Management of acute cervicofacial infections

Wednesday, February 29 th 2012 King’s College Hospital

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

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

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

Management of acute infections

Fungal

• • 1) 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

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.

region in a 446(1):28-33, 2005 Jan Combined mucormycosis and aspergillosis of the oro-sinonasal patient affected by Castleman disease . Virchows Archiv.

Chandu A. et al.

A case of mucormycosis limited to the parotid gland . Head Neck. 2005 Dec;27(12):1108-11.

Fungal

Management of acute infections Ref. : Maiorano E. et al.

region in a 446(1):28-33, 2005 Jan Combined mucormycosis and aspergillosis of the oro-sinonasal patient affected by Castleman disease . Virchows Archiv.

Chandu A. et al.

A case of mucormycosis limited to the parotid gland . Head Neck. 2005 Dec;27(12):1108-11.

Management of acute infections

Viral

• HSV, EBV, VZV, CMV, Paramyxovirus, Coxsackie virus, Picorna virus • Mostly symptomatic management, with the exception of Herpes zoster (Shingles)

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) : 561-70 2003

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.

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.

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.

Management of acute infections

Management of acute infections

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

Bacterial

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

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); 383-389

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); 383-389

Management of acute infections

Bacterial

• Management 1) Assess for potential airway compromise

Management of acute infections

Bacterial

• Management 1) Assess for potential airway compromise Tracheostomy – Gold standard Awake fibreoptic intubation - 1 st choice Reference : Ovassapian A, Airway management in adult patients with deep neck infections: a case series and review of the literature, Anesth Analg. 2005 Feb;100(2):585-9

Management of acute infections

Bacterial

• Management 1) Assess for potential airway compromise 2) Administration of broad spectrum antibiotics References: 1) 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 . 2) 3) Kuriyama T et al An outcome audit of the treatment of acute dentoalveolar infection: impact of penicillin resistance.

Br Dent J. 2005 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; 98:398-408 .

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; 98:398-408 .

Management of acute infections

Bacterial

• Management 1) Assess for potential airway compromise 2) Administration of broad spectrum antibiotics

Management of acute infections

Bacterial

• Management 1) Assess for potential airway compromise 2) Administration of broad spectrum antibiotics 3) Investigations FBE, U&E, CRP, ESR, Blood cultures

Management of acute infections

Bacterial

• Management 1) Assess for potential airway compromise 2) Administration of broad spectrum antibiotics 3) Investigations CT scan vs. MRI vs. USS

Management of acute infections

Bacterial

• Management 1) Assess for potential airway compromise 2) Administration of broad spectrum antibiotics 3) 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.

Management of acute infections

Bacterial

• Management 1) Assess for potential airway compromise 2) Administration of broad spectrum antibiotics 3) Investigations 4) Remove source of infection and establish surgical drainage

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.

Bacterial

Management of acute infections

Bacterial

Management of acute infections

Management of acute infections

Management of acute infections

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

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

Access

• Submandibular/sublingual space • Parapharyngeal • Buccal • Submassteric 35

Management of acute infections

Bacterial

• Management 1) Assess for potential airway compromise 2) Administration of broad spectrum antibiotics 3) Investigations 4) Remove source of infection and establish surgical drainage

Management of acute infections

Bacterial

• Management 1) Assess for potential airway compromise 2) Administration of broad spectrum antibiotics 3) Investigations 4) Remove source of infection and establish surgical drainage 5) Close evaluation in the immediate post-op phase

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) : 1379-82 1999 Dec

Salivary Gland Infections

• 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 swelling s

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

Complications

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