27
A SWOllEN FACE AND PERICORONITIS
Parotid gland
The patient IS pyrexIc and feels unwell. These features indicate that the Infection is exerting a systemi<: effect InfeclIOn appears to be spreadlllg relatIVely fast because the swelling has appeared o~ernight and there are already systemic signs.
• WIII'c/1 type af iI/fed ian is this? It IS difficult to tell because the tissues In~o""ed are deeply sited, Pus is dralmng from under the operculum Indicaling abscess formallOn, but this might edend into a soft tissue space or be limited to the tissues around the unerupted tooth. The rapid spread, firmness and tenderness 01 the tissues ('brawny' swelhng) IIxllcate cellulitiS. This might continue to spread or de~elop Into an abscess. There IS probably a nIIxed Infection With a local pericoronal abscess and a spreading cellulitiS.
• Ta w1lirll tissIII' sl'(I("/'s mllY il/fl'ctimr S/IN'atl from n low", third mO/llr? W/ml art' ti,e "VI/III/aries of tlrese S/JiIc.'S? Pus from lower third molars may track to many spaces and spread is unpredictable, depending 00 many factors Including the angulation of the tooth, the size of the follicle, relationship to the second molar, degree of bone loss around both teeth and the anatomical relalIOnshlps between the teeth, bone and muscle attachments in the region. Pus may drain Into the mouth from under an operculum. Into the buccal or hngual sulcus or Into one or more tissue spaces, The routes of spread to tissue spaces are shown in Figure 27,2 and are descnbed in Table 27.1
Table 27.1 Paths of spread 01
,nI~hon
Tissue space
Medlally abo~e the attachment of
~lngll3l
...
m_
Fig. 27.2 Paths of spread of IIIfeehon IIlto tISSue spaces from Ih,rd molars: A, IIItO the su~ingual and submandibular space; B. Into the parapharyngeal space; C, into the pterygCllTlandlbular space leading to the infratemporal fossa; D, IIIto the submasseWi(: space; E, Into the t>uccal space.
• luw/wl tissut' SI'IICt'S is tllI'lm's""t i"f"Clim, trackillg aud why? This swelling appears to be in the submandibular space. The main mfected tissue IS not Vlslble and lies around the submandibular gland deep to the body of the mandible. The
from lower thlld mola,s
Direction 01 spread
"""~
MasselOl
space, A
Boundaries Lies belween the floor mouth and rrry\QtryQId muscle W1th the body of the ,nand1ble lale'ally.
Submandibular space, A
Lies between mylohyoid muscle and pJatysma, W1th the hyoid bone medJally and lt1e ~er border 01 the mandible latetally. COfItallls the slbmandd)utar gland.
Parapha.-yngeal space. B
LiE'S betw~n Si.Jpefior constnctor muscle and the pterygoid muscles With the pterygOId plales.
PosterlOf and ~rlOf. oelween mandibular ramus and latetal pterygOId muscle
Infratemporal space VIa C wT1lCh commurucates W1th the cavernous $Onus
Base 01 51<... Si.JperlO/Iy. later!llly SIgmoid notch 01 marlchble and tempara~s muscle. medially laleral and pasterlOf wa" 01 maXilla.
Poste'lOf and medial to mandibular ramus, lateral to lateral pterygOId
PlerygCllTlandd)ula, space, C I~nd patenlia!ly on into the .,lratempOfa! space)
lJes between laleral and medial plerygoid muscles and the ascending lamus 01 mandible. Extends up to base of skull,
F'ostetlOf and late' (Ii to mandible ,arnus
Submassetenc Sllace, 0
liE'S between massele, muscle and the ascendlng ri'"\"S of the mandible.
PosterIOr and superiorly, lateral to buccinatOf
Buccal space, E
Between ltle bucc,""tor muscle and skill
Medially below
attachme~t
of
PostenOf and medrallo mandibular ramus, medial to lateral plerygOid ~~.
~~.
>3.