Infection in the Infection in the Maxillofacial regionMaxillofacial region

Bag./SMF BedahBag./SMF Bedah

FK UNPAD/RSHS BandungFK UNPAD/RSHS Bandung

Learning objectives :Learning objectives :

At the end of the lecture, you will be able to:At the end of the lecture, you will be able to:

Describe the basic anatomical Describe the basic anatomical considerations infection the head and neck considerations infection the head and neck regionregion

Explain the diagnostic approach to infection Explain the diagnostic approach to infection in the head & neck regionin the head & neck region

Learning objectives :Learning objectives :

Explain the common surgical infections in Explain the common surgical infections in cervical and head regions, including:cervical and head regions, including:

LymphadenitisLymphadenitis SinusitisSinusitis Deep neck abscessDeep neck abscess Salivary gland infectionSalivary gland infection Oral cavity: dento-alveolar abscess Oral cavity: dento-alveolar abscess

IntroductionIntroduction

Infections in the maxillofacial region can be Infections in the maxillofacial region can be simple or complex, and life threatening.simple or complex, and life threatening.

Type: community acquired, nosocomial Type: community acquired, nosocomial (surgically related procedure)(surgically related procedure)

Only infections which require surgical Only infections which require surgical interventionintervention

Anatomic Anatomic considerationsconsiderations

Anatomic location:Anatomic location: Maxillofacial bones: sinuses, osteomyelitis (rare), Maxillofacial bones: sinuses, osteomyelitis (rare),

dento-alveolar infectiondento-alveolar infection Soft tissue: oral mucosa, potential spaces, salivary Soft tissue: oral mucosa, potential spaces, salivary

glands, tonsils, lymph-nodesglands, tonsils, lymph-nodes

The patterns of spread of infection require the The patterns of spread of infection require the understanding of the anatomical relationship understanding of the anatomical relationship between structures and organbetween structures and organ

Anatomic considerations: Anatomic considerations: lymphnodelymphnode

Diagnostic approachDiagnostic approach

History:History: Lump, swelling, pain, fever, bleeding?, halitosis.Lump, swelling, pain, fever, bleeding?, halitosis. Life threatening signs: stridor, tachypneu (signs of Life threatening signs: stridor, tachypneu (signs of

airway obstruction)airway obstruction) Onset? Duration?Onset? Duration?

Physical Diagnosis:Physical Diagnosis: Determine the nature of the swelling or lump: size, Determine the nature of the swelling or lump: size,

location, shape, temperature, color, fluctuance, location, shape, temperature, color, fluctuance, tenderness, surface characteristicstenderness, surface characteristics

Diagnostic approachDiagnostic approach

Oral cavity examination:Oral cavity examination: Look for any possible sources: caries, gingivitis, Look for any possible sources: caries, gingivitis,

salivary glands: parotis, sublingual, salivary glands: parotis, sublingual, submandibular, tongue, pharyng, and tonsilssubmandibular, tongue, pharyng, and tonsils

Regional lymph-nodes: any enlargement, Regional lymph-nodes: any enlargement, tenderness.tenderness.

Skin: any change? Redness? ulcer? Skin: any change? Redness? ulcer? Special investigations:Special investigations:

Routine blood examinationsRoutine blood examinations X-rays: Skull, waters, panoramic, CT-scanX-rays: Skull, waters, panoramic, CT-scan MRIMRI

LymphadenitisLymphadenitis

Lymphnode enlargement due to infection: Lymphnode enlargement due to infection: acute or chronicacute or chronic

The cervical region:The cervical region: Specific infection: tuberculosisSpecific infection: tuberculosis Non specific: bacterial, virusNon specific: bacterial, virus

Etiology:Etiology: Primary: TBC, viralPrimary: TBC, viral Secondary: inflammatory response to adjacent Secondary: inflammatory response to adjacent

organ infections, organ infections,

LymphadenitisLymphadenitis

Management:Management:

Look for any primary causesLook for any primary causes For non specific infection: antibiotics is adequateFor non specific infection: antibiotics is adequate If no, improvement: Biopsy is required to If no, improvement: Biopsy is required to

determine the histopathologydetermine the histopathology TBC: tuberculostaticsTBC: tuberculostatics

SinusitisSinusitis

Common, but self limitedCommon, but self limited

can occur in :can occur in : maxillary, ethmoid, para nasal, and frontal sinusesmaxillary, ethmoid, para nasal, and frontal sinuses

Etiology:Etiology: secondary to allergies, viruses, or bacteria. secondary to allergies, viruses, or bacteria. patients who undergo prolonged nasal intubation. patients who undergo prolonged nasal intubation. Fungal infection (less frequent: diabetic, or Fungal infection (less frequent: diabetic, or

immuno-compromised patients)immuno-compromised patients)

SinusitisSinusitis

Complications: rare, spread to adjacent sinus, Complications: rare, spread to adjacent sinus, meningitis, abscess.meningitis, abscess.

Diagnosis:Diagnosis: Routine radiographsRoutine radiographs CT scans are often required: sinus opacificationCT scans are often required: sinus opacification

Treatment:Treatment: Uncomplicated: antibioticsUncomplicated: antibiotics Aspiration and drainageAspiration and drainage Chronic infection: Cadwell luc operation Chronic infection: Cadwell luc operation

Peri-tonsilar abscessPeri-tonsilar abscess

Etiology: complications of acute tonsillitis.Etiology: complications of acute tonsillitis.

Pathology:Pathology: Infection is deep to the tonsillar capsule: forms between the Infection is deep to the tonsillar capsule: forms between the

tonsillar capsule and the superior constrictor muscle. tonsillar capsule and the superior constrictor muscle.

Manifestations:Manifestations: Massive edema of the entire soft palateMassive edema of the entire soft palate edema of the lateral pharyngeal wall. edema of the lateral pharyngeal wall. inflammation of the pterygoid muscles can result in trismus. inflammation of the pterygoid muscles can result in trismus. may be so large that the airway is compromised. may be so large that the airway is compromised.

Peri-tonsilar abscessPeri-tonsilar abscess

Management:Management:

Tracheostomy may be necessary before it is safe Tracheostomy may be necessary before it is safe to drain the abscess.(air way obstruction) to drain the abscess.(air way obstruction)

Cellulitis: high doses of penicillin Cellulitis: high doses of penicillin If pus is present: incision and drainage, through a If pus is present: incision and drainage, through a

transoral approach, with an incision along the transoral approach, with an incision along the anterior tonsillar pillar, and drains when the patient anterior tonsillar pillar, and drains when the patient swallows. swallows.

These abscesses recur frequently: an indication These abscesses recur frequently: an indication for tonsillectomy. for tonsillectomy.

Parapharyngeal Parapharyngeal abscessabscess

Parapharyngeal infections and abscesses are Parapharyngeal infections and abscesses are unusual in adults. unusual in adults.

Can be secondary to tonsillitis or pharyngitis, Can be secondary to tonsillitis or pharyngitis, Often present as marked swelling in the Often present as marked swelling in the

anterior cervical triangle between the carotid anterior cervical triangle between the carotid sheath and superior constrictor muscles. sheath and superior constrictor muscles.

Common micro-organisms: streptococcusCommon micro-organisms: streptococcus

Parapharyngeal Parapharyngeal abscessabscess

Management:Management:

Penicillin is the antibiotic of choice,Penicillin is the antibiotic of choice, Because of the proximity of the carotid artery, Because of the proximity of the carotid artery,

these infections should be drained extra-these infections should be drained extra-orally through an incision anterior to the orally through an incision anterior to the border of the sternocleidomastoid muscle. border of the sternocleidomastoid muscle.

Retro-pharyngeal Retro-pharyngeal abscessabscess

Retropharyngeal infections are unusual in Retropharyngeal infections are unusual in adults and adults and

can be caused by tumor perforation or can be caused by tumor perforation or perforation by a foreign body. perforation by a foreign body.

Management: best drained by means of an Management: best drained by means of an incision through the posterior wall of the incision through the posterior wall of the pharynx; pharynx;

concomitant administration of antibiotics is a concomitant administration of antibiotics is a necessity. necessity.

Salivary gland infectionSalivary gland infection

are unusual are unusual most often are seen in patients with poor most often are seen in patients with poor

dental care. dental care. Acute inflammation may be seen when the Acute inflammation may be seen when the

salivary duct is obstructed, as with a stone: salivary duct is obstructed, as with a stone: usually self-limited and controlled with usually self-limited and controlled with antibiotics and removal of the stone. antibiotics and removal of the stone.

When unresponsive to antibiotics: excision of When unresponsive to antibiotics: excision of the necrotic gland may be necessary. the necrotic gland may be necessary.

ParotitisParotitis

can occur in :can occur in : The comunitiy (community acquired)The comunitiy (community acquired) surgical patients, particularly elderly, surgical patients, particularly elderly, dehydrated patients. dehydrated patients.

Therapy should be directed towards:Therapy should be directed towards: rehydration, rehydration, enhancing salivation, enhancing salivation, ensuring that no mechanical obstruction of the duct of ensuring that no mechanical obstruction of the duct of

Stensen is present, obtaining stains and cultures, Stensen is present, obtaining stains and cultures, administering antibiotics directed against S aureus (the most administering antibiotics directed against S aureus (the most

common offending organism). common offending organism).