Submandibular phlegmon treatment. What are phlegmons and abscesses of the maxillofacial area: causes of occurrence in the upper and lower jaw, types, treatment

Formation of an inflammatory purulent focus in the tissues of the maxillofacial area of ​​the face. It manifests itself as local swelling, redness and fluctuation (fluctuation) of the skin over the source of inflammation, facial asymmetry, difficulty and pain in swallowing, and symptoms of intoxication. It can develop into diffuse inflammation - phlegmon, involving 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 area. If abscesses are left untreated, purulent decay and purulent melting of adjacent tissues begin.

Causes of perimaxillary abscess

Abscess is caused by streptococcal and staphylococcal microflora, the most common cause are dental diseases and inflammatory processes in the maxillofacial area. Furunculosis, tonsillitis, and tonsillitis in chronic cases are complicated by perimandibular abscesses. Damage to the skin and mucous membranes in the mouth, infection during dental procedures can provoke an abscess in the perimaxillary area.

Are common infectious diseases, occurring as 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 perimaxillary zone. An abscess in the maxillary area can occur due to facial trauma. During military operations and natural disasters, due to the lack of first aid, dislocations and fractures of the jaw are often complicated by abscesses. Periapical and pericoronal foci of inflammation and periodontal pockets during exacerbations can provoke jaw abscess due to resorption bone tissue.

Symptoms of perimandibular abscess

The formation of an abscess is preceded by toothache, as in periodontitis. Biting on the affected area increases the pain. Next comes dense swelling with the formation of a painful compaction. An abscess developing under the mucous membrane is characterized by bright hyperemia and protrusion of the affected area. Facial asymmetry is sometimes noted.

In the absence of therapy, the patient’s general condition worsens: body temperature rises, refusal of food is observed. After spontaneous opening of the abscess, the pain subsides, the contours of the face take on normal shape, and general 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 worsen. Chronic suppuration from the fistulous tracts is possible; it is accompanied by an unpleasant odor from the mouth and ingestion of purulent masses. The body becomes sensitized by decay products, and allergic diseases worsen.

Abscesses of the floor of the mouth are characterized by hyperemia in the sublingual zone with rapid formation of infiltrate. Conversation and eating become sharply painful, and hypersalivation is noted. The mobility of the tongue decreases, it rises slightly upward so as not to come into contact with the forming abscess. As the swelling increases, the general condition worsens. Upon spontaneous opening, the pus spreads to the peripharyngeal region and neck, which leads to the appearance of secondary purulent foci.

Palate abscess most often occurs as a complication of periodontitis of the upper second incisor, canine and second premolar. During the formation of an abscess, hyperemia and soreness of the hard palate are observed; after the bulging, the pain becomes more intense, eating becomes difficult. Upon spontaneous opening, the purulent contents spread to the entire area of ​​the hard palate with the development of osteomyelitis of the palatine 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 oral mucosa. The soreness of the lesion is moderate; when the facial muscles work, the pain intensifies. The general condition is practically not affected, but an abscess of the cheek is dangerous if it spreads to neighboring parts of the face even before opening the abscess.

A tongue abscess begins with pain in the thickness of the tongue, the tongue increases in volume and becomes inactive. Speech, chewing and swallowing food are severely difficult and painful. Sometimes with an abscess there may be a feeling of suffocation.

Diagnosis and treatment of perimandibular abscess

The diagnosis is made based on a visual examination of the dentist and patient complaints. Sometimes during the survey it turns out that there have been boils in the facial area, or there are chronic infectious diseases. Before visiting a doctor, it is recommended to take analgesics and 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 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. The localization of abscesses in the perimaxillary area, the age of the patient and the presence of concomitant diseases significantly influence the principles of treatment. The more complicating factors, the more intense the therapy should be.

During the treatment of abscesses of the perimaxillary area, it is recommended to follow a diet with a predominance of pureed soups and purees. If there is a persistent refusal to eat, they resort to intravenous administration of protein solutions. If there is a formed abscess, its opening followed by drainage of the cavity is indicated. In other cases, antibiotic therapy is resorted to, and only if it is inappropriate, the question of surgical treatment is raised.

Antibiotics are prescribed by injection or in tablet forms, and an additional course of vitamin therapy is given. Immunostimulants and detoxification therapy are indicated. Rinsing the mouth with warm solutions of furatsilin and soda relieves swelling and prevents the spread of infection. In the presence of pronounced pain, analgesics are used. When complex therapy is started on time, the prognosis is usually favorable, recovery occurs within 6-14 days.

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Abscess, phlegmon of the chin area

The submental tissue space is located under the diaphragm of the mouth (mylohyoid muscle) and is limited above by its own, below by the superficial fascia of the neck, in front by the lower jaw, behind by the hyoid bone, and on the sides by the anterior bellies of the digastric muscle. The submental lymph nodes are located in the tissue.

The inflammatory process mainly begins with lymphadenitis. The source of infection is the lower incisors and canines; less often, inflammation spreads along the extension from the sublingual and submandibular spaces. Accordingly, infection from the submental space may spread to these areas.

The pain is localized in the submental area and intensifies with chewing and swallowing. General signs of inflammation: increased body temperature, manifestations of intoxication are not pronounced. Upon examination, some swelling in the submental area, smoothness of skin folds, and sometimes skin hyperemia are detected.

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 occur with acute submental lymphadenitis.

The limited nature of the 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. Abscess formation of lymphadenitis and the formation of adenophlegmon can be determined by ultrasound. It shows fluid formation, destruction of the lymph node. In doubtful cases, a puncture is performed; the receipt of pus indicates an abscess or phlegmon.

To open the submental phlegmon, a 3-4 cm long incision is made along the midline, 1-1.5 cm away from the edge of the lower jaw. Along the incision, the superficial layer of the fascia is dissected and the abscess is opened bluntly using a hemostatic clamp, directing it to the center of the inflammatory infiltrate. The pus is removed, and a tape drainage made of rubber gloves is inserted into the resulting cavity.

Submandibular (submandibular) phlegmon

Most often this is adenophlegmon, the source of damage to the lymph nodes is dental disease. Inflammation may spread to the submandibular tissue during periostitis, osteomyelitis of the mandible. The spread of a purulent process along the extension from the sublingual, submental areas, and from the pterygo-maxillary space is not excluded. Adenophlegmon becomes a consequence of acute submandibular lymphadenitis.

The disease manifests itself as pain in the submandibular region against the background of fever and intoxication; it is often preceded by diseases of the posterior lower molars, periodontitis, and periostitis. The pain intensifies when moving the jaw, trying to open and close the mouth. Upon examination, an infiltrate under the horizontal branch of the lower jaw closer to the rear, swelling of soft tissues, and sometimes hyperemia of the skin are determined. The infiltrate is located under the jaw and inward from its lower edge, closer to the corner.

With phlegmon in the subcutaneous tissue, the infiltrate is large, the skin over it is hyperemic. In case of an inflammatory process under the own fascia (bed of the submandibular salivary gland), i.e. with adenophlegmon, swelling may be absent, deep palpation is painful. The infiltrate may be unclear. Bimanual palpation allows you to determine the size and localization of the infiltrate and exclude involvement of the sublingual space in the inflammatory process.

When the abscess is localized under the fascia of the neck, the inflammatory process can spread to the sublingual, submental area, into the peripharyngeal cellular space and further into the posterior mediastinum. The spread of infection is possible through the retromandibular fossa into the fascial sheath of the neurovascular bundle of the neck and further into the anterior mediastinum.

The submandibular phlegmon is opened from a 5-6 cm long incision made 2 cm inward and parallel to the lower jaw. The skin, along with the tissue and superficial fascia, is peeled upward to the edge of the lower jaw. The subcutaneous muscle is dissected using the probe. In this case, it is possible to open the superficial abscess located under the superficial fascia. The proper fascia is dissected and then penetrated with a closed hemostatic clamp into the submandibular cellular space itself. The abscess is opened, the pus is removed, and the cavity is drained.

In case of purulent-necrotic phlegmon, after dissection of the native fascia, the facial artery and vein are isolated and ligated, the submandibular salivary gland is retracted downwards, necrotic tissue is removed, and the submandibular space is inspected for possible leaks.

The abscess of the submandibular space can be opened from an incision at the angle of the lower jaw.

The skin and subcutaneous tissue are dissected at the angle of the jaw and, using a Billroth forceps with closed jaws, moving it along the posterior edge of the mylohyoideus to the abscess, they bluntly penetrate into its cavity. By spreading the jaws, the abscess is opened, the pus is removed, the cavity is washed with an antiseptic solution and drained.

If phlegmon spreads to the submental area, a counter-aperture is performed under the chin and through drainage is carried out.

VC. Gostishchev

Cellulitis and abscesses of the maxillofacial area

Cellulitis, like abscesses, develops as a result of inflammation in the tissue. However, in contrast to the diffuse nature of inflammation of the fiber with its subsequent melting during phlegmon, an abscess is characterized by a limited area of ​​​​melting of the fiber. Cellulitis and abscess, having common etiological origins and pathogenesis, are considered together also because clinical clear differential diagnosis between them often 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 severe than a limited process.

Cellulitis of the maxillofacial area is a serious and extremely dangerous disease. The severity of the condition during a diffuse inflammatory process is determined by the high intoxication of the body. Well-defined innervation of the maxillofacial area determines severe pain with the development of an inflammatory infiltrate. In addition, such important functions like chewing, swallowing, breathing. The danger of phlegmon in the maxillofacial area is determined by both the proximity of vital formations and the anatomical and topographical 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 contracted 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 first phlebitis, and then thrombophlebitis. This process through the ophthalmic vein in an ascending manner 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 in the maxillofacial area are significantly aggravated.

Due to the rapid development of phlegmon in the maxillofacial area and the possibility of severe and sometimes fatal complications (despite modern methods treatment) inflammatory processes of this kind require emergency intervention. Delaying surgery even for a few hours in some cases can lead to serious consequences. Therefore, providing assistance to patients with phlegmon of the maxillofacial area should be urgent and urgent. It is quite natural that a doctor of any specialty can meet with such patients, especially at night. This places a special responsibility on doctors who are not dentists.

Topographically, phlegmons of the face, perimandibular, floor of the mouth, peripharyngeal, tongue and neck are distinguished. However, the localization of the purulent inflammatory process on the face can be varied, essentially wherever there is fiber. Often, phlegmon spreads to a number of areas, causing the diffuse nature of acute inflammation (Fig. 100).

Cellulitis of the maxillofacial region is 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 facial skin (furuncle, carbuncle), fracture of the jaws, etc. Phlegmon can develop as a result of the introduction of infection by hematogenous route or when introducing germs with a needle in the case of injection anesthesia.

Cellulitis develops in the tissue, where the infection enters percontinuitatem or directly (injuries, violation of asepsis). Based on the nature of the exudate, purulent, purulent-hemorrhagic and putrefactive phlegmon are distinguished.

The causative agents of phlegmon in the maxillofacial area are most often staphylococcus, streptococcus, E. coli, pneumococcus Pseudomonas aeruginosa, dental spirochete, as well as various anaerobes. Recently, the predominance of staphylococcus as the causative agent of phlegmon has become obvious. Staphylococcus turned out 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 causes of phlegmon are bacteroids, Escherichia coli and Pseudomonas aeruginosa. The latter circumstance especially requires an individual approach to the selection and prescription of antibacterial agents.

Gas phlegmon caused by anaerobes or anaerobes in symbiosis with other bacteria (mixed infection) has a particularly severe course and prognosis. With gas phlegmon, tissue necrosis occurs. The muscles resemble boiled meat, are pale, and do not bleed. Gas bubbles form in the affected tissues.

The inflammatory process in the tissue of the maxillofacial area 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 increases very quickly. At the same time, the development of local changes (infiltration, hyperemia, pain, etc.) is combined with high intoxication of the body, so even on the first day of the disease there is a rise in body temperature to 38-40 ° C, general weakness, tremendous chills, sometimes replaced by a feeling of heat, headache, changes in blood and urine. In the case of slower development of phlegmon, in particular with adenophlegmon, this is often preceded by toothache (periodontitis), periostitis, and lymphadenitis. The possibility of these phenomena subside and increase again is not excluded. Even when 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 and at the time of the development of true phlegmon they do not seek medical help for a long time, so 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 its subacute development, takes on the character of diffuse pus spreading into neighboring sections and tissues, without clearly identifying the infiltrate. This is facilitated by the anatomical and topographical features of the area, when pus spreads through the intermuscular and interfascial spaces in the deep layers of tissue without the external manifestation of typical infiltration and hyperemia of the skin. Therefore, one of the features of the treatment of phlegmon of the maxillofacial area is the need for surgical intervention even without the presence of a visible inflammatory infiltrate and fluctuation. This especially applies to the sublingual and neck areas. By opening the abscess and draining it, the intersection of the paths of exudate spreading to the side is achieved chest. For the same purpose, in some cases, several transverse incisions are made in the neck up to the level of the collarbone. An important point this involves dissection of the subcutaneous muscle of the neck, under which migration of exudate usually occurs.

The most common source of infection during the development of phlegmon of the maxillofacial area is acute or aggravated chronic periodontitis. In 96-98% of cases, phlegmon of the maxillofacial area is odontogenic, so their occurrence is usually preceded by dental disease. The development of phlegmon can be extremely rapid and, conversely, very slow. Phlegmon emanating from the lymph node (adenophlegmon) is characterized by slow development.

Typically, phlegmon of the maxillofacial area begins with the appearance of a painful infiltrate and increasing pain. As the inflammatory process develops, the infiltrate increases, the pain increases, becoming pulsating. When phlegmon is located superficially, the skin above the infiltrate becomes hyperemic, shiny, and does not form a fold.

Infiltration and inflammatory swelling of the tissues dramatically change the patient’s usual facial features: the natural folds of the face disappear, sometimes the swelling leads to a narrowing of the palpebral fissure and its complete closure. Localization of the process near the masticatory muscles causes the development of inflammatory contraction of the jaws, making it difficult to eat regular food.

As a rule, phlegmon of the maxillofacial area 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 and the presence of fluctuations indicate the melting of the infiltrate and the formation of pus. With deep-lying phlegmon, the inflammatory infiltrate is not detected either visually or by palpation for a long time. As the infiltrate develops, its contours become more blurred than with a superficial location. The absence of an infiltrate clearly felt during examination in the first days of the development of Phlegmon complicates both diagnosis and treatment. However, dynamic observation of the patient, the appearance of local symptoms (jaw constriction, 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 of phlegmon is combined with 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, and sleep is disturbed.

In severe cases, high intoxication causes disorders of cardiac activity and consciousness. If the infection that causes the development of phlegmon is anaerobic, 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 disturbances in cardiac activity and breathing.

On the blood side, with phlegmon of the maxillofacial area, 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 toxic nephritis occurring (as a complication), protein, sometimes casts and red blood cells are found in the urine.

It should be noted that the development of phlegmon in the maxillofacial area can occur 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 follow-up.

If treatment is not started in a timely manner, 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 the interstitial spaces into nearby organs and tissues with the development of an inflammatory process in them. Emptying the abscess into the mouth or out can essentially lead to self-healing. However, the spread of pus into surrounding organs and tissues is fraught with extremely serious complications, as discussed above.

Treatment. At the first signs of the development of inflammatory phenomena in soft tissues maxillofacial area, even before the occurrence of pronounced infiltration, if the patient’s condition is satisfactory, conservative treatment should be carried out. Prescribe dry heat, Sollux, rinsing the mouth with warm solutions, sulfonamides, calcium chloride. Such treatment is sometimes sufficient to relieve and eliminate inflammatory phenomena. To prevent relapse 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 treatment, surgical intervention is indicated.

A similar and only correct doctor’s tactics are necessary for already developed phlegmon. The use of thermal procedures and delaying surgery in such cases can only aggravate the process and contribute to the spread of pus. The operation of opening phlegmon of the maxillofacial area has its own characteristics that differ from opening phlegmon of another location. These features are as follows: 1) opening the phlegmon aims not only to empty the abscess, but also to intersect and drain the paths of 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 migration of exudate to neighboring sections, especially to the neck, even in the absence of fluctuation; 3) taking into account the aesthetic significance of the face, the incision for opening is made along the line of natural folds, under the edge of the lower jaw, sometimes slightly 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 further approach to the abscess is carried out bluntly. The proposed diagram illustrates the most advantageous incision lines for opening phlegmon.

The best type of anesthesia when opening phlegmon is anesthesia (fluorothane + nitrous oxide + oxygen, or even nitrous oxide + oxygen alone). Anesthesia allows, without injuring the patient both mentally and physically, to perform a mandatory digital inspection of the abscess cavity, eliminate pockets, bridges and, if necessary, create a counter-aperture.

After emptying the cavity of pus, an iodoform tampon or rubber strip is loosely inserted into it. If pus is not obtained upon opening the infiltrate or when the tissues in the wound are non-reactive, it is recommended to introduce a tampon with a hypertonic solution. A cotton-gauze bandage is applied on top, held in place by the bandage. Usually, starting from the next day after the operation, the tampon is tightened 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 obstruct the lumen of the wound and impede the outflow of pus. The abscess cavity is cleared of pus and dead tissue on the 7-10th day. To speed up the cleansing of the purulent cavity, dialysis is widely used. For this purpose, the cavity of the abscess during dressings is washed with a stream of various antiseptics (solutions of furatsilin 1:1000, chlordixidin 0.5%, etc.).

In chronic dialysis, when liquid is injected dropwise into the cavity of the abscess for sometimes several days, an isotonic solution of sodium chloride 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 as a result of the penetration of infection into neighboring sections. In such cases, repeated surgical intervention is indicated to eliminate the inflammatory process of a different localization.

If the phlegmon is anaerobic, the cavity of the abscess is opened using a wider incision, and sometimes 2-3 incisions. The wound is washed repeatedly with a solution of hydrogen peroxide. Tampons inserted into the wound are moistened in a 1-20Jo solution of potassium permanganate.

Good results were obtained in patients with severe forms of phlegmon of the maxillofacial area (especially in the presence of anaerobes) after 3-4 sessions of hyperbaric therapy. 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 regime 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 area. In severe cases of anaerobic infection, hyperbaric oxygen therapy is absolutely indicated.

Recently, ultrasound has been successfully used. “Sounding” the cavity of the abscess, which is pre-filled with one or another solution (furacilin, isotonic sodium chloride solution, silver water, etc.), leads to the destruction of bacteria in the wound and helps to normalize microcirculation.

First received positive results exposure of the abscess cavity and the wound itself to the rays of a helium-neon laser. This speeds up the process of wound cleansing and healing.

An increasing place in the treatment of purulent processes in the maxillofacial area 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 speeds up the process of cleansing the wound from dead tissue, which contributes to a faster recovery.

General treatment is of great importance in the outcome of the disease of persons with phlegmon of the maxillofacial area. Antibiotics are a powerful tool fight against infection, however, the different sensitivity of bacteria to certain antibiotics in some cases negates their therapeutic value. In this regard, when opening the phlegmon, it is necessary to take pus for laboratory determination of the sensitivity of bacteria to antibiotics. If this is not possible, patients should be prescribed a broad-spectrum antibiotic or a combination of 2-3 antibiotics. 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 units 3-5 times a day), tetraolean (250-500 mg 4 times) 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). In cases of intolerance to antibiotics, increase the dose of sulfonamides.

In case of severe intoxication of the body, for more active removal of toxins, intravenous infusion of isotonic sodium chloride solution, 5% glucose solution, antiseptic and protein solutions up to 1500-3000 ml per day is prescribed, and multivitamins are required.

In the presence of an anaerobic infection, anti-gangrenosis serum is used according to the scheme. For severe pain, analgin, injections of Promedol solution or Omnopon are prescribed. According to indications, especially in cases of high intoxication of the body and in elderly patients, cardiac medications should be used.

Recently, immunotherapy has become increasingly important for the treatment of purulent inflammatory processes. For this purpose, patients who are in satisfactory condition are given a one-time intramuscular injection 0.5 ml of staphylococcal toxoid, and also 100 mg of a solution of crystalline lysozyme (factory packaged) 3 times a day for 5 days, gamma globulin, etc. are administered. In cases of more severe phlegmon, an additional 4 ml is administered intravenously or intramuscularly 2 times per 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 speed up the recovery of patients and reduces the number of severe complications.

The organization of nutrition for patients is of great importance. Due to the fact that in patients with phlegmon of the maxillofacial area, as a rule, the act of chewing and sometimes swallowing is impaired, food should be liquid. In addition, due to the sharp pain that occurs when trying to chew or swallow, patients eat very little, so food should be high-calorie (cream, sour cream, eggs, cocoa, butter, strong broth, sugar, etc.) , Due to the absence of the normal act of chewing, the natural self-cleaning of the oral cavity of such patients is sharply disrupted, so they need special care: rinsing the oral cavity 3-4 times using a rubber balloon with a solution of furatsilin (1:5000) or pale pink (0. 1%) potassium permanganate solution. The final and mandatory stage of treatment should be a thorough sanitation of the oral cavity.

The most common phlegmons encountered in practice are the submandibular and submental areas and the floor of the mouth.

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. This area contains the submandibular salivary gland, lymph nodes, fiber.

Typically, submandibular cellulitis occurs as a result of odontogenic infection. The development of the inflammatory process most often begins with adenitis, which turns into periadenitis and adenophlegmon, less often as a consequence 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 ​​the submandibular triangle loses its outline, and a painful swelling appears (Fig. 105).

The skin color is initially unchanged. As the process progresses, hyperemia appears, tension increases, and the skin does not fold. Palpation becomes more and more painful. Collateral edema appears. Opening the mouth is painful. The reduction of the jaws can be of varying degrees. Sometimes swallowing is painful. The general condition of patients depends on the virulence of the infection.

Treatment of submandibular phlegmon consists of opening it with an incision parallel to the lower edge of the body of the lower jaw, 1.5-2 cm away from it. This prevents damage to the facial artery and the marginal branch of the facial nerve, which can cause bleeding and drooping 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 area. The submental region is limited by the anterior bellies of both digastric muscles and the hyoid bone. The submental lymph nodes are located in the intermuscular fatty tissue.

The most common sites of infection are the lower front teeth. The entry point for infection can be the mucous membrane of the anterior part of the oral cavity if its integrity is violated, as well as injuries, abrasions and pustular diseases of the skin of the chin area. In the presence of odontogenic infection, signs of lymphadenitis appear. Body temperature rises slightly. As inflammation increases, it rises to 38°C. The swelling increases. Mouth opening is free, swallowing is painless (Fig. 106).

However, involvement of the lymph nodes near the hyoid bone causes difficulty swallowing. The general condition of patients often remains satisfactory. For the purpose of treatment, the mental phlegmon is opened along the midline or with a transverse incision.

Cellulitis of the floor of the mouth. The floor of the mouth is a collection of soft tissues located between the mucous membrane lining the floor of the mouth and the skin. The basis of the floor of the mouth is the mylohyoid muscle, located between both halves of the lower jaw and the hyoid bone. Individual muscle groups are separated by fascial sheets and layers of loose tissue connective tissue and fatty tissue. The inflammatory process in this area is usually diffuse in nature, involving all or most of the floor of the mouth. A dense, painful swelling affects the submental and submandibular areas. The hyoid ridges are raised, their ridges are covered with a fibrous coating, the tongue swells, often does not fit in the mouth, and is coated. Thick saliva flows from the mouth. Speech, chewing and swallowing are difficult and painful (Fig. 107).

Treatment of phlegmon of the floor of the mouth (opening it) is urgent. Wide incisions are required to ensure drainage of exudate and sufficient aeration of deep tissues.

A wide collar incision, sometimes with an additional incision along the midline of the neck, meets these requirements.

Necrotic phlegmon of the floor of the mouth (Ludwig's tonsillitis). 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 clinical picture and treatment deserve attention. This disease is particularly severe and has the most severe outcome. The process most often begins in the submandibular triangle or immediately affects the entire floor of the oral cavity. The entry point for infection is teeth destroyed by caries. Initially, a dense, relatively painless swelling of the floor of the mouth appears. The inflammatory infiltrate involves the submandibular and submental areas 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 patient's general condition is progressively deteriorating. If left untreated, death usually occurs due to developing sepsis and a decrease in cardiac activity.

Treatment of Ludwig's angina involves wide incisions in the floor of the mouth as early as possible. Collar incisions are used along the neck 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 an incision is made in the depths of the tissue, necrotic foci are found with a scant amount of bloody fluid with a sharp putrefactive odor and the release of gas bubbles, which indicates the anaerobic nature of the bacteria that caused phlegmon. However, hemolytic streptococcus is often detected in cultures of material taken from a wound. 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 drugs, for which dressings are performed several times a day.

The treatment complex includes anti-gangrenous serum, shock doses of broad-spectrum antibiotics, intravenous administration of large quantities of isotonic sodium chloride solution and 5% glucose solution, and vitamins. It is necessary to maintain cardiac activity. In cases of difficulty breathing resulting from compression of the upper respiratory tract edematous tissue. Sometimes a tracheotomy is necessary. Delay in surgical intervention and initiation of active therapeutic treatment can result in death. Before the era of antibiotics, death from Ludwig's angina occurred in 80% of cases.

Version: MedElement Disease Directory

Cellulitis and abscess of the mouth area (K12.2)

general information

Short description

A. general information for the subsection as a whole.
1. Additional codes:

Alcohol abuse and dependence (F10. -)

Exposure to ambient tobacco smoke (Z77.22)

Perinatal exposure to tobacco smoke (P96.81)

History of tobacco use (Z87.891)

Occupational exposure to tobacco smoke (Z57.31)

Tobacco addiction (F17. -)

Tobacco use (Z72.0)

2. Excluded from the category altogether K12 Stomatitis and related lesions:

Necrotizing ulcerative stomatitis (cancrum oris) (A69.0);
- gangrenous stomatitis (A69.0);

Diseases of the lips (K13.0);

Gingivostomatitis caused by herpes simplex virus (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 subsection:
- Cellulitis (phlegmon) of the floor of the mouth;

Abscess of the submandibular region (submandibular abscess).

Clinical concepts sometimes used (or previously used) as synonyms:

Abscess oral cavity
- Abscess of oral tissue
- Abscess of the sublingual space
- Abscess of the submandibular region
- Cellulitis (phlegmon) of soft tissues of the oral cavity
- Cellulitis (phlegmon) of the submandibular region
- Inflammation of the uvula
- Ludwig's sore throat
- Abscess of the mouth (oral cavity)
- Sublingual abscess
- Abscess of the sublingual area
- Submandibular cellulite
- Submandibular abscess
- Inflammation of the uvula
- Cheek phlegmon (internal).

B. Definitions.
1. Abscess - limited purulent inflammation of the tissue with the formation of a cavity.

2. Cellulitis (cellulite) - diffuse purulent inflammation of the subcutaneous, intermuscular and interfascial tissue.

3. Adenophlegmon

- this is a diffuse purulent inflammation of the tissue that occurs as a result of 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 often localized in the lymph nodes of the submandibular triangle, less often in other anterior and lateral areas of the neck.

4. Ludwig's tonsillitis is one of the forms of phlegmon of the floor of the mouth of a putrefactive-necrotic nature, caused by anaerobic pathogens, usually coming from gangrenous teeth or due to injuries to the soft tissues 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 - the anterior and posterior belly of the digastric muscle, respectively; above - a deep layer of the neck's own fascia, which covers the mylohyoid muscle; below - the superficial leaf of the neck's own fascia. 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 of the lower jaw; behind - mylohyoid muscle; outside - the anterior bellies of the right and left digastric muscles; below - the hyoid bone. This cellular space is located between the deep layer of the neck's own fascia, which covers the lower surface of the mylohyoid muscle, and the superficial layer of this fascia. IN

In the anterior part of the cellular space and at the hyoid bone there are lymph nodes. In the submental region there are two groups of lymph nodes: 2-4 nodes behind the lower edge of the mental section of the body of the lower jaw and 1-2 at the hyoid bone.

The above-mentioned and chin areas should not be confused. The chin region is the lower part of the face, bounded above by the chin-labial groove, below by the lower edge of the lower jaw, and on the sides by lines descending down from the corners of the mouth.
3. The boundaries of the pterygomandibular space are: externally - the internal 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; above - the external pterygoid muscle; in front is the pterygomandibular suture, to which the buccal muscle is attached. The pterygomandibular space communicates with the retromandibular, infratemporal and pterygopalatine fossae, the buccal region, the peripharyngeal space and can extend to the outer surface of the branch of the mandible.

D. Discussion
Some authors introduce non-purulent (serous) odontogenic infiltrate into the concept of cellulite, distinguishing in a similar way between cellulite (as a serous inflammation that does not always turn into purulent) and phlegmon (as a 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 a purulent-inflammatory process.

Period of occurrence

An acute course is most typical for an abscess. The vast majority of patients (more than 90%) seek help within 5 days from the start of the process.
In elderly patients, a less rapid development and a weakened, sluggish (hypoergic type of reaction) course of the process are possible. Also, the increasingly slow development of the process is becoming a general trend in last years, regardless of the age of the patients. Apparently, this is due to the outpatient use of conservative antibacterial therapy, self-medication (which is often hidden by patients), general change spectrum of pathogens and their properties (pathogenicity, virulence, invasiveness). Quite often, patients with a slowly progressive form present 2 weeks or more after the onset of the disease.

Adenophlegmon develops slowly - over 2-3 weeks

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Classification

A. Primary and secondary abscesses are distinguished, which is important when choosing the volume and method of surgical intervention. For more details see etiology pathogenesis.

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, periodontal tissue and bone tissue.
In non-odontogenic purulent-inflammatory processes, the onset of the disease is associated with mechanical injury, infection of tissues during anesthesia, tonsillitis, otitis, rhinitis, etc. (Timofeev A.A. 2002)

B. Cellulitis of one area, one or two and two or three adjacent areas is isolated. Separately, septic phlegmon is distinguished. Accordingly, according to the severity of the disease, patients with phlegmon are conventionally divided into three groups:

Group 1 (mild) - patients with phlegmon localized in one anatomical area;

2nd (moderate) - patients with phlegmon localized in two or more anatomical areas;
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 fossa. (Timofeev A.A. 2002).
Abscesses of the anterior and posterior submandibular region are also distinguished. Phlegmon, as a diffuse process, cannot be divided in this way.

B. Stages of the process divided into:
1. Edema
2. Infiltration
3. Purulent melting of tissues.
4. Necrosis
5. Restrictions 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. Secondary damage is observed when the inflammatory process spreads from the sublingual and mental areas, the retromandibular fossa, the pterygomandibular and peripharyngeal spaces, and 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, when a patient arrives late, it is not possible to distinguish
Penetration of infection through lymphogenous and hematogenous routes is observed. The primary source of infection is acute ulcerative gangrenous stomatitis, boils 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 to the submandibular region are described.

Submandilbular abscesses are acute infections soft tissue 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 medications as needed and provide cold compresses as ordered.

The gauze may be removed from the oral surgery site into 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 press 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 completed completely to prevent the abscess from recurring. 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. Diagnosis is usually clinical. Treatment includes airway management, surgical drainage, and IV antibiotics. Submandibular space infection quickly spreads, bilateral, fixed cellulitis, occurring in the suprahyoid soft tissue, in the floor of the mouth, and both the sublingual and submandibular spaces without abscess formation. Although not truly an abscess, it resembles one clinically and is treated similarly. The condition usually develops from an odontogenic infection, especially of 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 signs Early manifestations of pain in any affected teeth, with severe, tender, localized submental and sublingual compaction. Boardlike hardness of the floor of the mouth and muscular compaction of the suprahyoid soft tissues can quickly develop. Drooling, trismus, dysphagia, stridor are caused by swelling of the larynx, and elevation of the posterior tongue toward the palate may be present. Fever, chills, and tachycardia are usually also present. The condition can lead to airway obstruction within a few hours, and does so more often than other neck infections. Diagnostics The diagnosis is usually obvious. If not, a CT is done. Treatment Maintaining a patent airway Surgical incision and drainage Antibiotics active against oral microflora Maintaining a patent airway is the top priority. Because the tumor makes oral tracheal intubation difficult, fiberoptic nasotracheal intubation done with topical anesthesia in the operating room or intensive care unit with the patient awake is preferred. Some patients require a tracheotomy. Patients without an immediate need for intubation require intensive monitoring and may benefit from a temporary nasal tube. Incision and drainage with placement of drainage deep into the mylohyoid muscles reduce pressure. Antibiotics should be chosen to cover both oral and anaerobes and aerobes (eg, clindamycin / sulbactam, high doses of penicillin). Last full review/revision October 2012 by 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 prevalence is unknown.
It is considered to be male predominant (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 incidence of odontogenic infections is highest. IN childhood the peak occurs during the period of change of occlusion in general and during the period of change of molars in particular.

Risk factors and groups

Diabetes.
Immunodeficiency.
Malignant tumors.
Interventions in the oral cavity.

Clinical picture

Symptoms, course

Ludwig's tonsillitis

Ludwig's angina (W. F. Ludwig; angina Ludovici) is a putrefactive-necrotic phlegmon of the floor of the mouth.
A number of authors classify Ludwig's angina as a pathological process 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, with 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), E. coli, etc. The infection penetrates more often from infected carious teeth and periodontal tissues, tonsil crypts and contaminated wounds and abrasions of the mucous membrane of the oral cavity and pharynx.
Pathologically, Ludwig's angina is characterized by extensive necrosis of the tissue in the floor of the mouth, swelling, and often necrosis of the muscles located here, the presence of gas bubbles in them and a pungent ichorous odor. The affected muscles initially have a pale red, later brown and dark brown color with a greenish tint, then turn into loose, easily torn tissue. The preserved tissues on the section are dry, only small accumulations of ichorous liquid of color are found meat slop. The absence of pus is an essential feature of Ludwig's angina. Some authors make the mistake of attributing cases of phlegmon of the floor of the mouth, accompanied by the formation of pus, to Ludwig's angina. The opinion that Ludwig's angina always begins with damage to 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 moves to the area of ​​the bottom of the mouth and, going down to the neck, concentrates at the hyoid bone. In 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 does not change in color, then becomes pale; later, individual bluish-purple and bronze spots appear.
The course of the disease is usually severe, only sometimes moderate. Most patients at the onset of the disease experience chills, general malaise, painful swallowing, headaches, and lack of appetite. The temperature for the first 1-2 days remains low-grade or does not exceed 38°, then reaches 39° and higher. Inflammatory swelling that occurs in the floor of the mouth spreads 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 swollen, raised, the mucous membrane above them is covered with fibrinous plaque. The tongue is enlarged, covered with a dark brown coating, dry, inactive. The mouth is half-open, there is bad breath, the face is pale, with a cyanotic tint or sallow color. Breathing is intermittent, the patient lacks air, his face expresses fear, his 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, heavy sweats, stunning chills appear, consciousness is darkened, delirium. The amount of hemoglobin decreases. Severe leukopenia, a sharp shift in the leukocyte formula to the left. With increasing general weakness, signs of decline in cardiac activity and a picture of sepsis, death can often occur by the end of the first, less often in the middle or end of the second week. Complications: inflammation and abscess of the lung, asphyxia, and mediastinitis. Before 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 worsening asphyxia, but their implementation should not delay measures to ensure airway patency.
Any radiological methods make it possible to identify the suspected source of infection, its prevalence and carry out differential diagnosis with other causes of asphyxia and dysphagia in doubtful cases.
The value of ultrasound as a method of emergency diagnosis confirmation 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 clinician.
Culture of the lesion should be performed whenever possible, especially in 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. An increase in the sublingual area can be caused by neoplastic processes in the floor of the mouth or abscesses and phlegmons of other and combined localizations.
3. Isolated cases of nocardial and filarial abscesses of the face have been described. However, there is no description of an isolated lesion of the sublingual region. However, with multiple abscesses this possibility cannot be excluded.
4. Erysipelas may imitate Ludwig's angina, but the differential diagnosis is not difficult.

Complications

Asphyxia
Sepsis
Expansion to other areas

Forecast

Depends on many factors. Generally regarded as favorable. The mortality rate is low. For example, between 1999 and 2007. there were 132 deaths reported in the United States where ICD-10 K12.2 was listed as the underlying 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 Emerg Med. 2013;45(2):163-167.

2.http://www.medical-enc.ru/

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Odontogenic abscesses and phlegmons of the maxillofacial area are common, since they can occur with any disease from the group of odontogenic infections - periodontitis, periostitis, osteomyelitis, with retention and dystopia of teeth, suppurating cysts, alveolitis, etc.

Abscess- This is a limited purulent inflammation of soft tissues.

Phlegmon- diffuse purulent-necrotic inflammation of cellular spaces, subcutaneous fat, interfascial spaces and other soft tissues. There are purulent, anaerobic or putrefactive phlegmon.

The causative agents of abscesses and phlegmon are staphylococci, streptococci, less commonly Pseudomonas aeruginosa, Escherichia coli, and anaerobes.

The spread of infection most often occurs by contact, along the length or with the flow of lymph.

The onset of the disease is often preceded by an acute respiratory infection, flu, sore throat, hypothermia, overheating, stress, anemia, tooth extraction, trauma, etc.

In the clinic of abscesses and phlegmon, acute and subacute stages are distinguished. The acute stage is characterized by an increase in local signs of inflammation (swelling, hyperemia, pain, formation of infiltrates, dysfunction), pronounced general reactions of the body in the form of fever, increased temperature, malaise, headache, leukocytosis in the blood. If timely opening of the abscess does not occur (through a fistula or surgically), the infectious and inflammatory process can spread to neighboring anatomical areas, into the cranial cavity, into the deep cellular spaces of the neck, and the mediastinum. In this regard, complications such as thrombosis of the dural sinuses, meningoencephalitis, mediastinitis, secondary destructive osteomyelitis of the jaws, and sepsis may develop.

Treatment consists of wide opening and drainage of the purulent focus, sometimes it is necessary to make several incisions in the maxillofacial area, daily washing of the purulent wound with antiseptic solutions, passive and active immunization, the introduction of desensitizing therapy and hormone therapy, and detoxification infusion therapy. Water-salt metabolism is normalized.

It is necessary to monitor the condition of the wound and general well-being daily, blood pressure, temperature, diuresis, personal hygiene. When acute inflammatory manifestations subside, physiotherapeutic treatment (electrophoresis, UHF, microwave, etc.) is prescribed.

The diet of such patients should be high in calories, gentle, and rich in vitamins.

Currently, several classification schemes for phlegmon of the maxillofacial area are known. From the point of view of practical dentistry, it is advisable to use Evdokimov’s scheme, built on topographic-anatomical principles:

1. Abscesses and phlegmons localized in the area upper jaw:
   • infraorbital region;
   • zygomatic region;
   • orbital region;
   • temporal fossa;
   • infratemporal and pterygopalatine fossae.
2. Abscesses and phlegmons localized in the lower jaw:
   • chin area;
   • buccal area;
   • submandibular region;
   • peripharyngeal space;
   • pterygomaxillary space;
   • areas of the parotid salivary gland and the retromandibular fossa.
3. Abscesses and phlegmon of the floor of the mouth.
4. Abscesses and phlegmons of the neck (superficial and deep).

Abscesses and phlegmons of the infraorbital region

Boundaries of the infraorbital region: upper - the lower edge of the orbit, lower - the alveolar process of the upper jaw; internal - the edge of the pear-shaped opening; external - zygomaticomaxillary suture.

foci of infection in the periodontium 543 | 345 teeth, wounds, infectious and inflammatory lesions of the skin of the infraorbital region, infection due to infected anesthesia.

Symptoms: severe throbbing pain, swelling of the tissues of the infraorbital region, eyelids, infiltrate, determined in the area of ​​the vault of the vestibule of the mouth, pain on palpation, fluctuation when the abscess matures.

Abscesses and phlegmon of the zygomatic region

Boundaries of the zygomatic region: upper - anterior-inferior section of the temporal region and the lower edge of the orbit; lower - anterior-superior section of the buccal region; anterior - zygomaticomaxillary suture; posterior - zygomaticotemporal suture.

Main sources and routes of infection: foci of infection in the periodontium 654 | 456 teeth, wounds, infectious and inflammatory processes of the skin of the zygomatic region, infection during infiltration anesthesia, spread of infection from the buccal and infraorbital region.

Symptoms: infiltration of tissues of the zygomatic region, swelling of the eyelids, skin hyperemia, fluctuation during suppuration, moderate pain, limited mouth opening, moderate intoxication.

Abscesses and phlegmon of the orbit

Region boundaries: walls of the orbit.

Main sources and routes of infection: sites of periodontal infection 543 | 345 teeth, wounds, infectious and inflammatory lesions of the skin and eyelids, spread of infection along the length of the maxillary sinus, infraorbital region, zygomatic region, infratemporal and pterygopalatine fossa.

Symptoms: pronounced swelling of the eyelids and conjunctiva; exophthalmos, limited movement of the eyeball, diplopia, partial or complete blindness, general reaction in the form of leukocytosis, fever, symptoms of intoxication.

Abscesses and phlegmons of the buccal area

Region boundaries: upper - the lower edge of the zygomatic bone, lower - the lower edge of the lower jaw, anterior - the line connecting the zygomaticomaxillary suture with the corner of the mouth, posterior - the anterior edge of the masticatory muscle.

In this area, superficial and deep phlegmons and abscesses (in relation to the buccal muscle) are distinguished.

Main sources of infection: foci of infection in the periodontium of molars and premolars of both jaws, wounds, infectious and inflammatory processes extending from the infraorbital, zygomatic and parotid-masticatory areas.

Symptoms: infiltration of tissues of the buccal area and eyelids; hyperemia and tension of the skin over the infiltrate; pain that increases with palpation of the infiltrate and opening the mouth; fluctuation in the center of the infiltrate, the general condition is satisfactory; with deep phlegmons and abscesses, local signs of inflammation in the oral cavity appear.

Abscesses and phlegmons of the subtemporal region

Boundaries of the infratemporal fossa: the upper one is the infratemporal crest of the main bone, the lower one is the buccal-pharyngeal fascia, the anterior one is the tubercle of the upper jaw and zygomatic bone, the posterior one is the styloid process with the muscles attached to it, the outer one is the inner surface of the branch of the lower jaw.

Main sources and routes of infection: foci of infection in the periodontium 87 | 78 teeth, infection during conduction anesthesia at the tubercle of the upper jaw, spread of infection along the length of the pterygomaxillary space, buccal area.

Symptoms: severe pain in the area of ​​infiltration, even at rest, radiating to the corresponding half of the head, intensifying when opening the mouth; local signs of inflammation are not clearly expressed due to the deeply located infiltrate; swelling of the soft tissues above and below the zygomatic arch; in the oral cavity, the infiltrate is located in the posterior sections of the vault of the vestibule of the mouth, painful on palpation; the mucous membrane over it is hyperemic; symptoms of intoxication are expressed.

Abscesses and phlegmons of the temporal region

Boundaries of the temporal region: the upper and posterior are the temporal line of the frontal and parietal bones, the lower is the infratemporal crest of the main bone, the inner is the temporal platform formed by the frontal, temporal, parietal and main bones, the outer is the zygomatic arch.

There are superficial abscesses and phlegmons located between the skin and the temporal aponeurosis, between the temporal aponeurosis and the temporal muscle, and deep ones, located between the temporal muscle and the bottom of the temporal bone.

Main sources and routes of infection: wounds and infectious-inflammatory lesions of the skin of the temporal region, spread of infection from the infratemporal fossa, buccal region, parotid-masticatory region.

Symptoms: with superficial localization of a purulent focus, pronounced swelling of the soft tissues of the temporal region, skin hyperemia, pain that increases with palpation, and fluctuation appear.

With deep phlegmons and abscesses, severe spontaneous pain, inflammatory contracture of the jaw, moderate swelling and hyperemia of the skin, and symptoms of intoxication come to the fore.

Abscesses and phlegmons of the parotid-masticatory area

Borders: upper - the lower edge of the zygomatic bone of the zygomatic arch, lower - the lower edge of the body of the lower jaw, anterior - the anterior edge of the chewing region, posterior - the posterior edge of the branch of the lower jaw.

Superficial phlegmons and abscesses are located between the skin and the parotid-masticatory fascia and the outer surface of the mandibular branch.

Deep abscesses and phlegmons are located between the masticatory muscle and the outer surface of the lower jaw branch.

Main sources and routes of infection: foci of odontogenic infection in the area of ​​the third molars, wounds, infectious and inflammatory processes of the skin of the parotid-masticatory area, spread of infection from the buccal area, the retromandibular, submandibular, parotid salivary gland.

Symptoms: with superficial abscesses and phlegmons, sharp swelling of the soft tissues of the parotid-masticatory area, hyperemia of the skin over the infiltrate, pain that increases with palpation and opening the mouth, fluctuation, moderate contracture of the jaw. With deep phlegmons and abscesses - intense pain when opening the mouth and at rest, pronounced contracture of the jaw, moderate swelling of the soft tissues, and general symptoms of inflammation are more pronounced.

Abscesses and phlegmons of the retromaxillary region

Region boundaries: upper - external auditory canal, lower - lower pole of the parotid gland, anterior - posterior edge of the branch of the lower jaw, posterior - mastoid process of the temporal bone and sternocleidomastoid muscle, internal - styloid process of the temporal bone with muscles attached to it; external - parotid-masticatory fascia.

Main sources and routes of infection: wounds and infectious-inflammatory lesions of the skin of the retromaxillary region, spread of infection from the parotid-masticatory region, submandibular, pterygo-maxillary space, parotid salivary gland.

Symptoms: pain in the retromaxillary region, intensifying when opening the mouth, swelling of soft tissues, tension and hyperemia of the skin over the infiltrate, fluctuation, moderate contracture of the jaws, general signs of inflammation.

Abscesses and phlegmons of the pterygomaxillary space

Borders: outer - inner surface of the branch of the lower jaw and lower - part of the temporal muscle, inner, posterior and lower - outer surface of the medial pterygoid muscle, upper - external pterygoid muscle, anterior - buccal-pharyngeal suture.

Main sources and routes of infection: foci of periodontal infection of the third molars of the lower jaw, infection during conduction anesthesia of the inferior alveolar nerve, spread of infection from the palatine tonsils.

Symptoms: limited opening of the mouth, sore throat, aggravated by swallowing; deep palpation of the supramillary region can reveal infiltration, hyperemia and swelling of the oral mucosa in the area of ​​the pterygomaxillary fold, severe aseptic condition, intoxication.

Abscesses and phlegmons of the parapharyngeal space

Borders: external - medial pterygoid muscle, internal - lateral wall of the pharynx and the muscle that lifts and stretches the soft palate, anterior - interpterygoid fascia, posterior - lateral facial spurs running from the prevertebral fascia to the wall of the pharynx, lower - submandibular salivary gland.

Rice. a - frontal plane: 1 - chewing muscle; 2- medial pterygoid muscle; 3 - lateral pterygoid muscle; 4 - temporal muscle; 6 - lower jaw; 7 - lateral wall of the pharynx; b - horizontal plane: 1 - chewing muscle; 2 - medial pterygoid muscle; 3 - parotid gland; 4 - pharyngeal-prevertebral fascia; 5 - inflammatory infiltrate; 6 - lower jaw; 7 - awl diaphragm; 8 - palatine tonsil; 9 - internal carotid artery; 10 - internal jugular vein; 11 - posterior part of the parapharyngeal space

Main sources and routes of infection: wounds, infectious and inflammatory processes of the pharyngeal mucosa, spread of infection from the pterygomaxillary space, submandibular region, sublingual, parotid-masticatory and retromandibular regions, from the palatine tonsils.

Symptoms: pain in the throat when swallowing and at rest, difficulty breathing, swelling of the soft tissues of the submandibular region, the infiltrate is located deep, can be palpated in the area of ​​the angle of the lower jaw, painful, swelling of the lateral wall of the oropharynx, the pharynx is asymmetrical, the general condition is severe, contracture of the lower jaw is pronounced.

Borders: the upper one is the mucous membrane of the floor of the mouth, the lower one is the mylohyoid muscle, the outer one is the inner surface of the body of the lower jaw, the inner one is the geniohyoid and geniohyoid muscles.

Main sources and routes of infection: foci of infection in the periodontium of the teeth of the lower jaw, most often in the area of ​​premolars and molars, wounds and infectious and inflammatory lesions of the mucous membrane of the sublingual region, the excretory duct of the submandibular salivary gland.

Symptoms: pain in the sublingual area, aggravated by swallowing, talking, moving the tongue, palpation. Characteristic appearance patient: the mouth is half open, saliva flows out, a putrid odor emanates from the mouth. Mouth opening is limited. The tongue is covered with a dirty gray coating and is raised. The mucous membrane of the floor of the oral cavity is hyperemic and swollen. The general condition is moderate.

Abscesses and phlegmons of the sublingual area

Phlegmon of the floor of the mouth. Phlegmon of the floor of the mouth is a diffuse purulent inflammation of the tissues located above and below the muscular diaphragm of the floor of the mouth (sublingual and submandibular areas).

Main sources and routes of infection: foci of infection in the periodontium of the teeth of the lower jaw, wounds, infectious and inflammatory lesions of the mucous membrane of the bottom of the cavity, the skin of the chin and submandibular region, the retromandibular and peripharyngeal space.

Symptoms: pain that increases with swallowing, talking, palpation of the infiltrate, difficulty breathing, up to asphyxia, forced position of the patient (he sits with his head tilted forward, a pained appearance, his mouth is half open, saliva flows from it, slurred speech, an unpleasant odor emanates from the mouth); the infiltrate is diffuse, the skin over it is hyperemic, tense, fluctuation is detected; the tissues of the submandibular region are swollen, the tongue is raised, swollen, with a gray coating; The mucous membrane of the floor of the oral cavity is hyperemic. The general condition is serious, symptoms of intoxication are pronounced.

Abscesses and phlegmons of the base of the tongue

Boundaries of the base of the tongue: the upper one is the intrinsic muscles of the tongue, the mandibular-hyoid muscle, the external one is the geniohyoid muscle, the external one is the geniohyoid muscle of the right and left side.

Main sources and routes of infection: foci of odontogenic infection and in the periodontium of the teeth of the lower jaw, wounds and infectious and inflammatory lesions of the mucous membrane of the tongue and floor of the mouth, the spread of infection from adjacent areas.

Symptoms: severe pain in the base of the tongue, aggravated by swallowing, talking, and palpation; the mouth is half open, saliva flows out of it, a foul odor emanates from the mouth; the tongue is raised, swollen, and difficult to move in the oral cavity; speech and breathing are difficult, the infiltrate is located closer to the hyoid bone, the skin over it is not changed; the general condition is serious, symptoms of intoxication are pronounced.

Putrefactive-necrotic phlegmon of the floor of the mouth (Zhensul-Ludwig angina)

The disease is rare. The causative agent is an anaerobic infection in symbiosis with Escherichia coli, streptococci, etc.

The disease is characterized by an acute onset and severe intoxication of the patient, accompanied by rapidly increasing swelling of the soft tissues, which spreads to the upper respiratory tract and leads to asphyxia. Body temperature is increased to 40-41°C, pulse is 130-140 beats per minute, shock may develop. During the first three days, the skin of the face and neck is pale, with an earthy tint, then characteristic spots of bronze color appear. The infiltrate is painful and has no clear boundaries. Necrosis develops in the tissues, there is no pus. The general condition sharply and progressively worsens, sepsis develops. The patient's death can occur as a result of intoxication and hypoxia against the background of increasing cardiovascular failure. Treatment is complex - in a hospital setting.

The dentist must be able to diagnose an abscess or phlegmon, determine the topography of the localization of the inflammatory process, assess the patient’s condition, identify concomitant diseases, and promptly refer the patient to the purulent-septic department of the hospital. First, the dentist can carry out general treatment - prescribe cardiac, desensitizing drugs, anti-inflammatory drugs, analgesics. With obstruction of the upper respiratory tract and increasing suffocation, the dentist should assist the dentist in performing a tracheotomy.

The dentist can take part in the treatment of the patient in the postoperative period in a clinic: irrigating the wound with antiseptics, applying medicinal dressings, carrying out hygienic measures, sanitation of the oral cavity, preventive measures, sanitary educational work.

"A practical guide to surgical dentistry"
A.V. Vyazmitina