Mandibular abscess. Phlegmon of the submandibular region: types, causes, symptoms, diagnosis and treatment. Abscesses and phlegmon of the sublingual region
![Mandibular abscess. Phlegmon of the submandibular region: types, causes, symptoms, diagnosis and treatment. Abscesses and phlegmon of the sublingual region](https://i1.wp.com/pro-zuby.com/wp-content/uploads/flegmona_shei_2-e1450563624674-300x174.jpg)
As a rule, patients who experience toothache or have other dental problems turn to medical institutions for help. Not everyone knows that the object of treatment in dentistry is the maxillofacial area. The patient may experience inflammation, which is difficult to associate with tooth extraction, but this is where the whole problem lies.
What is phlegmon?
Phlegmon is a purulent-necrotic inflammation of soft tissues that does not have clear boundaries. Subcutaneous fat is closely adjacent to the vessels, nerves and organs, which contributes to the rapid spread of the purulent process. Phlegmon of the maxillofacial region extends to bone tissue, muscles, tendons and internal organs. The area of inflammation can be determined by a couple of centimeters, or it can affect entire areas.
Localization
Any area of the body is not immune from the appearance of odontogenic phlegmon. Phlegmon of the maxillofacial region can develop due to the removal of the "eight", inflammation of the pulp, soft tissues surrounding the tooth root, tonsils, adenoids, etc.
Most often, the disease occurs due to:
- glossitis, contributing to the development of diffuse purulent inflammation in the glossopharyngeal space;
- inflammation of the lower jaw, capturing the chin area;
- sialadenitis, glossitis, periostitis, spreading along the bottom of the oral cavity.
Causes
Diffuse purulent inflammations are of an infectious nature. The waste products of pathogenic microorganisms, decomposed tissues of molars and anaerobic microflora of a filled tooth are the main sources of the development of the disease and intoxication of the body.
In the maxillary region, the source of the lesion is most often the wisdom tooth and the frontal incisal group. In the lower jaw, any tooth can cause phlegmon of the floor of the mouth.
Etiology of nonodontogenic phlegmons:
- external mechanical impact on soft and hard tissues and their subsequent infection;
- violation of asepsis during injection;
- infection from external sources of skin diseases (furuncle, carbuncle);
- stomatitis of infectious etiology.
With a weakened immune system, a tendency to allergies and the presence of chronic diseases, the phlegmon of the jaw is difficult and long. Such a disease has an infectious etiology, but is not transmitted by contact.
Diagnostics
The doctor will be able to correctly diagnose, knowing the history of the disease, identifying disturbing symptoms and obtaining laboratory test data. Clinical studies will determine the degree of damage to the body and the effectiveness of the chosen course of treatment.
With a deep spread of phlegmon of the maxillofacial region, to clarify the diagnosis, a tissue puncture is made and the composition of the extracted effusion is examined, the sensitivity of pathogenic microflora to medicinal preparations is determined. The duration and effectiveness of treatment depends on this.
Classification and symptoms
Phlegmon can be classified by:
- type of inflammatory exudate (serous, purulent, putrefactive-necrotic);
- stages of the disease (acute, chronic course);
- location (superficial or deep).
The inflammatory process begins with compaction of soft tissues, the appearance of edema with its subsequent increase, redness of the inflamed area from the side of the oral cavity and skin. Severe pain radiates over the entire half of the face: in the ears, eye socket and neck. The general condition of the patient worsens from intoxication.
In the blood test, characteristic changes are revealed that indicate the degree of damage to the whole organism. Phlegmon of the floor of the mouth is accompanied by a pronounced pain syndrome, the processes of eating, swallowing, articulation are disturbed. Trismus of varying degrees is observed.
Depending on location
Phlegmon, as seen in the photo, can affect the neck, cheeks, cheekbones and eye sockets. The inflammatory purulent process, depending on the location, is conditionally divided into superficial and deep. In the presence of superficial odontogenic phlegmon, the disease proceeds intensively, general symptoms rapidly develop, indicating intoxication of the body. Body temperature can reach values of 38-40 degrees, a person is shivering, his general condition worsens.
If the patient develops a deep phlegmon, then the general symptoms will prevail over the local ones. The patient's temperature rises sharply, up to 42 degrees. Intoxication leads to heart rhythm disturbances, a decrease in blood pressure, and shortness of breath appears. The excretory system suffers, a person can stop urinating.
By the nature of the course of the pathological process
The disease always develops in a different scenario. There are two main forms of the course of the inflammatory purulent process of the maxillofacial area:
- The acute stage is accompanied by a sharp increase in body temperature. The skin turns red, there is swelling of the soft tissues. There are signs of necrosis in the affected area. If help is not provided to the patient in time, there is a possibility of developing a fistula.
- The chronic stage proceeds with pain. In the place of inflammation during palpation, a seal can be detected. Affected tissues may become bluish in color.
How to treat?
An experienced doctor can easily make a diagnosis. When prescribing treatment for phlegmon of the maxillofacial region, it is necessary to take into account the stage of inflammation. In the initial stage, you can limit yourself to taking anti-inflammatory drugs and antibiotics.
If the inflammatory process is at a late stage, then surgical treatment is necessary. The surgeon will excise the affected tissue and treat the open wound.
Medical therapy
The appeal of the patient at the initial stage of the disease to specialized medical institutions will avoid surgery. At the initial stage, phlegmon of the maxillofacial region can be cured using antibacterial drugs. Dry heat is applied to the affected area, treated with a solution of calcium chloride.
The doctor prescribes rinsing the bottom of the mouth with antiseptic solutions and a course of physiotherapy. Drug therapy can help only if the source of infection has been eliminated before (sanation, the diseased tooth is removed, the injury is treated, etc.).
Physiotherapy
For the treatment of phlegmon of the jaw, different types of physiotherapy are used. This can be centimeter wave therapy, ultraviolet irradiation, UHF therapy used in the acute phase of inflammation. To increase immunity, laser irradiation of blood is used.
Light therapy is used if there is a compacted infiltrate in the affected area. When treating wounds with ultrasound, the treatment time can be reduced to 3-5 days. In severe cases of the disease, 3-4 procedures of hyperbarotherapy are performed.
Surgical intervention
All phlegmon, including the floor of the mouth, are treated by resorting to a surgical method only in a hospital setting. Experienced highly qualified surgeons perform the operation, monitor the patient in the postoperative period and provide comprehensive treatment.
During the operation, the patient may be under general anesthesia or local anesthesia. Depending on the size of the affected area, the doctor makes an incision in the skin and mucous membranes (as shown in the photo) with a scalpel, opening the affected area. If putrefactive-necrotic changes are observed, then the dead tissues are excised. Subsequently, the wounds are drained.
Plastic surgery
Surgical interventions to recreate the altered form of the MFR are carried out according to the following indications:
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Folk remedies
Abscesses and phlegmon of the maxillofacial region can be treated with the help of traditional medicine. Herbal cloves, mint basil, St. John's wort, propolis, blue eucalyptus, birch buds and leaves - this is a small list of herbs that are recommended for use in the treatment of inflammatory processes.
For the treatment of phlegmon of the lower jaw, you can use a decoction. Pour 60 g of herbal cloves with one liter of hot water, stand until cool and drink in small sips of 250 ml throughout the day. You can also take 40 g of St. John's wort, 25 g of propolis and 150 ml of alcohol-containing liquid, grind, leave the combined components for 10 days. Strained infusion is used for rinsing in proportion - a teaspoon per 250 ml of mineral water with gas.
Possible complications
Common complications of phlegmon of the maxillofacial region are: mediastinitis, thrombophlebitis of the facial veins, sepsis. With mediastinitis, a person experiences retrosternal pain, which can radiate to the area of the scapula. The patient takes a forced position, it is difficult for him to raise his head.
Cavernous sinus thrombosis is a common complication of odontogenic phlegmon. The patient experiences severe headaches, he is shivering.
Sepsis is characterized by elevated body temperature, changes in the qualitative and quantitative composition of leukocytes. The prognosis is unfavorable, a lethal outcome is possible.
The concept of an abscess of the maxillofacial region
An abscess of the maxillofacial region is an infectious formation on the mucous membranes of the oral cavity, containing pathological fluid (pus) inside. The disease can occur both on the upper and lower jaws, as a rule, the inflammatory process begins with the causative tooth. On palpation of the affected area, the patient experiences pain, the skin at the site of inflammation is thinned.
Causes of the pathological process
An abscess may appear as a result of an odontogenic infection entering a wound obtained after an injury to the maxillofacial area or a periodontal pocket.
The main pathogens are streptococci and staphylococci. The infection can enter the body from the outside or through the bloodstream. It is not uncommon for a submandibular abscess to occur at the site of exposure to chemicals under the skin.
Symptoms
The disease is determined by a number of signs:
- persistent headaches, loss of strength, chills;
- an increase in body temperature is possible, hyperemia of the focus of inflammation is observed;
- changes in the qualitative and quantitative composition of leukocytes;
- palpation revealed fluctuation.
If the patient experiences all of the above symptoms, he needs to seek specialized help. Odontogenic abscesses can affect neighboring areas and give complications to the respiratory system.
Types of abscesses
A person has an upper and lower jaw, based on this, odontogenic abscesses, depending on their location, are usually divided into maxillary and mandibular (this also includes submandibular). Doctors distinguish the following types of disease: abscess of the tongue, floor of the mouth, palate, gums, cheeks, tongue (we recommend reading: cheek abscess: causes and methods of treatment).
upper jaw
Often, inflammation in the upper jaw develops due to the eruption of the upper wisdom teeth. "Eights" injure the mucous membranes, the infection penetrates the fiber, which provokes the development of the inflammatory process. After an abscess has formed in the jaw area, it becomes difficult for a person to open his mouth and swallow, and the pain in the inflamed area increases.
lower jaw
The cause of the development of odontogenic abscesses in the submandibular region may be untreated molars. It is painful for the patient to chew food and swallow. A distinctive feature of inflammation localized in the lower jaw is painful swelling, which is visually noticeable. It affects the submandibular triangle, sometimes leading to a distortion of the face.
How to treat an abscess?
To get rid of inflammation, odontogenic abscesses are opened, drainage is installed and the affected areas are treated with disinfectants. At elevated body temperature, the patient is prescribed antibiotics.
With a weakened immune system, immunomodulatory drugs are indicated. In order to shorten the healing process of wounds, they resort to the help of physiotherapy procedures and carry out ultraviolet irradiation.
Prevention of the appearance of phlegmon and abscesses
Prevention of odontogenic phlegmons and abscesses consists in observing the rules of personal hygiene, timely dental treatment, eating foods rich in vitamins and minerals. It is also recommended to visit the dentist at least once every six months. In case of violation of the skin and mucous membranes of the oral cavity after the removal of molars, in order to avoid the development of phlegmon and abscesses, it is necessary to timely perform high-quality treatment with antiseptic agents.
The formation of an inflammatory purulent focus in the tissues of the maxillofacial zone of the face. It is manifested by local swelling, redness and fluctuation (swelling) of the skin over the focus of inflammation, facial asymmetry, difficulty and pain in swallowing, and intoxication phenomena. It can develop into diffuse inflammation - phlegmon, with involvement in the process of the peripharyngeal and infraorbital region, neck. Treatment is always surgical - opening and draining the abscess cavity.
General information
- This is a limited focus of purulent inflammation of the tissues of the maxillofacial zone. In the absence of treatment of abscesses, purulent decay and purulent fusion of adjacent tissues begin.
Causes of the maxillary abscess
An abscess is caused by streptococcal and staphylococcal microflora, the most common cause is dental disease and inflammation in the maxillofacial zone. Furunculosis, tonsillitis, tonsillitis in chronic course are complicated by maxillary abscesses. Damage to the skin and mucous membranes in the mouth area, infection during dental procedures can provoke an abscess of the maxillary zone.
General infectious diseases proceeding according to the type of sepsis, as a result of the spread of microorganisms by blood and lymph, cause multiple abscesses in various organs and tissues, including abscesses of the maxillary zone. Abscess of the maxillary zone may occur due to facial trauma. During military operations and natural disasters, due to the lack of first aid, dislocations and fractures of the jaws are often complicated by abscesses. Perioapical and pericoronal foci of inflammation and periodontal pockets during exacerbations can provoke a jaw abscess due to bone resorption.
Symptoms of a maxillary abscess
The formation of an abscess is preceded by toothache as in periodontitis. Biting in the affected area increases pain. Further, a dense edema joins with the formation of a painful seal. For an abscess that develops under the mucous membrane, bright hyperemia and protrusion of the affected focus are characteristic. Sometimes facial asymmetry is noted.
In the absence of therapy, the general condition of the patient worsens: the body temperature rises, food is refused. After spontaneous opening of the abscess, the pain subsides, the contours of the face take on normal outlines, and the general state of health stabilizes. But due to favorable conditions for microorganisms in the oral cavity, the process becomes chronic, so its spontaneous opening does not indicate a cure. With short-term weakening of the immune system, perimaxillary abscesses become aggravated. Chronic suppuration from fistulous passages is possible, it is accompanied by bad breath and ingestion of purulent masses. There is a sensitization of the body by decay products, allergic diseases are exacerbated.
Abscesses of the floor of the mouth are characterized by hyperemia in the sublingual zone with the rapid formation of an infiltrate. Conversation and eating become sharply painful, hypersalivation is noted. The mobility of the tongue decreases, it rises slightly upward so as not to come into contact with the emerging abscess. As the swelling increases, the general condition worsens. With spontaneous opening, pus spreads to the peripharyngeal region and neck, which leads to the emergence of secondary purulent foci.
The abscess of the palate often occurs as a complication of periodontitis of the upper second incisor, canine and second premolar. During the formation of an abscess, there is hyperemia and soreness of the hard palate, after bulging, the pain becomes more intense, food intake is difficult. With spontaneous opening, purulent contents spread to the entire area of the hard palate with the development of osteomyelitis of the palatal plate.
If a cheek abscess occurs, then, depending on the location and depth, swelling and redness may be more pronounced on the outside or on the side of the oral mucosa. The soreness of the focus is moderate, with the work of facial muscles, the pain intensifies. The general condition practically does not suffer, but the abscess of the cheek is dangerous by spreading to neighboring parts of the face even before the opening of the abscess.
Abscess of the tongue begins with soreness in the thickness of the tongue, the tongue increases in volume, becomes inactive. Speech, chewing and swallowing of food are sharply difficult and painful. Sometimes a feeling of suffocation can occur with an abscess.
Diagnosis and treatment of maxillary abscess
The diagnosis is made on the basis of a visual examination of the dentist and patient complaints. Sometimes during the survey it turns out that there were boils of the facial zone, there are chronic infectious diseases. Before a visit to the doctor, it is recommended to take analgesics, rinse the mouth with antiseptic solutions, self-administration of antibiotics is unacceptable. The ultimate goal of treatment is the complete elimination of the infectious process and the restoration of impaired functions in the shortest possible time.
The treatment regimen depends on the stage of the disease, on the virulence of the microorganism and on the characteristics of the response from the macroorganism. Localization of abscesses of the maxillary zone, the age of the patient and the presence of concomitant diseases significantly affect the principles of treatment. The more complicating factors, the more intensive the therapy should be.
During the period of treatment of abscesses of the maxillary zone, it is recommended to follow a diet with a predominance of pureed soups and mashed potatoes. If there is a persistent refusal of food, they resort to intravenous administration of protein solutions. In the presence of a formed abscess, its opening is shown, followed by drainage of the cavity. In other cases, they resort to antibiotic therapy, and only if it is inappropriate, the question of surgical treatment is raised.
Antibiotics are prescribed in the form of injections or in tablet forms, an additional course of vitamin therapy is carried out. Immunostimulants and detoxification therapy are shown. Rinsing the mouth with warm solutions of furacilin and soda relieves swelling and prevents the spread of infection. In the presence of a pronounced pain syndrome, analgesics are used. With complex therapy started on time, the prognosis is usually favorable, recovery occurs within 6-14 days.
Phlegmon and abscesses of the maxillofacial region
Phlegmon, like abscesses, develop as a result of inflammation in the fiber. However, in contrast to the diffuse nature of the inflammation of the fiber with its subsequent melting in phlegmon, the abscess is characterized by a limited area of \u200b\u200bmelting the fiber. Phlegmon and abscess, having common etiological origins and pathogenesis, are considered together also because often the clinical conduct of a clear differential diagnosis between them turns out to be an impossible task. Only dynamic observation in such cases helps to establish an accurate diagnosis. As a rule, phlegmon is much more difficult than a limited process.
Phlegmon of the maxillofacial region is a severe and extremely dangerous disease. The severity of the condition with a diffuse inflammatory process is determined by the high intoxication of the body. A well-defined innervation of the maxillofacial region determines a sharp pain in the development of an inflammatory infiltrate. In addition, such important functions as chewing, swallowing, and breathing are often violated. The danger of phlegmon of the maxillofacial region is due both to the proximity of vital formations and to the anatomical and topographic features of this area, which contribute to the spread of the inflammatory process to neighboring parts of the body (mediastinum, orbit, parapharyngeal spaces, etc.). The presence of venous plexuses, as well as veins without a clawed system, contribute to the rapid spread of the inflammatory process throughout the vascular system.
Thus, the penetration of pus into the venous system of the face can lead to the development of phlebitis first, and then thrombophlebitis. This process through the ophthalmic vein in an ascending way can quickly spread to the venous system of the skull with the development of thrombosis of its sinuses. The outcome may be similar if the infection penetrates through the pterygoid plexus to the base of the skull.
With the anaerobic nature of the inflammatory process, the course, nature and outcome of phlegmon of the maxillofacial region are significantly aggravated.
In view of the rapid development of phlegmon of the maxillofacial region and the possibility of severe and sometimes fatal complications (despite modern methods of treatment), inflammatory processes of this kind require emergency intervention. Postponing the operation even for a few hours in some cases can lead to serious consequences. Therefore, the provision of assistance to patients with phlegmon of the maxillofacial region should be urgent, urgent. It is quite natural that a doctor of any specialty can meet with such patients, especially at night. This imposes a special responsibility on doctors who are not dentists.
Topographically, phlegmons of the face, maxillary, floor of the mouth, peripharyngeal, tongue and neck are distinguished. However, the localization of a purulent inflammatory process on the face can be varied, essentially wherever there is fiber. Often, phlegmon spread to a number of areas, causing the diffuse nature of acute inflammation (Fig. 100).
Phlegmons of the maxillofacial region are mainly odontogenic in etiology. Their appearance is usually preceded by periodontitis, periostitis, osteomyelitis, pericoronitis, lymphadenitis, salivary stone disease, festering cyst or festering hematoma, pustular diseases of the skin of the face (furuncle, carbuncle), fracture of the jaws, etc. Phlegmon can develop as a result of infection by the hematogenous route or when microbes are introduced with a needle in case of injection anesthesia.
Phlegmon develops in the tissue, where the infection enters percontinuitatem or directly (injury, violation of asepsis). By the nature of the exudate, purulent, purulent-hemorrhagic and putrefactive phlegmon are distinguished.
The causative agents of phlegmon of the maxillofacial region are most often staphylococcus aureus, streptococcus, E. coli, pneumococcus aeruginosa, dental spirochete, and various anaerobes. Recently, the predominance of staphylococcus as the causative agent of phlegmon has become apparent. Staphylococcus proved to be the most resistant to drugs and, as a result, became the most common type of bacteria that causes the development of a purulent process. More often than before, the cause of phlegmon are bacteroids, Escherichia and Pseudomonas aeruginosa. The latter circumstance especially requires an individual approach to the choice and prescription of antibacterial agents.
The gas phlegmon caused by anaerobes or anaerobes in symbiosis with other bacteria (mixed infection) differs in the severity of the course and prognosis. With gas phlegmon, tissue necrosis occurs. Muscles resemble boiled meat, are pale, do not bleed. Gas bubbles form in the affected tissues.
The inflammatory process in the tissue of the maxillofacial region often develops acutely. The nature of the development of phlegmon depends on the virulence of microbes and the body's defenses. With acutely developing phlegmon, inflammation grows very quickly. At the same time, the development of local changes (infiltration, hyperemia, pain, etc.) is combined with high intoxication of the body, therefore, even on the first day of the disease, there is a rise in body temperature to 38-40 ° C, general weakness, stunning chills, sometimes replaced by a feeling of heat, headache, changes in the blood and urine. In the case of a slower development of phlegmon, in particular with adenophlegmon, this is often preceded by toothache (periodontitis), periostitis, and lymphadenitis. It is not excluded the possibility of subsiding of these phenomena and their growth again. Even if an inflammatory process occurs in the fiber, the severity of the disease can increase slowly. In this regard, patients often get used to long-lasting pain sensations and, at the time of development of a true phlegmon, they do not seek medical help for a long time, therefore, in such cases, the doctor first examines a patient with a purulent inflammatory process that has been developing for a long time.
Sometimes the inflammatory process, despite the subacute development, acquires the character of diffuse pus with the spread of pus into neighboring sections and tissues, without a clear identification of the infiltrate. This is facilitated by the anatomical and topographic features of the area, when pus spreads through the intermuscular and interfascial spaces in the deep layers of tissues without external manifestations of a typical infiltrate and hyperemia of the skin. Therefore, one of the features of the treatment of phlegmon of the maxillofacial region is the need for surgical intervention even without the presence of a visible inflammatory infiltrate and fluctuation. This applies especially to the sublingual region and the neck region. By opening the abscess, draining it, the intersection of the paths for the spread of exudate towards the chest is achieved. For the same purpose, in some cases, several transverse incisions are shown in the neck up to the level of the collarbone. An important point in this case is the dissection of the subcutaneous muscle of the neck, under which the exudate usually migrates.
The most common source of infection in the development of phlegmon of the maxillofacial region is acute or exacerbated chronic periodontitis. In 96-98% of cases, phlegmon of the maxillofacial region is odontogenic, so their occurrence is usually preceded by a tooth disease. The development of phlegmon can proceed extremely rapidly and, conversely, very slowly. For phlegmon emanating from the lymph node (adenophlegmon), slow development is characteristic.
Usually, phlegmon of the maxillofacial region begins with the appearance of a painful infiltrate and increasing pain. As the inflammatory process develops, the infiltrate increases, the pain increases, acquiring the character of pulsating. With a superficial location of phlegmon, the skin over the infiltrate becomes hyperemic, shiny, and does not gather into a fold.
Infiltration and inflammatory edema of the tissues dramatically change the patient's usual facial features: the natural facial folds disappear, sometimes the edema leads to narrowing of the palpebral fissure and its complete closure. The localization of the process near the masticatory muscles causes the development of inflammatory jaw reduction, making it difficult to eat ordinary food.
As a rule, phlegmon of the maxillofacial region is accompanied by regional lymphadenitis. Lymph nodes are enlarged and sharply painful.
The development of phlegmon can last from 2-3 to 7-10 days. The appearance of softening, the presence of fluctuations indicate the melting of the infiltrate and the formation of pus. With a deep-seated phlegmon, the inflammatory infiltrate is not detected either visually or by palpation for a long time. As the infiltrate develops, its contours acquire more vague features than with a superficial location. The absence in the first days of the development of Phlegmon, clearly felt during the examination of the infiltrate, makes it difficult both to make a diagnosis and to carry out treatment. However, dynamic observation of the patient, the appearance of local symptoms (jaw reduction, hyperemia of the skin, mucous membrane, etc.) allow us to establish the true cause of the disease in the next 1-2 days. Correct diagnosis is also facilitated by the localization of pain that occurs during palpation.
The local process with phlegmon is combined with the general manifestations of the disease. Already in the initial stage of developing phlegmon, the body temperature rises to high numbers (38-40 ° C), general weakness, headache appear, appetite disappears, sleep is disturbed.
In severe cases, high intoxication causes disorders of cardiac activity and consciousness. With the anaerobic nature of the infection that caused the development of phlegmon, the severity of the general condition is significantly aggravated. In such cases, already on the 2-3rd day of the disease, against the background of periodic loss of consciousness, patients experience life-threatening disorders of cardiac activity and respiration.
On the part of the blood with phlegmon of the maxillofacial region, leukocytosis is observed - 10-12 109 / l (up to 10,000-12,000 in 1 μl), increased ESR (up to 30-40 mm / h), a decrease in the number of eosinophils or their disappearance, a shift in the blood formula to the left. In cases of occurrence (as a complication) of toxic nephritis, protein, sometimes casts and red blood cells are found in the urine.
It should be noted that the development of phlegmon of the maxillofacial region can proceed atypically, without a sharp rise in body temperature, a significant change in the general condition and noticeable manifestations of inflammation. This makes it difficult to recognize the disease and requires careful dynamic monitoring.
With untimely treatment, the development of a purulent process can cause a breakthrough of pus into the oral cavity or through the skin to the outside, or migration of pus through interstitial spaces to nearby organs and tissues with the development of an inflammatory process in them. Emptying the abscess into the mouth or outward essentially can lead to self-healing. However, the spread of pus into the surrounding organs and tissues is fraught with extremely serious complications, which were mentioned above.
Treatment. At the first signs of the development of inflammatory phenomena in the soft tissues of the maxillofacial region, even before the onset of a pronounced infiltrate, in a satisfactory condition of the patient, conservative treatment should be carried out. Assign dry heat, solux, rinsing the mouth with warm solutions, sulfonamides, calcium chloride. Such treatment is sometimes sufficient to stop and eliminate inflammation. To prevent the recurrence of the disease, it is necessary to identify the diseased tooth that served as the source of infection, and take measures to treat or remove it.
In cases where the inflammatory process tends to increase, despite the ongoing treatment, surgical intervention is indicated.
A similar and the only correct tactics of a doctor is necessary with an already developed phlegmon. The use of thermal procedures and postponing the operation in such cases can only aggravate the course of the process and contribute to the spread of pus. The operation of opening the phlegmon of the maxillofacial region has its own characteristics, which differ from the opening of the phlegmon of another localization. These features are as follows: 1) the opening of the phlegmon aims not only to empty the abscess, but also to cross and drain the paths of the possible spread of pus; 2) the operation is often performed not only in cases where softening of the infiltrate is determined, but always when there is a threat of exudate migration to neighboring departments, especially to the neck, even in the absence of fluctuation; 3) taking into account the aesthetic value of the face, an incision for opening is made along the line of natural folds, under the edge of the lower jaw, sometimes somewhat away from the main focus 4) the presence of branches of the facial nerve in the operated area requires caution - the skin and tissue are sharply dissected, and the further approach to the abscess is carried out stupidly. The proposed scheme illustrates the most advantageous incision lines for opening phlegmon.
The best type of anesthesia when opening phlegmon is anesthesia (halothane + nitrous oxide + oxygen, or even just nitrous oxide + oxygen). Anesthesia allows, without injuring the patient both mentally and physically, to make a mandatory digital revision of the abscess cavity, eliminate pockets, lintels and, if necessary, create counter-opening.
After emptying the cavity from pus, an iodoform swab or rubber strip is loosely introduced into it. If pus is not obtained at the opening of the infiltrate or when the tissues in the wound are reactive, it is recommended to introduce a swab with a hypertonic solution. A cotton-gauze bandage is applied on top, held by the bandage. Usually, the tampon, starting from the next day after the operation, is pulled up and the end is cut off.
In cases of strong impregnation with pus, the tampon should be changed more often (2 times a day), otherwise it will obturate the lumen of the wound and make it difficult for the outflow of pus. The cavity of the abscess is cleared of pus and dead tissue on the 7-10th day. To speed up the cleansing of the purulent cavity, the dialysis method is widely used. For this purpose, the cavity of the abscess during dressings is washed with a jet of various antiseptics (solutions of furacilin 1: 1000, chlordixidine 0.5%, etc.).
In chronic dialysis, when liquid is dripped into the abscess cavity for sometimes several days, an isotonic sodium chloride solution or a weak solution of some antiseptic is used.
Sometimes, as a result of the operation, it is not possible to prevent the development of a new inflammatory focus that has arisen due to the penetration of infection into neighboring departments. In such cases, repeated surgical intervention is indicated to eliminate the inflammatory process of a different localization.
With the anaerobic nature of the phlegmon, the abscess cavity is opened with a wider incision, and sometimes with 2-3 incisions. The wound is repeatedly washed with a solution of hydrogen peroxide. The tampons introduced into the wound are moistened with a 1-20 Jo solution of potassium permanganate.
Good results were obtained in patients with severe forms of phlegmon of the maxillofacial region (especially in the presence of anaerobes) after 3-4 sessions of hyperbarotherapy. The beneficial effect of an increased oxygen content on the body as a whole and on the area of acute purulent inflammation in particular contributes to a faster recovery of patients, preventing the activation of anaerobes, reducing the duration of the purulent process, the mode of hyperbarotherapy sessions is normal: pressure in the chamber is 2 atm, compression and decompression time of 15 minutes, saturation (saturation) time of 45 minutes. Usually 3-4 sessions are enough to significantly improve the condition of patients with phlegmon of the maxillofacial region. In severe cases of anaerobic infection, hyperbaric oxygen therapy is absolutely indicated.
Recently, ultrasound has been successfully used. “Sounding” of the abscess cavity, which is pre-filled with one or another solution (furatsilin, isotonic sodium chloride solution, silver water, etc.), leads to the destruction of bacteria in the wound and contributes to the normalization of microcirculation.
The first positive results of exposure to the abscess cavity and the wound itself with helium-neon laser beams have been obtained. This accelerates the process of cleansing and healing the wound.
An increasing place in the treatment of purulent processes in the maxillofacial region is occupied by proteolytic enzymes, which are used both locally (on tampons) and in the form of intramuscular injections. The use of these enzymes significantly accelerates the process of cleansing the wound from dead tissue, which contributes to a faster recovery.
Of great importance in the outcome of the disease of persons with phlegmon of the maxillofacial region is the general treatment. Antibiotics are a powerful means of fighting infection, but the different sensitivity of bacteria to certain antibiotics in some cases nullifies their therapeutic value. In this regard, it is necessary to take pus when opening the phlegmon for laboratory determination of the sensitivity of bacteria to antibiotics. In the absence of such an opportunity, a broad-spectrum antibiotic or a combination of 2-3 antibiotics should be prescribed to patients. In cases of moderate severity, antibiotics should be administered after 3 hours. Zeporin (500 mg 3-5 times a day), oleandomycin (200,000-300,000 IU 3-5 times a day), tetraolean (250-500 mg 4 times a day), ampicillin (500 mg 4-6 times a day inside) are effective. In severe cases, sulfonamides are prescribed (sulfadimethoxine 1 g 2 times on the first day of the disease, then 0.5 g 2 times a day). With symptoms of intolerance to antibiotics, increase the dose of sulfonamides.
With severe intoxication of the body, for a more active removal of toxins, an intravenous infusion of an isotonic solution of sodium chloride, 5% glucose solution, antiseptic and protein solutions up to 1500-3000 ml per day is prescribed, multivitamins are required.
In the presence of anaerobic infection, antigangrenous serum is used according to the scheme. With severe pain, analgin, injections of Promedol Solution or Omnopon are prescribed. According to the indications, especially in cases of high intoxication of the body and in the elderly patients, cardiac remedies should be used.
Recently, immunotherapy has become increasingly important for the treatment of purulent inflammatory processes. For this purpose, patients in a satisfactory condition are given a one-time intramuscular injection of 0.5 ml of staphylococcal toxoid, and 100 mg of a solution of crystalline lysozyme (factory packaging) is administered 3 times a day for 5 days, gamma globulin, etc. lin (2-3 days), hyperimmune plasma. The inclusion of immunotherapy in the treatment of acute inflammatory processes in the maxillofacial area helps to accelerate the recovery of patients and reduces the number of severe complications.
The catering of patients is of great importance. Due to the fact that in patients with phlegmon of the maxillofacial region, as a rule, the act of chewing, and sometimes swallowing, is disturbed, the food should be liquid. In addition, due to the sharp pain that occurs when trying to make a chewing or swallowing movement, patients eat very little, so the food should be high-calorie (cream, sour cream, eggs, cocoa, butter, strong broth, sugar, etc.). Due to the lack of a normal act of chewing, the natural self-cleaning of the oral cavity of such patients is sharply disturbed, so they need special care: 3-4 times washing with a rubber balloon of the oral cavity solution of furacilin (1:5000) or pale pink (0.1%) solution of potassium permanganate. The final and mandatory stage of treatment should be a thorough sanitation of the oral cavity.
Most often in practice there are phlegmons of the submandibular and submental region, the bottom of the oral cavity.
Phlegmon of the submandibular region. The submandibular region is limited by the lower edge of the lower jaw and both bellies of the digastric muscle. In this area are located the submandibular salivary gland, lymph nodes, fiber.
Usually, submandibular phlegmon occurs as a result of an odontogenic infection. The development of the inflammatory process often begins with adenitis, which turns into periadenitis and adenophlegmon, less often as a result of the transition of inflammation from neighboring areas or as a result of periostitis or osteomyelitis of the lower jaw (osteophlegmon).
With phlegmon, the area of \u200b\u200bthe submandibular triangle loses its shape, a painful swelling appears (Fig. 105).
Skin color initially unchanged. As the process develops, hyperemia appears, tension increases, the skin does not fold. Palpation becomes more and more painful. There is collateral edema. Opening the mouth is painful. The reduction of the jaws is of varying degrees. Sometimes painful swallowing. The general condition of patients depends on the virulence of the infection.
Treatment of submandibular phlegmon consists in opening it with an incision parallel to the lower edge of the body of the lower jaw, retreating from it by 1.5-2 cm. This prevents damage to the facial artery and the marginal branch of the facial nerve, which can cause bleeding and prolapse of the corner of the mouth. The wound is drained with gauze. Healing occurs by secondary intention. Scar formation does not cause serious aesthetic disturbances.
Phlegmon of the submental region. The submental region is bounded by the anterior bellies of both digastric muscles and the hyoid bone. The submental lymph nodes are located in the intermuscular fatty tissue.
The foci of infection are most often the lower frontal teeth. The entrance gate of the infection can be the mucous membrane of the anterior part of the oral cavity in case of violation of its integrity, as well as injuries, abrasions and pustular skin diseases of the chin area. In the presence of an odontogenic infection, signs of lymphadenitis appear. The body temperature rises slightly. As inflammation increases, it rises to 38°C. The swelling increases. Opening the mouth is free, swallowing is painless (Fig. 106).
However, damage to the lymph nodes near the hyoid bone causes difficulty in swallowing. The general condition of patients often remains satisfactory. For the purpose of treatment, the chin phlegmon is opened along the midline or by a transverse incision.
Phlegmon of the floor of the mouth. The bottom of the oral cavity is a collection of soft tissues located between the mucous membrane lining the bottom of the oral cavity and the skin. The basis of the bottom of the oral cavity is the maxillohyoid muscle, located between both halves of the lower jaw and the hyoid bone. Separate muscle groups are separated by fascial sheets and layers of loose connective tissue and adipose tissue. The inflammatory process in this area is usually diffuse in nature, capturing all or most of the floor of the mouth. Dense painful swelling captures the submental and submandibular regions. The sublingual ridges are raised, their ridges are covered with fibrous plaque, the tongue swells, often does not fit in the mouth, is lined. Thick saliva flows from the mouth. Speech, chewing and swallowing are difficult, painful (Fig. 107).
Treatment of phlegmon of the bottom of the mouth (opening it) is urgent. Wide incisions are needed to ensure the outflow of exudate and sufficient aeration of deeply located tissues.
A wide collar incision meets these requirements, sometimes with an additional incision along the midline of the neck.
Necrotic phlegmon of the floor of the mouth (Ludwig's angina). A special type of phlegmon of the floor of the mouth was named after the author who described it in 1836. Despite the fact that phlegmon is rare, its clinic and treatment deserve attention. This disease is characterized by a particularly severe course and the most severe outcome. The process begins most often in the submandibular triangle or immediately affects the entire bottom of the oral cavity. The entrance gates of infection are the teeth destroyed by caries. Initially, a dense, relatively painless swelling of the bottom of the mouth appears. The inflammatory infiltrate captures the submandibular and submental regions and descends to the neck. The mouth is usually half open, the tongue is swollen. The sublingual ridges are raised and covered with dry fibrous plaque, the oral cavity is dry. The pulse is frequent, the temperature rises to 38-39°C. The general condition of the patient progressively worsens. If left untreated, death usually occurs due to the development of sepsis and a fall in cardiac activity.
Treatment of Ludwig's angina consists of wide incisions in the area of the floor of the mouth as early as possible. Collar incisions are used along the cervical fold from one corner of the lower jaw to the other in combination with an incision along the midline of the neck. Typical for this type of phlegmon is the almost complete absence of purulent exudate. When cut in the depths of the tissues, necrotic foci are found with a scant amount of bloody fluid with a sharp putrefactive odor, the release of gas bubbles, which indicates the anaerobic nature of the bacteria that caused phlegmon. However, in cultures of material taken from the wound, hemolytic streptococcus is often found. Obviously, the process is caused by a mixed infection (anaerobes and coccal flora), while the peculiarity of the course of the disease is mainly determined by anaerobes.
The wound must be frequently irrigated with oxygen-releasing preparations, for which the dressing is performed several times a day.
The complex of treatment includes anti-gangrenous serum, shock doses of broad-spectrum antibiotics, intravenous administration of large amounts of isotonic sodium chloride solution and 5% glucose solution, vitamins. It is necessary to support the activity of the heart. In cases of difficulty breathing resulting from compression of the upper respiratory tract by edematous tissues, a tracheotomy is sometimes necessary. Delay with surgery and the start of active therapeutic treatment threatens with a fatal outcome. Before the era of antibiotics, death from Ludwig's angina occurred in 80% of cases.
Version: Directory of Diseases MedElement
Phlegmon and abscess of the mouth (K12.2)
general information
Short description
A. General information for the subcategory as a whole.
1. Additional codes:
Alcohol abuse and dependence (F10.-)
Exposure to ambient tobacco smoke (Z77.22)
Exposure to tobacco smoke in the perinatal period (P96.81)
History of tobacco use (Z87.891)
Occupational exposure to tobacco smoke (Z57.31)
Tobacco addiction (F17.-)
Tobacco use (Z72.0)
2. Excluded in general from the rubric K12 Stomatitis and related lesions:
Necrotizing ulcerative stomatitis (cancrum oris) (A69.0);
- gangrenous stomatitis (A69.0)
Diseases of the lips (K13.0);
Herpes simplex virus gingivostomatitis (B00.2);
Noma (A69.0).
3. Excluded specifically from this subheading:
- salivary gland abscess (K11.3)
Tongue abscess (K14.0)
Periapical abscess (K04.6-K04.7)
Periodontal abscess (K05.21)
4. The following clinical concepts are included in this subheading:
- Cellulitis (phlegmon) of the floor of the mouth;
Abscess of the submandibular region (submandibular abscess).
Clinical terms sometimes used (or used previously) as synonyms:
oral abscess
- Abscess of oral tissue
- Abscess of the sublingual space
- Submandibular abscess
- Cellulitis (phlegmon) of the soft tissues of the oral cavity
- Cellulitis (phlegmon) of the submandibular region
- Inflammation of the tongue
- Angina Ludwiga
- Abscess of the mouth (oral cavity)
- Sublingual abscess
- Sublingual abscess
- Submandibular cellulitis
- Submandibular abscess
- Inflammation of the uvula
- Phlegmon of the cheek (internal).
1. Abscess - limited purulent inflammation of the fiber with the formation of a cavity.
2. Phlegmon (cellulitis) - diffuse purulent inflammation of the subcutaneous, intermuscular and interfascial tissue.
3. Adenophlegmon
- this is a diffuse purulent inflammation of the fiber, resulting from the spread of infection along the length of the affected lymph node. Adenophlegmon is usually a complication of acute lymphadenitis - melting of the lymph node capsule during purulent inflammation leads to the spread of pus into the surrounding tissue. The process is more often localized in the lymph nodes of the submandibular triangle, less often in other anterior and lateral areas of the neck.4. Ludwig's angina - one of the forms of phlegmon of the floor of the oral cavity of a putrefactive-necrotic nature, caused by anaerobic pathogens, usually coming from gangrenous teeth or with soft tissue injuries of the floor of the mouth. The inflammatory process in Ludwig's angina is characterized by muscle necrosis without the formation of pus. The process begins in the submandibular region and quickly moves to the muscles of the floor of the mouth.
B. Anatomical boundaries of the floor of the mouth and adjacent areas.
Due to the fact that phlegmon often affects one or two and two or three adjacent areas, the boundaries of the corresponding areas are given below.
1. The boundaries of the submandibular region are: outside - the inner surface of the body of the lower jaw; in front and behind - respectively, the anterior and posterior belly of the digastric muscle; on top - a deep sheet of the own fascia of the neck, which covers the maxillo-hyoid muscle; below - a superficial sheet of the own fascia of the neck. The submandibular triangle contains the anterior, middle, and posterior lymph nodes, as well as the submandibular gland, facial artery, and vein.
2. The boundaries of the submental region are: in front and above - the lower edge of the chin section of the lower jaw; behind - the maxillo-hyoid muscle; outside - the anterior bellies of the right and left digastric muscles; below - the hyoid bone. This cellular space is located between the deep sheet of the own fascia of the neck, covering the lower surface of the maxillohyoid muscle and the superficial sheet of this fascia. IN
The anterior part of the cellular space and the hyoid bone are the lymph nodes. In the submental region there are two groups of lymph nodes: 2-4 nodes behind the lower edge of the chin section of the body of the lower jaw and 1-2 - at the hyoid bone.
Do not confuse the above and the chin area. The chin region is the lower part of the face, bounded from above by the chin-labial groove, from below - by the lower edge of the lower jaw, from the sides - by lines descending from the corners of the mouth.
3. The boundaries of the pterygo-mandibular space are: outside - the inner surface of the branch of the lower jaw and the lower part of the temporal muscle; inside, behind and below - the outer surface of the medial pterygoid muscle; from above - the external pterygoid muscle; in front - the pterygomandibular suture, to which the buccal muscle is attached. The pterygo-mandibular space communicates with the retromaxillary, infratemporal and pterygopalatine fossae, buccal region, peripharyngeal space and can pass to the outer surface of the lower jaw branch.
D. Discussion
Some authors introduce a non-purulent (serous) odontogenic infiltrate into the concept of cellulite, thus distinguishing between cellulite (as a serous inflammation that does not always turn into purulent) and phlegmon (as diffuse purulent inflammation). According to A.A. Timofeeva (2002) inflammatory infiltrate can occur in two forms: the first - as an independent disease, the second - as an early phase of the purulent-inflammatory process.
Flow period
An acute course is most characteristic of an abscess. The vast majority of patients (over 90%) seek help within 5 days of starting the process.
In elderly patients, a less rapid development and an erased, sluggish (hypoergic type of reaction) course of the process is possible. Also, an increasingly slow development of the process has become a general trend in recent years, regardless of the age of patients. Apparently, this is due to the outpatient use of conservative antibiotic therapy, self-treatment (which is often hidden by patients), a general change in the spectrum of pathogens and their properties (pathogenicity, virulence, invasiveness). Quite often, patients with a slowly progressive form apply after 2 weeks or more from the onset of the disease.
Adenophlegmon develops slowly - within 2-3 weeks
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Classification
A. There are primary and secondary abscesses, which is important when choosing the volume and method of surgical intervention. See etiology pathogenesis for details.
All abscesses and phlegmons of the maxillofacial region and neck can be divided into two groups depending on the source of their occurrence: odontogenic and non-odontogenic.
With the odontogenic route of infection, the main cause is diseases of the hard tissues of the tooth, periodontium and bone tissue.
In case of non-odontogenic purulent-inflammatory processes, the onset of the disease is associated with mechanical trauma, tissue infection during anesthesia, tonsillitis, otitis media, rhinitis, etc. (Timofeev A.A. 2002)
B. The phlegmon of one area, one or two and two or three adjacent areas is allocated. Separately allocate septic phlegmon. Accordingly, according to the severity of the course of the disease, patients with phlegmon are conditionally divided into three groups:
Group 1 (mild) - patients with phlegmon localized in one anatomical region;
2nd (moderate) - patients with phlegmon localized in two or more anatomical regions;
3rd - seriously ill patients with phlegmon of the soft tissues of the floor of the mouth, neck, half of the face, as well as a combination of phlegmon of the temporal region with the infratemporal and pterygopalatine fossae. (Timofeev A.A. 2002).
There are also abscesses of the anterior and posterior submandibular region. Phlegmon, as a spilled process, cannot be divided in this way.
B. Process steps subdivided into:
1. Edema
2. Infiltration
3. Purulent fusion of tissues.
4. Necrosis
5. Limitations of the focus with the formation of a granulation shaft.
Etiology and pathogenesis
A. The main source of infection in this area is the pathological process in the large and small molars of the lower jaw. A secondary lesion is observed when the inflammatory process spreads from the sublingual and mental regions, the retromaxillary fossa, the pterygo-mandibular and peripharyngeal spaces, the submandibular gland (purulent sialadenitis). Moreover, phlegmon and abscess of the floor of the mouth can be both a cause and a consequence of the above processes. Often, with a late admission of the patient, it is not possible to distinguish
The penetration of infection by lymphogenous and hematogenous routes is observed. The primary focus of infection is acute ulcerative gangrenous stomatitis, furuncles of the submandibular and buccal region (L03.211), lip abscesses, septic phlegmons of other localizations.
Cases of occurrence after a fracture of the lower jaw and blunt trauma of the submandibular region are described.
Submandilbular abscesses are acute infections of the soft tissues below the mouth. These infections spread quickly and can be quite dangerous, resulting in airway obstruction, severe pain, and dysphagia.
Care care:
Ensure the airway is a patent for all time.
Give pain medication as needed and provide cold compresses as directed.
The gauze can be removed from the oral surgery site in the mouth when the patient reaches the floor. If there is still bleeding after removal, apply more gauze to the area and ask the patient to hold down until the bleeding slows.
Suction for bedside at all times.
Salt warm water rinses can be done as prescribed.
When discharges patients make sure they understand that any antibiotics ordered must be finished completely to prevent abscess recurrence. Do not smoke or drink.
Submandibular space infection is an acute cellulitis of the soft tissues below the mouth. Symptoms include pain, dysphagia, and potentially fatal airway obstruction. The diagnosis is usually clinical. Treatment includes airway management, surgical drainage, and IV antibiotics. Submandibular space infection is a rapidly spreading, bilateral, fixed cellulitis occurring in the suprahyoid soft tissues, in the floor of the mouth, and both sublingual and submandibular spaces without abscess formation. Although not a true abscess, it resembles one clinically and is treated similarly. The condition usually develops from an odontogenic infection, especially the mandibular 2nd and 3rd molars, or as an extension of peritonsillar cellulitis.Contributing factors may include poor oral hygiene, tooth extraction, and trauma (eg, mandibular fractures, lacerations on the floor of the mouth). Symptoms and signsEarly manifestations of pain in any involved teeth, with severe, tender, localized submental and sublingual induration. Boardlike hardness of the floor of the mouth and muscular thickening of the suprahyoid soft tissues can develop rapidly. Drooling, trismus, dysphagia, stridor caused by swelling of the larynx, and elevation of the back of the tongue toward the palate may be present. Fever, chills, tachycardia are usually also present. The condition can lead to airway obstruction within hours, and does so more often than other neck infections. DiagnosticsThe diagnosis is usually obvious. If not, CT is done. TreatmentMaintaining the airway Surgical incision and drainage Antibiotics active against oral microflora Maintaining a patent airway is a top priority. Because the swelling makes oral tracheal intubation difficult, fiber optic nasotracheal intubation done with topical anesthesia in the operating room or in intensive care with the patient awake is preferred. Some patients require a tracheotomy. Patients without an immediate need for intubation require intensive monitoring and may benefit temporarily from a nasal tube. Incision and drainage with placement of a drain deep into the mylohyoid muscle to reduce pressure. Antibiotics should be chosen to cover both oral anaerobes and aerobes (eg, clindamycin / sulbactam, high doses of penicillin). Last full review/revision October 2012 Clarence T. Sasaki, MD Content Last modified September 2013 |
Epidemiology
Age: teenagers and adults
Sex ratio (m/f): 1.3
The prevalence is highly variable. Apparently this is due to problems in coding and terminology. International distribution is not known.
It is believed that men predominate (1.1-1.3:1).
The average age of the patient is estimated to be 30-50 years. Apparently, it is at this age that the highest frequency of odontogenic infections occurs. In childhood, the peak falls on the period of change of bite in general and on the period of change of molars in particular.
Factors and risk groups
Diabetes.
Immunodeficiency.
Malignant tumors.
Interventions in the oral cavity.
Clinical picture
Symptoms, course
Angina Ludwig
Angina Ludwig (W. F. Ludwig; angina Ludovici) - putrefactive necrotic phlegmon of the floor of the mouth.
A number of authors attribute Ludwig's angina to the number of pathological processes caused by anaerobes (Cl. perfringens, Cl. oedematiens, Cl. histolyticum, Cl. septicum). However, anaerobic streptococci and staphylococci play a significant role in the occurrence of the disease. Compared with putrefactive necrotic phlegmon of other localization, for example, putrefactive necrotic phlegmon of the limb, with Ludwig's angina, a more diverse anaerobic microflora is found, including bacteria of the fusospirochete association (Bac. fusiformis, Spirochaeta buccalis), Escherichia coli, etc. The infection penetrates more often from infected carious teeth and periodontal tissues, crypts of the tonsils and contaminated wounds and abrasions of the oral and pharyngeal mucosa.
Pathologically, Ludwig's angina is characterized by extensive necrosis of the tissue of the floor of the mouth, swelling, and often necrosis of the muscles located here, the presence of gas bubbles in them and a sharp ichorous odor. Affected muscles are initially pale red, later brown and dark brown with a greenish tint, then turn into a loose, easily torn tissue. The surviving tissues on the section are dry, only small accumulations of ichorous liquid of the color of meat slops are found. The absence of pus is an essential feature of Ludwig's angina. Some authors make the mistake of referring to Ludwig's angina cases of phlegmon of the floor of the mouth, accompanied by the formation of pus. The opinion that Ludwig's angina always begins with a lesion of the submandibular salivary gland has not been confirmed.
An early typical clinical manifestation of Ludwig's angina is a dense woody swelling in the submandibular region. From here, the inflammatory process in severe cases quickly passes to the region of the bottom of the oral cavity and, descending to the neck, is concentrated at the hyoid bone. On the neck, swelling extends to the collarbones; at the same time, swelling of the face appears. The skin over the lesion in the first 2-3 days is not changed in color, then becomes pale; later, separate bluish-purple and bronze spots appear.
The course of the disease is usually severe, only sometimes moderate. In most patients, at the onset of the disease, chills, general malaise, painful swallowing, headaches, and lack of appetite are observed. The temperature for the first 1-2 days remains subfebrile or does not exceed 38°, then reaches 39° and above. Inflammatory edema that has arisen in the region of the floor of the mouth extends to the walls of the pharynx and the entrance to the larynx, as a result of which the voice becomes hoarse, speech and swallowing are difficult. The sublingual folds and carunculae sublinguales are edematous, raised, the mucous membrane above them is covered with a fibrinous coating. The tongue is enlarged, covered with a dark brown coating, dry, inactive. Mouth half open, bad breath, face pale, cyanotic or earthy. Breathing is intermittent, the patient does not have enough air, his face expresses fear, the pupils are dilated. The position is forced, semi-sitting, sometimes the patients are excited, in some cases they are apathetic. Every day the condition becomes more and more severe, pouring sweats appear, tremendous chills, consciousness is darkened, delirium. The amount of hemoglobin falls. Severe leukopenia, a sharp shift of the leukocyte formula to the left. With increasing general weakness, symptoms of cardiac decline and a picture of sepsis, often by the end of the first, less often in the middle or end of the second week, death may occur. Complications: inflammation and lung abscess, asphyxia, and mediastinitis. Prior to the use of antibiotics, the prognosis for Ludwig's angina was severe, with mortality reaching 40–60%.
Diagnostics
Diagnosis of the disease is based mainly on the clinic.
CT and MRI are indicated for severe or progressive asphyxia, but should not delay airway management.
Any radiological methods allow to identify the alleged source of infection, its prevalence and conduct differential diagnosis with other causes of asphyxia and dysphagia in doubtful cases.
The value of ultrasound as a method of emergency confirmation of the diagnosis in the emergency room has not yet been determined.
Laboratory diagnostics
Tests indicating an inflammatory response have high sensitivity but low specificity and should only be evaluated in conjunction with the clinic.
Isolation of culture from the focus should be carried out whenever possible, especially in patients at risk and vulnerable patients.
Blood culture, in emergency situations, is a poorly sensitive method, even in complicated cellulitis, and rarely leads to a change in ABT.
Differential Diagnosis
1. First of all, differential diagnosis should be carried out with diseases causing acute asphyxia and dysphagia:
- Stridor;
- Epiglotitis;
- Quincke's edema.
2. Enlargement of the sublingual region can be caused by neoplastic processes of the floor of the mouth or abscesses and phlegmons of other and combined localizations.
3. Isolated cases of nocardiosis and filarial abscesses of the face are described. However, there is no description of an isolated lesion of the sublingual region. However, with multiple abscesses, this possibility is not excluded.
4. Erysipelas can mimic Ludwig's angina, but differential diagnosis is not difficult.
Complications
Asphyxia
Sepsis
Spread to other areas
Forecast
Depends on many factors. Generally regarded as favorable. Mortality is low. For example, between 1999 and 2007. there were 132 deaths in the United States, where ICD-10 K12.2 was listed as the leading cause of death.
Information
Information
Blood Culture Results Do Not Affect Treatment in Complicated Cellulitis
William F. Paolo, MD, Andrew R. Poreda, MD, William Grant, EDD, David Scordino, MD, Susan Wojcik, PHD
J Emerge Med. 2013;45(2):163-167.
2.http://www.medical-enc.ru/
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Abscess, phlegmon of the chin area
The submental cellular space is located under the diaphragm of the mouth (maxillary-hyoid muscle) and is limited from above by its own, from below by the superficial fascia of the neck, in front by the lower jaw, behind the hyoid bone, from the sides by the anterior bellies of the digastric muscle. The submental lymph nodes are located in the fiber.The inflammatory process mainly begins with lymphadenitis. The source of infection is the lower incisors and canines, less often inflammation spreads along the length of the sublingual and submandibular spaces. Accordingly, the spread of infection from the submental space is possible in these areas.
The pain is localized in the submental region, aggravated by chewing, swallowing. General signs of inflammation: fever, manifestations of intoxication are not pronounced. On examination, some swelling is determined in the submental region, smoothness of skin folds, and sometimes skin hyperemia.
Palpation reveals a painful infiltrate between the hyoid bone and the lower jaw. The skin over the infiltrate (if the subcutaneous tissue is not involved in the inflammatory process) is not changed and is easily displaced. Similar manifestations can be with acute submental lymphadenitis.
The limited infiltration is more characteristic of lymphadenitis, and the absence of negative dynamics of the process or reverse development under the influence of antibiotic therapy speaks in favor of acute lymphadenitis. Abscessing of lymphadenitis, the formation of adenophlegmon allows us to determine ultrasound. It shows fluid formation, destruction of the lymph node. In doubtful cases, a puncture is performed, obtaining pus indicates an abscess, phlegmon.
To open the submental phlegmon, an incision 3-4 cm long is made along the midline, retreating 1-1.5 cm from the edge of the lower jaw. In the course of the incision, the surface sheet of the fascia is dissected and the abscess is opened in a blunt way using a hemostatic clamp, directing it to the center of the inflammatory infiltrate. Pus is removed, tape drainage from glove rubber is introduced into the resulting cavity.
Submandibular (submandibular) phlegmon
Most often it is adenophlegmon, the source of damage to the lymph nodes are diseases of the teeth. It is possible to spread inflammation to the submandibular tissue with periostitis, osteomyelitis of the lower jaw. The spread of the purulent process along the stretch from the sublingual, submental areas, from the pterygo-maxillary space is not excluded. Adenophlegmon becomes a consequence of acute submandibular lymphadenitis.The disease is manifested by pain in the submandibular region against the background of fever and intoxication, it is often preceded by diseases of the posterior lower molars, periodontitis, periostitis. The pain intensifies when moving the jaw, trying to open and close the mouth. On examination, an infiltrate is determined under the horizontal branch of the lower jaw closer posteriorly, soft tissue swelling, and sometimes skin hyperemia. The infiltrate is located under the jaw and medially from its lower edge, closer to the corner.
With phlegmon in the subcutaneous tissue, the infiltrate is large, the skin above it is hyperemic. In the inflammatory process under one's own fascia (bed of the submandibular salivary gland), i.e. with adenophlegmon, swelling may be absent, deep palpation is painful. The infiltrate may be indistinct. Bimanual palpation allows you to determine the size and localization of the infiltrate, to exclude the involvement of the sublingual space in the inflammatory process.
With the localization of the abscess under the own fascia of the neck, the inflammatory process can spread to the sublingual, submental region, to the peripharyngeal cellular space and further to the posterior mediastinum. The spread of infection is possible through the posterior mandibular fossa into the fascial sheath of the neurovascular bundle of the neck and further into the anterior mediastinum.
The submandibular phlegmon is opened from an incision 5-6 cm long, made 2 cm inside and parallel to the lower jaw. The skin, together with fiber and superficial fascia, is peeled upward to the edge of the lower jaw. The subcutaneous muscle is dissected along the probe. In this case, it is possible to open a superficial abscess located under the superficial fascia. Own fascia is dissected and then penetrated with a closed hemostatic clamp into the proper submandibular cellular space. The abscess is opened, the pus is removed, the cavity is drained.
In case of purulent-necrotic phlegmon, after dissection of one's own fascia, the facial artery and vein are isolated and bandaged, the submandibular salivary gland is retracted downward, necrotic tissue is removed, and the submandibular space is inspected for possible leaks.
An abscess of the submandibular space can be opened from an incision at the angle of the mandible.
The skin and subcutaneous tissue are dissected at the angle of the jaw and Billroth's clamp with closed jaws, moving it along the posterior edge of t. mylohyoideus to the abscess, stupidly penetrate into its cavity. By diluting the branches, the abscess is opened, the pus is removed, the cavity is washed with an antiseptic solution and drained.
With the spread of phlegmon in the submental region, counter-opening is performed under the chin and through drainage is performed.
VC. Gostishchev