Deforming oral & maxillofacial infections

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For every new medicine we discover & invent - antibiotic resistance develops to the older one. For every microorganism that we eradicate, another one emerges to take its place.

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  • There have been many advances in the management of head and neck infections.New classes of antimicrobial agents, noninvasive imaging techniques, improved culturing methods, and a clearer understanding of the normal and pathologic functioning of the immune system are just some of the changes that have occurred. These and other technologic advances have enhanced dramatically our ability to diagnose and treat these infections rapidly and accurately. As a result, the incidence of serious morbidity and mortality from odontogenic infections has fallen significantly over the years.
  • It should be noted, however, that vigilance regard- ing research and technologic change must be main- tained. Just as we have made many advances in the management of these infections, an equal number of new and serious issues have arisen to test our resolve. Newly recognized bacterial and viral strains, the effects of global antibiotic resistance to once univer- sally effective agents, viral mutations, ‘‘flesh eating’’ bacteria causing necrotizing fasciitis, currently un- treatable catastrophic infections, such as those caused by the Ebola virus, and even biologic warfare and bioterrorism have emerged as important issues over the last 10 years, and articles about these issues flood the public news media and professional journals almost daily. In some cases we even have created new sources of infection ourselves by developing environments conducive to bacterial growth, such as around implants.
  • we have attempted to address some of the important and topical areas of knowledge in the diagnosis and management of infectious diseases that practicing oral and maxillofacial surgeons face. Some articles examine new areas of interest, such as infections associated with facial skin resurfacing, whereas others provide timely updates of our understanding of continually evolving topics, such as HIV/AIDS, chronic sclerosing osteomyelitis, selection and use of anti-biotics, and the changing microbiology of infections of the head and neck.
  • We start of with the basic knowledge of Inflammation. A cascade of calor, rubor, tumor, dolor & functiolaesa. This lecture will focus on the Swelling part, or the tumor side.
  • The impressive ability of bacteria and viruses to adapt, change, and mutate in response to our pharmacologic bombardment is a testimony to the complex, surreptitious, and unpredictable nature of these small yet hardy microbes. For every new drug we formulate, resistance develops to an older and often- used one. For every organism that we eradicate, another one suddenly emerges to take its place. To those of us in the clinical trenches, it seems that we are in a war with an ever-expanding number of increasingly virulent and destructive bacteria, fungi, and viruses. At times it seems that despite our advances in technology and knowledge, the out- come of that war is not as clear as we might wish. It is our hope that the information provided by the outstanding contributors to this issue will help to resolve some of the important issues we currently face.
  • Infections originating in deeper structures can be severe, rapidly progressive and may cause prolonged morbidity, long term complications as well as potentially endanger life. Efficient treatment requires accurate diagnosis, early aggressive medical treatment and in most cases urgent decisive surgical management.
  • Complex and severe cases may require multidisciplinary approach including the GP, dental surgeon, radiologist, oral and maxillo-facial surgeon, ENT surgeon, a skilled anaesthetist as well as occasionally the infectious diseases specialist and possibly the intensivist. Ophthalmology and rarely neurosurgery may also be needed. Good nursing, speech pathology as well as a dietician can speed up the recovery phase.
  • The results reveal rapid resolution of the infections by adhering to fundamental principles in their management: recognition of airway compromise, surgical intervention, and the administration of the appropriate antibiotic. A protocol for the management of maxillofacial infections is described.
  • The patient presents with a swollen face and occasionally swollen neck. Toothache or facial pain may or may not be a feature. There is often general malaise and possibly rigors with fever. Patients may complain of trismus (inability to open the mouth fully), pain or difficulty in swallowing, drooling, sore throat and a hoarse voice.
  • One should document the usual historical features of the current complaint with additional attention to: Increased pain and swelling on exposure to food (salivary gland obstruction?).Recent dental treatment, especially root canal treatment and extractions.Any trauma to the face or teeth (either bony fractures or devitalized teeth).Recent oral surgery (surgical removal of wisdom teeth, cysts etc.).Past facial fractures fixation (infected plates, wires, etc?).Past salivary gland surgery.History of head and neck cancer with possible radiotherapy to the region (possible osteoradionecrosis of the jaw bones?).Upper respiratory tract viral infections, nasal discharge, etc.
  • ExaminationSpecific attention should be paid to the location of swelling, size, fluctuance, any possible pointing and coexistent lymph node enlargement. Good oral examination should include:presence of halitosis,evidence of intraoral pus draining and where, any tongue elevation, any sublingual or submandibular swelling,swelling in the mandibular or maxillary sulci,palatal swelling especially of the soft palate or uvula,general dental state, patency of salivary outlets (parotid, submandibular and sublingual),nature of saliva produced (clear, thick, pus?).Suspect teeth should be tapped with a metallic object to elicit any tenderness to percussion. Swelling should be palpated bimanually if possible with a finger of one hand intraorally and and the second hand extraorally (pushing towards the oral site). The neck should be evaluated for swelling, lymphadenopathy and possible tracheal deviation.
  • ExaminationSpecific attention should be paid to the location of swelling, size, fluctuance, any possible pointing and coexistent lymph node enlargement. Good oral examination should include:presence of halitosis,evidence of intraoral pus draining and where, any tongue elevation, any sublingual or submandibular swelling,swelling in the mandibular or maxillary sulci,palatal swelling especially of the soft palate or uvula,general dental state, patency of salivary outlets (parotid, submandibular and sublingual),nature of saliva produced (clear, thick, pus?).Suspect teeth should be tapped with a metallic object to elicit any tenderness to percussion. Swelling should be palpated bimanually if possible with a finger of one hand intraorally and and the second hand extraorally (pushing towards the oral site). The neck should be evaluated for swelling, lymphadenopathy and possible tracheal deviation.
  • OBJECTIVE:To assess the most common micro-organisms causing odontogenic infections and their antimicrobial susceptibility.METHODS:The study was conducted in 80 patients with orofacial infection. The pus sample was collected, cultured (aerobically and anaerobically) and stained for morphological study of the isolates. Antibiotic sensitivity test for the isolates were performed.RESULTS:A total of 109 micro-organisms were isolated, no pathogenic organism were isolated in 3 cases. Out of 109 micro-organism isolated, 107 bacteria and 2 fungi were identified. Pure aerobes were identified in 28(35%) of cases, pure anaerobes in 18(22.5%), mixed aerobes and anaerobes in 10(12.5%), mixed aerobes in 15(18.75%) and mixed anaerobes were isolated in 6(7.5%) cases. Among the entire pure gram positive isolates, ofloxacin was the most sensitive drug 83.33% followed by ciprofloxacin 76.2% and sparfloxacin 76.2%. The most resistant drugs were amoxicillin (92.85%) and ampicillin (92.85%). Cefotaxime was found sensitive in 75% of pure gram negative isolates.CONCLUSION:Ofloxacin was the most sensitive drug followed by ciprofloxacin and sparfloxacin for pure gram positive isolates. The most resistant drugs were amoxicillin and ampicillin. The gram negative colonies were sensitive to Cefotaxime.
  • J Maxillofac Oral Surg. 2009 Dec;8(4):329-33. doi: 10.1007/s12663-009-0080-1. Epub 2010 Apr 24.In vitro evaluation of microbiological flora of orofacial infections.Kohli M, Mathur A, Kohli M, Siddiqui SRSourceDept. of Oral and Maxillofacial Surgery, Saraswathi Dental College and Hospital, Lucknow, India ; 26, Napier Road Colony Part 1 Thakurganj, Lucknow Uttarpradesh, India.AbstractOBJECTIVE:To assess the most common micro-organisms causing odontogenic infections and their antimicrobial susceptibility.METHODS:The study was conducted in 80 patients with orofacial infection. The pus sample was collected, cultured (aerobically and anaerobically) and stained for morphological study of the isolates. Antibiotic sensitivity test for the isolates were performed.RESULTS:A total of 109 micro-organisms were isolated, no pathogenic organism were isolated in 3 cases. Out of 109 micro-organism isolated, 107 bacteria and 2 fungi were identified. Pure aerobes were identified in 28(35%) of cases, pure anaerobes in 18(22.5%), mixed aerobes and anaerobes in 10(12.5%), mixed aerobes in 15(18.75%) and mixed anaerobes were isolated in 6(7.5%) cases. Among the entire pure gram positive isolates, ofloxacin was the most sensitive drug 83.33% followed by ciprofloxacin 76.2% and sparfloxacin 76.2%. The most resistant drugs were amoxicillin (92.85%) and ampicillin (92.85%). Cefotaxime was found sensitive in 75% of pure gram negative isolates.CONCLUSION:Ofloxacin was the most sensitive drug followed by ciprofloxacin and sparfloxacin for pure gram positive isolates. The most resistant drugs were amoxicillin and ampicillin. The gram negative colonies were sensitive to Cefotaxime.
  • CONCLUSION:Ofloxacin was the most sensitive drug followed by ciprofloxacin and sparfloxacin for pure gram positive isolates. The most resistant drugs were amoxicillin and ampicillin. The gram negative colonies were sensitive to Cefotaxime.
  • The sample consisted of 256 patients with a mean age of 28 years. 7 patients were immunocompromised and 20 female patients were pregnant out of 84 female patients who were included in the study. Caries followed by implant failure were identified to be the most frequent cause for space infection. Trismus and dysphagia were present in over 70% of the cases. The vestibular masticator, perimandibular (submandibular, submental and/or sublingual) and parapharyngeal, submaxillary spaces were involved. Abscess was found in 76% of the cases. All the patients were drained under local anesthesia or conscious sedation except one patient who was drained under GA. Three deaths occurred.CONCLUSION:This study indicated that prompt incision and drainage along with intravenous antibiotic under local anesthesia or conscious sedation was the mainstay of treatment of severe space infection. Patients were relieved of their signs and symptoms by third day, however trismus may persist for 5-7 days.
  • RESULTS:The sample consisted of 256 patients with a mean age of 28 years. 7 patients were immunocompromised and 20 female patients were pregnant out of 84 female patients who were included in the study. Caries followed by implant failure were identified to be the most frequent cause for space infection. Trismus and dysphagia were present in over 70% of the cases. The vestibular masticator, perimandibular (submandibular, submental and/or sublingual) and parapharyngeal, submaxillary spaces were involved. Abscess was found in 76% of the cases. All the patients were drained under local anesthesia or conscious sedation except one patient who was drained under GA. Three deaths occurred.
  • J Maxillofac Oral Surg. 2010 Mar;9(1):35-7. doi: 10.1007/s12663-010-0011-1. Epub 2010 Jun 4.A retrospective study of 256 patients with space infection.Gupta M,Sing VSourceDept. of Oral and Maxillofacial Surgery, Postgraduate Institute of Medical Sciences, Haryana Ghaziabad, India ; Dept. of Oral and Maxillofacial Surgery, ITS Dental College and Hospital, Delhi-Merrut Road, Ghaziabad, India.AbstractAIM:The purpose of this study was to retrospectively evaluate a series of patients with space infection.PATIENTS AND METHODS:In this study 256 patients with space infection over a period of two years were treated with intravenous antibiotic and prompt incision and drainage followed by culture and sensitivity tests in some cases. Data collection included demographic, anatomic treatment and complication information.RESULTS:The sample consisted of 256 patients with a mean age of 28 years. 7 patients were immunocompromised and 20 female patients were pregnant out of 84 female patients who were included in the study. Caries followed by implant failure were identified to be the most frequent cause for space infection. Trismus and dysphagia were present in over 70% of the cases. The vestibular masticator, perimandibular (submandibular, submental and/or sublingual) and parapharyngeal, submaxillary spaces were involved. Abscess was found in 76% of the cases. All the patients were drained under local anesthesia or conscious sedation except one patient who was drained under GA. Three deaths occurred.CONCLUSION:This study indicated that prompt incision and drainage along with intravenous antibiotic under local anesthesia or conscious sedation was the mainstay of treatment of severe space infection. Patients were relieved of their signs and symptoms by third day, however trismus may persist for 5-7 days.
  • Most originate in the jaws, teeth, surrounding periodontal soft tissues as well as the paranasal sinuses and the major salivary glands. Teeth can contribute by:(1) Decay (caries) reaching the dental pulp=pulpitis, this in turn spreads to supporting bone resulting in (2) periapical abscess which in turn may spread subperiosteally. (2) Periapical abscess may occur in seemingly intact but devitalised teeth (trauma, cracks or decay under fillings). (3) Periapical and periodontal abscess may form as a result of chronic gingivitis and supporting bone and soft tissue loss (periodontal disease) - note again the tooth may be entirely intact clinically and radiographically. (4) Erupting teeth (especially partially impacted lower third molars) can result in inflammation and infection of the gum flap preventing eruption (operculum) with swelling pus etc. around the crown (pericoronitis). (5) Retained roots supragingival or subgingival. The jaws:(1) Can develop cysts or tumours that can range from odontogenic (=dental origin) to either primary or secondary malignancy. Most are derived from the dental apparatus and although benign can nevertheless continuously grow and become secondarily infected on breaching the surrounding bone. (2) Osteomyelitis although rare can be the result of chronic infection as mentioned before. (3) Osteoradionecrosis occurs readily in irradiated jaws subjected to further trauma (such as extractions). (4) Rarer are tuberculosis, Actinomycosis and syphilitic osteomyelitis. (5) Most jaw fractures in the tooth bearing segments are by definition compound to the oral cavity and can easily be infected by the oral microbes. (6) Extraction sites again are comparable to compound fractures and it is surprising that infection is so relatively rare. Major salivary glands:(1) May be the subject of either viral or bacterial infections often superimposed on obstruction of ducts (stone, stricture, etc). (2) Tumours rarely also become secondarily infected. Paranasal sinuses(1) May be primarily infected, obstruct and result in facial swelling. (2) May become infected secondary to infected teeth protruding into the maxillary sinus (upper premolar and molar teeth often do). (3) Tumours or cysts may become infected. (4) Fractures such as the orbital floor are by definition compound to the “outside” and may result in orbital cellulitis.
  • Most originate in the jaws, teeth, surrounding periodontal soft tissues as well as the paranasal sinuses and the major salivary glands. Teeth can contribute by:(1) Decay (caries) reaching the dental pulp=pulpitis, this in turn spreads to supporting bone resulting in (2) periapical abscess which in turn may spread subperiosteally. (2) Periapical abscess may occur in seemingly intact but devitalised teeth (trauma, cracks or decay under fillings). (3) Periapical and periodontal abscess may form as a result of chronic gingivitis and supporting bone and soft tissue loss (periodontal disease) - note again the tooth may be entirely intact clinically and radiographically. (4) Erupting teeth (especially partially impacted lower third molars) can result in inflammation and infection of the gum flap preventing eruption (operculum) with swelling pus etc. around the crown (pericoronitis). (5) Retained roots supragingival or subgingival. The jaws:(1) Can develop cysts or tumours that can range from odontogenic (=dental origin) to either primary or secondary malignancy. Most are derived from the dental apparatus and although benign can nevertheless continuously grow and become secondarily infected on breaching the surrounding bone. (2) Osteomyelitis although rare can be the result of chronic infection as mentioned before. (3) Osteoradionecrosis occurs readily in irradiated jaws subjected to further trauma (such as extractions). (4) Rarer are tuberculosis, Actinomycosis and syphilitic osteomyelitis. (5) Most jaw fractures in the tooth bearing segments are by definition compound to the oral cavity and can easily be infected by the oral microbes. (6) Extraction sites again are comparable to compound fractures and it is surprising that infection is so relatively rare. Major salivary glands:(1) May be the subject of either viral or bacterial infections often superimposed on obstruction of ducts (stone, stricture, etc). (2) Tumours rarely also become secondarily infected. Paranasal sinuses(1) May be primarily infected, obstruct and result in facial swelling. (2) May become infected secondary to infected teeth protruding into the maxillary sinus (upper premolar and molar teeth often do). (3) Tumours or cysts may become infected. (4) Fractures such as the orbital floor are by definition compound to the “outside” and may result in orbital cellulitis.
  • Most originate in the jaws, teeth, surrounding periodontal soft tissues as well as the paranasal sinuses and the major salivary glands. Teeth can contribute by:(1) Decay (caries) reaching the dental pulp=pulpitis, this in turn spreads to supporting bone resulting in (2) periapical abscess which in turn may spread subperiosteally. (2) Periapical abscess may occur in seemingly intact but devitalised teeth (trauma, cracks or decay under fillings). (3) Periapical and periodontal abscess may form as a result of chronic gingivitis and supporting bone and soft tissue loss (periodontal disease) - note again the tooth may be entirely intact clinically and radiographically. (4) Erupting teeth (especially partially impacted lower third molars) can result in inflammation and infection of the gum flap preventing eruption (operculum) with swelling pus etc. around the crown (pericoronitis). (5) Retained roots supragingival or subgingival. The jaws:(1) Can develop cysts or tumours that can range from odontogenic (=dental origin) to either primary or secondary malignancy. Most are derived from the dental apparatus and although benign can nevertheless continuously grow and become secondarily infected on breaching the surrounding bone. (2) Osteomyelitis although rare can be the result of chronic infection as mentioned before. (3) Osteoradionecrosis occurs readily in irradiated jaws subjected to further trauma (such as extractions). (4) Rarer are tuberculosis, Actinomycosis and syphilitic osteomyelitis. (5) Most jaw fractures in the tooth bearing segments are by definition compound to the oral cavity and can easily be infected by the oral microbes. (6) Extraction sites again are comparable to compound fractures and it is surprising that infection is so relatively rare. Major salivary glands:(1) May be the subject of either viral or bacterial infections often superimposed on obstruction of ducts (stone, stricture, etc). (2) Tumours rarely also become secondarily infected. Paranasal sinuses(1) May be primarily infected, obstruct and result in facial swelling. (2) May become infected secondary to infected teeth protruding into the maxillary sinus (upper premolar and molar teeth often do). (3) Tumours or cysts may become infected. (4) Fractures such as the orbital floor are by definition compound to the “outside” and may result in orbital cellulitis.
  • MicrobiologyFacial infections tend to be polymicrobial with a predominance of anaerobic organisms. In severe cases Gram-ve organism tend to be involved as well.
  • In many cases careful history and examination will make diagnosis clear, however certain investigation will still be necessary. Plain X rays: (1) The OPG (orthopantomogram) is invaluable in displaying the teeth, whole of mandible, tooth bearing segment of the maxilla as well as parts of the maxillary sinuses. Use for any suspected fractures of the mandible, periapical abscesses and bony cysts and tumours. Will show impacted third molars ('wisdom teeth'). (2) Occipito-mental 15 and 30 degrees (“Water’s view”) will show both maxillary sinuses (effusion?), orbital floor and most fractures of the maxilla. (3) Mandibular occlusal views and lateral oblique views may demonstrate stones in the submandibular gland. (4) 'Puffed cheek' view may demonstrate stones in the parotid duct.
  • In many cases careful history and examination will make diagnosis clear, however certain investigation will still be necessary.
  • In many cases careful history and examination will make diagnosis clear, however certain investigation will still be necessary.
  • In many cases careful history and examination will make diagnosis clear, however certain investigation will still be necessary. With axial and coronal views will demonstrate exact extent of the swelling, potential airway compromise and is invaluable to both the surgeon and anaesthetist. However patients unwell enough to potentially obstruct their airway should be taken straight to theatre rather than risk an emergency in the radiology dept.
  • In many cases careful history and examination will make diagnosis clear, however certain investigation will still be necessary.
  • The danger triangle of the face consists of the area from the corners of themouth to the bridge of the nose, including the nose and maxilla.[1][not in citation given] Due to the special nature of the blood supply to the human nose and surrounding area, it is possible (although very rare) for retrograde infections from the nasal area to spread to the brainThis is possible because of venous communication (via theophthalmic veins) between the facial vein and the cavernous sinus. The cavernous sinus lies within the cranial cavity, between layers of the meninges and is a major conduit of venous drainage from the brain It is a common misconception that the veins of the head do not contain one-way valves like other veins of the circulatory system. In fact, it is not the absence of venous valves but the existence of communications between the facial vein and cavernous sinus and the direction of blood flow that is important in the spread of infection from the face. Most people, but not all, have valves in the veins of the face.[2]
  • Without proper management of odontogenic infections complications such as: facial cellulitesmediastinitis,brain abscessSepticaemiaThromboembolism
  • Bony infection tends to perforate the cortical plates along path of least resistance. Subsequent subperiosteal spread tends to be directed by muscle and facial attachments. Thus infections of mandibular molar teeth for example tend to spread to the submandibular space.
  • A number of potential tissue spaces exist, the most important being: buccal space, sublingual space, submandibular space, parapharyngeal space and retropharyngeal space. Spread can occur throughout these with airway compression once the parapharyngeal and retropharyngeal spaces are filled.
  • Orbital floor can be perforated by pus from the sinus resulting in subperiosteal abscess or even orbital abscess. Preseptal cellulitis may result from buccal space infections and may progress to orbital cellulitis.
  • Lymphatic spread to the deep cervical lymphatics occurs commonly. Occasionally haematogenous spread may result in bacteraemia, distant septic foci and cavernous sinus thrombosis.
  • Antibiotics alone will not cure most deep facial infections. Most infections have a distinct cause and only surgical treatment (removal of the cause and drainage of accumulated pus) will prevent worsening and recurrence.
  • . In early cases the surgical treatment may be as simple as root canal treatment of the tooth suspected or alternatively simple tooth extraction by the patient’s dentist followed by oral antibiotics. More advanced cases need urgent admission for intravenous antibiotics followed by urgent surgery to remove the cause as well as achieve incision and drainage of tissue spaces involved.
  • More advanced cases need urgent admission for intravenous antibiotics followed by urgent surgery to remove the cause as well as achieve incision and drainage of tissue spaces involved. These cases may need expert fiberoptic endotracheal intubation with prolonged (few days) intubation and occasionally emergency surgical airway access such as cricothyrotomy or tracheostomy may be needed. These cases will need ICU postoperatively until the safety of airway is assured.
  • Surgically most cases can be approached transorally. Removal of the cause (tooth, stone, etc) is followed by incision and drainage and drain insertion. One should avoid the temptation to cut through facial skin for reasons of facial nerve preservation as well as to avoid the ugly puckered scar that invariably results.
  • Submandibular and sublingual spaces full of pus need to be drained trancutanously via neck incisions with drains insertion. The patient should be on triple IV antibiotics covering aerobic Strep species as well as anaerobes as well as Gram-ve organisms. Eg: Amoxycillin 1g tds-qid+Metronidazole 500mg tds+Gentamicin 5mg/kg/day in single dose.
  • Early diagnosis, prompt antibiotic treatment (Amoxy-cillin and Flagyl), together with early removal of the cause should prevent most complications and result in early recovery.
  • Treatment for Soft Tissue Swelling/Abscess FormationREMOVE THE CAUSE (i.e. extract the tooth, open & extirpate the pulp) INCISION & DRAINAGE (“Never Let The Sun Set On Undrained Pus”). ANTIBIOTICS (usually intravenously initially). Antibiotics are considered third in the management of infections after you have paid due consideration to removal of the cause and drainage of pus (which is often achieved by removing the cause). Try to get a sample of pus before you start antibiotics (swab, needle aspirate, blood culture) Amoxycillin (± metronidazole) is a sensible first choice for dentally related infections. Second choices include cefuroxime, erythromycin, clindamycin. Skin infections & other suspected staphylococcal infections and bites and should be treated with augmentin (or a combination of penicillin & flucloxacillin ± metronidazole) or erythromycin. If you have any doubts or queries consult a microbiologist. Take a full blood count noting particularly the white cell count – look for evidence of a normal neutrophilia in response to a bacterial infection. If white cell count very high or very low, is this indicative of immunosuppression or a blood dyscrasia. Check the glucose. Could this infection be a presentation of previously undiagnosed diabetes? If the patient is a known diabetic then concurrent infection may make diabetic control difficult.Treatment with Steroids, Acetazolamide, Mannitol and antihistamines should only be undertaken following senior consultation. Drains Extra-oral: Corrugated Blake type Intra-oral: Not usually of help. Can use corrugated drains (suitably secured) or ribbon gauze + Whitehead’s varnish. A drain usually stays in place for 24-48 hours until most/all of the pus has discharged. The instruction to “shorten a drain” means to gradually withdraw the drain from the incision site so that the abscess cavity closes down behind the drain leaving no residual dead-space. It does not mean cut the external end of the drain ever shorter until it disappears into the hole! Summary Maxillofacial infections are common and most can be treated by simple measures without the need for hospital admission. They are commonly due to teeth. Apply the principles: Remove the cause (if possible) Drain the pus Consider antibioticsThey are occasionally life-threatening due to airway compromise. Indicators of a serious infection include:Pyrexia/systemic upsetTrismusProblems speaking, swallowing or breathingInvolvement of the sublingual, paratonsillar or lateral pharyngeal spaces A simple mnemonic can be helpful:P pyrexiaU unwellS swelling – especially extra-oral T  tender U  unable to swallow L limitation in opening E eye involvement S speech problems If in doubt ask for advice from your senior. Do not underestimate maxillofacial infections.
  • Treatment for Soft Tissue Swelling/Abscess FormationREMOVE THE CAUSE (i.e. extract the tooth, open & extirpate the pulp) INCISION & DRAINAGE (“Never Let The Sun Set On Undrained Pus”). ANTIBIOTICS (usually intravenously initially). Antibiotics are considered third in the management of infections after you have paid due consideration to removal of the cause and drainage of pus (which is often achieved by removing the cause). Try to get a sample of pus before you start antibiotics (swab, needle aspirate, blood culture) Amoxycillin (± metronidazole) is a sensible first choice for dentally related infections. Second choices include cefuroxime, erythromycin, clindamycin. Skin infections & other suspected staphylococcal infections and bites and should be treated with augmentin (or a combination of penicillin & flucloxacillin ± metronidazole) or erythromycin. If you have any doubts or queries consult a microbiologist. Take a full blood count noting particularly the white cell count – look for evidence of a normal neutrophilia in response to a bacterial infection. If white cell count very high or very low, is this indicative of immunosuppression or a blood dyscrasia. Check the glucose. Could this infection be a presentation of previously undiagnosed diabetes? If the patient is a known diabetic then concurrent infection may make diabetic control difficult.Treatment with Steroids, Acetazolamide, Mannitol and antihistamines should only be undertaken following senior consultation. Drains Extra-oral: Corrugated Blake type Intra-oral: Not usually of help. Can use corrugated drains (suitably secured) or ribbon gauze + Whitehead’s varnish. A drain usually stays in place for 24-48 hours until most/all of the pus has discharged. The instruction to “shorten a drain” means to gradually withdraw the drain from the incision site so that the abscess cavity closes down behind the drain leaving no residual dead-space. It does not mean cut the external end of the drain ever shorter until it disappears into the hole! Summary Maxillofacial infections are common and most can be treated by simple measures without the need for hospital admission. They are commonly due to teeth. Apply the principles: Remove the cause (if possible) Drain the pus Consider antibioticsThey are occasionally life-threatening due to airway compromise. Indicators of a serious infection include:Pyrexia/systemic upsetTrismusProblems speaking, swallowing or breathingInvolvement of the sublingual, paratonsillar or lateral pharyngeal spaces A simple mnemonic can be helpful:P pyrexiaU unwellS swelling – especially extra-oral T  tender U  unable to swallow L limitation in opening E eye involvement S speech problems If in doubt ask for advice from your senior. Do not underestimate maxillofacial infections.
  • Take a full blood count noting particularly the white cell count – look for evidence of a normal neutrophilia in response to a bacterial infection. If white cell count very high or very low, is this indicative of immunosuppression or a blood dyscrasia. Check the glucose. Could this infection be a presentation of previously undiagnosed diabetes? If the patient is a known diabetic then concurrent infection may make diabetic control difficult.Treatment with Steroids, Acetazolamide, Mannitol and antihistamines should only be undertaken following senior consultation. Drains Extra-oral: Corrugated Blake type Intra-oral: Not usually of help. Can use corrugated drains (suitably secured) or ribbon gauze + Whitehead’s varnish. A drain usually stays in place for 24-48 hours until most/all of the pus has discharged. The instruction to “shorten a drain” means to gradually withdraw the drain from the incision site so that the abscess cavity closes down behind the drain leaving no residual dead-space. It does not mean cut the external end of the drain ever shorter until it disappears into the hole! Summary Maxillofacial infections are common and most can be treated by simple measures without the need for hospital admission. They are commonly due to teeth. Apply the principles: Remove the cause (if possible) Drain the pus Consider antibioticsThey are occasionally life-threatening due to airway compromise. Indicators of a serious infection include:Pyrexia/systemic upsetTrismusProblems speaking, swallowing or breathingInvolvement of the sublingual, paratonsillar or lateral pharyngeal spaces A simple mnemonic can be helpful:P pyrexiaU unwellS swelling – especially extra-oral T  tender U  unable to swallow L limitation in opening E eye involvement S speech problems If in doubt ask for advice from your senior. Do not underestimate maxillofacial infections.
  • Drains Extra-oral: Corrugated Blake type Intra-oral: Not usually of help. Can use corrugated drains (suitably secured) or ribbon gauze + Whitehead’s varnish.
  • A drain usually stays in place for 24-48 hours until most/all of the pus has discharged. The instruction to “shorten a drain” means to gradually withdraw the drain from the incision site so that the abscess cavity closes down behind the drain leaving no residual dead-space. It does not mean cut the external end of the drain ever shorter until it disappears into the hole!
  • There have been many advances in the management of head and neck infections.New classes of antimicrobial agents, noninvasive imaging techniques, improved culturing methods, and a clearer understanding of the normal and pathologic functioning of the immune system are just some of the changes that have occurred. These and other technologic advances have enhanced dramatically our ability to diagnose and treat these infections rapidly and accurately. As a result, the incidence of serious morbidity and mortality from odontogenic infections has fallen significantly over the years.
  • Deforming oral & maxillofacial infections

    1. 1. Deforming Oral &Maxillofacial Infections Frederick Mars Untalan MD MBA H FPSOHNS
    2. 2. Do not underestimatemaxillofacial infections.
    3. 3. 1. List the common causes of maxillofacial infections thatdeforms the face, head & neck region2. Describe the anatomical & pathophysiology of maxillofacial Infections3. Treatment of maxillofacial infections4. Some related studies5. List the danger signs of life threatening maxillofacial infectionsOBJECTIVES
    4. 4. • Facial infections are a relatively common presentation to both general medical and dental practice.• Most originate in superficial structures (skin, subcutanous tissue etc.) and are often easily diagnosed and treated.Introduction
    5. 5. • Infections originating in deeper structures can be severe, rapidly progressive and may cause prolonged morbidity, long term complications as well as potentially endanger life.• Efficient treatment requires accurate diagnosis, early aggressive medical treatment and in most cases urgent decisive surgical management.Introduction
    6. 6. • Complex and severe cases may require multidisciplinary approach • GP • intensivist. • dental surgeon • Ophthalmology • radiologist • neurosurgery • oral and maxillo-facial • Nurse surgeon • speech pathologist • ENT surgeon • Dietician • anaesthetist • IDSIntroduction
    7. 7. Results: reveal rapid resolution of the infections byadhering to fundamental principles in their management: recognition of airway compromise surgical intervention administration of the appropriate antibiotic Management of maxillofacial infections: a review of 50 cases Krishnan V, Johnson JV Helfrick JF. J Oral Maxillofac Surg. 1993 Aug;51(8):868-73; discussion 873-4.Introduction
    8. 8. Signs & symptoms
    9. 9. • swollen face• swollen neck• Toothache or facial pain• general malaise• Fever• trismus• dysphagia• drooling• sore throat• Hoarseness Signs & symptoms
    10. 10. • Increased pain and swelling on exposure to food• Recent dental treatment• Trauma to the face or teeth• Recent oral surgery• Past facial fractures fixation• Past salivary gland surgery• History of head and neck cancer with possible radiotherapy to the region• Upper respiratory tract viral infections, nasal discharge, etc. Signs & symptoms
    11. 11. • Good oral examination:• presence of halitosis• evidence of intraoral pus draining• any tongue elevation, any sublingual or submandibular swelling• swelling in the mandibular or maxillary sulci• palatal swelling especially of the soft palate or uvula• general oral & dental state• patency of salivary outlets• nature of saliva producedSigns & symptoms
    12. 12. Tooth percussion Neck palpation Bi-manual palpationSigns & symptoms
    13. 13. In vitro evaluation of microbiological flora of orofacialinfectionsN: 80 patients w/ orofacial infxnpus sample was collected & cultured (aerobically andanaerobically) & stained for morphological study of the isolates.Antibiotic sensitivity test for the isolates were performed. Kohli M, Mathur A, Kohli M, Siddiqui SR J Maxillofac Oral Surg. 2009 Dec;8(4):329-33. doi: 10.1007/s12663-009-0080-1. Epub 2010 Apr 24.microbiological flora oforofacial infections
    14. 14. In vitro evaluation of microbiological flora of orofacialinfectionsA total of 109 micro-organisms were isolated, no pathogenic organism were isolated in 3 cases.Out of 109 micro-organism isolated, 107 bacteria and 2 fungi were identified.Pure aerobes were identified in 28 (35%)pure anaerobes 18 (22.5%),mixed aerobes & anaerobes 10 (12.5%)mixed aerobes 15 (18.75%)mixed anaerobes 6 (7.5%) cases. Kohli M, Mathur A, Kohli M, Siddiqui SR J Maxillofac Oral Surg. 2009 Dec;8(4):329-33. doi: 10.1007/s12663-009-0080-1. Epub 2010 Apr 24.microbiological flora oforofacial infections
    15. 15. In vitro evaluation of microbiological flora of orofacial infectionsOfloxacinCiprofloxacin G+ AmoxicillinSparfloxacin & AmpicillinCefotaxime G- Kohli M, Mathur A, Kohli M, Siddiqui SR J Maxillofac Oral Surg. 2009 Dec;8(4):329-33. doi: 10.1007/s12663-009-0080-1. Epub 2010 Apr 24.microbiological flora oforofacial infections
    16. 16. 256 patients with space infection over 2 years weretreated w, IV antibiotic & prompt I & D followed byculture and sensitivity tests in some cases.Data collection included demographic, anatomictreatment and complication information.Gupta M, Sing V J Maxillofac Oral Surg. 2010 Mar;9(1):35-7. doi: 10.1007/s12663-010-0011- 1. Epub 2010 Jun 4.A retrospective study of 256patients with space infection
    17. 17. • Caries• Implant failure• 70% Trismus and dysphagia• The vestibular masticator, perimandibular (submandibular, submental and/or sublingual) parapharyngeal, submaxillary spaces• 76 % Abscess Gupta M, Sing V J Maxillofac Oral Surg. 2010 Mar;9(1):35-7. doi: 10.1007/s12663-010-0011-1. Epub 2010 Jun 4.A retrospective study of 256patients with space infection
    18. 18. Prompt I & D along w/ IV antibiotic under localanesthesia or consciousPatients were relieved of their signs and symptoms bythird day, however trismus may persist for 5-7 days.Gupta M, Sing V J Maxillofac Oral Surg. 2010 Mar;9(1):35-7. doi: 10.1007/s12663-010- 0011-1. Epub 2010 Jun 4.A retrospective study of 256patients with space infection
    19. 19. Aetiology of major facialinfections
    20. 20. Teeth• Dental pulpitis• Periapical abscess may occur in seemingly intact but devitalised teeth (trauma, cracks or decay under fillings).• chronic gingivitis and supporting bone and soft tissue loss (periodontal disease)• pericoronitis• Retained roots supragingival or subgingival.The jaws• Can develop cysts or tumours that can range from odontogenic (=dental origin) to either primary or secondary malignancy• Osteomyelitis• Osteoradionecrosis• Tuberculosis, Actinomycosis and syphilitic osteomyelitis.• fractures in the tooth bearing segments• Extraction sitesAetiology of major facialinfections
    21. 21. Major salivary glands• viral or bacterial infections often superimposed on obstruction of ducts (stone, stricture, etc).• Tumors rarely also become secondarily infected.Paranasal sinuses• facial swelling.• upper premolar and molar teeth• Tumors or cysts may become infected.• orbital floor - orbital cellulitis.Aetiology of major facialinfections
    22. 22. Microbiology• polymicrobial - anaerobic organisms.• severe cases Gram-negative
    23. 23. • Plain X rays:• orthopantomogram• Occipito-mental 15 and 30 degrees (“Water’s view”)• Mandibular occlusal views and lateral oblique viewsDiagnostics
    24. 24. • Sialography:• for suspected gland obstruction• CT sialogram is still the gold standard.Diagnostics
    25. 25. • Ultrasound:• confirming collections as well as a guide to aspiration.• stones in salivary ducts and glands.Diagnostics
    26. 26. • CT scan:• axial and coronal views • the swelling • potential airway compromiseDiagnostics
    27. 27. • Microbiology of any pus or discharge.• The usual blood tests.Diagnostics
    28. 28. complications of odontogenic infections : facial cellulites mediastinitis brain abscess Septicemia Thromboembolism
    29. 29. • Bony infection tends to perforate the cortical plates along path of least resistance.• Subsequent subperiosteal spread tends to be directed by muscle and facial attachments.• Thus infections of mandibular molar teeth for example tend to spread to the submandibular space.Spread of infections
    30. 30. • A number of potential tissue spaces exist, the most important being: buccal space, sublingual space, submandibular space, parapharyngeal space and retropharyngeal space.• Spread can occur throughout these with airway compression once the parapharyngeal and retropharyngeal spaces are filled.Spread of infections
    31. 31. • Orbital floor can be perforated by pus from the sinus resulting in subperiosteal abscess or even orbital abscess• Preseptal cellulitis may result from buccal space infections and may progress to orbital cellulitis.Spread of infections
    32. 32. • Lymphatic spread to the deep cervical lymphatics occurs commonly• hematogenous spread may result in: • bacteremia • distant septic foci • cavernous sinus thrombosisSpread of infections
    33. 33. Antibiotics alone will not cure most deep facial infections. Most infections have a distinct cause and only surgical treatment (removal of the cause and drainage ofaccumulated pus) will prevent worsening and recurrence.Treatment
    34. 34. • for early cases the surgical treatment • root canal treatment of the tooth suspected • simple tooth extraction followed by oral antibioticsTreatment
    35. 35. • More advanced cases need urgent admission for intravenous antibiotics followed by urgent surgery to remove the cause as well as achieve incision and drainage of tissue spaces involved. • fiberoptic endotracheal intubation with prolonged intubation • occasionally emergency surgical airway (cricothyrotomy or tracheostomy)• These cases will need ICU postoperatively until the safety of airway is assured.Treatment
    36. 36. Surgically most cases can be approached transorally.Removal of the cause (tooth, stone, etc) is followed byincision and drainage and drain insertion facial nerve preservation avoid the ugly scarTreatment
    37. 37. Submandibular and sublingual spaces full of pus need to bedrained trancutanously via neck incisions with drainspatient should be on triple IV antibiotics covering aerobic Strep species anaerobes Gram-ve organisms.Ex: Amoxicillin 1g tid-qid + Metronidazole 500mg tid+Gentamicin 5mg/kg/day in single dose.Treatment
    38. 38. Early diagnosis, prompt antibiotic together withearly removal of the cause should prevent most complications and result in early recoveryTreatment
    39. 39. • Should have maximal toxicity for the pathogen whilst causing the minimum damage to the host tissue.This is what’s called: ( Selective Toxicity )The Ideal Antibiotic
    40. 40. • REMOVE THE CAUSE • (i.e. extract the tooth, open & extirpate the pulp)• INCISION & DRAINAGE • (“Never Let The Sun Set On Undrained Pus”)• ANTIBIOTICS (usually IV initially).• Antibiotics are considered third in the management of infections after you have paid due consideration to removal of the cause and drainage of pus (which is often achieved by removing the cause).• Try to get a sample of pus before you start antibioticsTreatment for Soft TissueSwelling/Abscess Formation
    41. 41. • Amoxycillin (± metronidazole)• cefuroxime, erythromycin, clindamycin.• Co-amoxiclav –(or a combination of penicillin & flucloxacillin ± metronidazole) or erythromycin forSkin infections & other suspected staphylococcal infectionsand bitesTreatment for Soft TissueSwelling/Abscess Formation
    42. 42. • WBC Count • immunosuppression or a blood dyscrasia.• Check the glucose• Steroids, Acetazolamide, Mannitol and antihistamineTreatment for Soft TissueSwelling/Abscess Formation
    43. 43. • Drains• Extra-oral• Intra-oral: Not usually of help.DRAINS
    44. 44. • A drain usually stays in place for 24-48 hours until most/all of the pus has discharged.• “shorten a drain” means to gradually withdraw the drain from the incision site so that the abscess cavity closes down behind the drain leaving no residual dead-space.• (It does not mean cut the external end of the drain ever shorter until it disappears into the hole!)DRAINS
    45. 45. Do not underestimatemaxillofacial infections.
    46. 46. • “Never Let The Sun Set On Undrained Pus”
    47. 47. Deforming Oral &Maxillofacial Infections Frederick Mars Untalan MD MBA H FPSOHNS

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