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BATCH 2011 ORAL PATHOLOGY Spread of Infection Part II Dr. Michelle Marie Meneses Angel and Madel 07 09 09 MANDIBULAR SPACE INFECTIONS A. Submental Bounded by the anterior belly of digastric (bounds incisors), mylohyoid muscles (muscle that covers floor of the mouth) From infection of lower incisors vestibule chin or to submental space Isolated submental infection is rare FIG. 16-9 Submandibular space lies between mylohyoid muscle and skin and superficial fascia. Primarily second and third molars infect it B. Sublingual (SL) /Submandibular (SMd) Ludwig’s Angina Usually involves: Mylohyoid Line: creates a plane that divides submandibular and sublingual space When all the mandibular spaces are involved bilaterally (submental, sublingual and submandibular are all involved) Acute, rapid, diffused septic inflammatory indurated bilateral cellulitis on the floor of the mouth and neck Elevated tongue, high fever, rapid pulse, fast perspiration (difficulty Sublingual: (underneath tongue) PM – 1st M Submandibular: (parotid/lymph node area) 2nd & 3rd M Location of infection is dependent on mylohyoid muscle Tongue elevation (SL) (paangat ung expansion, tongue is pushed back, dyspnea occurs) Communicates with other spaces Lymph nodes enlarge at the angle of the mandible Infection ABOVE the mylohyoid line- spread to SUBLINGUAL SPACE Infection BELOW the mylohyoid line- spread to SUBMANDIBULAR SPACE in breathing due to swelling) 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 May lead to septic shock then death Incision & Drainage (I & D) with antibiotic therapy Submaxillary = submandibular daw (Penicillin/Streptomycin/Tetracycline) intramuscular (IM) for faster spread Fasciae are connected, so when there is expansion in one space, infection is spread easily -----------------------------------------------------------------------------------------------------------------------------------------------------------------------2nd Year Proper :: 2nd Semester :: ORAL PATHOLOGY : Spread of Infections II :: Page 1 of 3 ------------------------------------------------------------------------------------------------------------------------------------------------------------------------ SECONDARY SPACE INFECTIONS Severe cases, greater complications Poor blood supply, difficult to treat Occur when primary space infections are not treated Masticatory Space: masseteric, pterygomandibular and temporal spaces CERVICAL SPACE INFECTIONS From PMS Medial to the internal pterygoid, lateral to superior pharyngeal constrictor Styloid process divides it: A. Masseteric Between masseter and ramus of the mandible Spread from buccal space Trismus (diificulty in opening the mouth) Angle of the jaw is swollen B. Pterygomandibular Space (PMS) Between internal pterygoid muscle and ramus of the mandible Spread from Submandibular/Sublingual or due to pericoronitis or infected needle Pericoronitis (loose tissue covering partially erupted teeth, food enters and not brushed, inflammation develops) If PMS involvement only, no external swelling but trismus Inferior to infratemporal space, behind 3rd molar Anterior: muscles- internal pterygoid muscle Posterior: carotid sheath (internal jugular vein, internal carotid artery), cranial nerves (IX, X, XI), and cervical symphatetic trunk Lateral swelling of neck, trismus Lateral pharyngeal wall swelling dysphagia Involvement of the contents is dangerous A. Lateral Pharyngeal Cervical area of submandibular Thin fascia covering: blood vessels can perforate, infection can spread easily C. Temporal Superficial Temporal Extends to temporal fascia Deep Temporal Continuous with infratemporal space (ITS) Only in severe infections, rare Swelling in the temporal area is up to zygoma posterior to orbital rim FIG. 16-11 Lateral pharyngeal space is located between medial pterygoid muscle on lateral aspect and superior pharyngeal constrictor on medial aspect. Retropharyngeal and prevertebral spaces lie between pharynx and vertebral column. Retropharyngeal space lies between superi-or constrictor muscle and alar portion of prevertebral fascia. Prevertebral spaces lie between alar layer and prevertebral fascia. B. Retropharyngeal Between prevertebral space and superior constrictor muscle From base of the skull to C7 or T1 No contents but close to mediastinum (close to lungs and heart) Danger to the airway Signs and symptoms: Fever Pain and neck rigidity Dysphagia Dyspnea Laryngeal edema Airway obstruction C. Prevertebral Base of the skull to the diaphragm (proximity to thorax/mediastinum) Danger: airway obstruction -----------------------------------------------------------------------------------------------------------------------------------------------------------------------2nd Year Proper :: 2nd Semester :: ORAL PATHOLOGY : Spread of Infections II :: Page 2 of 3 ------------------------------------------------------------------------------------------------------------------------------------------------------------------------ perforation (aspiration) – septic (pus in the lungs) spread to mediastinum 5. Reevaluation Recall and check for recurrence of infection SUMMARY FIG. 16-12 If retropharyngeal space is involved, posterosuperior mediastinum may also become infected secondarily. If prevertebral space is infected, inferior boundary is diaphragm, so entire mediastinum is at risk. Alar fascia divides prevertebral and retropharyngeal spaces TREATMENT 1. Medical support (host defense/airway) Make patient comfortable- analgesia, maintain patent airway, boost host’s immune system, intravenous tx 2. Antibiotics Aerobic/anaerobic, infection) broad spectrum (determine 3. Surgical removal of source Extract tooth or RCT 4. Drainage I & D aids faster no waiting time for healing and profound effect of antibiotic FIG. 16-14 Typical incision and drainage (I&D) sites for various fascial space infections. Superficial and deep temporal space (A). Submandibular masseteric and pterygomandibular spaces (B). Sub-mental space (C). Lateral pharyngeal and retropharyngeal spaces (D). Hello ulit sa ting lahat…Mwaahhh…. NASIRA UNG NIRECORD KO. Huhuhu. Kaya kumuha nalang ako sa net ng idinagdag. Ung mga pic di maam di ko kasi mahagilap kaya kung ano nalang ung nakita ko, un nalang. Hehe. Hello sa mga GHC4 papas. Bwahahahaha. Kay mickomander, kay red hot chili pepper, sa naliligo sa batis na si kristo at sa kamukha ng crush ni bom. Hahahahahaha. Aun lang. Ingat po sa pag edit, madali po magulo ung mga pics ^_^ Angel -----------------------------------------------------------------------------------------------------------------------------------------------------------------------2nd Year Proper :: 2nd Semester :: ORAL PATHOLOGY : Spread of Infections II :: Page 3 of 3 ------------------------------------------------------------------------------------------------------------------------------------------------------------------------ -----------------------------------------------------------------------------------------------------------------------------------------------------------------------2nd Year Proper :: 2nd Semester :: ORAL PATHOLOGY : Spread of Infections II :: Page 4 of 3 ------------------------------------------------------------------------------------------------------------------------------------------------------------------------