odontogenic infections
DESCRIPTION
Management of Severe Odontogenic InfectionsTRANSCRIPT
Management of Severe Odontogenic
Infections
Dr Venezia Sharma
QVH East Grinstead
Overview
• Definition
• Complications
• Progression of Infection
• Fascial Spaces
• Assessment
• Management/Treatment
Definition
• An odontogenic infection is an acute or chronic infection originating from tooth related pathology
• 3 categories• Localised• Diffuse Widespread • Life threatening
Complications
Localised (periodontal, periapical, post surgical, pericoronal). They may begin as well-delineated, self limiting infections with a dangerous potential to spread
They could potentially track down into deep neck spaces and further still, become life threatening emergency referral
Presentation • Slowly enlarging swelling, dull ache or recurrent
draining abscess that swells and drains spontaneously not likely to require immediate treatment – patients immune response is effectively containing spread of infection
• Rapidly enlarging swelling causing dyspnoea, dysphagia and severe trismus requires aggressive and prompt attention – patients immune system unable to contain infection
Progression
If left untreated, odontogenic infections can spread and
contribute to polymicrobial infections at other sites:
• Sinuses Brain (Intracranial spread)• via Bloodstream (sepsis, cavernous sinus thrombosis)
• Deep Neck Spaces (Ludwig’s Angina)• Lungs, Pericardium (Mediastinitis)• Necrotizing fasciitis
Fascial Spaces
– Buccal space– Infraorbital space– Infratemporal space– Submental/Sublingual spaces– Submandibular space– Submasseteric space– Lateral and Retro pharyngeal spaces– Pterygomandibular space
Pathway of Spread:Infratemporal Space
• Usual Source – maxillary 3rd molars
• Boundaries – skull base, lat. pterygoid plate, continuous with temporal spaces
Pathway of SpreadInfraorbital Space Infection
Pathway of SpreadBuccal Space Infection
Pathway of SpreadMasseteric Space Infection
Pathway of SpreadSubmandibular Space Infection
(from lower molar)
Pathway of Spread Bilateral Submandibular and Sublingual
Space Infection(Ludwig’s Angina)
Assessment
• ABC (airway, stridor, anaesthetist support, HDU/ITU)
• Clinical assessment (source, location, nature)
• Full detailed History– Vital signs (systemically well? fever, tachycardia, malaise)
– Onset, duration, rapidity– Previous treatment ?– Radiographs ( locate source)
– Medically compromised (immunosuppressed, diabetic, alcoholism, neutropaenic)
Main Principles of Management
• Stabilise patient (airway, Sats/02)• IVI’s (antibiotics, fluids)• Investigations (Bloods, Xrays, US, CT)• Surgical Intervention
– Remove the cause– Establish drainage
• Regular review until signs of improvement• Care, nutrition, rest
Pathway of Spread Bilateral Submandibular and Sublingual
Space Infection(Ludwig’s Angina)
Ludwig’s Angina
• Rapidly spreading, indurated, bilateratal cellulitis that begins in the FOM and involves both the submandibular and sublingual spaces.
• Spreads along fascial planes. Not through lymphatics.• Commonly arises from odontogenic infections. (70-80%)
• 2nd and 3rd molars usually involved, as roots extend beyond mylohyoid muscle, thus crossing both submandibular and sublingual spaces
• Polymicrobial (commonly streptococcus, Staph and Bacteroides)
Ludwig’s AnginaClinical Manifestations:
Pain in FOM and anterior neck region, dysphagia, odynophagia, respiratory distress are common findings.
Fever, tachypnea, tachycardia, Stridor, hoarsness, cyanosis, resp. distress may suggest upper airway compromise.
Severe trismus, firm raised FOM, non pitting induration of submental and submaxillary spaces
Ludwig’s AnginaDiagnosis:Along with CT scans, plain radiographs of the neck are useful to show soft tissue swelling, presence of gas,extent of airway narrowing.Management:Airway management: Due to risk of rapid airway compromise, anaesthetic support and admission to ITUare important.IV antibiotic therapy, IV Dex.Surgical incision and drainage, removal of source.Close monitoring in ITU improvement.
Ludwig’s Angina
Ludwig’s Angina usually resolves without
complications, but in some unfortunate
situations, the condition can be FATAL!
Case Presentation 1
Ludwig’s Angina Associated
With Molar Infection
Resident & Staff Physician 2006; Vol. 52; 8
Case Presentation 1• 47 yr female • Presented to A&E, toothache assoc to LR molar along
with 4/7 Hx of facial swelling and pain• Drooling• Dysphagia• Difficulty speaking• Severe trismus
PMH: Hypertension, Cocaine use, poor OH Vital Signs: Temp 38 C, BP 108/63, HR 120, Resps 30
Resident & Staff Physician 2006; Vol. 52; 8
Case Presentation 1• 47 yr female • Presented to A&E, toothache assoc to LR molar along
with 4/7 Hx of facial swelling and pain• Drooling• Dysphagia• Difficulty speaking• Severe trismus
PMH: Hypertension, Cocaine use, poor OH Vital Signs: Temp 38 C, BP 108/63, HR 120, Resps 30
Resident & Staff Physician 2006; Vol. 52; 8
Case Presentation 1
O/E:
Swelling RT mandible and LT face, with overlying erythema, hot and tender to touch, taut but with no crepitus.
Tongue was protruding.
LR7 was necrotic.
No stridor.
Resident & Staff Physician 2006; Vol. 52; 8
Case Presentation 1
Investigations:
WBC 27.8Blood cultures (-) veUrine (+) ve cocaine
CT – swelling with inflamm. changes and air within soft tissues along the entire mandible
Resident & Staff Physician 2006; Vol. 52; 8
Case Presentation 1Diagnosis: Ludwig’s Angina secondary to necrotic
LR7
Treatment:
Pt was nasally intubated and transferred to ITU
Broad spec. IV Abs and IV fluids
On days 5 and 11, pt underwent surgery
Extraction of LR carious molars. Intra and extra oral
drains placed.
Patients condition continued to deteriorate.
Died on day 14. Autopsy revealed an abscess in the FOM
and upper RT neck region. Resident & Staff Physician 2006; Vol. 52; 8
Case Presentation 2
Mortality Associated With
An Odontogenic Infection !
BDJ 190, 529-530, 2001
Case Presentation 2• 25 male • 3/7 Hx rapidly advancing bilat neck swelling
O/E: Severe trismus (1cm opening)Raised FOMSlight dysphagiaNo respiratory problems
PDH: irregular attender, 4/12 general intermittent dental painOPG gross caries both RT and LT lower
Quads
PMH: NRMH
BDJ 190, 529-530, 2001
Case Presentation 2
BDJ 190, 529-530, 2001
Preoperative OPG showing carious teeth with assoc. periapical pathology
Case Presentation 2
• Treatment– Taken to theatre within 3 hrs of presenting– Awake FOI and IV Abs commenced– R/O carious teeth and E/O incisions– No frank pus located– E/O drains placed
Over next 2 days condition significantly improved
Dx home, oral Abs
BDJ 190, 529-530, 2001
Case Presentation 22/7 later pt reattendedPyrexial, not been taking medsDifficulty swallowing. Pus draining from E/O incision
Blood cultures IV Benzyl Pen / MetronidazoleMonitored regularlyMarked improvement in swelling and swallowingDx home, oral Abs, r/v 1/52
BDJ 190, 529-530, 2001
Case Presentation 2 No further contact made by pt
On day of f/u appt, pt in A&E - emergency ambulance
At home suffered sudden haemorrhaging from oral cavity respiratory arrest
O/E Hb 5.8
bleeding from aerodigestive tract NOT orally
Despite resuscitation died 2 hrs later
BDJ 190, 529-530, 2001
Case Presentation 2
At post mortem abscess found at root of neck communicating with op site. It involved subclavian vein and partially destroyed it.
Subsequent haemorrhage tracked behind pleura through into pleural cavity massive haemothorax
BDJ 190, 529-530, 2001
Case Presentation 2
On admission, CXR showed a mass RT chest, which on post mortem was found to be blood trapped beneath the parietal pleura.
BDJ 190, 529-530, 2001
Case Presentation 2 Post mortem showed lateral pharyngeal space to be
reservoir of infection, tracking down around carotid sheath, to the root of the neck.Further clarification – ideally MRI or US
(clearly define spaces and differentiate between abscess/cellulitis)
However, as the patients clinical condition was improving, there was no indications for further imaging.
This case highlights the importance of taking all odontogenic infections seriously.
BDJ 190, 529-530, 2001
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