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Chapter 16
Chapter 16
Infections
Larry ). Peterson
C H A P TOEU TRL I N E
FASCIAL SPACE INFECTIONS
Maxillary Spaces
MANDIBULAR SPACES
Secondary Fascial Spaces
Cervical Fascial Spaces
Management of Fascial Space Infections
dontogenic infections are usually mild and easily and causes infection in the adjacent tissue. Whether or
Primary hiaxillary This is the only tooth with a root sufficiently long to
Canine allow erosion t o occur through the alveolar bone supe-
R Buccal rior to the muscles of facial expression. The infection
U lnfratemporal erodes superior to the origin of the levator anguli oris
Primary Mandibular Spaces muscle and below the origin of the levator labii superi-
Submental oris muscle. When this space is infected, swelling of the
a Buccal anterior face obliterates the nasolabial fold (Fig. 16-2).
i Submandiibular Spontaneous drainage of infections of this space com-
m SublinguaI monly occurs just inferior t o the medial canthus of the
----1-7
Secondary EUSLZUI I
>puce> eye.
n Masseteric The buccal space is bounded by the overlying skin of
a Pterygomandibular the face o n the lateral aspect and the buccinator muscle
BI Superficial and deep temporal on the medial aspect (Fig. 16-3). This space may become
b~ Lateral pharyngeal infected from extensions of infection from either the
w Retropharyngeal maxillary or mandibular teeth. The posterior maxillary
BJ Prevertebral teeth, most commonly the molars, cause most buccal
space infections. The buccal space becomes involved
from the teeth when infection erodes through the bone
superior to the attachment of the buccinator muscle.
Maxillary Spaces Involvement of the buccal space usually results in
The canine space is a thin potential space between the swelling below the zygomatic arch and above the inferior
levator angulioris and the levator labii superioris mus- border of the mandible. Thus both the zygomatic arch
cles. The canine space becomes involved primarily as and the inferior border of the mandible are palpable in
the result of infections from the maxillary canine tooth. buccal space infections.
Complex Odontogenic Infections CHAPTER 16 369
Buccal
space
FIG. 16-3 A, Buccal space lies between buccinator muscle and overlying skin and superficial fascia,
This potential space may become involved via maxillary or mandibular molars (arrows). B, This buccal
space infection was result of maxillary molar. Typical swelling of the cheek is demonstrated, which does
not extend beyond inferior border of mandible. (From Cummings CW et a/, editors: Otolaryngology:
head and neck surgery, vol3, St Louis, 1998, Mosby.)
FIG. 16-5 Hematogenous spread of infection from jaw to cavernous sinus may occur anteri-
orly via inferior or superior ophthalmic vein or posteriorly via emissary veins from pterygoid
plexus. (From Cummings CWet al, editors: Otolaryngology: head and neck surgery, vol3, St Louis,
1998, Mosby.)
MANDIBULAR- SPACES--- -- - -- - -- - -- --
"
The buccal space can be infected as an extension of
Although most infections of the mandibular teeth infection from mandibular teeth, similar to the way in
erode into the buccal vestibule, they may also spread which it is involved from the maxillary teeth (see Fig.
into fascia1 spaces. The four primary mandibular spaces 16-3). The buccal space is most commonly infected from
are (1) the submental, (2) the buccal, (3) the sublingual, maxillary teeth but can also be involved from the
and (4) the submandibular spaces. mandibular teeth.
The submental space lies between the anterior bellies of The sublingual and submandibular spaces have the
the digastric muscle and between the mylohyoid muscle medial border of the mandible as their lateral boundary.
and the overlying skin (Fig. 16-6). This space is primarily These two spaces are involved primarily by lingual perfo-
infected by mandibular incisors, which are sufficiently ration of infection from the mandibular molars, although
long to allow the infection to erode through the labial they may be involved by premolars, as well. The factor
bone apical to the attachment of the mentalis muscle. The that determines whether the infection is submandibular
infection is thus allowed to proceed under the inferior or sublingual is the attachment of the mylohyoid muscle
border of the mandible and involve the submental space. on the mylohyoid ridge of the medial aspect of the
Isolated submental space infection is a rare occurrence. mandible (Fig. 16-7). If the infection erodes through the
medial aspect of the mandible above this line, the infec-
tion will be in the sublingual space and is most com-
monly seen with premolars and the first molar. If the
infection erodes through the medial aspect of the
mandible inferior t o the mylohyoid line, the sub-
mandibular space will be involved. The mandibular third
molar is the tooth that most commonly involves the sub-
mandibular space primarily. The second molar may
involve either the sublingual or submandibular space,
depending on the length of the individual roots, and may
involve both spaces primarily.
The sublingual space lies between the oral mucosa of
the floor of the mouth and the mylohyoid muscle (Fig.
16-8, A). Its posterior border is open, and therefore it
freely communicates with the submandibular space and
the secondary spaces of the mandible to the posterior
FIG. 16-7 Mylohyoid line is area of attachment of mylohyoid muscle. aspect. Clinically little or no extraoral swelling is pro-
Linguocortical plate perforation by infection from premolars and first duced by an infection of the sublingual space, but much
molar causes sublingual space infection, whereas infection from third intraoral swelling is seen in the floor of the mouth on the
molar involves submandibular space. (From Cummings CW et a/, editors: infected side (Fig. 16-8, B). The infection usually becomes
Otolaryngology: head and neck surgery, vol3, St Louis, 1998, Mosby.) bilateral, and the tongue becomes elevated.
FIG. 16-8 A, Sublingual space between oral mucosa and mylohyoid muscle. It is primarily involved
by infection from mandibular premolars and first molar. B, This isolated sublingual space infection pro-
duced unilateral swelling of floor of mouth. (From Curnmings CW et a/, editors: Otolaryngology: head
and neck surgery, vol3, St Louis, 1998, Mosby.)
372 PART IV Infections
The submandibular space lies between the mylohyoid become more severe, cause greater complications and
muscle and the overlying skin and superficial fascia (Fig. greater morbidity, and are more difficult to treat. Because
16-9). The posterior boundary of the submandibular a connective tissue fascia that has a poor blood supply
space communicates with the secondary spaces of the jaw surrounds these spaces, infections involving these spaces
posteriorly. Infection of the submandibular space causes are difficult to treat without surgical intervention to
swelling that begins at the inferior border of the drain the purulent exudate.
mandible and extends medially to the digastric muscle The masseteric space exists between the lateral aspect
and posteriorly to the hyoid bone (Fig. 16-10). of the mandible and the medial boundary of the masseter
When bilateral submandibular, sublingual, and sub- muscle (see Fig. 16-4). It is involved by infection most
mental spaces become involved with an infection, it is commonly as the result of spread from the buccal space
known as Ludwig's angina. This infection is a rapidly or from soft tissue infection around the mandibular third
spreading cellulitis that commonly spreads posteriorly to molar. When the masseteric space is involved, the area
the secondary spaces of the mandible. overlying the angle of the jaw and ramus becomes
Severe swelling is almost always seen, with elevation swollen. Because of the involvement of the masseter mus-
and displacement of the tongue, and a tense, hard cle, the patient will also have moderate-to-severe trismus
induration of the submandibular region superior to the caused by inflammation of the masseter muscle.
hyoid bone. The pterygomandibular space lies medial t o the
The patient usually has trismus, drooling of saliva, and mandible and lateral to the medial pterygoid muscle (see
difficulty with swallowing and sometimes breathing. The Fig. 16-4). This is the space into which local anesthetic
patient often experiences severe anxiety concerning the solution is injected when an inferior alveolar nerve block
inability to swallow and maintain an airway. This infec- is performed. Infections of this space spread primarily
tion may progress with alarming speed and thus may from the sublingual and submandibular spaces. When
produce upper airway obstruction that often leads to the pterygomandibular space alone is involved, little or
death. The most common cause of Ludwig's angina is an no facial swelling is observed; however, the patient
odontogenic infection, usually as the result of streptococ- almost always has significant trismus. Therefore trismus
ci. This infection must be aggressively managed with vig- without swelling is a valuable diagnostic clue for ptery-
orous I&D procedures and aggressive antibiotic therapy. gomandibular space infection. The most common occur-
Special attention must be given t o maintenance of the
airway.
Submandibular gland
Mylohyoid muscle
Submandibular abscess
FIG. 16-9 Subrnandibular space lies between mylohyoid muscle FIG. 16-10 This subrnandibular space infection produced large,
and skin and superficial fascia. Primarily second and third molars indurated swelling of subrnandibular space. (From Cummings CW et
infect it. (From Cummings CW et al, editors: Otolaryngology: head al, editors: Otolaryngology: head and neck surgery, vol 3, St Louis,
and neck surgery, vol3, St Louis, 1998, Mosby.) 1998, Mosby.)
Complex Odontogenic Infections . CHAPTER 16 373
rence of this clinical picture is caused by needle tract space. This space extends from the base of the skull at the
infection from a mandibular block. sphenoid bone to the hyoid bone inferiorly. It is medial
The temporal space is posterior and superior to the to the medial pterygoid muscle and lateral to the superi-
masseteric and pterygomandibular spaces (see Fig. 16-4). or pharyngeal constrictor on the medial side (Fig. 16-11).
It is divided into two portions by the temporalis muscle: It is bounded anteriorly by the pterygomandibular raphe
(1)a superficial portion that extends to the temporal fas- and extends posteromedially to the prevertebral fascia.
cia and (2) a deep portion that is continuous with the The styloid process and associated muscles and fascia
infratemporal space. Rarely are the superficial and deep divide the lateral pharyngeal space into an anterior com-
temporal spaces secondarily involved and usually only in partment, which contains primarily muscles, and a pos-
severe infections. When these spaces are involved, the terior compartment, which contains the carotid sheath
swelling that occurs is evident in the temporal area, supe- and several cranial nerves.
rior to the zygomatic arch and posterior to the lateral The clinical findings of lateral pharyngeal space infec-
orbital rim. tion include severe trismus as the result of involvement
When taken as a group, the masseteric, pterygoman- of the medial pterygoid muscle; lateral swelling of the
dibular, and temporal spaces are known as the masticator neck, especially inferior to the angle of the mandible; and
space, because the muscles and fascia of mastication swelling of the lateral pharyngeal wall, toward the mid-
bound them. These spaces communicate freely with one line. Patients who have lateral pharyngeal space infec-
another, so when one becomes involved the others may tions have difficulty swallowing and usually have a high
also. The term masticator space does have some general temperature and become quite sick.
clinical usefulness, but it lacks specificity and is therefore Patients who have infection of the lateral pharyngeal
less useful than specific space designations. space have several serious potential problems. When the
lateral pharyngeal space is involved, the odontogenic
infection is severe and may be progressing at a rapid rate.
Cervical Fascial Spaces Another possible problem is the direct effect of the infec-
Extension of odontogenic infections beyond the primary tion on the contents of the space, especially those of the
and secondary mandibular spaces is an uncommon posterior compartment. These problems include throm-
occurrence. However, when it does happen, spread to bosis of the internal jugular vein, erosion of the carotid
deep cervical spaces may have serious life-threatening artery or its branches, and interference with cranial
sequelae. These sequelae may be the result of locally nerves IX through XII. A third serious complication aris-
induced complications, such as upper airway obstruc- es if the infection progresses from the lateral pharyngeal
tions, or of distant problems, such as mediastinitis. space to the retropharyngeal space.
Infection extending posteriorly from the pterygo- The retropharyngeal space lies behind the soft tissue of
mandibular space first encounters the lateral pharyngeal the posterior aspect of the pharynx. It is bounded anteri-
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 prevertebralfascia. Prevertebral spaces lie between alar
layer and prevertebral fascia. (From Cummings CW et a/, editors: Otolaryngology: head and neck
surgery, vol3, St Louis, 1998, Mosby.)
374 PART IV . Infections
mandible prevents penetration of periosteal blood ves- with a "moth-eaten" appearance. There may also be areas of
sels, the mandibular cancellous bone is more likely t o radiopacity within the radiolucency. These radiopaque
become ischemic and therefore infected. areas represent islands of bone that have not been resorbed
Considering the opportunities that bacteria have to and are known as sequestra. In long-standing chronic
enter into the cancellous bone, osteomyelitis of the osteomyelitis there may actually be an area of increased
mandible rarely occurs if the body's host defenses are rea- radiodensity surrounding the area of radiolucency. This is
sonably intact. The major predisposing factors for osteo- the result of an osteitis type of reaction in which bone pro-
myelitis of the jaws are preceding odontogenic infections duction increases as a result of the inflammatory reaction.
and fractures of the mandible (Fig. 16-15). Even these two Treatment of osteomyelitis is both medical and surgi-
events rarely cause infections of the bone unless the host cal. Because patients with osteornyelitis almost always
defenses are suppressed by problems such as the alco- have depressed host defense mechanisms, the clinician
holism malnutritional syndrome, diabetes, intravenous must take these compromises into account during the
illicit drug use, and myeloproliferative diseases, such as treatment and seek medical consultation when necessary.
the leukemias, sickle cell disease, and chemotherapy- Acute osteomyelitis of the jaws is primarily managed
treated cancer. by the administration of appropriate antibiotics. The pre-
Recent carefully performed investigations o n the cipitating event, condition, or both must also be careful-
microbiology of osteomyelitis of the mandible have ade- ly managed. If the event is a fracture of the mandible,
quately demonstrated that the primary bacteria of con- careful attention must be given t o its treatment. The
cern are similar to those causing odontogenic infections, antibiotic of choice is clindamycin, because it is effective
that is, streptococci, anaerobic cocci such as Peptostrepto- against streptococci and the anaerobes that are usually
coccus spp., and gram-negative rods such as those of the involved in osteomyelitis. If the patient has a serious
genera F~isohactrriur?land Prrvotelln. Traditional investiga- acute osteomyelitis, hospitalization may be required for
tion of the microbioloby of osteomyelitis of the jaws has administration of IV antibiotics. Clindamycin is preferred
used culture specimens from surface drainage of pus (con- because it is an excellent drug for both streptococci and
taminated with Stnpl~ylococc~rs organisms) and not anaer- the usual causative anaerobes. Surgical treatment of acute
obic culture techniques (and thereby have not grown suppurative osteomyelitis is usually limited. It consists
anaerobes). Thus osteomyelitis of the mandible differs primarily of removing obviously nonvital teeth in the
substantially from osteomyelitis of other bones in which area of the infection, wires or bone plates that may have
staphylococci are the predominant bacteria. been used t o stabilize a fracture in the area, or any obvi-
Acute suppurative osteomyelitis shows little or no ously loose pieces of bone. For acute osteomyelitis that
radiographic change, because 10 to 12 days are required results from jaw fracture, the surgeon must stabilize the
for lost bone to be detectable radiographically. Chronic mobile segments of the mandible with tight intermaxil-
osteomyelitis usually demonstrates bony destruction in the lary fixation or some other technique.
area of infection. The appearance is one of increased radi- Chronic osteomyelitis requires not only aggressive
olucency, which may be uniform in its pattern or patchy, antibiotic therapy but also aggressive surgical therapy.
Because of the severe compromise in the blood supply to tion is primarily one of soft tissue and progresses by
the area of osteomyelitis, the patient is usually admitted to direct extension into adjacent tissues.
the hospital and given high-dose IV antibiotics to control Unlike other infections, actinornycosis does not follow
the initial symptoms. Clindamycin is the drug of choice. usual anatomic planes but rather burrows through them
An effort should be made to obtain culture material at the and becomes a lobular "pseudotumor." If the infection
time of surgery so that the selection of an antibiotic can be erodes through a cutaneous surface, which is common
based on the specific microbiology of the infection. with orofacial actinomycosis, multiple sinus tracts typi-
Therapy for both acute and chronic osteomyelitis, cally develop. Once drainage is established, the patient
most authorities agree, should ensure that antibiotics are has minimal pain, although the sinus tracts will continue
continued for a much longer time than is usual for odon- to drain spontaneously until the infection is brought
togenic infections. For mild acute osteomyelitis that has under control (Fig. 16-16).
responded well, antibiotics should be continued for at A definitive diagnosis depends on laboratory identifi-
least 4 weeks. For severe chronic osteomyelitis that has cation. Actinornyces is an anaerobic bacterium and there-
been difficult to control, antibiotic administration may fore must be incubated in an anaerobic environment,
continue for up to 6 months. usually on brain-heart agar or blood agar, for 4 to 6 days.
Osteomyelitis of the mandible is a severe infection In up to 50% of all actinomycotic infections the organism
that may result in loss of a large portion of the mandible. is not grown. However, the clinical presentation of the
Therefore a clinician who has the training and experience patient with actinomycosis is characteristic. The patient
to handle the problem expeditiously should manage this has an atypical infection of the jaws that responds well to
infection. In addition, it is likely that medical consulta- antibiotic therapy initially; however, after the antibiotic
tion will be required to help correct any underlying com- is stopped, the infection recurs. The patient with this dis-
promise of host defenses. ease has frequently had multiple episodes of recurrent
infection in the same area.
Therapy of actinomycosis include\ surgical I&D and
ACTINOMYCOSIS * - "
excision of all sinus tracts. This portion of the treatment
Actinomycosis is a relatively uncommon infection of the is important to ensure that adequate amounts of antibi-
soft tissues of the jaws. It is usually caused by Actinoniyce$ otic are actually delivered to the infected area.
israelii but may also be caused by A. naeslundii or A. visco- The antibiotic of choice for actinomycosis is penicillin
sus. Actii~ornycesis an endogenous bacterium of the oral in the nonallergic patient. The dose varies with the seri-
cavity that was once thought to be an anaerobic fungus. ousness of the disease. The usual recommended dose is
However, it has now been clearly established that actino- 500 mg 4 times a day for at least 3 months. The reason for
mycetes are anaerobic bacteria. the prolonged administration of the antibiotic is to pre-
Actinomycosis is a relatively uncommon disease, vent the recurrence of the infection. If the patient has had
because the bacteria have a low degree of virulence. For a serious infection or the bone of the jaws is involved,
the infection to become established, the bacteria muTt be high doses of penicillin should be given parenterally while
inoculated into an area of injury or locally increased sus- the patient is hospitalized. IV administration of 10 million
ceptibility, such as areas of recent tooth extraction, units of penicillin daily in divided doses is continued until
severely carious teeth, or minor oral trauma. The infec- the disease is clinically cured; this ranges from 3 to 14
FIG. 76-'16 This actinomycosis had multiple recurrences. The patient experienced a small
amount of swelling with multiple small sinus tracts.
378 PART lV 1~~fictiorr.s
days. The patient is then discharged from the hospital, ic wetness at the corner of the mouth and subsequent
and a course of oral penicillin is begun. yeast growth.
The drug of second choice is tetracycline, with doxy- Topical antifungal agents can usually deliver therapy
cycline being the preferred drug, because it can be admin- for oral candidosis. The two most commonly used drugs
lstered once per day during the long-term antibiotic for this purpose are (1) nystatin and (2) clotrimazole.
administration. Both of these drugs are prepared as lozenges and are
In summary, actinomycosis is an indolent infection delivered by sucking o n the Lozenge until it is totally dis-
that tends to erode through tissues rather than follow solved. Nystatin is the preferred drug, because the
typical fascia1 planes and spaces. It is difficult to eradicate chances for adverse reactions are essentially zero.
using short-term antibiotic regimens. Therefore ItSrD of Clotrimazole has a quite small risk of toxicity and
an>7 accumulation of pus and excision of chronic sinus therefore is usually viewed as being a drug of second
tracts must be accomplished. Finally high-dose antibiotic choice. The usual dose of either preparation is one
administration is recommended for initial control of the lozenge 4 or 5 times per day for 2 weeks. Patients usually
infection, with long-term antibiotic therapy to prevent experience rapid resolution of the signs and symptoms of
recurrence of actinomycosis. candidosis but must be informed that there will be a
recurrence of the infection unless they continue the ther-
apy for the entire 14 days. If the patient has a denture,
the denture should be soaked in chlorhexidine overnight
The organism Cnr7riiri~7nlbicr1rr.5 is a naturally occurring for the entire treatment.
fungus in the oral cavity. It rarely causes disease unless Systemically administered drugs, such as fluconazole,
the patient's health becomes compromised. The two can also treat oral candidosis. This antifungal drug is
most common causes of compromise are administration quite effective, especially in oropharyngeal candidosis,
of antibiotics, especially penicillin, for prolonged periods which is not responsive to topical therapy. Many author-
and chemotherapy for leukemias and other forms of can- ities recommend that if topical therapy has failed (i.e.,
cer. In these situations Cotiditin organisms overgrow the recurrence), then oral fluconazole 200 mg once daily for
oral cavity and cause a superficial infection, which usual- 10 days is the treatment of choice. Patient compliance is
ly appears intraorally as distinct white patches that can higher (1 pill versus 4 lozenges), so relapse is unusual.
be easily rubbed off with gauze to expose an underlying It is important to remember that candidosis usually
red, raw surface (Fig. 16-17). Caizdido spp. can be easily occurs only in medically compromised patients. Patients
cultured and diagnosed by their typical appearance on without histories of recent antibiotic therapy, cancer
Gram's stain. chemotherapy, or other types of immunocompromise
Angular cheilitis can be aggravated by the presence of should be suspected of having an underlying, undiagnosed
Carltlirln organisms. Most patients who have this problem immunocompromising disease. Predominant among these
are edentulous and overclosed and have a resultant chron- is acquired immunodeficiency syndrome (AIDS).
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