5. Orofacial & neck infections for .pptx

Orofacial & neck infectionsOrofacial & neck infectionsOrofacial & neck infectionsOrofacial & neck infectionsOrofacial & neck infectionsOrofacial & neck infectionsOrofacial & neck infectionsOrofacial & neck infectionsOrofacial & neck infectionsOrofacial & neck infectionsOrofacial & neck infectionsOrofacial & neck infections

1. Orofacial infections & their management BY: Dr. Abrham J (MD) 1

2. Outline Etiology Pathways of Odontogenic Infection Microbiology Spread of Orofacial Infection Evaluation of the Patient with Orofacial Infection Potential Spaces Classification of Fascial Spaces Possible Untoward or Life-Threatening Complications of Orofacial Infection 2

3. Etiology A. General classification: It is based on the origin of the infection . 1. Odontogenic : are those arising from: Pulp disease, ( ii) Periodontal disease , ( iii) Secondarily infected cysts ( iv) Remaining root fragment ( v) Residual infection, and (vi) Pericoronal infection 3

4. Cont … These manifest in the following forms: ( i ) Periapical abscess ( ii ) Periodontal abscess, (iii ) Infected cyst , ( iv ) Residual abscess, and (v ) Pericoronal abscess. 4

5. Cont … 2. Traumatic: Occasionally, trauma from penetrating wounds of soft and hard tissues of the face can lead to orofacial infection. 3. Implant surgery 4. Reconstructive surgery 5. Infections arising from contaminated needle punctures . 6. Others: as infected antrum , salivary gland , etc. 7. Secondary to oral malignancies 5

6. Cont … B. On the basis of causative organisms : 1. Bacterial infections: a. The odontogenic infections are mostly bacterial infections. b. Nonodontogenic infections: ( i ) Tonsillar , and (ii) Nasal infections and (iii) Furuncle of overlying skin. 2. Fungal infections: have slow rate of spread and difficult to diagnose in early stages. 6

7. Pathways of odontogenic infections Invasion of dental pulp by bacteria after decay of a tooth  Inflammation, edema & lack of collateral blood supply  Venous congestion or avascular necrosis (pulpal tissue death)  7

8. Cont … Reservoir of bacterial growth(anaerobic)  Periodic egress of bacteria into surrounding alveolar bone 8

9. Microbiology Aerobic gram positive cocci bacteria-streptococci milleri, strep. Sanguis, strep. Salivarius, strep. Mutans. Anaerobic Cocci-peptostreptococcus. Bacteriodes-porphyromonas, prevotella 9

10. General Course of an Odontogenic Abscess 1. Early stage: There is intrabony collection of pus. The adjoining soft tissues do not undergo any necrosis. 2. Intermediate stage: With perforation of the cortex, the infection progresses ; soft tissues become indurated and brawny. Subsequently, a small area of central softening can be palpated. 10

11. Cont … this is the time to intervene surgically either by, ( i ) doing incision and drainage; or (ii) extraction of the offending tooth. 11

12. Acute Periapical Abscess Etiology: The main cause is infective necrosis of pulp. Causes of infective necrosis of pulp include: (i) Carious involvement, (ii) Contamination of traumatic exposure of pulp, (iii) Sterile necrosis, where apical vessels are torn by blow on the teeth, (iv) following inadvertent chemical or thermal damage to pulp. 12

13. Cont … Micro-organisms from infected pulp invade periapical tissues. usually through ( i ) apical foramina (ii) accessory canals, (iii) an endodontic perforation, (iv) an opening in the floor of the pulp chamber (v) from an area of surface resorption , (vi) root fracture. 13

14. Cont … Clinical features: Severe throbbing pain in the affected tooth. The offending tooth may show carious involvement, and may be sensitive to percussion. Mobility may or may not be present. Radiographic presentation: The involved tooth show carious lesion with periapical pathology, root fracture, erosion or absorption as the case may be. 14

15. Cont … Treatment: The treatment modalities comprise (1) Antibiotics (2) Analgesics (3) Drainage through the pulp chamber (4) Extraction of the offending tooth (5) Endodontic treatment. 15

16. Acute Dentoalveolar Abscess it is a continuation of periapical abscess. Clinical features : 1. Pain: 2. Submucosal swelling in the sulcus If left untreated, the swelling bursts and produces sinus tract discharging pus. Radiographic presentation : the area of radiolucency is more marked in dentoalveolar abscess. Treatment: The same treatment modalities hold true for dentoalveolar abscess. In addition, intra or extraoral incision and drainage may be required. 16

17. Acute Periodontal Abscess Etiology : It arises in periodontal membrane adjacent to a periodontal pocket. Clinical features : Dull pain, rarely severe, and variable in intensity. Pus discharges via gingival pocket. It may produce a sinus on either inner or outer aspect of alveolar process; and rarely tracks through the skin 17

18. Cont … Medical Therapy Consists of supportive care—Hydration, soft or liquid diet, rich with high protein, analgesics and use of antiseptic mouthwashes to maintain the oral hygiene. Antibiotic Therapy should be decided after knowing the patient‘s systemic condition status. i . In non compromised patient with well localized abscess surgical drainage and dental therapy will resolve the infection without antibiotic cover. In cases of poorly localized, extensive abscess and diffuse cellulites, antibiotic therapy is a must. 18

19. Cont … ii. In compromised patients, as well as in patients with systemic signs and symptoms like trismus , airway compromise, fever, etc. antibiotic cover is mandatory. Patients with diminished host defence , like uncontrolled or insulin dependant diabetics, immunosuppressed patients, chronic alcoholics, intravenous drug abusers, patients on renal dialysis also require antibiotic cover . In these patients, there is always a danger of sudden serious sepsis spreading from even a small septic focus. 19

20. Choice of Antibiotic Therapy Thirty percent of the microorganisms are reported as resistant. As these orofacial infections are a mixed flora of aerobes and anaerobes , growth of different types of organisms may be disrupted by the use of penicillin and metronidazole can supplement the penicillin. Oral clindamycin, Augmentin, 1st and 2nd generation cephalosporins are also useful in orofacial infections. In compromised patient‘s—Clindamycin alone or in combination with Gentamycin or 1st or 2nd generation cephalosporins can be used parenterally . 20

21. Surgical Therapy Surgical Technique for Incision and Drainage of an Abscess Incision and drainage helps i . To get rid of toxic purulent material ii. To decompress the edematous tissues iii. To allow better perfusion of blood , containing antibiotic and defensive elements iv. To increase oxygenation of the infected area. 21

22. Cont … Steps 1. anesthesia 2. Stab incision: Made over a point of maximum fluctuation in the most dependent area along the skin creases, through skin and subcutaneous tissue. 3. If pus is not encountered, further deepening of surgical site is achieved with sinus forceps (to avoid damage to vital structures). 4. Closed forceps are pushed through the tough deep fascia and advanced towards the pus collection. 5. Abscess cavity is entered and forceps opened in a direction parallel to vital structures. 6. Pus flows along sides of the beaks. 7. Explore the entire cavity for additional loculi . 8. Placement of drain: A soft yeat’s or corrugated rubber drain is inserted into the depth of the abscess cavity 9. Drain left for at least 24 hours. 10. Dressing: Dressing is applied over the site of incision taken extraorally without pressure. 22

23. SPREAD OF OROFACIAL INFECTION Routes of Spread a. By direct continuity through the tissues. b. By lymphatics to the regional lymphnodes c. By the blood stream 23

24. Cont … Factors Influencing Spread (A) General factors, and (B) Local factors. General Factors (a) Host’s resistance; They depends upon: Humoral factors, and cellular factors. (b) Virulence of micro-organisms; invasiveness of the causative micro-organisms . production of lytic enzymes, potent endotoxins and exotoxins (c) Combination of both. 24

25. Con t … Local Factors (i) Alveolar bone The site of perforation of the cortex is dependent upon proximity of the root apices to alveolar process. (ii) Periosteum : can delay further spread leading to development of a sub periosteal abscess. (iii) Adjacent muscles and fascia; site of localization. 25

26. Evaluation of the patient with orofacial infection Patients with an orofacial infection, may present themselves with various signs and symptoms ranging from unimportant to the extremely serious. A quick assessment of the situation is a must. If the patient i . Toxic ii. Exhibits central nervous system changes and iii. Airway compromise. 26

27. Cont … Then i . Immediate hospitalization ii. Aggressive medical treatment iii. Aggressive surgical intervention (including intubation and tracheostomy ) should be done. The basic principles of patient evaluation must be followed. These include: complete history, physical examination, clinical features, appropriate laboratory investigations, radiological investigations, and proper interpretation of findings. 27

28. History Taking It helps in obtaining information regarding the origin, extent, location and potential seriousness of the problem. (a) History of present illness; especially, onset. (b) History of toothache; or headache, or chills; their nature, location, and duration . ( c) Previous hospitalization with infection the treatment instituted and it’s response ( d) Previous trauma to soft and hard tissues in the region. ( e) History of recurrent infections. (f) History of recent rate of increase in extent of swelling, or airway difficulty 28

29. Physical Examination General Examination It includes: ( i ) Examination of thorax, (ii) Abdomen, (iii) Extremities, (iv) Heart and its murmurs, (v) Recording the vital signs: this serves as a useful baseline for noting progression or regression of disease process. Pulse rate is increased, 10 beats/minute for each degree F of rise in temperature. 29

30. Extraoral examination (1) Inspection : (a) Skin of face (redness), head and neck, (b) Swelling, injuries, (c) Fixation of skin, or mucosa to underlying bone, and (d) Sinus or fistula formation. (2) Palpation : (a) Size of swelling, (b) Tenderness, (c) Local temperature, (d) Fluctuation, (e) Enlargement of underlying bone, (f) Salivary glands, (g) Regional lymph nodes (enlargement, tenderness). 30

31. Intraoral examination: (1) Trismus : The interincisal opening should be measured. (2) Teeth: their number, presence of caries, and large restorations, and mobility. (3) Localized swelling and fistulae. (4) Sites of tooth extraction. (5) Percussion (6) Heat and cold testing. (7) Electric pulp testing. (8) Visualization of Stenson’s and Wharton’s ducts: (9) Soft palate, tonsillar fossa, uvula and oropharynx. (10) Displacement of tissues, presence of swelling, and drainage of pus. 31

32. Radiological Examination Conventional Radiography The radiological examination is helpful in locating the offending teeth or other underlying causes. The various radiographs useful are: ( i ) Intraoral periapical radiographs, (ii) Orthopantomographs (OPG), (iii) Lateral oblique view of the mandible, (iv) AP, and lateral view of the neck for soft tissues can be helpful in detecting retropharyngeal space infections 32

33. CLASSIFICATION OF FASCIAL SPACES Based on the Mode of Involvement Direct involvement: Primary spaces—(a) Maxillary spaces (b) Mandibular spaces. ii. Indirect involvement: Secondary spaces. Spaces involved in odontogenic infections: a. Primary maxillary spaces: Canine, buccal , and infratemporal spaces. b. Primary mandibular spaces: Submental , buccal , submandibular, and sublingual spaces. c. Secondary fascial spaces: Masseteric , pterygomandibular , superficial and deep temporal, lateral pharyngeal,retropharyngeal , and prevertebral spaces,parotid space. 33

34. Potential Primary Spaces Related to Upper Jaw Upper lip: An abscess occurring in upper incisors or canine region leads to infection of the base of upper lip. The abscess is formed on the oral side of orbicularis muscle; and therefore, is vestibular abscess, and tends to point in the vestibule. 34

35. Canine Fossa Involvement ( Infraorbital Space) a. Odontogenic infections b. Nasal infections; less frequent. Usually presents as labial sulcus swelling; and less commonly as palatal swelling. 35

36. Cont … Involvement: The teeth which frequently give rise to abscess in the area are the maxillary canines and premolars and sometimes the mesiobuccal root of first molars. The periapical abscess discharges buccally superior to the origin of the caninus muscle and pus accumulates in the canine fossa . 36

37. Cont … Clinical features • Swelling of cheek and upper lip (vestibular abscess). • Obliteration of nasolabial fold (pus accumulates in canine fossa). Drooping of angle of the mouth. • Edema of lower eyelid; it indicates pointing of abscess below medial corner 37

38. Cont … Incision and drainage : The approach to this area is through the mucosa of buccal vestibule in the region of lateral incisor and canine. A curved mosquito forceps is inserted superior to the attachment of caninus muscle, and the infraorbital space is entered. Pus is evacuated and a drain is inserted and is secured to one of the margins with a suture. 38

39. Palatal space Periodontal abscesses from palatal pockets and apical abscesses from the palatal roots of the posterior teeth are the source of palatal infection. Occasionally the lateral incisor is the frequent cause, as the infection can migrate posteriorly , as far as the soft palate owing to the more palatal orientation of it’s roots. Surgical anatomy: Boundaries—The palatal space is bounded by the cortical plate of hard palate inferiorly, and the overlying periosteum and mucosa superiorly; and laterally by the alveolar process of maxilla and the teeth. 39

40. Cont … Clinical features : Intraorally , a well defined circumscribed fluctuant swelling is seen, which is confined to one side of the palate, adjacent to the offending tooth. Discoloration may not be present. The offending tooth is tender to percussion 40

41. Cont … Incision and drainage : An anteroposterior incision is made through the mucosa, down to the bone, keeping in mind the course of greater palatine nerve and vessels. A curved mosquito forceps is inserted and the pus is evacuated. A small piece of rubber drain is inserted into the abscess cavity and secured with a suture. 41

42. Buccal Space Buccal space is the potential space between buccinator and masseter muscle. Boundaries • Anteromedially : Buccinator muscle • Posteromedially : Masseter overlying the anterior border of ramus of mandible • Laterally: By forward extension of deep fascia from the capsule of parotid gland and by platysma muscle. Contents : Buccal pad of fat, Stenson‘s (parotid ) duct, facial artery. 42

43. Cont … Teeth commonly involved: Maxillary and mandibular premolars and molars . In this case, pus pools intraorally opposite 1st or 2nd molars. If pus penetrates the muscle in the retromolar area, then it is directed laterally into the buccal space. 43

44. Cont … Clinical features When pus accumulates on oral side of the muscle—‘Gum boil’ is seen in the vestibule. If pus accumulates lateral to the muscle, prominent extraoral swelling is seen extending from lower border of mandible to the infraorbital margin and from the anterior margin of masseter muscle to the corner of mouth. Spread: Continuation with pterygomandibular space to infratemporal space along the fascia, accompanying the Stenson‘s duct. To submasseteric space—if infection tracks backwards and penetrates the paratidomasseteric fascia. 44

45. Cont … Incision and drainage: Horizontal incison through the oral mucosa of the cheek in the premolar, molar region. If the pus is lateral to the muscle, then the muscle is penetrated with curved mosquito forceps to enter the buccal space. Drain is placed and secured with suture 45

46. Infratemporal Fossa Space It is also called ‘ retrozygomatic space’ by Sicher , as it is partly situated behind the zygomatic bone. The space is continuous with upper part of pterygomandibular space anteriorly. Involvement : (i ) the infection of the buccal roots of the maxillary second and third molars , particularly, from unerupted third molars, and (ii) Local anesthesia injections with contaminated needles in the area of tuberosity, 46

47. Cont … Contents : The fossa contains origins of medial pterygoid and lateral pterygoid muscles. The lower head of lateral pterygoid muscle border the pterygomandibular and infratemporal spaces. It contains pterygoid venous plexus of veins . It is traversed by maxillary artery , mandibular nerve, and middle meningeal artery. 47

48. Cont … Clinical features a. Extraoral ( i ) Trismus : marked limitation of oral opening, (ii) Bulging of temporalis muscle (iii) Marked swelling of the face on the affected side in front of the ear, (iv) The eye is often closed and is proptosed . b. Intraoral: Swelling in the tuberosity area. Elevation of temperature up to 104ºF. 48

49. Cont … Incision and Drainage a. Intraoral approach: If the trismus is not marked, and fluctuation is detected early, an intraoral incision is given in the buccal vestibule opposite the second and third molars. The exploration is carried out medial to coronoid process and temporalis muscle upwards and backwards with a sinus forceps, or a curved hemostat. The space is entered, and drained; and a small piece of corrugated rubber drain is kept and secured with a suture. b. Extraoral approach: In severe intractable infection, extraoral incision is the only method of drainage. 49

50. Cont … Spread: Pus can extend upwards to involve the temporal space, or inferiorly to involve the pterygomandibular space. infection can track upwards to the cavernous sinus via: (i) The deep facial veins, or (ii) Emissary veins and via other foramina directly from the infratemporal fossa to the middle cranial fossa. 50

51. Potential Primary Spaces Related to Lower Jaw Submental Space Involvement: infections originating from the six anterior mandibular teeth; then perforate the cortical plate below the origin of mentalis muscle labially ; and mylohyoid lingually . The space can be secondarily involved due to infection of submental lymph nodes , following lymphatic spread from lower incisors, lower lip, skin overlying the chin, anterior part of the floor of the mouth, tip of the tongue and sublingual tissues. 51

52. Cont … Clinical Features a. Extraoral findings: Distinct, firm swelling in midline, beneath the chin. Skin overlying the swelling is board like and taut. Fluctuation may be present. b. Intraoral findings: The anterior teeth, are either nonvital , fractured or carious The offending tooth may exhibit tenderness to percussion and may show mobility. The patient may experience considerable discomfort on swallowing. 52

53. Cont … Incision and drainage It is performed by making a transverse incision in the skin below the symphysis of the mandible. Blunt dissection is carried out by inserting a Kelly’s forceps or sinus forceps through this incision, upward and backward. A small piece of corrugated rubber drain is inserted in the abscess cavity, and is secured to one of the margins of the wound with a suture. Spread: The infection can spread: ( i ) Posteriorly , to involve submandibular space, or (ii) It may discharge on the face, in the submental region. 53

54. Submandibular Space The space lies between the anterior and posterior bellies of the digastric muscles . The upper part lies beneath the inferior border of mandible and the lower part lies deep to the investing layer of deep cervical fascia. The submandibular spaces are considered to be the anterior extensions of parapharyngeal space. 54

55. Cont … Involvement : (i) It is involved most frequently by infections originating from the mandibular molars. (ii) The infection from the submandibular salivary gland may pass via lymphatics to the submandibular lymph nodes. (iii) It is also involved, as an extension of infection from submental space ; or from the submental lymph nodes (iv) It is also involved by an infection originating from the posterior part of sublingual space. (v) It is also involved from infection originating from middle third of the tongue, posterior part of the floor of the mouth, maxillary teeth, cheek, maxillary sinus and palate. 55

56. Cont … Surgical anatomy: Boundaries • Anteromedially , the floor is formed by mylohyoid muscle , which is covered by loose areolar tissue and fat. • Posteromedially , the floor is formed by hyoglossus muscle. • Superolaterally , medial surface of mandible below the mylohyoid ridge. • Anterosuperiorly , anterior belly of digastric . • Posterosuperiorly posterior belly of digastric , stylohyoid and the stylopharyngeus muscles. Laterally, platysma and skin. Contents : Superficial lobe of submandibular salivary gland and submandibular lymph nodes, facial artery and vein . 56

57. Cont … Clinical features a. Extraoral : ( i ) Firm swelling in submandibular region, below the inferior border of mandible. (ii) Generalized constitutional symptoms, (iii) Some degree of tenderness, (iv) Redness of overlying skin. b. Intraoral: ( i ) Teeth are sensitive to percussion. (ii) Teeth are mobile, (iii) Dysphagia, and (iv) Moderate trismus . 57

58. Cont … Incision and drainage ; An incision of about 1.5 to 2 cm length is made 2 cm below the lower border of mandible, in the skin creases. Skin and subcutaneous tissues are incised. A sinus forceps is inserted through the incision superiorly and posteriorly on the lingual side of the mandible below the mylohyoid to release pus from submandibular space. A corrugated rubber drain is inserted in the abscess cavity and is secured with a suture and dressing is applied 58

59. Cont … Spread i. There are no major anatomic barriers between the two submandibular and submental spaces Hence, infection can extend into the submental space. ii. There are no anatomical barriers, hence infection can spread extend easily across the midline, and involve the submandibular space on the contralateral side . iii. The submandibular space communicates with sublingual space around the posterior border of mylohyoid muscle iv. Infection can spread backwards to involve parapharyngeal spaces . 59

60. Sublingual Space This space is a V-shaped trough lying lateral to muscles of tongue, including hyoglossus , genioglossus and geniohyoid . Involvement: The teeth which frequently give rise to involvement of sublingual space are the mandibular incisors, canines, premolars and sometimes first molars. The apices of these teeth are superior to the mylohyoid muscle. The infection perforates lingual plate below the level of the mucosa of the floor of the mouth and passes into the sublingual space. 60

61. Cont … Contents: Major contents include: Geniohyoid and genioglossus muscles, the hyoglossus muscle complex. It also contains ( i ) Deep part of the submandibular salivary gland and it’s duct anteriorly , (ii) Sublingual salivary gland, (iii) Lingual nerve, and (iv) Hypoglossal nerve. 61

62. Cont … Clinical feature Extraoral : There is little or no swelling. The lymph nodes may be enlarged and tender. Pain and discomfort on deglutition. Speech may be affected. ii. Intraoral: Firm, painful swelling seen in the floor of the mouth The floor of the mouth is raised. The tongue may be pushed superiorly. This will bring about airway obstruction. 62

63. Cont … Incision and drainage i . Intraorally : An incision is made close to the lingual cortical plate, lateral to the sublingual plica , as the important structure at this site is the sublingual nerve which is deeply placed and less likely to be damaged by this approach. The other important structures lie medial to the plica and include the Wharton’s duct, sublingual artery and veins and the lingual nerve. The sinus forceps is then inserted and opened to evacuate the pus. 63

64. Cont … ii. Extraorally : When both the submental and sublingual spaces contain pus, they can be drained via a skin incision placed in the submental region, pushing a closed sinus forceps through the mylohyoid muscle. Similarly, when the submandibular space is involved, a sublingual space abscess can be approached and drained through an incision in the skin overlying the submandibular space, via the submandibular space. 64

65. Cont … Spread i . Infection always crosses the midline, and can affect the opposite side. ii. Infection from the posteroinferior part of the space, Can spread into submandibular space , and again can spread posteriorly, into the pterygomandibular and parapharyngeal spaces 65

66. Life threating complications orofacial infection Which may be classified as follows: 1. Those related to the lower jaw a. Ludwig‘s angina. b. Descending deep cellulitis of the neck, resulting in mediastinitis . c. Carotid sheath invasion. 2. Those related to the upper jaw a. Intracranial complications, with possibilities of cavernous sinus thrombosis, brain abscess, dural meningitis and osteomyelitis of the skull. b. Retrobulbar cellulitis with possibility of blindness. 66

67. Ludwig’s Angina Historical background and definition: It is the name given to a massive, firm, brawny cellulitis / induration , and acute, toxic stage, involving simultaneously, the submandibular , sublingual and submental spaces bilaterally. It was first described by Wilhelm Friedreich Von Ludwig (1836). As the definition suggests, only the bilateral involvement of above-mentioned spaces is considered to be classical, disease entity. All other types of presentations, though massive are not considered as Ludwig’s angina. 67

68. Etiology The following causes can be attributed to Ludwig‘s angina: 1. Odontogenic : This is the cause in majority of cases (90% in some studies). It can cause infections in various other forms: • Acute dentoalveolar abscess • Acute periodontal abscess • Acute pericoronal abscess. • Acute dentoalveolar abscess: The most common teeth involved are mandibular second and third molars. • Acute periodontal abscess: Deep abscess may involve sublingual spaces. 68

69. Cont …. Pericoronal abscess: in relation to erupting mandible third molars, which can extend to the following spaces: i . Submandibular space ii. Buccal space iii. Sublingual space iv. Pterygomandibular space. • Infected mandibular cyst also can spread to form Ludwig‘s angina. 2. Iatrogenic: Use of a contaminated needle for giving local anesthesia. 69

70. Cont … Traumatic injuries to orofacial region: These can be in the form of: (a) Mandibular fractures, if the fracture is compounded and comminuted, (b) Deep lacerations or penetrating injuries such as punctured wounds. 4. Osteomyelitis secondary to compound mandibular fractures; 5. Submandibular and sublingual sialadenitis : Acute or chronic infection from these glands. 6. Secondary infections of oral malignancies : The associated malignancies of the region may give rise to secondary infection, leading to the condition. 70

71. Cont … Miscellaneous causes: It includes rare causes such as: a. Infection in the tonsils or pharynx such as purulent tonsillitis, etc. b. Foreign bodies such as fish bone , etc. c. Oral soft tissue lacerations. 8. Cervical lymphoid tissues 71

72. Cont … Pathology: The condition is a cellulitis—a diffuse inflammation of soft tissues which is not circumscribed or confined to one area, but in contrast to the abscess, tends to spread through tissue spaces and along facial lanes. Microbiology: staphylococci , streptococci, gram negative enteric micro-organisms, such as E. coli and Pseudomonas; and anaerobes including Bacteroides ( B. melaninogenicus , B. oralis , and B. corrodens ), anaerobic streptococci, Peptostreptococcus and fusospirochaetes 72

73. Cont … Clinical features : The following signs and symptoms are present with varying degree of severity General examination: It includes: (i) General constitutional symptoms: Patient looks toxic, very ill and dehydrated. (ii) Marked pyrexia (iii) Difficulty in swallowing (Dysphagia) (iv) Impaired speech, and hoarseness of voice. 73

74. Cont … b. Regional examination : Extraoral examination i . Firm/Hard brawny ( boardlike , woody hard) swelling in the bilateral submandibular and submental regions, which soon extends down the anterior part of the neck to the clavicles. Swelling is non-pitting, minimally or non-fluctuant associated with severe tenderness. Classically shows ill-defined borders with induration . 74

75. Cont … (ii). Severe muscle spasm may lead to trismus with restricted mouth opening and also jaw movements. Typically mouth remains open due to edema of sublingual tissues leading to raised tongue almost touching the palatal vault. In extreme circumstances, tongue may actually protrude from the mouth; the tongue movements are reduced. iii. Airway obstruction. 75

76. Cont … c. Intraorally ; raises the floor of mouth, woody edema of the floor of the mouth and tongue (ii) Tongue may be raised against palate; (iii) Increased salivation, stiffness of tongue movements, difficulty in swallowing (iv) Backward spread of infection leads to edema of glottis, resulting in respiratory obstruction/ embarrassment. 76

77. Cont … Fate of Ludwig’s angina: Ludwig’s angina, if untreated, can be fatal within 12 to 24 hours; death arising from asphyxia . Established cases may become more complicated with involvement of other spaces. The other causes of death include: septicemia/septic shock, mediastinitis , and aspiration pneumonia, which are also caused by the complications of the disease. 77

78. Cont … Principles of treatment: It should be taken as a life threatening emergency situation. The treatment is based on the combination of the following factors: (1) Early diagnosis, (2) Maintenance of patent airway, (3) Intense and prolonged antibiotic therapy, (4) Extraction of offending teeth, and (5) Surgical drainage or decompression of fascial spaces 78

79. Cont … • S urgical intervention : It has two aims: (i) Remove the cause, (ii) Surgical decompression: Decompression of the spaces involved. Removal of the cause : Removing the offending tooth may facilitate evacuation of pus present in close vicinity of the tooth without any special surgical intervention. In most cases of Ludwig’s angina, small amount of pus is always associated with the offending tooth close to its lingual cortex. The initial stage of Ludwig’s angina or those cases which progress to Ludwig’s angina are seen to be managed by simple extraction coupled with antibiotics. 79

80. Cont … Surgical Decompression As Ludwig’s angina is, in fact cellulitis , its treatment by aggressive surgical intervention is a debatable issue. The advantages of early surgical decompression include the following: i. reduces pressure of edematous tissues on the airway ii. It allows prompt drainage should suppuration develop. iii. It allows obtaining specimen or samples for Gram staining, and culture and sensitivity, iv. It allows placement of drains , which may be valuable to drain pus collection as time progresses 80

81. Cont … Bilateral submandibular incisions and if required amidline submental incision 1 cm below the inferior border of mandible are sufficient to drain the involved spaces. Care: It should be taken to preserve or avoid trauma to: (i) Facial vessels near angle, (ii) lingual nerve, and (iii) Jugular vein, laterally below angle region. 81

82. Cont … Antibiotic Therapy Ludwig‘s angina. Usually, IV antibiotics with proper dosage and frequency are necessary . i . Penicillins are the first line of antibiotics as it covers the majority of aerobic gram positive. penicillin G, 2 to 4 million units, IV 4 to 6 hourly; or 500 mg six hourly orally ii. Semisynthetic of penicillin: Ampicillin/ amoxycillin ; 500 mg 6 and 8 hourly, IV and orally respectively . iii . Cloxacillin ; 500 mg orally, 8 hourly. iv. In case of allergy to penicillin; Erythromycin 600 mg 6 to 8 hourly 82

83. Cont … vi. Clindamycin IV 300 to 600 mg 8 hourly, orally and intravenously. gram positive cocci including penicillinase resistant staphylococci, and Bacteroides . vii. Metronidazole: It is a useful antibiotic against anaerobic flora found in oral infections. 5 00 mg 8 hourly orally or intravenously. viii. Cephalosporins : These are closely related to penicillin and have similar spectrum of their activity. These are usually reserved for resistant infections. Usually, a combination of antibiotic therapy is indicated for aggressive management of Ludwig’s angina, a penicillin or it’s derivative along with metronidazole or gentamicin. 83

84. Cont … Hydration: Most cases of Ludwig‘s angina are dehydrated, because of two reasons: (i) Diminished liquid intake due to pain, discomfort associated with swallowing (dysphagia). (ii) Due to the toxic nature of the condition, there is usually excessive urination and perspiration which further diminishes body fluids. For these reasons patients should be encouraged to have liquids frequently and if required intravenously, fluids can maintain hydration and even calories 84