Surgical Management of Orofacial Infections ‘Thomas R. Flynn, DMD This article provides a practical guide to the sugial management of the mst ‘common orofacial nections that are tated by oral and masa surgeons. The Prindples of management of thee infections and the surgial tchigues used for Srainage of orfasal inecuors by Invaoral and extreoral routes ae discussed; however the reacar should be aware thatthe principles and techniques recom mended here have not been subjected to the sertiny of the scientific method. For fevample, the autor blieves, as do many oral and. maxilfacal surgeons, that ‘Simpl drainage of all spaces aeted by calli or abeoas best acumplshed ‘8 soon athe condition b diagnosed. On he oer hand, the older dental erature fad the otolaryngology Urature have never even questioned the promise that ‘odontogenic infectons should be treted with anibitcs unt the presence of ps is Slagnosedeaceptin airway compromise or rapid clinical dctrration. Therefore the bellowing dicmon sho be considered a 4 ct of gusains brand on the foils experience ofthe autor and other oral ahd maxlfacal surgeons, rather than ae defntive tandards based on scenic established fas PRINCIPLES OF SURGICAL MANAGEMENT OF OROFACIAL INFECTIONS Determine the Severity of Infection ‘Within the fst 5 minotes after the presentation of patint with orofacial {nfection, the oa and maxillofcl surgeon should have determined the event of the infection and arived ata general plan of management. The Ast sep a i the ‘valuation ofthe tama patent, i sirway evalton. Subjective the tent may report difculty breathing, swallowing, speaking, or handling scretons A petient® ‘complaint of dyspnen (ificay brewing) san ominous sign. Less severe com Plains are dlicuty wallowing soi foods, but not igus. A distant or muled ‘ans hae ena AON 7voice quality indicts a sveling In or nar the gots sich an lateral pharyngeal (or setvopharyngel space Infecons, or epilotiss. Objetvely, the surgeon may wate an abnormal hendPoture, ich ae the srfing ostion or a latral deviation ‘lth head inom attempt to pation the upper away over the deviated aches, at ina Inter pharynges sce infection (Fg. mS ren tabarst ithe, Seah dcars con a meres ee ea ere agate aes SESS acre a “The surgeon also may note tse of the accesory muscles of respiration such a the Palys and the intrnsal, which indicts Sncrensod upper airway Fesstance, ‘Some infctons progress more rpily into he deep ‘asda spaces than others “Thi may be brosnee ofthe virulence of the bacterl pthogensInvaved or the lnnmuine competence of the host. Expeclly rapid progression of ifetion may be seem in necrtiing fsci, which fen involves an immunocompromised patent, or particularly virulent stun of proup A beta-hemalyticsroptoeoce. The patent Should be questioned about the recent rate of incense im the extent of swelling oF rway dieu. “The neat step f to determine the anatomic location of the infection. With linia! experienc the surgeon wll develop « menial picture of the orl fc, of ‘cervical sling ssiocatd with each of the deep fascial spaces. Examples of some ‘of those ial elings are shown in Figure 2.Alay to potrae the tongue past the vermin border ofthe upper lpi fly folabe sigh thatthe sbingual space is not ssverly involved inthe infection. ‘Tesows"may-mask the oral view of = significant plerygomandislar or Iter pharyngeal infection. Ie important fr dhe examiner to direct opty lighting foto the oropharynx wile maximally depressing the tongue in oer to visualize the sweling ofthe tosilar pillar and devaion ofthe uvula away fom the affected side Fg 3h BES nome comesAvot cep fern pac pce invent a he pecs of Sealing oe ial net Xl te hyo bos and jut sor othe china mune Tite pote when pay pet S'S te sn and where any dependent cet ee ond by thc binng of teal gr ol ewe Gx 2D “res afin 3 i of nical opring a en aed wh 2 stesifentyincesed tod of dia inbatn The surgeon oe ie fillin conntany wih he patents mening fey oa SS tens ayn ce ites fia One dc iSvethown ta ims bcus ef con wil nec under petal ans Minchaoe baeg smeieiyps musi pop a hand dueg tate pm ine omy be aval ego meant open th “alps common svlite mio or ring tw aeqcy of rpc sey tin in ned patent ep te Ass Sgr Sstuion bw 96% en oom. In pee wl wnag pmcly Sto nd spel net des ov te tne fare tad ace Inport Sinkaed ongen a po «ply cnpnied sway ening ined aero ecu tal ection of th dag anton pce tt diet when ts eve superal spe tel or we as Ms a 1 an ike caphayies ontrtentated cout tiogephy (ED tan fe lutein doprosegdepy satel neces. The ie of cnt grove i pra soa te hyperemic pele ong taning ca SSsctl mpudenpuhy, a ney vnc crs, eh ae bs ts Sad shh Magn nance A aging aloha shows ae SS mgng dep ace econ. Ulrcmeney tas tn howe he ec i lean Sie ister tetra Red a nok ness heres CT i oes found fo fe approsmaiay 4% fave mange ncrmton fore depo en large tad raphael opr ee ‘Tryon tte CT exaniatin cn be agai within mins ming the ne apn cers. apd sai ot ule MOS PRD ap raced ne pepo Sey tet Sten o exomoury te pte te lg) ei the Teton, Te Sation woul tan be tac meron spiicaon oxygen Stren Selo ccue A ney W mayb we nt ta an way Sy te ‘Sin nay bor te oped dy opting Seam the sivey 8 iaten tne snl op sad he ‘Sion wile cadewunding Gat ltr rdogphe ee ay ie 3 mee eum Evaluate Host Detenses ‘The most common diseases that compromise the function ofthe immune 5y5- tern ae Indo lowes Diabetes Stroud therapy within the past 2 years ‘athena ‘Suitommne or inammatory disease (Organ transplant therapy Cancer chemtherpy within the past yar Renal dais HIV seropotivityPrimary immunodeiciences Wisk Aldrich syndrome Faminfa ged ‘Agummagiobulneria ‘Agranuocytsis ‘The immunocompromised potent has a deceased ability to “dean up" the microscope detitsa nfecion Therefore, His espotant for the icin Wo reco ‘ize immune system compromise inthe inicted patent and to mel eaten ‘ceding. Sach a ptient would require the we O clercida abt such a8 the beter lctams, ncacng the cephalosporins, cindamycin in high doses, retro azole, vancomycin, andthe aminoglycosides Antiotcsto avo in the immno- ‘compromised patient include the macrolides (erythromyein fama) andthe ltacy- lines. The surgeon aso should be especially thorough i draining, debeiding, and Inigating all infected sites Even relatively minor ses of oral infection, such as ‘motos ulcers in the neutropenic of bone marrow eansplant patient should be egreaively tented Decide on the Setting of Care The presence of any of the flowing criteria cn justify hospital admission of the infected patient Fever over 100 Dabydrtion Iumpending airway compronine ‘Thea otal structures Infection of dep cervical spaces or the mastator space Need for general anesthesia [Neod for inpatient contol of ystomicdseave "When in dou i ble to er on these of ogptl admin esse ll cts menus f hepa wl fo uaa fo th ate sei Soni or pect svat ofthe operating rome alge! ane {has The aty to tain Highest ingest Nady ney a ct ad ‘Moundthe-dck proinal naring cae ae une advantages of bop “The potlent tho ruses hpi admiion pos diffe prolem for the surgron. Any paint rfsing Weaiment should be informed of the ature and tenes of th proposed treatment and the onsonce f resin fe Many oop {Sr tae an tdorbed ful of treromet fon fr enuentng Sach dco betreun the patent andthe surgeon. Mt hate patent Hower wil ent ffom the unfortunate dadsion when faced ith acer monsrson ofthe sr son's concem, Secure the Airway ‘As in cases of rsusaation from trauma and cardiac aerst, he fist and most Important step in treatment ofthe infcted pation sto secure the aleway. Table 1 Hat the more commonly ured airway management techniques tat ate appropriate forthe infcted patient, The advantages and disadvantages ofeach ae iste,‘ssp era ep Sup NEE FeO ARNE = eee, me Sie oe ee OSE pene ere es SETS, MLE, Geta, “PE, 131) epee eens alone tap wow aaa tesco mmdasn soon cre inusenony "SHED ouman sa eons go tage femmes pads Meeetiaco ewmmioy 300 emiwisusmomy — "ome coon ot — ‘Sor orp antes pipe Team mo wemmtor peo se iactey "oman sess tome ems jog ituce “owe OGM Ses — tomimatity "Treo 0 an senromics fen puns Testy GERI tomumainewy “too Semaine eaginey ome tat meson “SNOUSSaNI-TWOVIOUO WERFONNGAL INBRGOWNWA AYMNY 30 NOSTEVGNOD RL“The surgeon's olen arway management procedures includes the follwing 1. The surgoon should respect the experience and ski of 3 qualified anesthe ‘logit in nonsurpcal management ofthe away. The surgeon remains ul imal responsible forthe welfare ofthe patent, however, and must make the final decision whether or not to surgically establish a patent away, ‘pecily when faced wth a patent whose oxygen saturn cot Be ‘mattanod during» nonsungal iway management procedure 22 The surgeon should mak the indsion for crceiyroidotomy or tracheotomy ‘before the away management procedure Is begun. Ths will haston the surgical procedure, if it becomes necessary, and minimize erors in incision Plcement 13 The surgeon should be scrubbed and ready for an emergency surgical ap- proach to the airway. The tracheotomy instrument set should be in the Sperating room before the intubation attempt Is begun. ‘Another simple technique that may be helpful to prevent the aspistion of Infected materia Is needle decompression of the abecex before Intubation, Ths technique is especially appropriate Inthe case ofa perygorsndbulr, pertonsla, ‘or Lateratpharymgentabecestthat has thins the distended cveyng mucosa that {is tkly te rupture during passage ofthe endotracheal tube, The advantages ofthis technique are that it decreases the hkelinoed of the siden discharge of lange mounts of ps imo the away, and st reditets the fw of pus intra or extave ally, whore ft an readily be suctone. It also allows the immediate submission of {an appropmate culture specimen, especially the puncture ste has previously been Prepared with antiseptic The disadvantages of reed decompresion of such an Shstess are patient discomfort and Bleeding fom the puncture st, Which can ‘shacure visualization of the glottis during dine or Aberopte laryngoscopy. ‘Surgea! Drainage All spaces involved. by cellitis or abscess caused by adontogenic infection ‘many surgeons prefer to teat callie with antbotics and to achieve surgical Aranage only i the deteriorating patient of When an abscess has been diagnosed ‘The rationale forthe more aggressive approach includes the flowing t's poss. be to diagnose deep abscess formation by ether cncal & racographic examina- Yom with 100% accuracy drsinage ofa cellaitis seems to abort the spread of the Infection into neighboring deep fascial spaces adequate culture specimens can be tained fom coulis fuid; physial debridement and ingation ofthe infected Spaces may hasten healing by decreasing the sze ofthe bacenalInculum and the amount of necro sie present drainage ely in the course ofthe infection may preven later colonization ofthe nie By more highiyanbbioc etn organisms bd the length of hoopital stay may be decresed by early incision and drainage ‘The resolution of ths controversy ais further scenic investigation, Fagure 4 iustrates potential incision placement for extaoral drainage of the varioue deep space Infections covered in this ati. Figure §iustratesintaral Incision placementThe principles guaing incon placement inthe infested cae are that they shoul allow dependent drainage of the infection, be parallel to the lines of reaxed skin tension, and lie n'a conmetiallyaccepable ate whenever posible The incon should be supported by healthy onderying dermis and subewtansous tisue tf fen tempting t incise dretly throagh the thin. ehiny skin that bas been ander ‘mined by an aces burning i way 10 the surface. To do woul, however Fesult na puckered contacted sear that has collapsed into the abe avy Such a ca erated in gure 6 ln case of spontancos exteaoral drainage oF ‘dontogenic infection (Oral incisions should not cross frenulum atachmens, and in the region of the rental nerve they should be made parallel to the nerve fibers the cause of the infection, such 88 an infact tot a segment of nerotie ‘bone ora foreign body, has not already en remaved, then this should be done at the ime of ince and desnage“The surgical technique for drainage ofan infected deep fascial space Is gener ally straighorwar. It ivalves the blunt exploration of the ene anatomic space ‘vith the opening up ofall ofthe tissue planes within that space. A dean i then Inverted into the depth ofthe space Tt may be a voughvand-thoagh dain, oe it ‘ay simply pass rom a single incision into the depth of the facial gpce. The drain Js then secured either to one ip ofthe incsion oro sel ithe case of @ Unough- Sd-hvoagh denn, a 8 Pigae7 eZ. tment dn. Th ni pt peo lB heSURGICAL MANAGEMENT OF CFOFACAL MFECTONS 89 Figure 8 depicts combined sublingual can be dained efecively by throught Shown in FigureFigur 10 aad 11 slustrate the placement of 2 Jackson-Prat drain in the pterygomandibulay apace 40 42 fo allow through-and-hrough imigation from the [etaoral wound tothe extracel wound SSE ut nee Sampara Pera sage poe Doeeten © cme Sect pet) em be pnygomardou. aaSURGICAL MANGEMENT OF OROFACIAL NFECTINS “Tho tubular ond o! tho Jackon-Prtt drain can be comfortably secre tothe buccal sucon appronimately $ mm posterior tothe orl cmminsure The dein doce 28 ‘ed to be secured thea ncnon. The orl eaten removed a the tame of drain removal. ‘The purpose of druinage sto allow the gravity dependent egress of uid from the wound by keping it opn. The drain also may alow for debridement of the Infected ste by trigtion. Tasue fide Now along the enteral surace of 2 Inox rain Therefore, fe not pecesary to make perforations in the dai, which could ‘weaken i and perhaps cause fragmentation within the tsues. The Jackson Patt Grain lows inlgation of tho infeed wound with unidvetional Dusd fw. The {ubular end, which adapts to a syringe or an intravenous catheter should therefore be pontioned suport the Mat pofoated end The perforation law ome of he insgan uid to lw out ofthe din and into the tise, while some simply passes Uteough the drain Internal ies inthe fat pat ofthe dain prevent it collapse. ‘Drains shoulé be removes! when the drainage hus realy completly Sabd, Drains have been shown to allow ingress of skin flora along thet surface. In so ints ran in para ae ating te sronding tes an may ‘timate come @udaton on thei own. Thus, drains are usually left in infected wounds for 2107 days, ‘When the Intra pharyngeal space i infeed, the surgeon should abserve for sient of lavolverent of the cod shenth The most ominous of these signe “horald Bled” which are intermittent ‘piodes from the nose of the pharynx that are caused by inipent erosions ofthe carotid artery oe the internal {eur ven, Other signs of involvement of the carotid sheath Include palsie of (anil nerves IX. X. oF Xl Homer's syncrome, nd an ening hematoms in he ‘Beck Such patents wil ‘ypically manstssepie shock, a history of perastent Swolling afer drainage of petonslar abscess and a prouacted coure. Involve ‘ment ofthe carol shenth fe suspected, then vascular contol ofthe eat artery ‘shouldbe established before the net of the lteral pharyngeal space sds.‘The technique for extraorl drainage ofthe lateral pharyngel space has not lnen described Irequenlly im our irate, so, i deste ere. A'S Sm Inston is placed low over the submandibular spoce just superior and parallel to the hyoid fone Gncson D in Fig. The posterior end should lie jst over the stron border ofthe steroclidomastoid msc. The secon is cared through ‘iin, subcutaneous tissue, auperical fac, and playa mse to expone the Supercar anterior yer ofthe deep cervical faci Enough of this fausia ‘expose to alow the surgeon to Sent the submandibular gland and the posterior ‘aly of the digastic muscle. Soon the surgeon will be able to Ment by finger lssetion and palpation the angle ofthe mandie the hyeid bone, and the sternor ‘evdomastoid mace. The dinection is then carried ist poster to the ponterior [aly of the digastric muscle in superior, medial, nd posterior diction (Fig 12). Pea bay dose ‘meen eda.) Figur 12 Surges apes he er panos epee. = mud = ei inger dsection of the lateral pharyngeal space complete when the surgeon ‘sable to palpate the endotracheal ube madly the ipslateral wansverse processes of the vertebrae posteromedaly, and the carotid sheath posterlatealy. Because the infected tissues may be quite fable the surgeon should ey to avoid rupturing ‘he pharyngeal mucosa by using only gente force during the finger dissection,Surgical drainage ofthe supra portion of the rtropharyngeal spac canbe accomplished ying the same incon decribed previously forthe lateral pha Fynqeal space. The reropharyngea spce is approached though the ltr phaty {eal epce 4 the dave the sane unt the lateral pharyngeal space has been ‘SNplord by blune Ginger discon. The disaton is then conned unl the sare fein fe able to palpate th contralateral transverse processes ofthe vertebrae, the xowrachel tbe fom its posterior anpet, and if heesary, the oppose cartid arery Tf the retrophermgeal space is invlved below the hyoid Bone, thn the posto: rior end of the low horizontal mandibular incon described above fe extended lnveriony along the anterior border ofthe stemoceMomostld muscle (onnecting lnssions D and En Fig, As the dissection passes deep wo the anterior layer of the deep ceria adn the stemocekdemastoid muscle rezacted postrolatorlly toroxpone the cold sheath (Fg 13 neath sepeeven spore toen cents een prt oat TE FN ae ‘The look connective tawe ying between the carotid sheath and the esophagus is blunty sisted medially nd posterorly to expose the visceral fascia, which sue Fours the tocken, esophagus, and tyro gland. lint finger diction i then teed io follow ie visceral fascia int the reropharyngest space. Mulple soft Arsne are then paced inthe supenor and interior portions ofthe rtropharyngel Space as well sn he lateral pharyngeal space‘Antibitle Therapy Recent changes in the antbite sensitivity patterns ofthe most frequent patho- ‘gens of orfacal infscions have suggested that penilln may no longer be the fmpirc antibiotic of choke fr serious cases requiing hosptalization*=» Mulple ‘recent sues in outpatients, however, have confirmed tht thee sno diference in ‘ukimate therapeutic succes Between pein and clindamycin, amosilin sith ot Watont cevtsnans tod setienlae Thee cemierciste bee gueel fe sung of the emplicanublodes of colce for odontogenic ofa Infectons found in Table “te 2 EMPIC ANTIBIOTICS OF CHOICE FOR ODONTOGENIC INFECTIONS Type ot ineton rb of Soke apts sens Medical Supportive Care ‘The scouts ofthe surgical and antibiotic therapy fr serious orofacial infections depen on adequate contol of syetmic lense that may affect the hoe ree tance mechanisms. Dsbers mellitus, especialy the insuli-dependent type, i the most frequent serous immunocompromising disease. Good corte of Bidod sugar Fevel hasbeen shown to favorably affect host resistance. Therefore, the tating ‘surgeon should attempt to obtain opemium consol of ths and othr inmunocom promising diseases ouch as these sted previously in tari ‘serious infection accompanied by fever sgnfcantly icrases the patients retabolic rajurement: and id. needs, Minimum dally fkl requirements are Increased by 300 ml. per degre of fever per day. Similarly, caloric requirments are Ineretsed By 5 to 8 per degree of fver pr day. In order #9 mest these fd roguremen, the surgeon should maintain ah inavenousinfsion of 10) mL par Tour to meet the base Auld needs, plus replacement for the Increased uid Toes ‘benuse of fever and dares or anyother unas ul wes, Hypotonicintave- ous solutions such as one fourth ot one half normal saline with or without ‘dotrose are suggested in order to provide excess fre water f0 replace insensible Icewes Enteral or parenteral mutton may be required, expcally orl ike as been impaired ty swelling, pn, ras, cr endotracheal intuution. Dung peo longed Hopi stays It ty be acesary to monitor the paints ckectrlye Ba ‘ance, proving supplementation as necessary. Ths ks espdally important in cases (of necrotizing fasts, where hypocalcemia may be cused by soquetation of {slem ons in necrotic ot meleeURQCAL MANAGEMENT OF OROEACIL NFECTIONS Frequent Re-evaluation In the postoperative peal, the treatment objectives are to maintain airway puteney and extateIhe pales, verily the effecivenes of antbiete Werf, nine to leans the surgical wound, and monitor systemic and local ign of ‘eovery Eetubationctera snd technique guidlines ar sted as fellows Criteria for eutation Recovery fem general anesthesia and paalying agents Stable and ceptable vil sgn ‘Accopable ventory parameters ‘Nonna respiratory rate Vital expasty 15 mL/kg Inopiaory force 25 cm HO ute veration = 6-10 L/min [Normal Bou gases or oxygen saturation and end-tidal carbon dioxide Positive ar leak Gresthing around a cestucted endotracheal tubo) ‘Aaa 19 swallow (raehectomy patents) Extubation technique “Consider exabston inthe operating oom ‘Suction theendotrachsal tube and the oropharyn ‘Administer 100% oxygen ‘elt the cul with simultaneous endotracheal tube suction ‘Administer 10% onygen ‘leak test “Lidocaine tpi anesthesia by way of the endotracheal be ‘Adminster 1008 oxygen Extubte ser an endotracheal tube changer (or tle) Resnubat if necessary, over the tube changes of Remove the tbe changer oxtpersive wound cate in the infsted patent ices frequent wound i tation aed dani changes and drain removal at dined abe. The swing Soul be decenang by 88 t72 hour postoperatively, allowing fora temporary inerese in sweling betuoe of surge trauma Teisme, fever and white blood ell fount usually ae trending downward by 24 to 48 hours afer surgery. One of the ‘let and moe sentvesyemic indicator is dhe degree of malaise I the patient Simply fel beter eis avery good Sgn16 improvement has not boon noted by 48 to 72 hous postoperatvly, then a re-evaluation ofthe effectiveness of woul drainage and anioitetheapy, a ll 5a seach for 2 previous undetected source of infection, may” guide farther ‘management. Postoperative CT as been ery def in Sdentiyng the adesicy of Surgleal drainage. Figure 14 shows a cave in which swelling was noe decreasing ‘spite adoquate drain placement. Ths eas guid a change in anubioue therapy and Iter proved to have peniilin-esstant organisms. gure 18 shows a cae 1h ‘which the infection was not adequately drained. This ase required a scond oper or epatmen nr rela ro, Ccrteri for changing antibiotics in the postoperative period are Hse as fo lowe Development ofallengyo toxicity (linia deterioration ater 48 hours of antibiotic therapy, Repest surgery has been done, or Postoperative CT demonstrates adequate surgical drainage Culture an sensitivity or Gram stain indeating resistant organams [Necrotring fast ee brosdspectrm coverage)rains wl have teen removed. The outpatient foow-up interval should be fe- {quent at fist, especally because 2 deep-seated infection sometimes may resume ‘raining ater ting stopped Before dlcharge. Thi may be a sign of eitant ‘organisms. In the abwence of worsening, gs of infection, this my be tested “succesfully with change of antbiaie eapewally to one that covers gaps or weak- nesses in the spectrum ofthe prior ansbiotl Physiotherapy fr tists should be gale to avoid tearing of the inflamed smastistry nunc, Therefore, the tse of stacked tongue Blade o foray distract the uandible may be counterpreductve and painful. Belter compliance and esl tote can be achieved by encouraging the tent to chew sugzess gum sever timer per day, wich brnge up the pot of general dewal care. The final step in ‘ehalitaton serious infection cases i to strongly encourage the pant to eck [mediate and gular preventive and vetoratve dental cre summary ‘This overview ofthe surgical management of orofacial odontogenic infections i “designed as a praical guide for the ova and maxillofacial surgeon: Fortunately, the Incidence of stows odontogenic infections i dereming, This decreased however, necesisterdiiget study and. mental peepration in advance of the smergont tuations in which su cues present AckvowLeDanent ‘The thr we noes th pr arti of Aude Mao repumice te mana etc 1 te And Arn weit aT Mea iment ct ‘Sie deter snc Dae) TST, QSPRS ativan Saas" Mente pn cat es idemesates Sacvacayess 1 BR iceman EGE EER esa Ge WE fen Gate Sat, Ren a ile cingmyen he tee ee so ‘Sempre ets Om! nos oS Sod pay eh Bee 5 Haim A, Yor Kapow Sth Tt 10 eg Me Heyman Anon ot a Tew ‘Sting ages ricci poh tipo Oot ne gs | Cn icant 2227, 185 Est soa cima fe i a a Weel SS Sah a ee eather npr oer 20 AM Suggested Reading ‘yg TR Oteopnelcion, O Malas “Sug cSn a an Pci Bhd sna age Gene" iewoar te amr ann ohana pe Sn Rll Gas iti Topiary Ot Mat “ita aes Sl one MA eS TeSys vada