neck and mediastinum. ❑ The Parapharyngeal space includes Lateral Pharyngeal space and Retropharyngeal space. Lateral Pharnygeal Space ❑Source of Infection • From other spaces which includes; Pterygomandibular space&Submandibular space • From tonsils • From the lower third molar region ❑Contents • Lymph nodes • Ascending Pharyngeal artery and Facial artery • Carotid sheath • Glossopharyngeal nerve, Spinal Accessory nerve, Hypoglossal nerve Lateral Pharnygeal Space ❑ Boundaries • Superior: Base of the skull. • Inferior: Hyoid bone. • Anterior: Pterygomandibular raphe, Superior and middle pharyngeal constrictor. • Posterior: Carotid sheath, Stylohyoid, Styloglossus, and Stylopharyngeus. • Medial: Superior constrictor of Pharynx and Retropharyngeal space. • Lateral: Medial pterygoid muscle, Deep lobe of the parotid gland. Lateral Pharnygeal Space ❑Clinical Features 1. No or minimal external swelling on the lateral aspect of the neck. 2. Moderate limitation of mouth opening. 3. Rotation of neck to contralateral side is painful. 4. Dysphagia. 5. Uvula is pushed to opposite side. 6. Pharyngeal bulging is seen (Swelling over pillars of fauces and superior constrictor). Lateral Pharnygeal Space ❑ Management ✓ A combination of intra-oral and extra-oral approaches are advised for the management of infections of the lateral pharyngeal space. They are preferably done under general anesthesia with care taken to secure the airway. Retropharyngeal Space ❑Source of infection • From Lateral pharyngeal space. • From the lymph nodes that drain into Waldeyer’s ring. • Rarely from upper respiratory infections. ❑Contents • Lymph nodes. Retropharyngeal Space ❑Clinical Features 1. Stiff neck. 2. Sore throat. 3. Dysphagia. 4. Lateral neck swelling and occasional erythema. 5. Fever. 6. Dyspnea. 7. Mediastinitis is the most feared complication of this space. Retropharyngeal Space ❑ Boundaries • Superior—Base of the skull. • Inferior—Fusion of alar and Prevertebral fascia. • Anterior—Superior and Medial constrictors. • Posterior—Alar fascia. • Lateral—Carotid sheath and Lateral pharyngeal space. Retropharyngeal Space ❑ Management ➢ Most important is to secure airway, may be an elective tracheostomy or fiber optic intubation is considered for airway maintenance. ➢ Combination of intraoral and extraoral approach. Peritonsillar Abscess ❑ Source of infection • From tonsillitis. • Rarely from Pericoronitis. • From Lateral pharyngeal space. ❑Clinical Features 1. Pain in the throat radiating to ear. 2. Fever. 3. Dehydration. 4. Dysphagia. 5. Swelling visible at anterior pillar of tonsillar fauces. 6. Redness and edema may be extended to soft palate. 7. Drooling of saliva. 8. Change of voice and speech difficulty in case of bilateral involvement. 9. Mouth opening difficulty may not be present. Peritonsillar Abscess ❑ Boundaries • Anterior—Anterior pillar of fauces. • Posterior—Posterior pillar of fauces. • Medially—Tonsil. • Laterally—Superior constrictor muscle ❑Management • Intraoral approach Sequelae of Space Infections, if Ignored Sequelae of Space Infections, if Ignored Ludwig’s Angina Ludwig’s Angina ❑ Ludwig’s Angina is defined as an acute, involving bilateral firm, non-suppurating, necrotizing cellulitis Submandibular, Sublingual, and Submental spaces. ❑ The condition has been described by medical practitioners, by three unique features, starting with the alphabet ‘F’—Feared, Fluctuant rarely, Fatal often. Ludwig’s Angina ❑ • • • • • • • Source of infection Predominantly (90%) odontogenic in origin, from the lower jaw. Infection from 2nd and 3rd molar teeth may be Acute dentoalveolar abscess, Periodontal Abscess. Pericoronal Abscess. Infected cyst at the body and the angle of the mandible. Traumatic injuries especially to the mandible, either ignored or not managed well leading to sepsis. Salivary gland infections. Iatrogenic reasons. Hematogenous infections. Predisposing Factors • Immunosuppression. • Uncontrolled Diabetes. • Steroid therapy. • Debilitating conditions. Ludwig’s Angina ❑Clinical Features Ludwig’s Angina ❑Management • It should be treated as life-threatening situation and intervened aggressively. • The treatment of Ludwig’s Angina is primarily surgical. • The first priority in the management is always the life-saving measure. • If the patient shows any signs of dyspnea, Tracheostomy should be performed promptly Ludwig’s Angina Necrotizing Fasciitis • Necrotizing fasciitis is an uncommon soft tissue infection, occurs due to polymicrobes and spreads rapidly in the subcutaneous tissue and above superficial fascia, and as the disease progresses, muscle and skin involve giving rise to myonecrosis. • The other name for this condition is Hospital Gangrene given by Brooks in 1966 and Hemolytic streptococcal gangrene. • Necrotizing fasciitis may affect any part of the body; however, it most commonly affects the extremities, abdominal wall, and the perineum following trauma or surgery. The condition shows no clear boundaries or palpable limits, mainly occurs with immunocompromised patients and those suffering from systemic illnesses. Necrotizing Fasciitis Cavernous Sinus Thrombosis ❑Cavernous sinuses are the venous sinuses situated on either side of the sella tursica. The cavernous sinus on either side communicates freely with each other by anterior and posterior intracavernous sinuses they also communicate with sagittal sinus, transverse, sinus and sigmoid sinus. ❑The cavernous sinus communicates extra cranially with veins of the head and neck. Cavernous Sinus Thrombosis • The area of the face between the inner canthus of the eyes and the corners of the mouth is called `Danger Triangle` of the face and any kind of severe sepsis in this area can spread in a retrograde manner and can extend to the cavernous sinus through the angular vein and ophthalmic vein. • The ophthalmic vein and angular veins into the anterior facial vein. • Through emissary veins from the pterygoid plexus of veins. Meningitis It is one of the neurological complications resulting from the infection of oro-facial region. It may develop from metastatic spread or may be due to nearby thrombophlebitis. ❑ Clinical Features 1. High fever with chills 2. Irritability and mental confusion 3. Head ache 4. Vomiting 5. Stiff neck 6. Convulsions THANK YOU.. MAXILLARY SINUS DISEASES and TREATMENTS Asst. Prof. Canseda Avağ SINUS PARANASALES MAXILLARY SINUS BORDERS BORDERS ANTERIOR---- Maxilla surface POSTERIOR---- maxillary tuberosity and Infratemporal fossa MEDIAL (INNER) SIDE---- Nasal cav