Abscesses, phlegmons of the MFA: definition, classification, etiology, pathogenesis, clinical features, principles of treatment, complications, prevention. Etiological and pathogenetical principles treatment of inflammatory processes of the MFA. Lymphadenitis of the MFA, etiology, pathogenesis, clinical features, diagnosis, treatment and prevention. Furuncles and carbuncles of the MFA: etiology, pathogenesis, clinical course, treatment.

An abscess is a localized collection of pus in part of the body, formed by tissue disintegration and surrounded by an inflamed area, collection of pus (neutrophils) that has accumulated within a tissue because of an inflammatory process in response to either an infectious process (usually caused by bacteria or parasites) or other foreign materials (e.g., splinters, bullet wounds, or injecting needles).

Phlegmon is a spreading diffuse inflammatory process with formation of suppurative/purulent exudate or pus. This is the result of acute purulent inflammation which is due to bacterial infection.

Potential pathways of extension of deep fascial space infections of the head and neck

Fascial spaces around the mouth and face

Figure 69-4 Natural progression of dental infection Figure 69-4 Natural progression of dental infection. The pathways by which such infections may travel are: 1, postzygomatic (from canine fossa in cuspid and bicuspid region; pterygomaxillary fossa communicates from rear); 2, vestibular; 3, facial; 4, submandibular; 5, sublingual; 6, palatal; 7, antral; 8, pterygomandibular; 9, parapharyngeal; 10, masseteric. (Redrawn from Rose LF, Hendler BH, Amsterdam JT: Temporomandibular disorders and odontic infections. Consultant 22:125, 1982.) Downloaded from: Rosen's Emergency Medicine (on 15 January 2009 05:57 PM) © 2007 Elsevier

Early appearance of patient who has Ludwig’s angina with characteristic submandibular ‘’woody’’ swelling

Anatomic relationships in submandibular infections

Routes of spread of odontogenic orofacial infections along planes of least resistance

Early Ludwig's angina

Early Ludwig's angina

Figure 69-6 Extensive spread of infection of odontogenic origin involving masseteric, sublingual, submental, and submandibular spaces with extension to mediastinum. A, Preoperative. B, Postoperative. Note drainage from mediastinum. (From Guernsey LH: Practical problem solving in oral surgery. In Cohen DW [ed]: Continuing Dental Education, vol 2, suppl 10. Philadelphia, University of Pennsylvania School of Dental Medicine, 1979.) Downloaded from: Rosen's Emergency Medicine (on 15 January 2009 06:09 PM) © 2007 Elsevier

Figure 69-6 Extensive spread of infection of odontogenic origin involving masseteric, sublingual, submental, and submandibular spaces with extension to mediastinum. A, Preoperative. B, Postoperative. Note drainage from mediastinum. (From Guernsey LH: Practical problem solving in oral surgery. In Cohen DW [ed]: Continuing Dental Education, vol 2, suppl 10. Philadelphia, University of Pennsylvania School of Dental Medicine, 1979.) Downloaded from: Rosen's Emergency Medicine (on 15 January 2009 06:07 PM) © 2007 Elsevier

Potential pathways of extension of deep fascial space infections of the head and neck

Retropharyngeal abscess

Retropharyngeal space

Buccal Cellulitis (Hib)

Masticator space infection with trismus

Deep temporal space infection with spread to parotid space

The admission decision Airway issues High fever Dehydration Need for I+D Inpatient control systemic disease Immune compromise

Airway security Protect against aspiration ETT ruptures abscess Trismus / Swelling Maintain airway reflexes during intubation

Surgical treatment Gravity dependent surgical drainage Antibiotics secondary Tooth extraction

Antibiotic therapy Predominately anaerobic nature Initially: aerobic streptococci ( penicillin ) Later: anaerobic bacteria ( penicillin resistant ) Synergistic interaction

Mediastinitis Airway security Contrast CT Open thoracotomy Broad spectrum antibiotics

Cavernous sinus thrombosis Ascending septic thrombophlebitis Anterior route – angular vein (infraorbital space) Posterior route – facial vein (buccal space) Congestion retinal veins CN 6 paresis → ophthalmoplegia / blindness Severe orbital / periorbital / infraorbital swelling

Cavernous Sinus Thrombosis Treatment: Tooth extraction root canal Drainage deep spaces High dose IV antibiotics Anticoagulation

THE MAINS WAYS OF FLOWING LYMPH FROM LOWER AND APPER LIPS

Lymphadenitis is often a complication of a bacterial infection of a wound, although it can also be caused by viruses or other disease agents. Lymphadenitis may be either generalized, involving a number of lymph nodes; or limited to a few nodes in the area of a localized infection. Lymphadenitis is sometimes accompanied by lymphangitis, which is the inflammation of the lymphatic vessels that connect the lymph nodes.

Causes Streptococcal and staphylococcal bacteria are the most common causes of lymphadenitis, although viruses, protozoa, rickettsiae, fungi, and the tuberculosis bacillus can also infect the lymph nodes. Diseases or disorders that involve lymph nodes in specific areas of the body include rabbit fever (tularemia), cat-scratch disease, lymphogranuloma venereum, chancroid, genital herpes, infected acne, dental abscesses, and bubonic plague. In children, tonsillitis or bacterial sore throats are the most common causes of lymphadenitis in the neck area. Diseases that involve lymph nodes throughout the body include mononucleosis, cytomegalovirus infection, toxoplasmosis, and brucellosis.

Physical examination The diagnosis of lymphadenitis is usually based on a combination of the patient's history, the external symptoms, and laboratory cultures. The doctor will press (palpate) the affected lymph nodes to see if they are sore or tender. Swollen nodes without soreness are often caused by cat-scratch disease. In children, the doctor will need to rule out mumps, tumors in the neck region, and congenital cysts that resemble swollen lymph nodes.

PALPATION OF SUBMANDIBLE LYMPH NODES

PALPATION OF SUBMENTAL LYMPH NODES

PALPATION OF RETROMANDIBLE LYMPH NODES

CLINICAL CLASSIFICATION OF LYMPHADENITIS -Acute: serous, purulent. -Chronic: hyperplastic, purulent.

Symptoms Lymphadenitis is marked by swollen lymph nodes that are painful, in most cases, when the doctor touches them. If the lymphadenitis is related to an infected wound, the skin over the nodes may be red and warm to the touch.

Acute lymphadenitis

Chronic lymhadenitis

Operation of removed lymph nodes attached chronical inflammation

Operation of removed lymph nodes attached chronical inflammation

Removed lymph nodes

Treatment The medications given for lymphadenitis vary according to the bacterium or virus that is causing it. If the patient also has lymphangitis, he or she will be treated with antibiotics, usually penicillin G (Pfizerpen, Pentids), nafcillin (Nafcil, Unipen), or cephalosporins. Erythromycin (Eryc, E-Mycin, Erythrocin) is given to patients who are allergic to penicillin. Supportive care of lymphadenitis includes resting the affected limb and treating the area with hot moist compresses. Cellulitis associated with lymphadenitis should be treated surgically because of the risk of spreading the infection. Pus is drained only if there is an abscess and usually after the patient has been started on antibiotic treatment. In some cases, a biopsy of an inflamed lymph node is necessary if no diagnosis has been made and no response to treatment has occurred.

A furuncle is an infection of a hair follicle. A carbuncle is a skin infection that often involves a group of hair follicles.

Risk factors Although anyone — including otherwise healthy people — can develop boils or carbuncles, the following factors can increase your risk: Poor general health. Having chronic poor health makes it harder for your immune system to fight infections. Diabetes. This disease can make it more difficult for your body to fight infection, including bacterial infections of your skin. Clothing that binds or chafes. The constant irritation from tight clothing can cause breaks in your skin, making it easier for bacteria to enter your body. Other skin conditions. Because they damage your skin's protective barrier, skin problems, such as acne and dermatitis, make you more susceptible to boils and carbuncles. Immune-suppressing medications. Long-term use of corticosteroids, such as prednisone or other drugs that suppress your immune system, can increase your risk.

FURUNCLE (the first stage of development)

FURUNCLE (the second stage of development)

Furuncle of face

Furuncle of face

Carbuncle of face

Carbuncle of the lower lip

Signs and symptoms A boil usually appears suddenly as a painful pink or red bump that's generally not more than 1 inch in diameter. The surrounding skin also may be red and swollen. Within a few days, the bump fills with pus. It grows larger and more painful for about five to seven days, sometimes reaching golf ball size before it develops a yellow-white tip that finally ruptures and drains. Boils generally clear completely in about two weeks. Small boils usually heal without scarring, but a large boil may leave a scar. A carbuncle is a cluster of boils that often occurs on the back of the neck, shoulders or thighs, especially in older men. Carbuncles cause a deeper and more severe infection than single boils do. In addition, carbuncles develop and heal more slowly and are likely to leave a scar. Carbuncles sometimes occur with a fever. Boils and carbuncles often resemble the inflamed, painful lumps caused by cystic acne. But compared with acne cysts, boils are usually redder or more inflamed around the border and more painful.

Treatment Doctor may drain a large boil or carbuncle by making a small incision in the tip. This relieves pain, speeds recovery and helps lessen scarring. Deep infections that can't be completely cleared may be covered with sterile gauze so that pus can continue to drain. Sometimes doctor may prescribe antibiotics to help heal severe or recurrent infections.

Self-care The following measures may help the infection heal more quickly and prevent it from spreading: Apply a warm washcloth or compress to the affected area. Do this for at least 10 minutes every few hours. If possible, first soak the cloth or compress in warm salt water. This helps the boil rupture and drain more quickly. To make salt water, add 1 teaspoon of salt to 1 quart of boiling water and cool to a comfortable temperature. Gently wash the boil two to three times a day. After washing, apply an over-the-counter antibiotic and cover with a bandage. Never squeeze or lance a boil. This can spread the infection. Wash your hands thoroughly after treating a boil. Also, launder clothing, towels or compresses that have touched the infected area.

Prevention Although it's not always possible to prevent boils, especially if you have a compromised immune system, the following measures may help you avoid staph infections: Thoroughly clean even small cuts and scrapes. Wash well with soap and water and apply an over-the-counter antibiotic ointment. Avoid constricting clothing. Tight clothes may be stylish, but make sure they don't chafe your skin.

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