DRAINAGE OF SUBMANDIBULAR ABSCESSES

1. British Journal of Oral and Maxillofacial Surgery 51 (2013) e199–e200
Available online at www.sciencedirect.com
Technical note
Minimally-invasive catheter drainage of submandibular
abscesses
Florian A. Probsta,∗, Sven Ottoa, Rainer Sachseb, Carl-Peter Corneliusa
a Department of Oral and Maxillofacial Surgery, Ludwig Maximilians University of Munich, Germany
b Broward Plastic Surgery, Fort Lauderdale, United States
Accepted 28 June 2012
Available online 21 July 2012
Keywords: Deep head and neck infection; Odontogenic infection; Submandibular abscess; Needle aspiration; Catheterised drainage; Minimally invasive
drainage
Management of deep abscesses of the head and neck has
not changed substantially during past decades. Open sur-
gical drainage, including wide incisions, is still part of the
standard protocol. This regularly requires general anaesthe-
sia and subsequent postoperative intensive or intermediate
care management of swelling of traumatised tissue. Though
a few approaches to intraoperative image-guided (com-
puted tomography (CT) or ultrasound) minimally-invasive
drainage of such abscesses have been reported, aspiration
and catheterised drainage has not so far become popular.1–5
No protocol has been reported for submandibular abscesses,
in particular, which are the most common severe odontogenic
abscesses. We therefore present a practicable, minimally-
invasive procedure for draining abscesses using the Seldinger
technique, which is independent of intraoperative imaging.
Before the drainage procedure, contrast-enhanced CT is
recommended to verify the presence, topography, and locu-
larity of a drainable fluid collection. By means of a sharp
hollow aspiration needle (trocar) the drainable fluid col-
lection is punctured, starting percutaneously at the anterior
submandibular region about 3 cm below the lower border of
the mandible. The needle is pushed towards the expected fluid
collection until pus can be evacuated into a 20 ml syringe
(Fig. 1). If no pus can be evacuated, the puncture procedure
∗ Corresponding author at: Department of Oral and Maxillofacial Surgery,
Ludwig Maximilians University of Munich (LMU), Lindwurmstr. 2a, 80337
Munich, Germany. Tel.: +49 89 5160 2971; fax: +49 89 5160 4746.
E-mail addresses: florian.probst@med.uni-muenchen.de,
flo.probst@web.de (F.A. Probst).
should be retried with the direction of the needle modified.
A second aspiration is then attempted from the posterior part
of the submandibular region into the drainable collection.
If no pus can be evacuated, despite a fluid collection being
clearly detectable on CT, a switch to the standard protocol
withextraoralincisionanddrainingisreasonabletoguarantee
sufficient drainage.
After aspiration, catheters (Abscess Drainage Set,
Optimed, Ettlingen, Germany) are inserted using the
Seldinger technique. A guidewire is advanced through the
lumen of the aspiration needle (Fig. 2), and the needle is
withdrawn. Dilators of increasing calibres are then passed
over the Seldinger wire into the abscess (6, 8, 10, 12, 14 F).
Finally, pigtail catheters can be inserted over the Seldinger
wire for continuous drainage (Fig. 3).
These catheters consist of buckled resistant polyurethane.
At the inner parts of the pigtail coil, apertures allow suc-
tion and rinsing. As they are in the inner coil, the risk of
adherence to the surrounding tissue is reduced. After the
final catheter has been put in place, the guidewire is with-
drawn. The catheters are placed at both sites of the puncture
(anterior and posterior). An initial drilling fluid circulation
is begun by introducing a volume of physiological saline,
roughly 20 ml (Fig. 4). It should be confirmed that the vol-
ume of fluid installed is similar to that which has been flushed
out. We used two catheters, which permits better drainage of
theabscesscavity,andrinsingplusdrainingbecomespossible
without the existence of a dead space.
Finally, after adhesive drapes have been placed around
the catheters (KCI Drapes, KCI, San Antonio, USA), they are
0266-4356/$ – see front matter © 2012 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.bjoms.2012.06.013

2. e200 F.A. Probst et al. / British Journal of Oral and Maxillofacial Surgery 51 (2013) e199–e200
Fig. 1. Puncture with a needle anteriorly, and aspiration of pus.
Fig. 2. Catheterisation using the Seldinger technique: a guidewire is
advanced through the lumen of the aspirating needle.
connected to a conventional Redon drain for vacuum suction.
Alternatively, an exactly-defined vacuum can be established
by VAC Therapy (KCI, San Antonio, USA). As soon as there
is the exudates ceases to be purulent, the catheters can be
removed.
In conclusion, closed catheter drainage seems to be a reli-
able and effective way of draining odontogenic abscesses,
particularly of the submandibular space. It is particularly
suitable for unilocular collections, and so preoperative CT
is valuable.
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Fig. 3. Pigtail catheters inserted along the Seldinger wire for continuous
drainage.
Fig. 4. After catheters have been placed at the anterior and posterior sites,
drilling fluid is circulated.
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