Introduction
The prevalence of purulent-inflammatory diseases of the maxillofacial region (MFR) is at a consistently high level. Untimely assistance, and sometimes irrationally chosen treatment tactics at the initial outpatient appointment, leads to severe complications and hospitalization in maxillofacial surgery hospitals, often in intensive care. According to various sources, every year from purulent-inflammatory diseases of the maxillofacial area die from 0.1 to 0.3% of patients from the total number of patients hospitalized in hospitals in the Russian Federation. Unfortunately, at present there are no uniform standards for the treatment of purulent-inflammatory diseases of the maxillofacial area both in our country and abroad. Due to the lack of standardization of treatment plans, the results of such treatment are unstable, which increases the risks of complications and associated life-threatening conditions for the patient [1].
Phlegmon of the floor of the mouth is a common purulent-inflammatory process that involves two or more cellular spaces located above or below the diaphragm of the floor of the mouth. Among all the phlegmons of the maxillofacial area, it is more common than others. Odontogenic infection is the most common cause (70% of cases) of the development of phlegmon of the floor of the mouth. Representatives of the genus Streptococcus (Viridans group) are most often isolated — in more than 40% of cases, in addition, in 27% of cases — Staphylococcus aureus and Staphylococcus epidermidis — in 23% of cases [2].
A number of authors point out the need for topographic-anatomical analysis of the oropharynx to understand the rate of progression of phlegmon of the floor of the mouth. The presence in the area of the floor of the oral cavity of numerous intermuscular and fascial communication pathways, through which the ducts of the salivary glands, vessels and nerves pass, makes it possible for the infectious process to spread to all the cellular spaces of this area [2]. The anatomically close course of the infectious process to the bloodstream, in the case of phlegmon of the floor of the mouth, can contribute to the development of transient bacteremia and toxemia, with subsequent septic complications [3, 4].
Wilhelm Friedrich von Ludwig in 1836 first described a condition characterized by diffuse bilateral lesions of the floor of the mouth, involving three sections: sublingual, submental and submandibular. Subsequently, this condition was called «Ludwig’s tonsillitis” [5]. An infectious process spreading from the molars of the lower jaw is a characteristic cause of true Ludwig’s angina; however, the term is often applied to any infection of the floor of the mouth involving the sublingual or submandibular space [6]. In addition to odontogenic infection, soft tissue trauma during piercing can lead to damage to the floor of the mouth, which the authors cite as a rare cause of diffuse, generalized inflammation [7]. In addition to the classic course, rare forms can also be found, with the spread of pus through the peritonsillar and parapharyngeal tissue into the submental, sublingual and submandibular spaces, despite empirical intravenous antibacterial therapy [8, 9].
For emergency diagnostic purposes, computed tomography may be the best imaging choice, although magnetic resonance imaging is the modality of choice for assessing soft tissue and compartment involvement [10].
Subsequent admission to the intensive care unit requires close monitoring of the airway because airway compromise is the leading cause of death in these patients. An option for airway support is flexible intubation endoscopy with preparation for surgical intervention, including preoperative examination of the cardiovascular system (measurement of heart rate, blood pressure), assessment of respiratory parameters and others. Broad-spectrum antibiotics and surgical control of the source of infection are key aspects of the treatment plan [11—14].
Prevention of phlegmon of the floor of the mouth can be achieved by timely sanitation of foci of chronic and acute odontogenic infection through regular medical examinations and preventive dental measures. It is rational to include modern methods and technologies in the complex therapy of odontogenic infectious diseases, such as ozone therapy, high-intensity laser therapy, methods of decontamination and obturation of tooth dentin spaces with modern nano preparations that have prolonged antimicrobial activity, and photodynamic therapy [15, 16].
Ludwig’s tonsillitis is a life-threatening condition that all doctors in the emergency and emergency care system must remember. It’s important to be aware of modern data concerning the features of diagnosis, treatment, management and medical examination of such patients [17—19].
The purpose of the study — to increase the effectiveness of treatment and prevention of phlegmon of the floor of the mouth and deep cellular spaces of the neck, using an integrated clinical and anatomical approach
Material and methods
We describe a clinical case of managing a patient who was diagnosed with «Exacerbation of chronic odontogenic osteomyelitis of the mandible to the right of tooth 4.6. Diffuse putrefactive-necrotic phlegmon of the floor of the mouth, chewing, pterygomaxillary, parapharyngeal, retropharyngeal spaces on the right, root of the tongue. Phlegmon of the deep cellular spaces of the neck on the right. Sepsis». To assess the patient’s condition, an initial examination was carried out to identify complaints, anamnesis, examination, palpation, percussion, and auscultation. Additional research included instrumental and laboratory (general blood count, biochemical blood test, coagulogram, electrocardiography), radiological (multispiral computed tomography) methods. Treatment included drug therapy (antiseptic, antibacterial, detoxification, analgesia) and surgical debridement with extensive opening and drainage of purulent foci under endotracheal anesthesia.
Results and Discussion. Case Report
Patient S., 41 years old, was sent from the dental clinic to the department of maxillofacial surgery with a diagnosis of «Acute purulent periostitis from the 4.6 tooth. Abscess of the maxillo-lingual groove».
History of the disease: according to the patient, pain has periodically occurred in the area of the 4.6 tooth for the last 2 years. About a week ago, constant pain appeared in tooth 4.6, swelling in the gum area. Regarding this, on June 23, 2022, I turned for help to a dental surgeon at the place of residence where tooth 4.6 was removed; soda-salt rinses of the mouth were recommended. Antibiotic therapy is not prescribed. After 2 days, the pain intensified, swelling appeared along the transitional fold in the area of teeth 4.5—4.7. The pain intensified on June 25, 2022, and pronounced swelling of the right cheek area appeared. On the same day, he again turned for help to the on-duty dental clinic, where he was diagnosed with: Acute purulent periostitis from the 4.6th tooth. Abscess of the maxillo-lingual groove. Two incisions were made, one of which was along the transitional fold in the area 4.5—4.7, the other — in the projection of the right maxillolingual groove, about 1 cm long; given a referral to the maxillofacial surgery department.
On June 25, 2022, he was examined by the on-duty maxillofacial surgeon and hospitalized in the maxillofacial surgery department on an emergency basis.
Objective status: upon admission, the patient’s general condition is moderate, the severity of the condition is due to the course of the inflammatory process in the maxillofacial area and intoxication of the body. An external examination reveals a violation of the facial configuration due to swelling of the soft tissues in the right submandibular region. The skin is not hyperemic, not tense, and folds easily. Palpation in the right submandibular region reveals a conglomerate of enlarged lymph nodes up to 1.7 cm, mobile, not fused with the surrounding tissues, and painful. By palpation, the masseter muscle itself on the right is somewhat infiltrated. When palpating in the projection of the attachment of the medial pterygoid and the masticatory muscles to the angle of the lower jaw on the right, there is discomfort. The neck is not externally changed; there is no pain upon palpation along the sternocleidomastoid muscles on both sides. Mouth opening up to 3 cm, moderately painful. In the oral cavity, the hole of the extracted tooth 4.6 is under a blood clot. Along the transitional fold of the lower jaw on the vestibular side in the projection of teeth 4.5, 4.6, 4.7, a postoperative wound 1.5 cm long is identified; 2 glove drains emerge from the wound, through which blood mixed with pus is separated. In the projection of the right maxillo-lingual groove, a 1.0 cm long incision is made; blood is separated from the wound through a glove drainage. The mucous membrane along the maxillo-lingual groove on the right is swollen and hyperemic. Palpation is moderately painful. The pterygomaxillary fold is not swollen. The pharynx is symmetrical. There is no displacement of the lateral pharyngeal wall. On the intraoral contact periapical radiograph dated June 25, 2022, which the patient brought with him on paper, the socket of the extracted tooth 4.6 is determined.
Considering the clinical symptoms, the patient underwent an examination, including a general blood test, biochemical blood test, coagulogram, electrocardiography. Based on the results of the examination, the diagnosis was made: «Exacerbation of chronic odontogenic osteomyelitis of the lower jaw to the right of tooth 4.6. Subperiosteal abscess of the lower jaw in the projection of 4.5, 4.6, 4.7 teeth. Abscess of the maxillo-lingual groove on the right. Acute serous lymphadenitis of the submandibular region on the right.”
Treatment: the wounds were inspected, drains were changed, and the wounds were washed with a 0.05% solution of chlorhexidine Di gluconate. Antibiotic therapy was prescribed: Ciprofloxacin 0.2% 100 ml 2 times a day intravenously, Metronidazole 100 ml 3 times a day intravenously; detoxification therapy.
Features of the dynamics of the disease: at 23:50 on June 25, 2022, the patient complained of increased swelling, difficulty swallowing, and limited mouth opening. With external on examination, there was an increase in edema in the submandibular region on the right, spreading to the submental region. Due to negative dynamics in the form of increasing edema, a decision was made to open and drain the purulent lesion using external access. Since the patient ate heavily and drank water 30 minutes before the examination, preoperative preparation began and a fasting regimen was prescribed. At 06:35 on June 26, 2022, during a reexamination before surgery, the patient complained of a deterioration in his condition in the form of increased pain and difficulty swallowing, and the appearance of pain when turning his head. An external examination reveals the spread of edema to the anterolateral surface of the neck on the right. The skin in this area is not hyperemic, the tissues are slightly tense. Palpation along the sternocleidomastoid muscle to the border with the lower third of the neck on the right is painful. Pain on palpation in the projection of the attachment of the medial pterygoid and masticatory muscles to the angle of the lower jaw on the right. Opening the mouth up to 2 cm, painful. In the oral cavity, increased swelling of the hyoid ridge on the right. The tongue is raised. Swelling of the pterygomaxillary fold on the right. Moderate swelling of the lateral wall of the pharynx on the right. Bloody-purulent discharge is separated from the wounds through previously installed drainages.
Considering the negative dynamics and the appearance of edema in the neck area, the patient was prescribed multislice computed tomography (MCT) of the facial skeleton and neck (fig. 1). MCT conclusion: condition after removal of the 4.6 tooth. MCT picture of phlegmon in the floor of the mouth and soft tissues of the neck on the right. Right-sided submandibular, cervical lymphadenopathy. Deviation of the nasal septum. Signs of bilateral sinusitis, frontal sinusitis, ethmoiditis.
Fig. 1. MCT of the neck: gas bubbles are visualized anterior to the sternocleidomastoid muscle.
Progress of the operation: Under endotracheal anesthesia, an incision was made in the submandibular region on the right parallel to the edge of the lower jaw from the angle of the lower jaw on the right to the submandibular region of the opposite side. Soft tissues are cut layer by layer. The facial artery and vein were isolated and ligated in turn. The tissue was dissected along the upper pole of the submandibular gland on the right — no pus was obtained. Along the posterior pole of the gland, the mosquito bluntly passed into the parapharyngeal space — a large amount of foul-smelling pus was obtained. A smear was taken to determine the sensitivity of the microbiota to antimicrobial drugs. Using raspatory, the medial pterygoid muscle was detached from the bone — a small amount of pus was obtained. The lower part of the masticatory muscle is covered with necrotic films, the muscle is cut off from the bone using a rasp, the masticatory space is inspected — no free pus is obtained. When revising the upper floor of the floor of the oral cavity on the right, a connection with the oral cavity (postoperative wound) is determined. The tissue along the lower pole of the submandibular gland was dissected, the gland was retracted upward, the gland bed was inspected, and pus was obtained. The anterior bellies of the digastric muscles were crossed on both sides — a large amount of effusion was obtained. Passed between the geniohyoid muscles into the sublingual area — pus is obtained. When inspecting the wound, a purulent cavity is identified, spreading along the fascia in the bed of the gland. To ensure adequate drainage, the geniohyoid muscle on the right is divided. A mosquito passes to the measles of the uvula — pus is obtained.
Next, the incision is extended along the anterior edge of the sternocleidomastoid muscle on the right to the level of the jugular notch. Subcutaneous fatty tissue is infiltrated, effusion is released (what kind?). Soft tissues are cut layer by layer. Along the entire length of the neurovascular bundle, thick pus with gas bubbles was obtained. An inspection of the pretracheal space was carried out — pus was obtained in the upper and middle thirds, the purulent cavity communicates with the gland bed and the root of the tongue. Along the anterior edge of the neurovascular bundle, it was bluntly passed into the retroesophageal space — a small amount of pus was obtained in the upper third, the tissues were exfoliated by the inflammatory process, infiltrated, and edematous. The process does not spread along the prevertebral fascia to the healthy side (fig. 2). Hemostasis control. The wounds are washed generously with an antiseptic solution and drained with glove drains and half-tube drains. The drains are sewn. Aseptic dressing with hypertonic solution.
Fig. 2. Opening the floor of the mouth and deep cellular spaces of the neck.
After the operation, the final diagnosis was made: Exacerbation of chronic odontogenic osteomyelitis of the lower jaw to the right of tooth 46. Diffuse putrefactive-necrotic phlegmon of the floor of the mouth, masseter, pterygomaxillary, parapharyngeal, retropharyngeal spaces on the right, root of the tongue. Phlegmon of the deep cellular spaces of the neck on the right. Sepsis. Considering the diffuse nature of the purulent-inflammatory process, as well as the scope of surgical intervention, after opening the purulent focus, the patient was transferred to the anesthesiology and intensive care unit for further treatment and observation. Due to the presence of upper airway edema, extubating was not performed. Detoxification therapy and empirical antibacterial therapy were prescribed: Meropenem 1 g. 3 times a day intravenous drip, Metronidazole 100 ml 3 times a day intravenous drip, Amikacin 1 g. 1 time per day intravenously. To prevent thrombotic complications, Nadroparin calcium (Fraxiparine) 0.3 ml was prescribed subcutaneously once a day. A nasogastric tube was installed to provide nutrition.
On June 29, 2022, dressing was performed under anesthesia (fig. 3). Drainage was removed under the endotracheal anesthesia under aseptic conditions. An audit of previously opened cellular spaces was carried out. The wound is wide open. There is no data on the spread of the process. In the area of the apex of the cervical flap there is necrotic film, along the fascia near the bed of the submandibular gland there is necrosis and is difficult to separate. In the area of the root of the tongue and the bed of the gland there is copious purulent discharge with an unpleasant odor. Hemostasis control. The wounds are washed abundantly with an antiseptic solution and drained with glove drains and half-tube drains. Additional installed drainages into the area of the tongue root and gland bed to ensure adequate drainage. The drains are sewn. Aseptic dressing with hypertonic solution.
Fig. 3. Wound with drains installed after dressing under anesthesia.
On July 1, 2022, in order to assess the quality control of treatment over time, MSCT of the facial skeleton and neck was performed (fig. 4). MCT conclusion: condition after surgical interventions — massive wound defects, drainages, edema and gas bubbles are visible. No signs of circumscribed fluid accumulations were found. On 07/01/2022, after sanitary fibro bronchoscopy (FBS), the trachea was extubated and the nasogastric tube was removed.
Fig. 4. Dynamic MCT of the neck: massive wound defects with drains installed are visualized.
Results of a bacteriological study with determination of sensitivity to antimicrobial drugs dated June 26, 2022: Streptococcus viridans: 106 CFU/ml: Meropenem — P, Amoxicillin — P, Ciprofloxacin — P, Tetracycline — P, Erythromycin — P, Lincomycin — P, Ceftriaxone — R, Vancomycin — P (where R is resistant, P is sensitive).
On July 02, 2022, the patient was transferred to the maxillofacial surgery department, and tolerated the transfer satisfactorily. Daily dressings were performed, and necrotomy was performed if indicated. 07/04/2022, taking into account the persistent formation of wound channels, drainage half-tubes were removed from the wound. On 07/09/2022, the drainage from the wound was completely removed. On July 12, 2022, the wound cleared (fig. 5). Taking into account the pronounced diastasis of the wound edges, to prevent the development of cicatricial deformity of the neck, secondary sutures were applied. Under local anesthesia Sol. Lidocaini hydrochloridi 10%, soft tissue was separated in the subcutaneous fat layer for 2 cm along all wound edges. The flap is moved until the wound surfaces touch. The wound was sutured with polypropylene 3.0. Drainage with glove graduates. Aseptic dressing.
Fig. 5. Cleaned wound. Pronounced diastasis of the wound edges is determined.
On the 12th day from the moment of application, the secondary sutures were removed. Wound healing proceeded without any features (fig. 6). After the sutures were removed, the patient was discharged for outpatient treatment with a dental surgeon at his place of residence (fig. 7).
Fig. 6. Stage of wound healing after application of secondary sutures.
Fig. 7. View of the patient on the 12th day after surgery (a) and of the postoperative scar on day 12 (b).
Conclusion
Cellulitis of the floor of the mouth is a rapidly progressive infectious disease that, under unfavorable conditions, can lead to the death of the patient. Computed tomography of the soft tissues of the neck, especially with intravenous contrast, is an accurate imaging method for planning adequate surgical intervention. For the successful treatment of purulent-inflammatory diseases of the maxillofacial area, the primary task is a wide opening and adequate drainage of the purulent focus. The tactics of gentle, small incisions are unacceptable, since they do not provide the necessary outflow of exudate from the wound. An important aspect of the management of such patients is the need for consultation with an anesthesiologist and otolaryngologist, due to the threat of rapid airway obstruction. Broad-spectrum antimicrobial therapy and surgical source control are key factors in controlling infection. Ambulance and emergency doctors should be well informed about the features of diagnosis, clinical course and prevention of complications of phlegmon of the floor of the mouth and neck. The presented clinical case once again proves the importance of sanitation of foci of odontogenic infection and the need for regular medical examinations, preventive dental measures with control of oral biofilm.
Participation of authors:
Concept and design of the study — Yu.L. Vasil’ev, M.S. Malykh, R.V. Mellin, E.I. Karpova
Data collection and processing — M.S. Malykh, R.V. Mellin, Yu.V. Vasil’ev, D.A. Moiseev, V.V. Tatarkin, N.V. Tiunova.
Text writing — M.S. Malykh, R.V. Mellin, Yu.V. Vasil’ev, D.A. Moiseev, B.R. Zaitdinov, A.A. Bakhmet
Editing — D.A. Moiseev, Yu.V. Vasil’ev, E.I. Karpova, L.V. Vdovina
Consent for publication.
Patient were informed verbally and in writing about the study and gave written informed consent.