Management of acute cervicofacial infections

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Management of acute cervicofacial infections
Wednesday, February 29th 2012
Kings College Hospital
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Management of acute infections
Types of infection
Fungal
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Management of acute infections
Types of infection
Fungal Viral
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Management of acute infections
Types of infection
Fungal Viral Bacterial
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Management of acute infections
Fungal

• Aspergillosis
• A. fumigatus, A. niger, A. flavus
• Granulomatous inflammation of the sinuses which
  may involve the orbit and intracranial
  extensions.

Ref. Maiorano E. Favia G. Capodiferro S.
Montagna MT. Lo Muzio L. Combined mucormycosis
and aspergillosis of the oro-sinonasal region
in a patient affected by Castleman disease.
Virchows Archiv. 446(1)28-33, 2005 Jan
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Management of acute infections
Fungal

• 2) Mucormycosis
• Rhino-orbital-cerebral pulmonary infections are
  the most common form.
• Survival rate 36-50

Ref. Maiorano E. et al. Combined mucormycosis
and aspergillosis of the oro-sinonasal region in
a patient affected by Castleman disease.
Virchows Archiv. 446(1)28-33, 2005 Jan Chandu
A. et al. A case of mucormycosis limited to the
parotid gland. Head Neck. 2005 Dec27(12)1108-
11.
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Management of acute infections
Fungal
Ref. Maiorano E. et al. Combined mucormycosis
and aspergillosis of the oro-sinonasal region in
a patient affected by Castleman disease.
Virchows Archiv. 446(1)28-33, 2005 Jan Chandu
A. et al. A case of mucormycosis limited to the
parotid gland. Head Neck. 2005 Dec27(12)1108-
11.
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Management of acute infections
Viral

• HSV, EBV, VZV, CMV, Paramyxovirus, Coxsackie
  virus, Picorna virus
• Mostly symptomatic management, with the exception
  of Herpes zoster (Shingles)

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Management of acute infections
Viral

• 15-35 of HZ patients has postherpetic neuralgia
  (PHN)
• Early antiviral therapy has been found to reduce
  the risk and duration of PHN in elderly patients.

Lilie HM, Wassilew S, The role of antivirals in
the management of neuropathic pain in the older
patient with herpes zoster. Drugs Aging 20 (8)
561-70 2003
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Management of acute infections
Bacterial

• Dental infection is the most common cause of deep
  neck abscess.
• Common acute bacterial infection
• 1) Cellulitis Ludwigs angina

Parhiscar A., Har-El G. Deep neck abscess a
retrospective review of 210 cases. Annals of
Otology, Rhinology Laryngology.
110(11)1051-4, 2001 Nov.
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Management of acute infections
Bacterial

• Dental infection is the most common cause of deep
  neck abscess.
• Common acute bacterial infection
• 1) Cellulitis Ludwigs angina
• 2) Abscess - Parapharyngeal/tonsillar, dental

Parhiscar A., Har-El G. Deep neck abscess a
retrospective review of 210 cases. Annals of
Otology, Rhinology Laryngology.
110(11)1051-4, 2001 Nov.
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Management of acute infections
Bacterial

• Dental infection is the most common cause of deep
  neck abscess.
• Common acute bacterial infection
• 1) Cellulitis Ludwigs angina
• 2) Abscess - Parapharyngeal/tonsillar, dental
• 3) Necrotising fasciitis

Parhiscar A., Har-El G. Deep neck abscess a
retrospective review of 210 cases. Annals of
Otology, Rhinology Laryngology.
110(11)1051-4, 2001 Nov.
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Management of acute infections
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Management of acute infections
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Signs of Infection

• Local
• Redness, pain, swelling, heat, /- pus (abscess)
• Loss of function
• Systemic
• Temperature gt 37C (or spikes), malaise, pallor,
  irritability, fatigue, dehydration
• lymphadenopathy
• Severe signs dysphagia (sublingual,submandibular
  ), drooling, dysphonia, stridor (airway
  compromise),trismus

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Management of acute infections
Bacterial
Taken from Petersons Principles of Oral and
Maxilofacial Surgery Chapter 15
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Management of acute infections
Bacterial

• Erysipelas
• Cellulitis of the skin with lymphatic involvement
• Mainly involves leg but often occurs on the face
• Strep. Pyogenes S. aureus main pathogen

Lazarini L et al, Erysipelas and cellulitis
clinical and microbiological spectrum in an
Italian tertiary care hospital. Jour. of
Infection, 2005(51) 383-389
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Management of acute infections
Bacterial

• Erysipelas
• Area of erythema and swelling has sharp
  demarcation
• Treatment Augmentin or Penicillin Clindamycin

Lazarini L et al, Erysipelas and cellulitis
clinical and microbiological spectrum in an
Italian tertiary care hospital. Jour. of
Infection, 2005(51) 383-389
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Management of acute infections
Bacterial

• Management
• Assess for potential airway compromise

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Management of acute infections
Bacterial

• Management
• Assess for potential airway compromise
• Tracheostomy Gold standard
• Awake fibreoptic intubation - 1st choice

Reference Ovassapian A, Airway management
in adult patients with deep neck infections a
case series and review of the literature,
Anesth Analg. 2005 Feb100(2)585-9
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Management of acute infections
Bacterial

• Management
• Assess for potential airway compromise
• Administration of broad spectrum antibiotics

• References
• Kuriyama T et al, Bacteriologic features and
  antimicrobial susceptibility in isolates from
  orofacial odontogenic infections,
  Oral Surg Oral Med Oral Pathol Oral Radiol
  Endod. 2000 90(5)600-8.
• Kuriyama T et al An outcome audit of the
  treatment of acute dentoalveolar infection
  impact of penicillin resistance.Br Dent J. 2005
  Jun 25198(12)759-63
• Stefanopoulos PK et al, The clinical significance
  of anaerobic bacteria in acute orofacial
  odontogenic infections. Oral Surg Oral Med
  Oral Pathol Oral Radiol Endod. 2004 98398-408.

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Management of acute infections
Bacterial
Taken from Stefanopoulos PK et al, The
clinical significance of anaerobic bacteria in
acute orofacial odontogenic infections. Oral
Surg Oral Med Oral Pathol Oral Radiol Endod.
2004 98398-408.
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Management of acute infections
Bacterial

• Management
• Assess for potential airway compromise
• Administration of broad spectrum antibiotics

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Management of acute infections
Bacterial

• Management
• Assess for potential airway compromise
• Administration of broad spectrum antibiotics
• Investigations
• FBE, UE, CRP, ESR, Blood cultures

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Management of acute infections
Bacterial

• Management
• Assess for potential airway compromise
• Administration of broad spectrum antibiotics
• Investigations
• CT scan vs. MRI vs. USS

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Management of acute infections
Bacterial

• Management
• Assess for potential airway compromise
• Administration of broad spectrum antibiotics
• Investigations
• Contrast enhanced CT scan clinical exam
• Sens 95
• Spec 80

Ref Miller WD et al, A prospective, blinded
comparison of clinical examination and computed
tomography in deep neck infections.Laryngoscope.
109(11)1873-9, 1999 Nov.
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Management of acute infections
Bacterial

• Management
• Assess for potential airway compromise
• Administration of broad spectrum antibiotics
• Investigations
• Remove source of infection and establish surgical
  drainage

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Warning Signs

• Rapid onset.
• Progressive trismus.
• Painful trismus that is out of keeping with with
  the clinical picture should raise your suspicion
  regarding a submasseteric/pterygoid space
  infection.

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Management of acute infections
Bacterial
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Management of acute infections
Bacterial
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Management of acute infections
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Management of acute infections
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Reasons for Admission

• Rapidly progressing infection
• Difficulty breathing
• Difficulty Swallowing
• Fascial space involvement
• Elevated temperature - gt38
• Severe jaw trismus lt 10mm
• Toxic appearance
• Compromised host defences

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Investigations

• Bloods inc glucose and CRP.
• Consider blood cultures if appropiate
• If pus, send swab and pus for gram stain
• Radiological investigations, but these shoudl not
  defer treatment.
• WARN THE ANAESTHETIST EARLY

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Access

• Submandibular/sublingual space
• Parapharyngeal
• Buccal
• Submassteric

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Management of acute infections
Bacterial

• Management
• Assess for potential airway compromise
• Administration of broad spectrum antibiotics
• Investigations
• Remove source of infection and establish surgical
  drainage

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Management of acute infections
Bacterial

• Management
• Assess for potential airway compromise
• Administration of broad spectrum antibiotics
• Investigations
• Remove source of infection and establish surgical
  drainage
• Close evaluation in the immediate post-op phase

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Management of acute infections
Bacterial

• Recurrent deep neck infections
• Consider congenital abnormalities
• Proper imaging aids in diagnosis
• Most common cause
• Branchial cleft cyst
• Lymphangioma, thyroglossal duct cyst

Ref Nusbaum AO et al, Recurrence of a deep neck
infection a clinical indication of an underlying
congenital lesion. Arch Otolaryngol Head Neck
Surg 125 (12) 1379-82 1999 Dec
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Salivary Gland Infections

• Salivary Gland Infections
• Bacterial ascending infections especially with
  xerostomia, in the presence of salivary calculi.
  Painful, swelling in F.O.M or as an acute
  pre-auricular swelling.
• Treatment involves giving patient fluids to
  increase saliva flow, antibiotics and /-
  drainage depending on the presence of a
  collection.
• Amoxycillin metronidazole flucloxacillin
  (staph)
• Think of and exclude viral infection eg mumps
  most often bilateral parotid swellings

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Ludwigs Angina

• (Spreading Cellulitis in the FOM)
• Potentially life threatening, a cellulitis
  starting in the floor of the mouth and often
  arising from a mandibular molar
• Bilateral submandibular and sublingual space
  infection
• Clinical signs
• Oedema on both sides of the floor of the mouth
• Raised tongue
• Bilateral submandibular space involvement
• Oedema spreading down the neck often with loss
  of definition of anatomical structures
• Progressive trismus, pain, dysphagia, dysphonia
• For hospital admission

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Complications

• Trismus (Classically sub masseteric space/lateral
  pharyngeal space infections)
• Extra-oral incisions CNVII marginal mandibular
  branch, scarring, drains and ascending infection

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