Lecture № 7 « Abscesses of - PowerPoint Presentation

1. Lecture № 7 «Abscesses of glossal groove, palate, sublingual region. Phlegmons of submandibular, buccal, masseteric, retromandibular, submental spaces. Phlegmons of the mouth floor and cervical spaces. Ludwig’s angina. Abscesses of tongue and sublingual space. Clinical course, etiology, pathogenesis, diagnosis, complications, and treatment.»

2. OverviewInflammation is a defense reaction of the organism to local injuries of any type, e.g. to infection. Infection is a pathological state resulting from the invasion of the body by pathogenic microorganisms and their proliferation within the organism. Unspecific odontogenic infections of soft tissues belong to the most common diseases in the oro-maxillofacial region.

3. General symptoms of inflammation Classic signs of acute infection appear: Heat ,redness,tumour (oedema), pain,loss of function (e.g. trismus, difficulties in swallowing) in addition: leucocytosis (> 7500/µl)CRP increase

4. CRP (C-reactive protein) is synthesised in the liver. It is one of the chemical mediators of inflammation and its serum level increases faster and to higher levels than that of any other parameters in acute infectious and non-infectious inflammation.

5. At present, CRP is the most important indicator of acute inflammation since it increases within 6-12 hours to 10 to 1,000 times its normal level (< 5 mg/L); it reacts as quickly to a subsiding acute-phase reaction with a reduced concentration (short half-life).

6. Abscesssubmucous abscess, smooth vestibulelocalized collection of pus in a cavity caused by necrosis of tissue due to bacterial infectiondemarcation by abscess membrane (granulation tissue)firm-elastic consistencyfluctuation can be palpated only in superficial abscessesOedemaOedematous swelling of the ocular region in abscess of the canine fossa concomitant oedema of the upper lip in submucous abscess in region 11accumulation of fluid in tissueclassic sign of any acute inflammation (tumour)soft and elastic on palpation

7. Phlegmon (cellulitis)diffusely spreading inflammation between superficial tissue levels (without being limited to them)no demarcationinfection by highly virulent bacteria (release of lytic enzymes)impaired defence mechanisms of the organismserous-purulent and necrotising inflammationfirm to hard on palpation Differential diagnosisswelling caused by neoplasms (sarcomas, malignant lymphomas, carcinomas)salivary gland diseases

8. Causesbacterial infections of soft tissues in the head and neck regionOdontogenic causes of soft tissue infectionsIn 92-94% of the cases, infections in the oro-maxillofacial region are of odontogenic origin (Schmelzle and Schwenzer 1988).periapical periodontitisinfection after tooth extractiondifficult dentition (pericoronitis)marginal periodontitisinfected retained root fragmentsinfected cystsNon-odontogenic causes of soft tissue infectionsinfected fracture gapinfected soft tissue wounds or tumoursinfection by foreign bodiesinfection after injectioninflammatory skin or mucous membrane disordershaematogeneous or lymphogeneous spreading 

9. TherapyWith regard to the pathophysiology of abscess genesis, the increasing size and spreading tendency of abscesses is not only due to the pathogens' virulence but, in an advanced stage, also to biophysical characteristics of the abscess. Therefore, mechanisms exist that may reduce the effectiveness of antibiotics (Wiese et al. 1999);

10. Surgical intervention  The statement that Galen made almost 2,000 years ago - "ubi pus, ibi evacua" (if there is pus, remove it) which is still valid in the era of antibiotics could be considered the clinical conclusion from the abscess pathophysiology explained above. Therefore, incision and drainage are the primary therapy of an abscess. Incision of an abscess is advisable, possibly by a sufficiently wide incision at the maximum point of the swelling.

11. Antibiotic therapyIndications for antibiotic treatment may be as follows: possible tendency for spreading of an abscess or other infections to adjacent regions. Risk factors for spreading include: diabetes mellitus, alcoholism, cardiological, neurological and nephrological diseases (Mischkowski et al. 1997)

12. Antibiotics for oral treatment Aminopenicillin + β-lactamase inhibitor For patients allergic to penicillin: Clindamycin or "modern makrolids" See: Antibiotic treatment: Recommendations for the treatment of bacterial infectious diseases in practice (adults)

13. Classification of abscessesIn the gingival region periodontal abscesssubmucous abscessIn the maxillapalatal abscessabscess of the canine fossaretromaxillary abscess

14. In the mandiblesublingualsubmandibularpterygomandibularparamandibularretromandibularperimandibularmassetericomandibularchin abscess

15. Abscesses of adjacent spacesparatonsillaryperitonsillarybuccal abscess (paramandibular)lingual abscesssubmentalparapharyngeal

16. Treatmentperi-focal anaesthesia incision discharge of pus spreading of the abscess cavity rinsing of the abscess cavity drainage of the abscess cavity elimination of causeFacultative antibiotic treatment 

17. Submandibular space: This is actually a combination of two spaces partially separated by the mylohyoid muscle. The space below the mylohyoid muscle is known as the submaxillary space while the space above the muscle is known as sublingual space. 

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19. Boundaries: Superior – Oral mucosa and tongueMedial – oral mucosa and tongueLateral – Superficial layer of deep cervical fascia with its tight attachment to the mandible and hyoid bone laterallyInferior – Hyoid bone

20. The mylohyoid cleft separates the submaxillary from sublingual space. Structures passing through mylohyoid cleft include:  1. Wharton’s duct 2. Lingual nerve 3. Hypoglossal nerve 4. Branch of facial artery 5. Lymphatics There is free communication across midline between these spaces. Ludwig’s angina is the characteristic example of infections of this space

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22. Buccal Space AbscessAnatomic Location. The space in which this abscess develops is between the buccinator and masseter muscles.Superiorly, it communicates with the pterygopalatine space; inferiorly with the pterygomandibular space. The spread of pus in the buccal space depends on the position of the apices of the responsible teeth relative to the attachment of the buccinators muscle. Etiology. The buccal space abscess may originate from infected root canals of posterior teeth of the maxilla and mandible.

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24. Clinical Presentation. It is characterized by swelling of the cheek, which extends from the zygomatic arch as far as the inferior border of the mandible, and from the anterior border of the ramus to the corner of the mouth. The skin appears taut and red, with or without fluctuation of the abscess, which, if neglected, may result in spontaneous drainage.

25. Treatment. Access to the buccal space is usually intraoral for three main reasons:1. Because the abscess fluctuates intraorally in the majority of cases.2. To avoid injuring the facial nerve.3. For esthetic reasons.

26. The intraoral incision is made at the posterior region of the mouth, in an anteroposterior direction and very carefully in order to avoid injury of the parotid duct. A hemostat is then used to explore the space thoroughly. An extraoral incision is made when intraoral abccess would not ensure adequate drainage, or when the pus is deep inside the space. The incision is made approximately 2 cm below and parallel to the inferior border of the mandible.

27. Submandibular AbscessAnatomic Location. The submandibular space is bounded laterally by the inferior border of the body of the mandible, medially by the anterior belly of the digastric muscle, posteriorly by the stylohyoid ligament and the posterior belly of the digastric muscle, superiorly by the mylohyoid and hyoglossus muscles, and inferiorly by the superficial layer of the deep cervical fascia.This space contains the submandibular salivary gland and the submandibular lymph nodes.

28. Etiology. Infection of this space may originate from the mandibular second and third molars, if their apices are found beneath the attachment of the mylohyoidmuscle. It may also be the result of spread of infection from the sublingual or submental spaces.

29. Clinical Presentation. The infection presents as moderate swelling at the submandibular area, which spreads, creating greater edema that is indurated and redness of the overlying skin. Also, the angle of the mandible is obliterated, while pain during palpation and moderate trismus due to involvement of the medial pterygoid muscle are observed as well.

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31. Treatment. The incision for drainage is performed on the skin, approximately 1 cm beneath and parallel to the inferior border of the mandible.During the incision, the course of the facial artery and vein (the incision should be made posterior to these) and the respective branch of the facial nerve should be taken into consideration. A hemostat is inserted into the cavity of the abscess to explore the space and an attempt is made to communicate with the infected spaces.Blunt dissection must be performed along the medial surface of the mandibular bone also, because pus is often located in this area as well. After drainage, a rubber drain is placed.

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35. Masticatory space:This space is formed by the splitting of the superficial layer of deep cervical fascia as it encloses the mandible and the primary muscles of mastication. Contents of this space include: 1. Masseter muscle 2. Medial & lateral pterygoid muscles 3. Ramus & posterior portion of the body of mandible 4. Insertion of the temporalis muscle

36. Supero medially this space communicates with the temporal space medial to the zygomatic arch. Infections involving this space involve the temporal space also. The most common cause of infection within this space is from abscessed third molar tooth

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38. Anatomic Location. The space in which this abscess develops is cleft-shaped and is located between the masseter muscle and the lateral surface of the ramus of the mandible. Posteriorly it is bounded by the parotid gland, and anteriorly it is bounded by the mucosa of the retromolar area.

39. Etiology. Infection of this space originates in the mandibular third molars (pericoronitis), and in rare cases because of migratory abscesses.

40. Clinical Presentation. It is characterized by a firm edema that is painful to pressure in the region of the masseter muscle, which extends from the posterior border of the ramus of the mandible as far as the anterior border of the masseter muscle. Also, severe trismus and an inability to palpate the angle of the mandible are observed. Intraorally, there is edema present at the retromolar area and at the anterior border of the ramus. This abscess rarely fluctuates, while it may present generalized symptoms.

41. Treatment. Treatment of this abscess is basically intraoral, with an incision that begins at the coronoid process and runs along the anterior border of the ramus towards the mucobuccal fold, approximately as far as the second molar. The incision may also be performed extraorally on the skin, beneath the angle of the mandible.In both cases, a hemostat is inserted, which proceeds as far as the center of suppuration and until it comes into contact with bone.Because access is distant from the purulent accumulation, often it is difficult to drain the area well, resulting in frequent relapse.

42. Ludwig's angina Otherwise known as angina Ludovici, is a serious, potentially life-threatening cellulitis, or connective tissue infection, of the floor of the mouth, usually occurring in adults with concomitant dental infections and if left untreated, may obstruct the airways, necessitating tracheotomy. It is named after the German physician, Wilhelm Friedrich von Ludwig who first described this condition in 1836. Other names include "angina Maligna" and "Morbus Strangularis".

43. Ludwig's angina should not be confused with angina pectoris, which is also otherwise commonly known as "angina". The word "angina" comes from the Greek word ankhon, meaning "strangling", so in this case, Ludwig's angina refers to the feeling of strangling, not the feeling of chest pain, though there may be chest pain in Ludwig's angina if the infection spreads into the retrosternal space.The life threatening nature of this condition generally necessitates surgical management with involvement of critical care physicians such as those found in an intensive care unit.

44. Causes Dental infections account for approximately eighty percent of cases of Ludwig's angina. Mixed infections, due to both aerobes and anaerobes, are of the cellulitis associated with Ludwig's angina. Typically, these include alpha-hemolytic streptococci, staphylococci and bacteroides groups.

45. The route of infection in most cases is from infected lower molars or from pericoronitis, which is an infection of the gums surrounding the partially erupted lower (usually third) molars. Although the widespread involvement seen in Ludwig's usually develops in immunocompromised persons, it can also develop in otherwise healthy individuals. Thus, it is very important to obtain dental consultation for lower-third molars at the first sign of any pain, bleeding from the gums, sensitivity to heat/cold or swelling at the angle of the jaw.

46. Symptoms and signs True Ludwig's Angina is a cellulitic facial infection. The signs are bilateral (meaning both sides) lower facial swelling around the lower jaw and upper neck. This is because the infection has spread to involve the Submandibular, Sublingual and Submental spaces of the face

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49. Swelling of the Submandibular space, while externally is concerning the true danger lies in the fact that the swelling has also spread inwardly - compromising, or in effect narrowing the airway. Dysphagia (difficulty swallowing), Odynophagia (pain during swallowing) are symptoms that are typically seen and demand immediate attention.

50. The Sublingual and Submental spaces are anterior (beneath the middle and chin areas of the lower jaw) to the Submandibular space. Swelling in these areas can often push the floor of the mouth, including the tongue upwards and backwards - further compromising the airway.

51. Localisation of infection to the sublingual space is accompanied by swelling of structures in the floor of the mouth as well as the tongue being pushed upwards and backwards.Spread of infection to the submaxillary spaces is usually accompanied by signs of cellulitis rather than those of an abscess. Submental and submandibular regions are swollen and tender.

52. Additional symptoms include malaise, fever, dysphagia (difficulty swallowing), odynophagia (pain during swallowing) and, in severe cases, stridor or difficulty breathing. There may also be varying degrees of trismus. Swelling of the submandibular and/or sublingual space is imminent. 

53. Treatment Treatment involves appropriate antibiotic medications, monitoring and protection of the airway in severe cases, and, where appropriate, urgent maxillo-facial surgery and/or dental consultation to incise and drain the collections. The antibiotic of choice is from the penicillin group.

54. Incision and drainage of the abscess may be either intraoral or external. An intraoral incision and drainage procedure is indicated if the infection is localized to the sublingual space. External incision and drainage is performed if infection involves the perimandibular spaces.

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