Management of acute cervicofacial infections

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

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

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

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

5. 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. 2005 Dec;27(12):1108-11.

7. Management of acute infections Fungal 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. 2005 Dec;27(12):1108-11.

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. 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

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

17. 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

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); 383-389

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

20. 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. 2005 Feb;100(2):585-9

21. 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. 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.

22. Management of acute infections Bacterial 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.

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

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

26. 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. 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. 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. 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. 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

39. 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 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