Jaw abscess. What are phlegmons and abscesses of the maxillofacial region: causes on the upper and lower jaws, types, treatment

Phlegmon and abscesses maxillofacial area

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, it often violates such important features like chewing, swallowing, breathing. 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.

Due to the rapid development of phlegmon of the maxillofacial region and the possibility of severe and sometimes fatal complications (despite modern methods treatment) in inflammatory processes of this kind, emergency intervention is required. 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 germs 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 already true phlegmon they do not seek medical help for a long time, so the doctor in such cases examines the patient for the first time with already long time developing purulent inflammatory process.

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 ways of spreading the exudate to the side is achieved. chest. 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 this is a 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 tissue edema dramatically change the patient's usual facial features: the natural facial folds disappear, sometimes the edema leads to a 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 (adjustment of the jaws, hyperemia of the skin, mucous membrane, etc.) make it possible 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, shift of 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 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 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 times are 15 min, saturation time (saturation) 45 min. 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.

First positive results exposure to the cavity of the abscess and the wound itself of the rays of the helium-neon laser. 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 powerful tool fight infection, however, 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) are effective. per day), ampicillin (500 mg 4-6 times a day orally). 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.

Everything lately greater value for the treatment of purulent inflammatory processes acquires immunotherapy. 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. In cases more severe course of phlegmon additionally intravenously or intramuscularly injected 4 ml 2 times a day antistaphylococcal gamma globulin (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, because of the sharp pain that occurs when trying to make a chewing or swallowing movement, patients eat very little, so 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, therefore they need special care: 3-4 times washing with a rubber balloon of the oral cavity with a 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 floor 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 in wide incisions in the region of the floor of the oral cavity, possibly early dates. 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 antigangrenous serum, loading doses of broad-spectrum antibiotics, intravenous administration large quantities 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 edematous tissues, sometimes a tracheotomy is needed. 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.

A jaw abscess (like a maxillary abscess) most often develops as a result of traumatic damage to periodontal pockets and further infection with streptococci and staphylococci. The cause of injury can be very different.

Cause of an abscess

Staphylococci and (or) streptococci, which are in small quantities in humans, enter the soft tissues at the site of injury, and as a result, inflammatory processes begin in nearby tissues.

Symptoms of a jaw abscess

The disease is characterized by the following symptoms:

Pain at the site of the abscess;

Redness of the mucous membrane of the mouth and face;

limited swelling;

Nausea and vomiting;

fever and chills;

Severe pain on palpation;

- headache and fatigue;

Pain when trying to fully open the mouth (in some cases, pain occurs when swallowing).

For any of the above symptoms, it is recommended to visit a dentist. If at the same time your condition noticeably worsens, you should immediately contact the emergency department.

Diagnostics

Diagnosis is made by examination by a dentist. To confirm the diagnosis, you will most likely be sent for an x-ray. X-ray examination helps to identify even the smallest abscesses. A complete blood count is recommended.

Abscess treatment

Abscesses are subject to surgical treatment. The abscess is opened, drained, and a course of antibiotic therapy is prescribed to prevent complications. The treatment uses local anesthesia. Self-treatment (alternative medicine,

Fatty tissue here is located in three layers: the first is subcutaneous, in which the subcutaneous muscle can be included, located between the skin and the outer sheet of its own fascia, the second - between its own fascia and the maxillo-hyoid muscle (the so-called lower floor of the floor of the mouth) and the third - above the maxillohyoid muscle, limited by the mucous membrane of the floor of the mouth and the muscles of the root of the tongue (Fig. 2).

The complex topographic structure of the floor of the oral cavity is the cause of not only the severe clinical course of phlegmon in this area, but also the difficulties of their treatment. These circumstances are further complicated by the fact that the muscles of the floor of the oral cavity are intimately intertwined with the muscles of the root of the tongue and form a complex muscular-fascial-cellular complex, the fascial node of which is the hyoid bone. The complexity of the structure of this area is aggravated by the location of the submandibular and sublingual salivary glands here and the close proximity of the initial sections of the respiratory and digestive systems(Fig. 3).

Abscesses and phlegmons of the chin area occur with diseases of the central teeth of the lower jaw or the spread of infection with skin pustular diseases.

The clinical course of an abscess or phlegmon is not severe, topical diagnosis is simple: the face is sharply elongated due to the hanging "second chin", the mouth is free to open, the tongue is in a normal position, the skin of the submental region is quickly involved in the infiltrate, hyperemia appears. The infiltrate can freely descend to the neck, since the hyoid bone does not prevent the spread of infection through the superficial cellular space. There is also no median suture of the neck in this layer, so the infiltrate can freely spread to both sides. Upon reaching the handle of the sternum, the abscess does not penetrate into the mediastinum, but spreads through the subcutaneous tissue to the anterior surface of the chest.

During the surgical opening of the phlegmon of the superficial cellular layer of the submental region, the incision is made depending on the prevalence of the process: if the abscess is located closer to the chin, an incision can be made along the midline or arcuate along the lower edge of the abscess, as if blocking the path to its further spread. If the lower border of the abscess is determined closer to the projection of the hyoid bone, then the most reasonable and cosmetically justified is a horizontal incision along the upper cervical fold.

On the front surface of the neck and chest, it is also most rational to make horizontal cuts along the lower edge of the abscess.

Phlegmon and abscesses of the buccal region. The buccal region is enclosed between the muscle of laughter, the chewing muscle itself, the edge of the zygomatic arch and the edge of the lower jaw. The infection penetrates into this area from the upper or lower large molars, less often with the spread of purulent exudate from subperiosteal abscesses in this area, more often as a result of the spread of pus from the infratemporal, pterygopalatine and temporal fossae. The indicated spread of infection is promoted by the communication of the listed cellular spaces through the fatty lump of the cheek.

The purulent process can also spread in the opposite direction along the same cellular pathways, when, for example, when the fatty tissue of the cheek is infected through the damaged mucous membrane or hematogenously with ulcerative stomatitis, a cheek abscess is initially formed, which quickly spreads and turns into a diffuse phlegmon.

A harbinger of generalization of infection is the involvement of Bish's fat lump in the inflammatory process. At the same time, against the background of a sluggish course of the disease, the condition worsens, both local and general, which is explained by the relatively large volume of the fat lump, and most importantly, by the rapid absorption of toxins from all interested cellular spaces.

Other local symptoms of involvement of the fat lump in the process are a rapid increase in edema of the cheeks, eyelids, and the appearance a day or even earlier of an initially painless cushion-like swelling in the temporal region above the zygomatic arch. On palpation, “false fluctuation” is determined, muscle contracture increases due to the inclusion of both pterygoid muscles in the process.

Surgical treatment of an abscess, and even more so a phlegmon of the cheek, is not simple, despite the apparent accessibility of the abscess. This is due to the fact that the exudate can be in different layers of this area. If the edema is insignificant on the outside of the cheek, and a sharp swelling of the mucous membrane is noted in the oral cavity, this indicates the location of the abscess between the submucosal layer and the buccal muscle. With such localization, an autopsy can be successfully performed through the mucous membrane. With the predominant distribution of edema outward, relatively little involvement in the process of the mucous membrane, the abscess is located between the buccal aponeurosis and the buccal muscle. Successful treatment of an abscess can be achieved either by opening the skin along the lower edge of the inflammatory bulge, or from the side of the oral cavity, but with drainage of the abscess cavity through a tube.

With a late referral to the surgeon, the process, as a rule, extends to all layers of the fiber of this localization, and it is often necessary to open the abscess both through the mucous membrane and through the skin, according to the type of counter-opening.

Abscesses and phlegmon of the submandibular triangle.

The anatomical boundaries of the submandibular triangle are the lower edge of the body of the lower jaw, the anterior and posterior belly of the digastric muscle, the upper wall is the maxillohyoid muscle, covered with a deep sheet of its own fascia, the lower wall is the superficial sheet of its own fascia of the neck. The tissue that fills this space contains the submandibular salivary gland, facial artery, anterior facial vein, and lymph nodes.

Submandibular cellular space along the submandibular duct salivary gland and its additional lobe, located along the Wharton duct, communicates with the submental cellular space.

In the submandibular triangle, the infection penetrates from the area of ​​the focus of inflammation with difficult eruption of the wisdom tooth, as well as from the periapical foci of the lower molars and premolars. The clinical course of moderate severity, however, when the abscess spreads to neighboring cellular spaces, the severity of the patient's condition worsens. Inflammatory contracture of I-II degree, swallowing is somewhat painful, the inflammatory reaction in the area of ​​the floor of the mouth is almost not determined.

In addition to the marked cellular spaces, the spread of the abscess often occurs in the peripharyngeal space and on the neck.

Surgical opening of the phlegmon of the submandibular triangle is performed with an incision from the side of the skin, 2 cm away from the edge of the lower jaw. By dissecting the skin, subcutaneous tissue, subcutaneous muscle and the outer sheet of the own fascia of the neck, an abscess is opened, a digital revision is made to combine all existing streaks and spurs of the abscess into one common cavity.

In order to avoid damage to the facial artery and anterior facial vein, when dissecting tissues during surgery, one should not approach the bone of the body of the lower jaw with a scalpel, over the edge of which these vessels are thrown along the line of the anterior border of the masticatory muscle proper. And in general, in order to prevent unexpected damage to blood vessels during the opening of phlegmon of any localization, the operation must be performed, observing all the rules of classical surgery: layer-by-layer dissection of tissues, taking into account the characteristics of the surgical anatomy of this area, mandatory dilution of the edges of the wound with hooks, ligation of vessels during the operation, prevention of narrowing of the wound as you deepen.

With sufficient gaping of the edges of the wound, drainage of the abscess of the submandibular region can be done with two rubber tubes, around which on the 1st day a gauze swab moistened with a hypertonic solution of sodium chloride can be loosely inserted.

Phlegmon of the pterygo-jaw space. The anatomical boundaries of the pterygo-jaw space are: the branch of the lower jaw, the medial pterygoid muscle; from above - the lateral pterygoid muscle, covered with interpterygoid fascia; in front - the pterygo-jaw suture, to which the buccal muscle is attached; behind the fiber of the pterygo-maxillary space passes into the fiber of the maxillary fossa, where the parotid salivary gland is located.

In addition to the maxillary fossa, there is communication with the peripharyngeal space, the infratemporal and pterygopalatine fossae, the fatty lump of the cheek, and through the semilunar notch, with the masticatory space.

The pterygo-maxillary space is a narrow gap where a significant exudate tension can be created, therefore, before the spread of pus to neighboring cellular spaces, the leading symptoms of the disease are inflammatory contracture of II-III degree as a result of involvement of the medial pterygoid muscle in the inflammatory process and intense constant pain as a result of compression exudate and infiltrate of the lower alveolar nerve passing here. Changes in the nerve can be so profound that sometimes paresthesia occurs in the corresponding half of the lip and chin (Vincent's symptom), which makes it difficult differential diagnosis phlegmon and osteomyelitis of the lower jaw.

In the first days of the disease, there are completely no objective external changes in the face, since there is a branch of the lower jaw between the abscess and the superficial tissues. The Salt point, located on the inner surface of the angle of the lower jaw in the area of ​​attachment of the tendon of the medial pterygoid muscle to the bone, helps to clarify the diagnosis. With the developed process in this place, you can feel the swelling.

The second pathognomonic symptom is pastosity, and sometimes swelling and hyperemia in the region of the pterygo-mandibular fold (Fig. 4).

Surgical opening of the phlegmon of the pterygo-maxillary space is performed from the side of the skin in the submandibular region with an incision bordering the angle of the lower jaw, departing from the edge of the bone by 2 cm. A part of the tendon of the medial pterygoid muscle is cut off with a scalpel, the edges of the entrance to the cellular space are bluntly pushed apart with a hemostatic clamp. Purulent exudate comes out from under the muscles under pressure, a rubber outlet tube is inserted into the cavity.

Phlegmon of the peripharyngeal space. The anatomical boundaries of the peripharyngeal space are: the inner wall - the lateral wall of the pharynx; the outer wall is the internal pterygoid muscle and the interpterygoid fascia, anteriorly, both side walls approach and grow together at an acute angle with the pterygo-maxillary suture; the posterior border is formed by lateral spurs of the prevertebral fascia, leading to the wall of the pharynx. The muscles extending from the styloid process (ryolan bundle), covered with the pharyngeal aponeurosis, form the Jonesque diaphragm, which divides the peripharyngeal cellular space into the anterior and posterior sections.

Thus, the indicated aponeurosis is an obstacle that prevents the penetration of pus from the anterior part of the space into the posterior one, where the neurovascular bundle of the neck passes.

In the event of a breakthrough of the abscess into the posterior part of the space, there is a direct threat of its spreading down along the fiber around the vessels and nerves up to the anterior mediastinum. The anterior part of the peripharyngeal space has free communication with several surrounding cellular formations: the infratemporal and retromaxillary fossae, the pterygo-maxillary space, the upper part of the floor of the mouth and the root of the tongue along the stylohyoid and stylohyoid muscles; the bed of the parotid gland, with its pharyngeal spur, through the oval opening in the inner leaf of its fascial sheath, also goes directly into the anterior part of the peripharyngeal space (Fig. 5, 6, 7).

A large number of communications of parapharyngeal tissue with the surrounding cellular spaces is the reason for its frequent inclusion in the area of ​​the purulent process, while primary phlegmon rarely occurs here.

The clinical course of phlegmon of the peripharyngeal space at the very beginning is not severe, since its inner wall is supple, due to which the exudate tension is insignificant, inflammatory contracture of I-II degree. As the pus spreads down to the floor of the mouth and to the neck, the severity of the condition quickly increases due to increased pain, impaired swallowing. The severity of the patient's condition is aggravated by the involvement of the epiglottis base in the process, which is accompanied by the appearance of signs of difficulty in breathing.

In the topical diagnosis of phlegmon, an examination of the lateral wall of the pharynx is important: in contrast to the phlegmon of the pterygo-maxillary space, pain in this localization is less intense and there is a pronounced painful swelling of the lateral wall of the pharynx. The mucous membrane is hyperemic, the soft palate is displaced by the infiltrate to the healthy side.

Surgical opening of the abscess of the peripharyngeal space in the initial phase is performed by an intraoral incision passing somewhat medially and posteriorly from the pterygo-maxillary fold, the tissues are dissected to a depth of 7-8 mm, and then stratified with a blunt hemostatic forceps, adhering to the inner surface of the medial pterygoid muscle, until pus is obtained . A rubber strip is used as drainage.

With phlegmon of the peripharyngeal space that has spread downward (below the level of the dentition of the lower jaw), the intraoral opening of the abscess becomes ineffective, so it is immediately necessary to resort to an incision from the side of the submandibular triangle closer to the angle of the lower jaw. After dissection of the skin, subcutaneous tissue, superficial fascia, subcutaneous muscle and outer leaf of the own fascia of the neck, the inner surface of the medial pterygoid muscle is found and the tissue is bluntly stratified along it until pus is obtained. This method of opening abscesses in the maxillofacial region can be called universal, since from the side of the submandibular triangle it is possible to revise the pterygo-maxillary, peripharyngeal and submassicular cellular spaces, the upper and lower parts of the floor of the mouth, the root of the tongue, the infratemporal, and through it the temporal and pterygopalatine pits. The versatility of this method also lies in the fact that when the abscess spreads after opening to another space, including the neck, the incision can be expanded in the appropriate direction. With diffuse phlegmon, the incision is always made below the level of the abscess of any cellular space of the maxillofacial region.

After a digital revision of the abscess and combining all its spurs into one common cavity for drainage, a tube and a loose gauze swab moistened with a solution of enzymes are inserted on the first day. The swab is removed the next day, leaving 1-2 tubes.

Abscesses and phlegmons of the submasserial space. The anatomical boundaries of the submassicular space are: the inner surface of the masticatory muscle proper, the outer surface of the lower jaw branch, the edge of the angle of the lower jaw, the zygomatic bone and the zygomatic arch. The submassicular space communicates with the temporal and retromandibular fossae, and in the anterior region with the buccal fat pad. These messages are formed in connection with the incomplete fusion of the parotid-masticatory aponeurosis, covering the masticatory muscle, with the anterior and posterior edges of the lower jaw branch.

The clinical course of the phlegmon of the submassular space, as a rule, is not severe, since the abscess does not spread to neighboring cellular spaces for a long time. The leading symptoms are the characteristic delineation of the abscess by the boundaries of the masticatory muscle, especially along the zygomatic arch and the edge of the angle of the lower jaw, inflammatory contracture of II-III degree. The space is closed, with unyielding walls, therefore, from the very beginning, pains of a bursting nature appear. At the same time, it is possible to determine the presence of pus under the muscle only with puncture, since fluctuation cannot be felt by palpation.

The incision during the surgical opening of the abscess is made parallel to the edge of the angle of the jaw, departing from it by 2 cm. The skin, subcutaneous tissue, fascia, and subcutaneous muscle are dissected. The tendon attachment of the chewing muscle itself is cut off from the bone for 2 cm, the muscle is bluntly peeled off with a clamp inserted under it, the abscess cavity is drained with a rubber tube.

Abscesses and phlegmon of the region of the parotid salivary gland and the retromaxillary fossa. The anatomical boundaries of the retromaxillary fossa are: the posterior edge of the branch of the lower jaw and the medial pterygoid muscle, behind the mastoid process and the sternocleidomastoid muscle extending from it; the inner border is made up of the styloid process and the muscles of the riolan bundle extending from it, on top - the ear canal, on the outside - the parotid-chewing fascia.

The parotid salivary gland is located in the retromaxillary fossa. The retromandibular region has communications with several surrounding cellular spaces: parapharyngeal, submassterior, pterygo-maxillary, and infratemporal fossa.

The infection penetrates into the retromaxillary cellular space either from the listed areas, or directly from the area of ​​​​foci of inflammation of the molars of the lower jaw.

The severity of the clinical course of phlegmon depends on the prevalence of the abscess in neighboring areas, especially in the parapharyngeal space. In the initial period of the disease, a dense, painless swelling appears, occupying the entire fossa. During this period, phlegmon is not easy to differentiate from mumps. A carefully collected anamnesis, the condition of the excretory duct and the nature of the saliva released from the duct help to correctly assess the condition of the gland. The state of the medial pterygoid muscle matters: with parotitis, inflammatory contracture is less pronounced than with phlegmon.

Surgical opening of the phlegmon is performed with an external vertical incision parallel to the posterior edge of the lower jaw branch and, depending on the prevalence of the abscess, the angle of the jaw is included. Drain the cavity with a rubber tube. When the abscess spreads into the peripharyngeal space, the incision is continued down, bordering the angle of the jaw with the transition to the submandibular triangle, and after a thorough digital revision of the cavity, drainage is performed during the day.

Causes of the formation of a boil on the chin

Furuncle is a purulent inflammation of the hair follicle, sebaceous gland and surrounding soft tissues. The reason for the formation of boils is a staphylococcal or streptococcal infection, pathogenic bacteria begin to actively multiply and affect the epidermis with a sharp decrease in immunity, exacerbation of chronic diseases, metabolic disorders, dermatitis.

A furuncle on the chin most often occurs in men due to frequent skin injury during shaving, rubbing with hands, and excessive sweating.

Causes of pathology

It is known that on the surface of the epidermis lives a large number of bacteria that do not cause disease in healthy person. With a decrease in the reactivity of the immune system, creating conditions of high humidity, pathogenic microorganisms begin to actively multiply, penetrate into the mouths of the sebaceous glands, cause inflammation of the hair follicle and surrounding tissues.

A furuncle on the chin may appear for the following reasons:

• facial hyperhidrosis;
• oncological diseases;
• long-term use of hormonal drugs, immunosuppressants, cytostatics;
• obesity;
• diabetes;
• unbalanced diet;
• hormonal imbalance, increased levels of androgens in the blood;
• lack of vitamins in the body;
• poor hygiene;
• frequent trauma to the skin of the chin;
• work in hazardous production, requiring contact with dust, lubricating oils;
• face dermatitis;
• exacerbation of chronic diseases.

A sharp weakening of immunity is observed in HIV-infected people, people who have undergone radiation or chemotherapy. Excessive production of sebum is noted with an increase in testosterone levels in the body of men and women. A viscous secret is an excellent nutrient medium for staphylococci and contributes to blockage of the mouths, the formation of an inflammatory process, suppuration.

Symptoms and stages of maturation

A boil on the chin in the initial stages looks like a red, painful, dense spot, which rapidly increases in size, swells. A few days later, a white purulent head is formed in the center of the infiltrate, consisting of dead necrotic tissues. As the boil matures, the skin bursts, and the purulent contents leak out. After that, the person feels better, the tissues begin to heal. If the boil was large, a scar may remain in its place.

General complaints of patients:

• soreness and burning sensation in the area of ​​infiltration;
• headache, aggravated by tilting the head, sudden movements, while eating;
• cosmetic defect, facial asymmetry;
• general weakness;
• increase in body temperature up to 38 °.

Multiple boils on the chin are called carbuncles. With this form of the disease, several follicles become inflamed at once, they can merge into a single, large focus, have several rods.

Chirya development stages:

1. The infiltrative form is characterized by the formation of a red, edematous spot around the hair. The size of the affected area can reach 3 cm in diameter, on palpation the skin is hard, painful, the person feels an unpleasant tingling, burning sensation.
2. The purulent stage occurs 3-4 days after the first signs of a boil appear. In the center of the hyperemic spot, a purulent core is formed, its head is clearly visible through the thinned skin. The infiltrate acquires a conical shape, rises above the surrounding tissues. After maturation, perforation of the epidermis occurs, pus flows out.
3. The stage of regeneration occurs after the rejection of necrotic masses. The patient's symptoms of malaise disappear, soreness, swelling decrease, wound healing begins.

You can not try to squeeze out the boil on the chin on your own. Since the face has a large number of blood and lymphatic vessels, pus can easily enter the systemic circulation and provoke the development of serious complications.

Treatment

It is necessary to treat any boil on the face in a hospital setting. With home extrusion, there is a high risk of secondary infection of tissues, damage to nerve endings, the formation of subcutaneous abscesses, phlegmon, lymphadenitis, and even sepsis.

At the stage of infiltration, it is enough to treat the abscess with solutions of antiseptics (Chlorhexidine, Furacilin), apply compresses with Ichthyol, Vishnevsky ointment, which accelerates the ripening of the boil. When forming a necrotic pustule, the use of Salicylic acid helps to quickly open the abscess. In some cases, surgical treatment is required, the dermis is cut with a scalpel and a thin rubber drain is installed.

After perforation, the doctor carefully removes the rod and rinses the wound, then applies a loose bandage with hypertonic sodium chloride solution, puts turundas with Methyluracil. If the discharge of necrotic masses is difficult, proteolytic enzymes are used: trypsin, chymotrypsin.

If boils often recur, physiotherapy is prescribed: ultraviolet radiation, laser exposure. Patients are prescribed immunomodulators (Immudon, T-activin), vitamin complexes(Vitrum, Milgamma), antistaphylococcal immunoglobulin.

When a boil forms on the face, antibiotic treatment is mandatory.

Prescribe drugs of the penicillin group, cephalosporins, tetracyclines. Accept medicines can be taken in tablet form or intramuscular injections. The course of treatment is 5-7 days.

If the cause of the formation of a boil is concomitant diseases internal organs, then in combination with the elimination of the abscess, the treatment of the underlying ailment should be carried out, otherwise the boils will appear again.

Ointments for external use

Local treatment of boils can be carried out with ointments:

Medicines are used for compresses on the affected area, they are recommended to be placed during the purulent stage. The active components of the gels kill pathogenic microflora, eliminate the risk of complications.

Ichthyol ointment and Vishnevsky's liniment accelerates the maturation of the boil, relieves swelling. Such funds are used in the stage of infiltration until the boil is opened. Compresses with Dimexide help to eliminate severe pain and reduce swelling.

During treatment, it is recommended to limit the use of sweets, rich pastries, give preference to fresh vegetables, fruits, dairy products. This is necessary to reduce the amount of carbohydrates in the body, which are a good breeding ground for bacteria.

My husband has very problematic skin. After shaving, constant irritation and acne. Recently, a furuncle popped up on my chin. He was treated with Elon ointment as prescribed by the doctor. He applied the ointment to the boil and covered it with a bandage. Helped to draw out the pus very well. Literally on the third day, the boil burst.

The information on the site is provided for informational purposes only, does not claim to be reference and medical accuracy, and is not a guide to action. Do not self-medicate. Consult with your physician.

Subcutaneous abscess of the zygomatic region. Abscess, phlegmon of the chin

Subcutaneous abscess of the zygomatic region

Opening of the abscess of the subperiosteal zygomatic region by intraoral access:

a - incision of the mucous membrane; b - opening of the abscess (according to Solovyov M.M., Bolshakov O.P.)

With subcutaneous phlegmon, abscess of the nasolabial region, the incision is made along the nasolabial fold.

Abscess, phlegmon of the chin

All surgical instruments can be assembled into kits that allow you to perform typical surgical procedures. On the instrumental table of the operating sister there should be “connecting instruments” - i.e. those that only the operating sister works with: scissors, small anatomical tweezers, etc.

For an error-free interpretation of changes in the analysis of the ECG, it is necessary to adhere to the scheme of its decoding given below.

For the convenience of describing the features of the relief or localization of pathological processes, 5 surfaces of the tooth crown are conditionally distinguished.

Video about the sanatorium Hunguest Helios Hotel Anna, Heviz, Hungary

Only a doctor can diagnose and prescribe treatment during an internal consultation.

Scientific and medical news about the treatment and prevention of diseases in adults and children.

Foreign clinics, hospitals and resorts - examination and rehabilitation abroad.

When using materials from the site, the active reference is obligatory.

Jaw abscess is a dangerous inflammatory disease

The diagnosis of "jaw abscess" is by no means pleasant. And if a doctor put it on you, then most likely the treatment has already been carried out and the precautions have been observed. If you only suspect this species diseases oral cavity we recommend that you read this article. From it you will learn not only about what a jaw abscess is, but also about how an abscess of the upper jaw differs from the lower jaw, how it is treated in a dental clinic, as well as how it should not be treated at home and what steps to take to avoid a similar problem in the future.

Most patients go to the dentist because of a toothache or any other problem related to their teeth, but they are not the only objects of treatment in dentistry. The fact is that the maxillofacial region is capable of presenting many unpleasant surprises associated with diseases of the neck, mucous and soft tissues of the oral cavity. You may experience an inflammatory process that will be difficult to tie to your teeth, but they may be the likely cause of the disease. Thus, knowing in advance the signs of inflammatory processes, you will be able to respond to the situation in time and not bring the disease to a chronic form by contacting a specialist for treatment.

Causes

The most likely cause of a jaw abscess is mechanical damage, trauma, or periodontal pockets (gaps between the tooth and gum that can become infected). An abscess can be caused by any infection that has entered the damaged area both from the outside and through the body's bloodstream. If a patient has chronic tonsillitis, streptococci and staphylococci, which constantly multiply in hypertrophied palatine tonsils, can be the cause of inflammation. In this case, the patient is recommended not only to treat the abscess itself and damaged soft tissues of the oral cavity, but also to remove the tonsils if their treatment is not possible. Otherwise, infection may recur repeatedly.

Symptoms and signs

To determine the presence of an inflammatory process, it is enough to know a number of common signs inherent in this disease:

• persistent severe headaches, general malaise, chills;
• in some cases, an increase in body temperature, in particular hyperemia of the inflamed area;
• leukocytosis;
• the presence of fluctuation (accumulation of pus) under the mucosa in the form of a small reddened swelling.

If the above signs are present, the patient is advised to immediately consult a doctor for prompt treatment, otherwise the inflammation may intensify, grow into neighboring areas, develop into more serious diseases or give complications to the respiratory system.

Based on the presence of the upper and lower parts of the jaw in a person, these inflammatory processes can be divided into two types: abscess of the lower jaw (the abscess of the submandibular can also be attributed to the same type, since their sources of origin are the same) and the upper jaw.

Maxillary abscess

The most common source of infection is the upper wisdom teeth. Causes difficulty in opening the mouth and swallowing.

Mandibular abscess

Most often, the infection spreads from the lower large molars (molars and premolars). The patient's complaints are mostly associated with pain when chewing and swallowing.

A submandibular abscess is characterized by visually noticeable and painful swelling in the submandibular triangle, and the shape of the face may be distorted.

Treatment and prevention

Treatment of a jaw abscess consists in opening the abscess and draining the fluid, after which the damaged area is disinfected. When high temperature the patient is prescribed antibiotics, with a general weakening of the immune status - immunomodulatory drugs, recommendations for taking analgesics are also given by the doctor. In rare cases, for better healing of the postoperative incision, physiotherapy procedures, UVI are prescribed.

To prevent inflammation of this kind, it is advisable to visit the dentist every six months, heal periodontal pockets on time, adhere to a sparing diet enriched with vitamins, and also use appropriate therapeutic toothpastes.

Some adherents of alternative medicine believe that the above inflammations of the maxillofacial region can be easily cured without resorting to surgery. Of course, there is a possibility that the abscess will open on its own, however, if it is not cleaned and the remnants of dead particles and pathogenic bacteria are not removed from the wound, there will be a high probability of an acute state becoming chronic or phlegmon, as well as intoxication of the body with decay products remaining in the untreated abscess .

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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 infiltrate 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.

With purulent-necrotic phlegmon, after dissection of one's own fascia, the facial artery and vein, submandibular salivary gland withdraw downward, remove necrotic tissue, perform an audit of the submandibular space for possible streaks.

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