Surgical management of facial infections

2021-02-02 12:00 AM

An antibiotic is a substance of biological or synthetic origin, that works against the life of bacteria by specifically acting on a major stage.

Principles of infection management

In general, oral and facial infections (due to teeth or not from teeth) meet the following four treatment principles: eliminate the cause, incision and drain, use appropriate antibiotics, and improve the health. .

Eliminate the cause

The first step in developing an anti-infection treatment plan is to identify the source of the infection. Acute oral and facial infections often arise from apical, periodontal, or periostatic diseases, or diseases of the sinuses, salivary glands. weakness at the time of surgical intervention against etiology.

The question arises: When is the intervention aimed at eliminating the dental cause of the infection indicated? Delaying tooth extraction, waiting for the infection to be repelled thanks to the patient's own resistance is a common management attitude of the antibiotic-free period. Today, surgical interventions (extraction of teeth are carried out early along with the use of antibiotics and improving the condition. for surgical intervention A passive attitude of administering antibiotics to the patient and waiting for the cap to rupture on its own, the swelling and collapse is considered inappropriate.

Slit and drain

Since the time of Hippocrates, people have come to know the importance of hat drainage. As the infection progresses to the cystic formation stage, the expulsion incision and continuous expectoration (drainage) plays a decisive role in the treatment. the facial jaw must understand the anatomy of the head-face-neck space, the relationship between these compartments and the sites of infection originating (teeth, sinuses, middle ear ... important anatomical structures as well as the relationships between these compartments. Infection from a certain place of origin as progresses will form a cyst in the related cavities. From these compartments, if not promptly and thoroughly, the infection continues to spread to the structures. key anatomy, causes serious complications that can lead to death. Therefore, technically and especially in severe infections, deep spread, incision and drainage is not a simple procedure but a real surgery that requires preparing the patient for the method of anesthesia (usually performed under endotracheal intubation or tracheostomy), the experience and skills of a facial surgeon and sometimes a combination of specialties: Facial surgery , Ear, Nose and throat, beyond chest ..

Use antibiotics

An antibiotic is a substance of biological or synthetic origin, that works against the life of bacteria by specifically acting on a major stage in the bacterial metabolism (antibiotic) or fungus (antifungal antibiotic).

Antibiotics fight off bacterial survival in two ways: either inhibit the growth of bacteria - bacteriostatic or bacterial cell destruction - antibiotics that kill bacteria depending on whether the concentration is low or high. . For antibiotics whose bactericidal effect is shown only at very high concentrations that can be toxic to the patient, these antibiotics can only be used as bacteriostatic agents, not as bacteriostatic agents. bactericidal antibiotic. In the case of the use of bacteriostatic antibiotic, the antibiotic only inhibits the growth of bacteria that facilitates the natural resistance mechanism (humoral and cellular-mediated immunity) of the body destroys bacteria.

Antibiotics are an indispensable, if not fatal, factor in the treatment of facial infections. However, in order to use antibiotics effectively and limit the harmful and even dangerous effects of indiscriminate use of antibiotics, physicians need to have a clear understanding of the mechanism of action of antibiotics, spectrum, and formulation of antibiotic combination, side effects, as well as knowledge of bacteriology and features of the oral microbiota

Increase the total status

A healthy patient is better able to resist the spread of infection than an impaired patient. It has been found that in infected patients also have other medical conditions such as diabetes or impairment. immunology ... the treatment process is usually long and easily leads to serious life-threatening complications such as mediastinal inflammation, cerebral abscess, pleural effusion ... Fever due to infection increases catabolism leading to energy expenditure and exhaustion of the body.

Overall improvement is very important in the treatment of infection. Patients with oral or perioral infections often do not eat, so patients must be provided with adequate nutrition through the route. Improving the total condition not only ensures adequate supply of nutrients, fluids and electrolytes, but also pays attention to psychological factors and prevents pain with pain relievers. suitable.

Surgical intervention for oral and facial infections 

Except for some facial infections such as sinusitis or salivary gland inflammation, which usually requires only non-surgical treatments or surgical operations to be performed only after a period of conservative treatment, facial infections. otherwise when progression to the stage of cystic formation (in the localized form of an abscess or diffuse phlegmon), surgical incision and drainage play the most important role in the treatment of infection. The incision and drainage must be considered an emergency surgery meaning that it must be performed as soon as possible after the socket is formed and must be done so that it is truly effective, ie, the socket is accessible. expires and drains well after that. For effective incision and drainage, the physician necessarily understands the anatomy of the scales (fascia) of the face and neck, compartments form from these fascial spaces and the relationship that holds these compartments together. Based on the anatomical knowledge of the cervical cavities, we understand the locating ability of the cervical cavities (corresponding to the origin of the infection), the path of propagation of the cervical cavity, the cystic propagation and incision and drainage techniques.

Consider anatomy

There are 3 scales in the neck: shallow neck scale, mid-neck scale (or front tracheal weight and deep neck weight (or weight before spine).

Shallow neck scale

Derived from the spine of the cervical vertebrae, it is the only scale that surrounds the entire neck and a part of the face. At the back of the neck, the scales are split into 2 children covering the trapezoidal muscle, then fold into one on the anterior margin of the trapezium, then continue to cover the posterior triangle to reach the sternum muscle. cling to the collarbone. The scale continues to split, enveloping the sternum, and then folded, covering the triangle of the anterior neck to the midline connected to the isosceles on the opposite side. is divided into 2 parts: under the nail and on the nail.

The lower part of the nail: Going from the nail plate to the sternum. When approaching the sternum split, 2 children cling to the anterior margin and posterior margin of the sternum forming a cavity on the sternum Burns. is the mid-neck balance that covers the anterior trachea. The anterior tracheal cavity forms between the leaves (pretracheal space). Infection of the lower jaw cavity can spread to the anterior tracheal cavity, followed down the posterior sternum leading to complications of mediastinal (anterior part).

Top of the nail: Go from the base of the nail to the lower edge of the lower jaw. Weighed the front abdomen of the binocular muscle in the inner and the lower jaw gland outside. Parotid gland. From the anterior margin of the parotid gland, the two children were shallow and deep, joined together and continuously with the biting weight. Shallow neck balance from lower margin continuously with lower jaw with external occlusal balance and inner calf muscle

Summary: Shallow neck scale:

2 muscles: the sternum muscles and the trapezoid muscle.

2 glands: lower jaw gland and parotid gland.

In addition, the shallow neck balance clings to bone markers: the superior nuchal line, the spiny crown, the cymbals, the lower margin of the lower jaw, the lower margin arcs.   

Weigh the mid neck or weigh before the trachea

This scale is present only the front half of the neck. Upper middle neck scale attached to the nail bone, thyroid cartilage; below clinging to the back of the clavicle and sternum, the two sides cling to the child deep, the pectoral muscle of the shallow neck. - Shallow shade; 2 muscles - the thyroid and the thyroid - the nail are deep. In addition to this weight also covers the vocal cord - trachea, esophagus, thyroid, so it is also called the visceral leaf.

Balance in front of spine

Cover the back half of the neck. This scale above clings to the floor of the skull (in the rock of the temporal bone), below goes to the coccyx (coccyx). In the neck, posterior to anterior cover the muscles around the spine, when reaching the transverse apex of the cervical vertebrae, it is divided into two leaves: the anterior leaf is called the alar fascia and the posterior leaf is the anterior column. live covering just before the spine. Thus, at the posterior wall there are 3 isosceles: viscera of the anterior trachea covering the airway - esophagus, alar fascia, and anterior spine. These three scales form 3 cavities:

Retropharygeal space or retrovisceralspace: located between the visceral leaf and the alar fascia, which stick together at the lower end of the thoracic vertebra T1-2.

Middle - The danger space wing and leaf in front of spine. This cavity goes from the floor of the skull to the calf muscles, and is directly related to the posterior mediastinum.                 

Prevertebral space: Located between the anterior trachea and spinal column 

These cavities do not contain within it important anatomical structures but are of very important pathological significance: they are the paths connecting the neck to the chest.

The posterior oropharyngeal cavity contains the open organ and the lymph nodes receive the tracheal vessels from the posterior nose, the paranasal sinuses, the nasopharynx, the soft palate, the atrial tube. primary due to inflammation of the lymph nodes due to infection from the concerned regions, especially otitis media. After this age the lymph nodes shrink, so infection of this cavity is mainly secondary infection spread from infection of the lateral pharyngeal space. The posterior oropharyngeal cavity is the most infectious of the 3 upper and is the indirect cause of complications of mediastinal inflammation due to spread to the dangerous sinus right behind. Clinical manifestations include: posterior pharyngeal bulging, chest pain, neck pain, neck stiffness, difficulty breathing, difficulty speaking, difficulty swallowing.

The hazard compartment contains a loosely connected organization and usually only secondary infection from adjacent compartments (posterior pharynx, posterior chamber of the parotid compartment).

Infection from this cavity spreads rapidly to the posterior mediastinum and this is the most common path of transmission of infection to the mediastinum.

 Pre-spinal cavity: rarely infected due to its dense and small structure. In the absence of antibiotics, the cavity may be secondary to spinal tuberculosis. Today primary infection can occur, albeit very rarely, from trauma or surgical intervention and can lead to a lumbar abscess.

In addition to the upper chambers (4 cavities: the anterior tracheal cavity in the aforementioned shallow trachea and the 3 deep cavities mentioned above), there are a number of other compartments on the face of the neck, which are often described as follows:

Lateral pharyngeal space: The lateral pharyngeal space: inverted cone-shaped, the apex in the large horns of the nail bone, the base is across the rocky part of the temporal bone. ); outside is the inner calf muscle and parotid gland deep lobe; anterior is the pterygomandibular ligament - the pterygomandibular ligament, also known as the pterygomandibular raphae - is a small ligament that goes from the hamulus hook to the posterior end of the inner diagonal. attachment to 2 muscles: the gum muscle (anterior) and the spasmodic muscle of the upper pharynx (posterior), only the mucous cover above, the buccal fat pad (buccal fat pad) of the cheeks); Behind is many scenes.

This compartment with the pharyngeal (from the brooch to the lateral wall) passing should be divided into 2: the anterior chamber or the muscular compartment; the rear or visceral compartment.

Anterior conpartment: closely related to the amygdala (amygdala tissue abscess can spread to this anterior or lateral chamber). below the pomelo, lower jaw, around the amygdala and deep lobe of the parotid gland. Infection from the anterior chamber can spread to the posterior pharynx and clinical manifestations such as fever, jaw tightness, pharyngeal bulging, palpitations  

Rear Chamber: An important anatomical feature of the posterior chamber is the containment of the carotid-menstrual vessel bundle. The envelope of the carotid-menstrual bundle is formed from both a frontal weight of the trachea and anterior weight of the spine, so infection of the chamber later leads to 3 possibilities: 1 / infection spread to the dangerous compartment, from which it may spread. down the mediastinum.

Causes complications to the inner carotid artery and cranial nerves (internal carotid thrombosis, internal carotid artery ..)

Infection spreads down to the mediastinum (Mosher (1929) likens this pathway to the mediastinum as "Lincoln's highway"). Infections of the posterior chamber have more severe clinical manifestations such as: infected expression, slight jaw tightening, difficulty breathing, decreased or hearing loss due to obstruction of the ear canal (Eustachian tube), difficulty speaking due to reversible laryngeal branch compression ( wire X).

Sublingual cavity: Upper limit is the oral mucosa; below is the jaw muscle; anterior surface is inside of jawbone under chin area; behind is the nail bone; outside is the inside surface of the lower jaw bone and inside is the chin muscle to the chin.

 Infection of this cavity is usually secondary to trauma or tooth trauma and rapidly spreads to the lower jaw cavity (usually both sides) if not treated in time. (because the tooth tip is above the inner diagonal); while the first and second molars are usually related to the lower molars and wisdom teeth are related to the chewing cavity. Infection of this cavity leads to swelling of the floor of the mouth that pushes back, pain, and difficulty swallowing.           

Submaxillary space: This is under the jaw muscle and on the nail bone, divided into 2 compartments:

Submental space: Located in front of the abdomen anterior to the biceps. The upper limit is the nail jaw muscle; below is the skin, held under the skin, shallow neck; the anterior side of the jawbone below the chin area; behind the nail plate; outward is the inner surface of the lower jaw; the interior is connected to the other compartment.

Submandibular space (submandibular space): Upper limit is the jaw muscle, lower jaw bone; below is the nail bone; the anterior abdominal cavity is the biceps; posterior abdomen is posterior biceps; outwardly is skin, subcutaneous, shallow neck; inside is the nail muscle, the claw muscle. The cavity contains the lower jaw of the facial vein, lymph nodes. This is the most often infected cavity that is mainly caused by teeth, other cases can be due to underlying jaw disease, jaw fracture. Clinical manifestations include: swelling in the lower jaw area, unable to touch the lower jaw bone, pain, difficulty swallowing

Infection from this cavity can spread down the neck along the anterior tracheal cavity to reach the mediastinum (anterior) or to the lateral cavity.

Buccal space: Upper limit: lower margin arcs; lower: lower margin of lower jaw; before: modiolus; posterior: anterior marginal muscle bite; inside: the sucking muscles; External: skin, organized under the skin. This compartment contains the facial artery, branches VII cord, Sténon tube, Bichat fat lump. The Bichat ointment is located between the cheeks and the pararynx, acting as a barrier to prevent the spread of the infection from the cheek to the parietal space.

Infection of this cavity can come from the upper or lower jaw, but usually from the upper jaw. The lower molars are closer to the plate than the cheekbone, so infection often leads to infection of the lower and lower jaw. External foot infection of the maxillary molars can lead to infection of the cheek cavity, while infection of the inner leg leads to an oral abscess. This infection has a fairly good prognosis, usually only resident in place. In healthy people, without cap intervention it can be spontaneous, but in the weak, the infection can spread dangerously into the temporal cavity.

Mandibular space: Shallow neck balance when reaching the lower margin of the lower jaw bone splits into 2 consecutive with the periosteal covering the outer and inner surface of the bone. This cavity, therefore, is also called the space of body of mandible, and opens the periosteal cavity with the posterior chewing cavity. This is the virtual and mediating compartment when the infection spreads from the jawbone to the lower and / or subjaw spaces.

Masticator space: At the back of the lower jaw cavity, the neck is shallow when reaching the lower edge of the lower jaw bone, corresponding to the high branch that splits into 2 to cover the outer biting muscle and the inner calf muscle. The chewing chamber is limited to the outer surface by the bite muscle, the inner surface by the inner calf, anterior by the anterior margin of the biting muscle and the inner calf muscle, behind by the high posterior margin, above by the arched lower margin and below is the lower margin of the lower jaw corresponding to the high branch. Thus, this compartment contains 2 chewing muscles and lower jaw bone high branches. Infection of this cavity is usually caused by the lower wisdom teeth and can spread to the temporal cavities, parotid gland.

Infratemporal space: This is limited anteriorly by the protrusion of the maxilla, posterior by the extrasystole, protruding, temporal muscles, externally by the temporal tendons, parrots and inward. by the butterfly's outer wing, the inner calf muscle. The cavity contains the inner jaw artery and the pterygoid plexus of veins, which are often caused by infection of the upper wisdom teeth and play an important role in the spread of infection. Infection of this cavity can spread to the orbit through the socket under the orbit. In addition, it usually spread to the cheeks, temporal cavity, chewing cavity and, more rarely, the paranasal cavity, the lower jaw

The temporal space: is divided into two compartments: the shallow temporal cavity is located between the balance and the temporal temporal cavity of the deep temporal space : located below the deep temporal cavity, between the temporal muscle and skull. Usually secondary infection that spreads from infection of the temporal or chewing cavity.

Drainage slitting technique

Cheek cavity infection

Incision and drainage in the mouth, under local anesthesia. Incision in the cheekbones, the most bulging, 1-2 cm long. Using hemostatic forceps in closed position put through the incision of the mucosa towards the socket. When entering the socket, there are a few caps flowing out along the clamp, while opening the clamp and pulling it out so that the hat comes out. Perform many times in many different directions, with clamping when inserting, opening the clamp when withdrawing to break the bearing partitions if any. Drain with rubber flakes. A stitch can be attached to the edge of the mucosa to keep the rubber piece off.

Chewing cavity infection

Slit and drain the outside of the mouth, under the angle of the jaw. Due to swelling in this area, it is difficult to determine the exact bone mold, so the incision should be a little lower than normal, about 3-4 cm from the lower edge of the lower jaw bone (normally about 2cm). Cut through the skin, muscle clings to the skin, thread the clamp upwards to touch the lower margin of the lower jaw bone. From here, always keep the clamps close to the bones, facing outwards or inwards depending on the bearing position. Drain with tube or rubber piece.

Infection of the lower temporal cavity

Often difficult to diagnose if based solely on clinical practice due to deep hat and jaw tightening. CT or MRI scans are of great help in the diagnosis. Slit and drain the sugar in the mouth. Slit the upper and outer lining of the upper jaw bone. Slide the clamp up-in in the direction of the bulbous convex. Drain with rubber flakes.

Infection of the temporal cavity

Incision and whether or not the sugar is left inside the mouth or a combination of the two:

Outside of the mouth: Transverse incision on the temporal arcs. The clamp pierces the temporal scale to enter the shallow temporal cavity or pushes the nose to touch the temporal bone to drain the deep temporal cavity

Sugar in the mouth: stretching the cheeks, touching the bow with your hand. Slit the lower cheek lining - in the next arc. Slide the clamp below the arc further up - outward or up - inward (touching the bone) to enter the 2 compartments. In case of using both lines, the circulating drain (tube or piece of rubber) is placed from the outside in.

Cavity below

In case the nest is localized and shallow, it is possible to make an incision in the mouth. Incise the most bulging, incision parallel to the inside of the jawbone. When the infection spreads to the lower chin cavity, incision and drain the outer line. Transverse incision under the chin, through the skin, the muscles sticking to the skin, the neck should be shallow into the space under the chin; Then continue using forceps to pierce through the jaw muscle in the middle way to go into the lower chamber. Note: to avoid puncturing the oral mucosa (causing saliva detection), the PTV puts 1 index finger in the mouth, gently presses the floor of the mouth down to guide the clamp. 

Cavity under the jaw

Cut and drain through the mouth. The skin incision is parallel and a few centimeters below the lower margin of the jawbone. Through the skin, the muscles attach to the skin and the neck is shallow to walk and the lower jaw cavity.

Infection of this cavity can be individual, and the cause is usually the tooth or has spread from the lower chamber. In the case of an orchid from the lower chamber, we have a phlegmon rather than a simple abscess with the classic condition first described by Ludwig (1836) as Ludwig'angina (angine de Ludwig) This is 1 infection of the oral floor (lower chamber) caused by anaerobic and aerobic bacteria, causing damage to the connective tissue, muscles, and weight (but not affecting the salivary glands), producing very little but oozing a lot of serum fluid, spreading very quickly to the lower jaw, usually bilateral. At this stage, without timely and proper surgical intervention, the infection continues to spread to the deep cavities of the neck and ends death due to complications such as mediastinal inflammation, lung abscess, sepsis ... In this form of the disease, patients deteriorate rapidly and the risk of airway obstruction is very high. Incision and drainage are performed under endotracheal anesthesia placed in any way (nose, mouth) or through the tracheostomy. Tracheostomy is often indicated in the presence of airway obstruction or to prevent airway obstruction.

Incision and drainage: perform skin incision in 2 ways:

1% Cut the skin from below the corner of the jaw to the bottom of the jaw to the other. Cut the jaw muscle along the middle longitudinal line. Use your index finger to separate to go into the lower jaw cavity on both sides and the lower chamber through the nail jaw muscle.

2% Rach along 3 lines, 2 side roads in the lower jaw area and 1 longitudinal line

Place several drains or rubber tubes while dripping continuously.

Incise and drain the parietal cavity

Infection of this cavity is very dangerous because it can reach deep cavities such as the posterior pharynx, the dangerous compartment, the anterior spine.

 Oral incision and drainage: rarely used because of the risk of bleeding. Mucous incision just above the pterygomandibular raphe ligament. This incision directly enters the inner oropharyngeal cavity (and the chewing chamber outside).

Incision and drainage out of the mouth: The incision is described by Mosher (1929). Use the skin incision as in sub-jaw surgery. Cut through the skin, muscle clinging to the skin. Forced facial veins. Flip the upper skin flap right on the shallow neck scale. the anterior and posterior chambers of the paranasal compartment. Drain with rubber flakes.

Infection of the deep neck cavities

Consists of the posterior pharynx, danger compartment and the anterior tracheal space.

Incision and drainage: The incision, described by Dean in 1918, is a longshore incision in front of the sternum sternum. The latter is improved by extending the lower incision down to the palate and bending across the midline to the opposite side. This incision allows access to the mediastinum in case the infection spreads to the mediastinum. Cut the skin, the dermal muscles, the anterior sternum and the lower scapula are pulled back. If the socket is above the neck, it should expose the hypotenic cord (XII), the upper laryngeal branch. The larynx is pulled to the opposite side. Use fingers to separate the posterior upper pharyngeal spasm muscle from the alar fascia to enter the posterior pharyngeal cavity, the dangerous cavity or If the abscess spread below the neck, tie the medial veins, the lower backbone, cut the nail shoulder . The trachea and thyroid are pulled to the opposite side and manually dissociate the posterior pharyngeal cavity to the posterior mediastinum and the anterior tracheal cavity until the tracheal bisection (carina). Do not forget to take the specimen for the bacteriological test to filter for mortality. Place the drainage drain alternately with a drip of antibiotic.