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Management of swellings of infective origin in head neck region.
- 1. Management of Swellings of Infective Origin in Head and Neck Region Dr Nakul Parasharami MDS Oral and Maxillofacial Surgery Ex- Registrar Cooper Hospital, Mumbai Former HOD Dental Department, Oncolife hospital, Shendre, Satara. Consultant Maxillofacial Surgeon - Jupiter Hospital, Pune. Mangalmurti Hospital ,Satara. Co- Founder Canopy Dental Care and Implant Center, Pune..
- 2. Aims and Objectives 1.GAIN KNOWLEDGE ON VARIOUS INFECTIONS OF HEAD AND NECK REGION WITH IMPORTANCE TO BACTERIAL infections. 2. General Dentist and GPs are the first point of reference to the patients. 3. Get acquainted with the “Eight Step Approach” in managing Acute Bacterial infections of Dental origins. 4. Gain information regarding antibiotics and its judicial use. 5. Learn about latest literature on use of antibiotics. 6. Case Discussion
- 3. CLINICAL SCENARIO Name- Suresh** Age- 45. H/O having tooth pain for past few days. General Examination- • Temperature- 101*F • RR- 25 • P- 100 bpm • Dry Tongue Intraoral examination- • Few carious teeth on side of swelling. • Reduced mouth opening. • Difficulty in pronouncing words.
- 5. How to treat these Patients ? BACTERIAL INFECTIONS Clinical Anatomy Diagnostic Studies Specific Treatment Techniques Treatment Goals Recent Studies Complications
- 6. CLINICAL ANATOMY Once infection is set it has 3 fates- The body's defence systems over- power the microorganisms. The infection changes from acute to chronic form and persists. Spreads in aggressive manner. 1 2 3
- 7. CLINICAL ANATOMY Subcutaneous • Infraorbital • Buccal Perioral • Vestibular • Palatal Perimandibular • Submandibular • Sublingual • Submental Masticator • Submassetric • Pterygomandibular • Superficial Temporal • Deep Temporal Deep Neck Spaces • Lateral Pharyngeal • Retropharyngeal • Pretracheal Mediastinal • Danger Space • Superior Mediastinum • Anterior Mediastinum • Middle Mediastinum • Posterior Mediastinum
- 8. CLINICAL ANATOMY- TAKE HOME POINTS Spread of Infection is dependent on Host response and Bacterial load. Infection tends to follow path of least resistance. As spaces are interconnected- need for rapid action. 1 2 3
- 9. DIAGNOSTIC STUDIES- BLOOD WORK UP Blood work up- 1.CBC 2.HB1AC 3.HIV and HbSAg 4.CRP 5.LFT, KFT.
- 10. DIAGNOSTIC STUDIES-IMAGING 1&3 - Radiopedia.org 2-Original Article DOI : 10.7860/JCDR/2013/5617.2990
- 11. DIAGNOSTIC STUDIES- TAKE HOME POINTS CT with Contrast is the Gold Standard USG useful in Superficial infections CRP is an expensive test but a useful one. 1 2 3
- 12. Treatment Goals- l Eight Step Protocol 1.Determine Severity 2.Evaluate Host Defence 3. Hospitalization??? 4.Treat Surgically 5.Support Medically 6.Choose Antibiotics Appropriately 7.Administer Antibiotics Appropriately 8.Re-evaluate Frequently In first 5 mins **Current therapy in oral and Maxillofacial Therapy- Thomas Flynn
- 13. Subcutaneous • Infraorbital • Buccal Perioral • Vestibular • Palatal Peri mandibular • Submandibular • Sublingual • Submental Masticator • Submassetric • Pterygomandibular • Superficial Temporal • Deep TemporalDeep Neck Spaces • Lateral Pharyngeal • Retropharyngeal • PretrachealMediastinal • Danger Space • Superior Mediastinum • Anterior Mediastinum • Middle Mediastinum • Posterior Mediastinum High Severity Low Severity Moderate Severity Extreme
- 14. Most common immune compromising dieases/ Clinical Scenarios- 1.Diabetes. 2.Steroid Therapy. 3.Organ transplant 4.End Stage renal Disease 5.Malignancy 6. Chemotherapy 7.Alcoholism End Stage AIDS
- 15. Following Guidelines can help make a decision- 1.T- >101*F 2.Signs of Dehydration 3.Impending Airway compromise 4.Infection of Deep Neck Spaces/ Masticator space 5.Out of Control Systemic Disease
- 16. Cervical Xray- AP and Lateral Surgical Objectives- Secure Airway Establish drainage Remove cause of infection
- 17. ”: ! Establish Adequate Nutrition Rehydration Control of Systemic Disease Appropriate Antibiotic Therapy Appropriate Pain management.
- 19. Indications- Severity of Infection. Need of Admission Immunologic Compromise Non Responsive Previous treatment Nosocomial Infection Indian Clinical scenario needs to be taken into consideration. Need for Culture and Sensitivity Testing-
- 20. ICMR Guidelines for Antimicrobial Use in Common Syndromes- 2019.
- 21. Gram negative infections more common in genitourinary and lower GI region. Conclusion - Metronidazole to be added only if Patient having co morbidities.
- 22. 7.Administer Antibiotics Appropriately ICMR Guidelines for Antimicrobial Use in Common Syndromes- 2019.
- 23. The ICMR guidelines and reference articles will be uploaded on this webpage www.canopydent.com
- 24. Approximate Treatment cost of antibiotics Injection Augmentin- Rs 137 per vial 137*3*7 =Rs 2877. Tab Augmentin- Rs200 for pack of 10 tablets. Inj Piptaz- Rs 450 per vial 450*3*7=9450 Injection Clindamycin- Rs 250/ vial 250*3*7= 5250
- 25. For Out Patient Patient Follow up is important the nexr day. To inform you in case of deterioration.. 8.Re-evaluate Frequently Criteria for hospital discharge T <100 for 24 hours Increase in oral intake of food Drains out Clinically decrease in swelling size Systemic disease under control ambulation For In Patient- Daily follow up Post surgical care- monitor tempreture, WBC COUNTS, C-RP levels, BSL levels Manage the drain.
- 26. Treatment goals- Take Home Points Surgery + Medicine = Success Knowledge of antibiotics is a must for a successful treatment outcome. 1 2 3 Determining the anatomical spread of infection is foundation of entire treatment. When in doubt about patients condition, always hospitalize. 4
- 27. Specific Treatment Technique- Surgical aspect Identify the spaces.1 2 3 4 Blunt Exploration of entire anatomic spaces, opening up of all tissue planes. Placement of Drain. Secure Drain.
- 29. • Nasal intubation done. • LA infiltration. • Palpation for most dependent area.
- 30. Incision on most dependent area.
- 31. Abscess drained Mid stream abscess collected.
- 32. Drain is placed and secured with sutures.
- 34. Eight Step Protocol 1.Determine Severity 2.Evaluate Host Defence 3. Hospitalization??? 4.Treat Surgically 5.Support Medically 6.Choose Antibiotics Appropriately 7.Administer Antibiotics Appropriately 8.Re-evaluate Frequently
- 35. Eight Step Protocol 1.Determine Severity 2.Evaluate Host Defence 3. Hospitalization??? 4.Treat Surgically 5.Support Medically 6.Choose Antibiotics Appropriately 7.Administer Antibiotics Appropriately 8.Re-evaluate Frequently
- 36. Eight Step Protocol 1.Determine Severity 2.Evaluate Host Defence 3. Hospitalization??? 4.Treat Surgically 5.Support Medically 6.Choose Antibiotics Appropriately 7.Administer Antibiotics Appropriately 8.Re-evaluate Frequently
- 37. Eight Step Protocol 1.Determine Severity 2.Evaluate Host Defence 3. Hospitalization??? 4.Treat Surgically 5.Support Medically 6.Choose Antibiotics Appropriately 7.Administer Antibiotics Appropriately 8.Re-evaluate Frequently
- 38. Eight Step Protocol 1.Determine Severity 2.Evaluate Host Defence 3. Hospitalization??? 4.Treat Surgically 5.Support Medically 6.Choose Antibiotics Appropriately 7.Administer Antibiotics Appropriately 8.Re-evaluate Frequently
- 39. Complications- Ludwigs angina ACUTE, NON- SUPPURATIVE, NECROTISING CELLULITIS INVOLVING SUBMANDIBULAR, SUBLINGUAL AND SUBMENTAL SPACES BILATERALLY. CAUSATIVE ORGANISM: a- HEMOLYTIC STREPTOCOCCI https://litfl.com/
- 40. Clinical Features Acute. Double chinned appearance Tense Skin. Lifted Tongue. Dyspnea. Extreme Fever, Malise https://litfl.com/
- 41. Surgical Treatment Priority one – Airway management Immediate Surgical decompression. separate incision in submandibular region and Submental incision. Placement of Rubber drain Medical management- Piptaz+clinda Metro can be added in extreme cases where there is gangrenous material.
- 42. Ludwigs Angina- Take Home Points Primary treatment is surgical.1 2 3 Due to advent of antibiotics, the incidence of Ludwigs Angina has decreased. Fast action in containment of spread.
- 43. OTHER Swellings NON DENTAL ORIGIN INFECTIONS BACTERIAL Tuberculosis FUNGAL Mucormycosis VIRAL Measles Mumps
- 44. Tuberculosis Clinical Feature Tuberculosis Non Tuberculosis Cervical Lymphadenitis Multiple, B/L supra clavicular Around neck. Fever, malise etc present absent history Present Absent Sinus formation High Low Tuberculin test Positive negative Chest x ray Signs of tb Normal Ganesan A, Kumar G. Scrofuloderma: A rare cutaneous manifestation of tuberculosis. J Indian Acad Oral Med Radiol [serial online] 2017 [cited 2020 Apr 17];29:223-6.
- 45. OTHER NON DENTAL ORIGIN INFECTIONS- Mucormycosis • Most fatal, opportunistic, acute fungal infection. • Source- mucorace family, found normally in the oral cavity. Type Clinical notes Rhinonasal/ Rhinocerebral Involves- orbit, nose, CNS Pulmonary Seen in patients with malignancy GIT Malnourished patients Cutaneous Burns patients Disseminated Rare, severe
- 46. OTHER NON DENTAL ORIGIN INFECTIONS- Mucormycosis . Management- 1. Use of GMS stain, culture with saboraud glucose agar. 2. Start with antifungal – amphotericin B.(0.5mg/kg) 3. Debridement of entire tissue, if orbital involvement- exenteration is mandatory 4. Management of acidosis and neutropenia 5. Monitor renal health- amphotericin B is renal toxic. 6. Extremely poor survival rate. Doni BR, Peerapur BV, Thotappa LH, Hippargi SB. Sequence of oral manifestations in rhino-maxillary mucormycosis. Indian J Dent Res 2011;22:331-5
- 47. OTHER NON DENTAL ORIGIN INFECTIONS- - Take Home Points A suppurative lesion can also be tuberculous in nature. 1 2 3 3 In case of facial swellings the cause may also be non- dental in origin. Mucormycosis needs urgent intervention.
- 49. THANK YOU 101 Sneh building, Survey. no 32/2 Pancard Club road, Lane Next To Shreyas Colonade, Baner Pune 411045 www.canopydent.com
Editor's Notes
- It’s a nice Saturday evening. Less Rush in the OPD There is a live India Pakistan Match tomorrow… you are looking forward to it He is a trader, a known patient of yours. U know he is under some financial stress due to an expansion he had undertaken in his shop Taken Medications from Local chemist He definitely has some disease. As we know there are primarily 4 types of diseases- deficiency, genetic, physiological, infectious Infectious diseases of head neck region- Fungal, viral, protozoal, bacterial.
- It’s a nice Saturday evening. Less Rush in the OPD There is a live India Pakistan Match tomorrow… you are looking forward t Taken Medications from Local chemist He definitely has some disease. As we know there are primarily 4 types of diseases- deficiency, genetic, physiological, infectious Infectious diseases of head neck region- Fungal, viral, protozoal, bacterial.
- The aim of understanding these aspects will help n delivering optimum standard of care.
- This is one of the most fundamental aspect of infection happening in the body. Whenever there is decrease in host resistance, the normal oral inhabitant microbes become dominant. Which leads to infection. 1. either completely eliminate them or the infection gets localized to form an abscess which drains spontaneously on the surface. 2. It under- goes acute exacerbations intermit- tently whenever the environments are conductive. 3. and produces local and systemic complications- Life threatening
- As clinicians we should be able to atleast demarcate the extent of spread of infections as that is he basis of treatment we need to do.
- Once we identify the
- Once we identify the
- The severity is dictated by criteria- its effect on airway or vital structures. Low severity- Usually can be treated on out pt basis Moderate severity- potential to hinder the airway and thus making intubation difficult. High severity have the ability to directly deviate or compress the airway or affect vital structures. One with extreme severity are already in a compromised state and need immediate, surgical/medical intervention
- Taking a through history we can confirm about the same. Never rely on Fasting PP….always use HB1Ac. Involving a physician is mandatory for adjusting insulin units.
- Why to choose antibiotics carefully- Pathology- Initiated by Streptococci+Increased by anerobes
- Why to choose antibiotics carefully-
- Dosa
- In case no improvement ?????
- Once we identify the
- Once we identify the
- Once we identify the