Abscesses and phlegmons (cellulitis) of the tongue root, floor

of mouth and neck.

Necrotic phlegmon of the maxillofacial area.
 Definitions
• Abscess (from lat, abscedo, • Phlegmon (from the Greek
abscessum - to separate, tear) is phlegmone - inflammation,
an accumulation of pus in phlegma - fire, heat,
various tissues and organs inflammation) - diffuse purulent
delimited by a pyogenic inflammation of the cellulose.
membrane. Phlegmon can develop in any
part of the body, with a
turbulent current - to capture
several anatomical areas.
Odontogenic phlegmons of the floor
of mouth and neck. Anatomy
There are two levels of soft tissue in the floor of the mouth -
upper and lower.
Boundaries of the upper floor of the floor of the mouth:
• upper - the mucous membrane of the floor of the mouth;
• lower - the jaw-hyoid muscle;
• front and outer - inner surface of the mandible;
• back - the base of the tongue.
The boundaries of the lower floor of the floor of the mouth:
• upper - the maxillary-hyoid muscle;
• Antero-outer - the inner surface of the lower jaw;
• posterior - the muscles that attach to the styloid process, and
the posterior
the abdomen of the digastric muscle;
• lower - the skin of the right and left submandibular and
submental areas.
Odontogenic phlegmons of the floor
of mouth and neck. Anatomy
Odontogenic phlegmons of the floor
of mouth and neck. Anatomy
Phlegmon (cellulitis) of soft tissues of the
bottom of the oral cavity and neck are
phlegmon of the sublingual and submandibular
regions, which extend to the anatomical regions
of the same name on the opposite side,
involving in the inflammatory process the
cellular spaces located between them. The
phlegmons of the floor of the mouth include
inflammatory processes that capture the upper
and lower floors of one side
Etiology, pathogenesis
• On the neck, phlegmon are most often
of a secondary nature, that is, they
arise as a result of the transition of the
inflammatory process from the soft
tissues of the floor of the mouth.
Abscesses and phlegmon of the neck
primary character with non-
odontogenic foci of infection - festering
wounds, scratches, punctures, boils,
cysts, dermatitis, tonsillitis, etc. The
microorganisms thought to be
responsible are aerobic and anaerobic
streptococci and staphylococci.
Etiology, pathogenesis
Clinical picture
• This disease is characterized by edema, headache, and
reddish skin. The edema, whose margins are diffuse and not
defined, may present in various areas of the face and its
localization depends on the infected tooth responsible. For
example, if the mandibular posterior teeth are involved, the
edema presents as submandibular, and, in more severe
cases, spreads towards the cheek or the opposite side,
leading to grave disfigurement of the face. When the
infection originates in the maxillary anterior teeth, the
edema involves the upper lip, which presents with a
characteristic protrusion. In the initial stage, cellulitis feels
soft or doughy during palpation, without pus present, while
in more advanced stages, a board-like induration appears,
which may lead to suppuration. At this stage, the pus is
localized in small focal sites in the deep tissue.
Clinical picture
Clinical picture
• The patient complains of pain when swallowing,
talking, moving the tongue. Due to mechanical
compression In the larynx, swelling of the
surrounding soft tissues or edema of the epiglottis
may cause difficulty breathing. The disease
proceeds with pronounced symptoms of
intoxication and is accompanied by high body
temperature. The patient's position is forced - he
sits with his head tilted forward, view suffering,
slurred speech, hoarse voice. Due to the swelling
of soft tissues of the submental and submandibular
regions, lengthening of the face occurs.
Clinical picture
When involved in the inflammatory process of
the subcutaneous tissue the skin becomes
hyperemic, edematous, tense, shiny, in not
going to fold. Palpation determines a dense,
sharply painful infiltrate. Sometimes a symptom
of fluctuation is determined. Mouth half open,
out it gives off an unpleasant odor. Tongue dry,
coated with dirty gray colors, his movements
are limited. The tongue often protrudes from
the mouth cavity. The mucous membrane of the
floor of the oral cavity is hyperemic, edematous.
Sharp edema of the tissues of the sublingual
region
Clinical picture
• The location of neck abscesses depends on
the cause. A bowl they are localized on the
anterior and lateral surfaces of the neck.
Clinically, abscesses are characterized by the
presence of a limited, painful, sedentary
inflammatory infiltrate of soft tissues,
localized in its superficial or deep sections,
Depending on the depth of the abscess, the
skin over it is hyperemic or unchanged,
collected or does not fold. Abscesses on the
neck most often occur with suppuration
(abscess formation) of the lymph nodes and
are complicated by periadenitis and, in fact,
are adenophlegmons.
Anatomy
Clinical picture of phlegmon
of mouth and neck
• Mouth floor (a phlegmon here
is also called Ludwig's angina)
• dental pain.
• fatigue.
• ear pain.
• confusion.
• swelling of tongue and neck.
• difficulty breathing.
 Complications.
Mediastinitis.
Cellulitis of the neck are diffuse in nature and often
develop during the transition of the inflammatory
process with a number of located anatomical areas.
Palpation determines spilled, dense, painful,
motionless infiltration localized in the superficial or
deep parts of the neck. When edema of the epiglottis
there is difficulty in breathing, with edema of the
vocal ligaments - voice change (hoarseness appears).
With the localization of an abscess in the esophagus,
it is impossible to eat food, even liquid. The spread of
phlegmon to the lower parts of the neck contributes
to the development of mediastinitis, which makes
the prognosis of the disease unfavorable. Phlegmon
of the soft tissues of the floor of the mouth and neck
are often complicated by sepsis, mediastinitis,
thrombosis of the veins of the face and sinuses of the
brain, pneumonia, brain abscesses and other
diseases.
Mediastinitis. a) Even a mild pericoronitis b) if left untreated may progress to the
formation of an abscess that could expand in the submandibular and submental
spaces c) or further to the neck and pretracheal spaces d) requiring extensive
drainage and airway protection though a tracheostomy
Complications. Mediastinitis.
 Complications. Sepsis
• Sepsis (from the Greek.sepsis - putrefaction) - a common infectious disease non-cyclic
type, caused by constant or periodic penetration into the bloodstream of various
microorganisms and their toxins into conditions of inadequate resistance of the
organism. Sepsis is poly-etiological disease. Its causative agent can be any
microorganism, but most often - staphylococcus, E. coli and Pseudomonas aeruginosa,
Proteus, anaerobes, less often - streptococcus, pneumococcus and other microbes.
Classification of sepsis depending on the pathogen:
• staphylococcal;
• streptococcal;
• colibacillary;
• Pseudomonas aeruginosa, etc.
 Complications. Sepsis
Classification of secondary sepsis with localization of the focus in the maxillofacial region:
• odontogenic - the primary focus of purulent inflammation is localized in periodontium;
• stomatogenic - the primary focus of purulent inflammation is localized in
the mucous membranes surrounding the oral cavity;
• wound - the cause of development is infected wounds of the maxillofacial region;
• tonsillogenic - the primary focus of purulent inflammation is localized
in the area of ​the tonsils or periopharyngeal cellular tissue;
• rhinogenic - the primary focus of purulent inflammation is localized in the nasal cavity;
• otogenous - the primary focus of purulent inflammation is localized in the middle ear.
 Complications. Sepsis
• Seven principles to achieve the best outcome in managing odontogenic
infections:
• Establish the severity of the infection
• Assess host defences
• Elect the setting of care
• Surgical intervention
• Medical support
• Antibiotic therapy
• Frequently evaluate the patient.
Sepsis. Medical therapy
Zhansul-Ludwig's angina
The clinical symptoms of anaerobic
phlegmon of the soft tissues of the
bottom of the mouth and neck
(earlier it was called Zhansul-
Ludwig's angina) is different special
severity. General manifestations of
the disease: yellowness of the skin
and subjective sclera, significant
intoxication, high body temperature,
tachycardia, anemia. Blood tests
show leukocytosis, high ESR.
Zhansul-Ludwig's angina
• Local signs of anaerobic infection: an
abundance of necrotic masses in purulent
foci, a dirty gray color of purulent contents,
the presence of air bubbles and inclusions of
fat droplets in it, a sharp (unpleasant) smell
of exudate, the muscles look like boiled
meat, the tissues can be stained dark brown.
The use of antibacterial drugs is ineffective.
By clinical manifestations of ns always
manage to distinguish an infection that
occurs as a result of the action of anaerobic
microflora, from putrefactive aerobic
infection caused by E. coli, Proteus,
hemolytic streptococcus and other
microorganisms
Treatment
• With phlegmon of soft tissues of the
bottom of the oral cavity, incisions are
made in the submandibular regions on the
right and left, leaving a skin bridge
between them about 1–2 cm wide If the
outflow purulent contents from the
submental area is difficult, then an incision
is additionally made along the midline of
this area. We consider it expedient to
carry out a collar-shaped incision, the line
of which goes parallel to the upper
cervical fold, followed by active drainage
of the purulent focus with double
perforated tubular drainage
Treatment
 Treatment.
ENT-surgeons performing a
tracheostomy in the case of
necrotic phlegmon.
• The operation of opening the phlegmon of the
neck is a difficult intervention, since arrosion
may develop (violation of the integrity of the
blood vessel wall due to a purulent or
ulcerative necrotic process) or damage vessels
and organs (esophagus, trachea, larynx,
thyroid gland). With phlegmon of the neck,
there is often a threat of asphyxia, which
requires a tracheotomy. For prompt access
when opening neck phlegmon, most often use
access through the anterior edge of the
sternocleidomastoid muscle or in the area
jugular fossa, less often - above the collarbone
or along the natural folds of the neck.
 Abscesses and phlegmons of the tongue root
Anatomy borders of the root of the tongue:
• upper - own muscles of the tongue;
• lower - the maxillary-hyoid muscle;
• external - chin-lingual and hypoglossal muscles right and left side.
On the pharyngeal surface of the root of the tongue is the lingual tonsil,
which is part of the lymphoid ring of the Pirogov-Valdeyer pharynx
(palatine, tubal, pharyngeal and lingual tonsils).
 Etiology of the tongue root phlegmon.
Purulent processes of the tongue can occur both in the own muscles of
the movable part of the tongue, and in the cellular spaces of its root.
Abscesses of the movable part of the tongue often occur in as a result of
infection of wounds, as well as when foreign bodies are introduced into
the tongue food nature, most often fish bones.
A purulent-inflammatory process that develops in the area of ​the root of
the tongue, can spread from the lingual tonsil, from the sublingual,
submental and submandibular cellular tissue spaces. Less often, the
source of infection is the foci of odontogenic infection located in areas of
the large molars of the lower jaw. Do not forget about the suppuration of
congenital cysts of the tongue.
Clinical
picture The patient complains of sharp pain when swallowing
and moving the tongue. The pain radiates to the ear.
Swallowing saliva and liquid is sharply painful, and
sometimes even impossible. When trying to do sip, the
liquid enters the respiratory tract and causes a painful
cough. As a rule, due to edema of the epiglottis,
breathing is disturbed, sometimes as a result of
eustachnitis, hearing decreases. The course of phlegmon
of the root of the tongue is heavy. The tongue is
dramatically increased in size, does not fit in the oral
cavity, its mobility is sharply limited. Swelling and density
of the tongue, pressure on its back but in the middle line
causes sharp pain. Mucous the membrane of the tongue
is hyperemic, cyanotic. There is no fluctuation, since a
purulent focus is located between the muscles. The back
of the tongue is covered with dry purulent bloom.
Treatment
• Surgical access for purulent-inflammatory
processes the root of the tongue is
extraoral. A 4 cm incision is made on the
side of the skin along the midline or in the
submental area. Having pushed the edges
of the wound apart with hooks, the jaw-
hyoid muscles are dissected along the
seam. Stupidly push apart soft tissues,
penetrate to the purulent focus. Drainage
of the focus is carried out with an active
double tubular drainage. Sometimes with
increasing phenomena of hypoxia, there is
a need for the formation of a
tracheostomy.