1. Management of acute cervicofacial infections
Wednesday, February 29th 2012
King’s College Hospital

2. Types of infection Fungal Management of acute infections Least common
Most common

3. Types of infection Fungal Viral Management of acute infections
Least common
Most common

4. Types of infection Fungal Viral Bacterial
Management of acute infections
Types of infection
Fungal
Viral
Bacterial
Least common
Most common

5. Fungal Aspergillosis A. fumigatus, A. niger, A. flavus
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

6. 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 Dec;27(12):

7. Fungal Management of acute infections
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 Dec;27(12):

8. Management of acute infections
Viral
HSV, EBV, VZV, CMV, Paramyxovirus, Coxsackie virus, Picorna virus
Mostly symptomatic management, with the exception of Herpes zoster (Shingles)

9. Viral 15-35% of HZ patients has postherpetic neuralgia (PHN)
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) :

10. Management of acute infections
Bacterial
Dental infection is the most common cause of deep neck abscess.*
Common acute bacterial infection :
1) Cellulitis – Ludwig’s 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.

11. Management of acute infections
Bacterial
Dental infection is the most common cause of deep neck abscess.*
Common acute bacterial infection :
1) Cellulitis – Ludwig’s 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.

12. Management of acute infections
Bacterial
Dental infection is the most common cause of deep neck abscess.*
Common acute bacterial infection :
1) Cellulitis – Ludwig’s 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.

13. Management of acute infections

14. Management of acute infections

15. Signs of Infection Local
Redness, pain, swelling, heat, +/- pus (abscess)
Loss of function
Systemic
Temperature > 37°C (or spikes), malaise, pallor, irritability, fatigue, dehydration
lymphadenopathy
Severe signs : dysphagia (sublingual,submandibular), drooling, dysphonia, stridor (airway compromise),trismus

16. Bacterial Management of acute infections
Taken from Peterson’s “Principles of Oral and Maxilofacial Surgery” Chapter 15

17. Bacterial Erysipelas Cellulitis of the skin with lymphatic involvement
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);

18. 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);

19. Bacterial Management Assess for potential airway compromise
Management of acute infections
Bacterial
Management
Assess for potential airway compromise

20. Bacterial Management Assess for potential airway compromise
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 Feb;100(2):585-9

21. Bacterial Management Assess for potential airway compromise
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 Jun 25;198(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; 98:

22. Bacterial Management of acute infections 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; 98:

23. Bacterial Management Assess for potential airway compromise
Management of acute infections
Bacterial
Management
Assess for potential airway compromise
Administration of broad spectrum antibiotics

24. Bacterial Management Assess for potential airway compromise
Management of acute infections
Bacterial
Management
Assess for potential airway compromise
Administration of broad spectrum antibiotics
Investigations
FBE, U&E, CRP, ESR, Blood cultures

25. Bacterial Management Assess for potential airway compromise
Management of acute infections
Bacterial
Management
Assess for potential airway compromise
Administration of broad spectrum antibiotics
Investigations
CT scan vs. MRI vs. USS

26. Bacterial Management Assess for potential airway compromise
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.

27. Bacterial Management Assess for potential airway compromise
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

28. 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. 28

29. Management of acute infections
Bacterial

30. Management of acute infections
Bacterial

31. Management of acute infections

32. Management of acute infections

33. Reasons for Admission Rapidly progressing infection
Difficulty breathing
Difficulty Swallowing
Fascial space involvement
Elevated temperature - >38
Severe jaw trismus < 10mm
Toxic appearance
Compromised host defences 33

34. 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 34

35. Access Submandibular/sublingual space Parapharyngeal Buccal
Submassteric

36. Bacterial Management Assess for potential airway compromise
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

37. Bacterial Management Assess for potential airway compromise
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

38. Bacterial Recurrent deep neck infections
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) : Dec

39. 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 39

40. 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 40

41. Complications
Trismus (Classically sub masseteric space/lateral pharyngeal space infections)
Extra-oral incisions – CNVII marginal mandibular branch, scarring, drains and ascending infection 41