What kind of disease is phlegmon of the maxillofacial area and how to treat it?

Description of the disease

Cellulitis of the maxillofacial area

Phlegmon is a purulent inflammation that occurs in soft tissues.

The pathological process does not have clear boundaries, which is why it quickly spreads to blood vessels, nerve endings and organs.

Phlegmon of the maxillofacial area mainly affects bone tissue and tendons, salivary glands, and muscle tissue.

Cellulitis is a dangerous pathological condition. Due to the purulent-inflammatory process, a large amount of toxic substances enter the bloodstream, which causes general intoxication of the body.

The disease is acute, characterized by the rapid development of symptoms, against the background of which the functions of the masticatory apparatus, swallowing, and breathing are impaired in patients.

Phlegmon in ICD 10

In the international classification of diseases, phlegmon of the maxillofacial area is included in the group of diseases of the skin and skin tissue (L00 - L99). The pathology is included in the block of infectious skin diseases and is designated in the ICD by code value L 03.2.

Odontogenic infection

Odontogenic periostitis

Depending on the clinical course, periostitis can be acute (serous, purulent) or chronic (simple, hyperplastic).
In the area of ​​the affected tooth - the probable source of infection - pain is felt, radiating to the ear and temple. Swelling of the cheek and asymmetry of the face due to unilateral swelling of soft tissues are often visually noticeable. Difficulty opening the mouth. With odontogenic periostitis, general health suffers: weakness, febrile temperature, headache, sleep and eating disturbances. Regional lymph nodes are enlarged and painful.

Odontogenic osteomyelitis

It is more often diagnosed in men in the age group of 20-40 years, in 68% of cases it affects the lower jaw. Against the background of a pronounced intoxication syndrome, intense local pain in the tooth or diffuse pain in the entire jaw, which spreads to the corresponding half of the head, is disturbing. The configuration of the face is changed due to swelling on the side of inflammation.

There are difficulties when opening the mouth, pain when chewing and swallowing food, impaired speech function, paresthesia of the upper or lower lip. There may be a putrid odor from the mouth. The temperature curve for odontogenic osteomyelitis ranges from 37.5 to 39-40°C.

Odontogenic sinusitis

Odontogenic sinusitis accounts for 10 to 30% of all cases of infections of the maxillary sinuses. Acute sinusitis manifests itself with headache, temperature reaction, and a feeling of pressure in the projection of the corresponding sinus. Swelling of the nasal cavity increases, breathing becomes difficult, and the sense of smell decreases. After some time, a mucopurulent or purulent secretion begins to separate from the sinus. The soft tissues of the infraorbital region and cheeks look swollen.

Odontogenic abscesses and phlegmons

About 57% of purulent infections of the soft tissues of the head and neck have a dental etiology. Odontogenic abscesses are usually localized in the infraorbital, buccal, submandibular, and parotid regions. Accompanied by the appearance of swelling in the face or neck, hyperemia of the skin over the abscess. With a superficial abscess, a symptom of fluctuation is felt. There is local pain and pulsation in the projection of the abscess. Signs of intoxication are moderate.

Based on localization, odontogenic phlegmons of the floor of the mouth, submandibular, submental, peripharyngeal space, and neck area are distinguished. There is swelling of soft tissues without clear boundaries with the presence of a dense painful infiltrate. The pain is spontaneous, diffuse, and constantly present. Depending on the location of the phlegmon, chewing, swallowing, breathing, and speech are impaired. Characterized by a pronounced deterioration in general health, febrile fever, chills.

Odontogenic lymphadenitis

Usually develops in the area of ​​the submandibular or cervical lymph nodes. They are characterized by local swelling, pain, and dense consistency. Facial asymmetry occurs. When lymph nodes become abscessed, body temperature rises, chills and malaise appear. When palpating a purulent focus, fluctuation is felt.

Causes of phlegmon of the maxillofacial area

The causative agent of phlegmon is bacterial microorganisms: streptococci, pneumococci, staphylococci, E. coli

Cellulitis of the maxillofacial area is an infectious disease.

The causative agent is predominantly bacterial microorganisms: streptococci, pneumococci, staphylococci, E. coli.

Pathogenic microflora penetrates the subcutaneous fatty tissue through small skin lesions.

Most often the cause is odontogenic, but infection through the lymphatic or circulatory system is possible.

Anaerobic bacteria (clostridia) and non-spore-forming microorganisms (peptococci, poststreptococci) also act as pathogens.

The presented microorganisms are able to reproduce in the absence of oxygen. They cause the rapid development of necrotic processes in tissues.

Factors contributing to the development of the disease:

• Reduced immunity;
• The presence of allergies with severe skin manifestations;
• Acute or chronic tonsillitis;
• Carious lesions of teeth;
• Contact with aggressive substances under the skin;
• Furunculosis;
• Use of low-quality cosmetics;
• Failure to comply with hygiene standards.

Opening an abscess, phlegmon of the maxillofacial area

The frequency of development of abscesses and phlegmon of the maxillofacial area of ​​the head is due to the high prevalence of chronic focal odontogenic and tonsillogenic infections, as well as infectious and inflammatory lesions of the skin and oral mucosa. Based on data on the localization of the infectious-inflammatory process in various anatomical sections, zones, regions, as well as spaces of the head and neck, their systematization is built. From the description of the topographic-anatomical structure of the areas of the face, the perimandibular and adjacent areas of the neck, one can see the complexity of their anatomy. There are many cellular spaces, numerous lymph nodes and vessels scattered throughout all areas of the face, an abundant network of arteries and veins with rich innervation of these areas.

The basic principle of treating inflammatory diseases is opening the source of inflammation and draining it. Complete drainage reduces pain, promotes the outflow of wound fluid, improves local microcirculation, which naturally has a beneficial effect on local metabolic processes, the transition of the wound process to the regeneration phase, reducing intoxication and interstitial pressure, limiting the necrosis zone and creating unfavorable conditions for the development of microflora.

The incisional drainage method of treating phlegmons and soft tissue abscesses is quite widespread to this day. It involves opening a purulent focus and open wound management in the postoperative period. The incisional drainage method is a classic one; in general, it determines the tactics for the treatment of acute purulent diseases of soft tissues and purulent wounds.

Opening of the purulent focus is carried out by external access from the skin, or intraoral access from the mucous membrane.

During the operation of opening an abscess (phlegmon), the skin, mucous membrane, and fascial formations above the purulent focus are dissected; the muscles are cut off, peeled off from the place of attachment to the bone of the temporal, medial pterygoid and chewing muscles (m. temporalis, i.e. pterygoideus mcdialis, i.e. masseter) or using a hemostatic clamp, the muscle fibers of the temporal, mylohyoid and buccal muscles (m. temporalis) are pulled apart , T. mylohyoideus, T. buccalis). The exception is the subcutaneous muscle of the neck (m. platysma) and often the mylohyoid muscle, the fibers of which intersect in the transverse direction. which ensures the wound gapes and creates good conditions for the outflow of purulent exudate. Loose tissue located on the way to the purulent focus, in order to avoid damage to the vessels, nerves, and excretory flow of the salivary glands located in it, is stratified and pulled apart with a hemostatic clamp.

Development mechanism

When an infection enters the subcutaneous environment, inflammation rapidly develops. The high intensity of the pathological process is explained by several factors.

These include:

• Rapid development of intoxication;
• Lack of an adequate immune response of the body;
• Decreased local immunity;
• The presence of optimal conditions for the growth of bacteria.

Due to the rapid development, granulation tissue does not have time to form, which should protect the source of inflammation from healthy tissue. Therefore, the pathological process spreads quickly.

Symptoms

Symptoms of inflammation occur quickly, which is explained by the short incubation period of bacteria

The nature of clinical manifestations varies depending on the location of inflammation.

As a rule, the pathology is acute. Symptoms of inflammation occur quickly, which is explained by the short incubation period of the bacteria.

Main features:

• High body temperature;
• Symptoms of general intoxication (nausea, vomiting, dizziness);
• Muscle weakness, tremors;
• Chills;
• Headache;
• Toothache;
• Decreased appetite;
• Pain when swallowing.

Important to remember! Local symptoms, such as swelling, swelling of the skin, redness, do not appear immediately. Therefore, the symptoms of phlegmon are often mistaken for other diseases. A distinctive feature is intense pain at the site of inflammation.

External signs

After symptoms of inflammation appear on the skin at the site of the lesion, local symptoms occur.

These include:

• Swelling;
• Change in skin color;
• Hyperemia;
• Cracks in the skin;
• Pain when moving;
• Formation of a purulent fistula.

Conventionally, the course of phlegmon can be divided into 2 stages. At the first stage, a dense formation appears under the skin, which is easily felt by palpation. At the next stage, the compaction softens, indicating the secretion of pus.

Abscess of the maxillary

The formation of an abscess is preceded by toothache, as in periodontitis. Biting on the affected area increases the pain. Next comes dense swelling with the formation of a painful compaction. An abscess developing under the mucous membrane is characterized by bright hyperemia and protrusion of the affected area. Facial asymmetry is sometimes noted.

In the absence of therapy, the patient’s general condition worsens: body temperature rises, refusal of food is observed. After spontaneous opening of the abscess, the pain subsides, the contours of the face take on normal shape, and general health stabilizes. But due to favorable conditions for microorganisms in the oral cavity, the process becomes chronic, so its spontaneous opening does not indicate a cure.

With short-term weakening of the immune system, perimaxillary abscesses worsen. Chronic suppuration from the fistulous tracts is possible; it is accompanied by an unpleasant odor from the mouth and ingestion of purulent masses. The body becomes sensitized by decay products, and allergic diseases worsen.

Abscesses of the floor of the mouth are characterized by hyperemia in the sublingual zone with rapid formation of infiltrate. Conversation and eating become sharply painful, and hypersalivation is noted. The mobility of the tongue decreases, it rises slightly upward so as not to come into contact with the forming abscess. As the swelling increases, the general condition worsens. Upon spontaneous opening, the pus spreads to the peripharyngeal region and neck, which leads to the appearance of secondary purulent foci.

Palate abscess most often occurs as a complication of periodontitis of the upper second incisor, canine and second premolar. During the formation of an abscess, hyperemia and soreness of the hard palate are observed; after the bulging, the pain becomes more intense, eating becomes difficult. Upon spontaneous opening, the purulent contents spread to the entire area of ​​the hard palate with the development of osteomyelitis of the palatine plate.

If a cheek abscess occurs, then depending on the location and depth, swelling and redness may be more pronounced on the outside or on the oral mucosa. The soreness of the lesion is moderate; when the facial muscles work, the pain intensifies. The general condition is practically not affected, but an abscess of the cheek is dangerous if it spreads to neighboring parts of the face even before opening the abscess.

A tongue abscess begins with pain in the thickness of the tongue, the tongue increases in volume and becomes inactive. Speech, chewing and swallowing food are severely difficult and painful. Sometimes with an abscess there may be a feeling of suffocation.

Types of phlegmon

Phlegmons of the maxillofacial area in dentistry are classified depending on the location.

The main types of pathology are presented in the table below:

Cellulitis of the jaw space occurs against the background of carious lesions and other dental diseases

Oral abscess - symptoms and treatment

Symptoms of oral abscesses are variable and depend directly on the type and location of the abscess. In acute purulent periostitis, patients complain of pain in the area of ​​the causative tooth or jaw segment, swelling of the soft tissues. The face of such a patient is asymmetrical.

When the causative tooth is localized in the frontal part of the upper jaw, the swelling is located in the upper lip and infraorbital region, the nasolabial fold is smoothed. If the diseased tooth is located in the frontal region of the lower jaw, swelling of the soft tissues is noted in the area of ​​the lower lip and chin. When the causative tooth is located in the lateral part of the dentition, perifocal edema (near the infectious focus) is located in the buccal region.

Acute purulent periostitis is usually not accompanied by restrictions in mouth opening. Palpation of regional lymph nodes often reveals signs of acute lymphadenitis (enlarged lymph nodes). When examining the oral cavity, the causative tooth is identified, which usually reacts sharply to tapping (percussion). This is explained by the presence of a pathological process behind the root apex. When examining the vestibule of the oral cavity, a painful inflammatory infiltrate is determined, over which there is an edematous and hyperemic (red) mucous membrane. According to the literature, periostitis is most often located on the side of the cheek or lips, less often on the palatal and lingual side [5][8].

Often abscesses of the maxillo-lingual groove, buccal region, and pterygomaxillary space are considered as a complication of acute purulent periostitis. However, in some cases these diseases develop independently, so there is no reason not to consider them in this review.

Abscess of the maxillo-lingual groove is characterized by a more serious course. The patient complains of pain when swallowing, moving the tongue to the sides, and limited mouth opening. A visual examination reveals swelling of the submandibular area and acute lymphadenitis. Examination of the oral cavity is often difficult and is only possible after blocking the motor branches of the mandibular nerve. When examining the oral cavity, acute or aggravated periodontitis of the chewing tooth of the lower jaw or difficult eruption of the lower wisdom tooth is determined. When examining the maxillo-lingual groove, its bulging is determined; upon palpation, an inflammatory, sharply painful infiltrate can be detected.

With an abscess of the pterygomaxillary space, the patient notes an increase in body temperature, pain in the pharynx, difficulty swallowing, mouth opening is limited, in some cases almost impossible. Visually, perifocal edema is often absent. An examination of the oral cavity can be carried out only after blocking the motor branches of the mandibular nerve. In the oral cavity, difficult eruption of the lower wisdom tooth is usually detected, as well as a hyperemic and edematous pterygomandibular fold.

The clinical picture of an abscess in the buccal region largely depends on the depth of the abscess. With a superficial abscess, hyperemia (redness) of the skin, a local increase in temperature, the skin is tense and does not fold. With a medium and deep location, there is pronounced swelling of the buccal area, the skin is not externally changed, it is difficult to fold into a fold. Local hyperthermia (increased temperature) is usually not observed. When the abscess is deeply located on the mucous membrane of the cheek, marks from teeth are detected.

The condition of patients with these abscesses is usually assessed as moderate. Treatment is usually carried out in a maxillofacial surgery hospital under supervision in order to prevent the development of severe complications. Patients often exhibit symptoms of general intoxication of the body (fever, headaches and muscle pain).

Diagnostic procedures

The diagnosis is made on the basis of anamnesis and external examination of the patient. The presence of acute or chronic infectious diseases is taken into account. Auxiliary diagnostic procedures are prescribed to determine the severity of the pathology.

During diagnosis, it is extremely important to determine the type of infection that provokes the pathology. This will allow further effective antibacterial treatment.

To determine the type of pathogen, a puncture biopsy is performed, during which purulent contents are collected, which are further studied in the laboratory.

Treatment

The nature of therapeutic procedures depends on the severity of phlegmon and its location. The pathology is potentially life-threatening, and therefore requires hospitalization of the patient.

Drug therapy

Treatment involves taking medications in strict accordance with the dosages prescribed by the doctor.

The following groups of drugs are used:

• Treatment involves taking medications in strict accordance with the dosages prescribed by the doctor.

  Antibiotics. The action is aimed at destroying pathogenic microflora, thereby stopping the development of inflammation. Antibacterial therapy is most effective at an early stage, before tumor formation. In later stages, antibiotics are used as an adjuvant. Patients are prescribed intramuscular injections of Erythromycin, Cefuroxime and Gentamicin. On average, the duration of therapy is 3-5 days.

• Anti-inflammatory drugs. They are used to reduce tissue swelling, eliminate hyperemia, and pain. Medicines are prescribed by a doctor taking into account pharmacological interactions with antibiotics. In most cases, drugs based on Diclofenac and Nimesulide are used.
• Local antiseptics. Used for local treatment of phlegmon, which is required in the formation of a purulent fistula. For disinfection, a solution of chlorhexidine, Furacilin, and less commonly Boric acid and hydrogen peroxide are used.

Surgery

The operation can be performed during planned treatment or urgently, if the patient’s condition worsens.

Purulent phlegmon is treated surgically. The operation can be performed during planned treatment or urgently, if the patient’s condition worsens.

The presented treatment option is considered more preferable than drug therapy, as it eliminates the risk of complications and re-development of the pathology.

The main indication for surgery is the presence of an inflammatory focus and elevated body temperature of the patient.

The procedure is performed under general anesthesia. The phlegmon is opened with a wide incision, which allows for the outflow of purulent substance.

After the pus is released, the affected area is washed and disinfected. Bandages containing antibacterial ointments are applied to the incision. If the skin does not heal well, dermoplasty is performed.

Physiotherapy

The use of physiotherapeutic procedures is considered appropriate only at the early stage of pathology. Physiotherapy methods can also be used for symptomatic treatment.

Basic methods:

• UHF therapy;
• Ultraviolet irradiation;
• Light therapy;
• Ultrasonic treatment of opened phlegmon;
• Laser treatment of the wound.

Alternative medicine

Traditional methods are not recommended for use in acute illness. The use of unconventional methods is possible during the period of postoperative rehabilitation.

For better healing of affected skin, it is recommended to apply sea buckthorn or rosehip oil. For general strengthening of the body, medicines made from the herbs Eleutherococcus, Chinese magnolia vine, ginseng, and rose hips are used.

Forecast

The likelihood of complications increases significantly in the absence of timely assistance

If you seek medical help in a timely manner, the prognosis is favorable.

The pathology can be successfully treated surgically, and with the help of auxiliary drug therapy, the symptoms are eliminated and the general condition of the patient is normalized.

The likelihood of complications increases significantly in the absence of timely assistance.

In such situations, phlegmon can cause conditions that threaten the patient's life.

Possible complications

Possible complications of phlegmon in the maxillofacial area include:

• Blood poisoning and septic shock;
• Impaired brain activity due to intoxication;
• Asphyxia;
• Impaired cerebral circulation due to compression of blood vessels;
• Thrombosis of the neck veins;
• Development of a brain abscess.

Important to remember! In the absence of timely treatment, phlegmon can cause a skin defect that will persist even if treatment is successful.