Dr. Mohamed El Sayed

1. M.Zayady
Management principles ofManagement principles of
odontogenic facial infectionsodontogenic facial infections
Dr. Mohammed El Sayed
OMF Consultant
2017

2. 07/22/17 M.Zayady

3. 07/22/17 M.Zayady
Clincal features
 Diffuse swelling
 Pain
 Fever
 Malaise
 Swelling is tense and tender
 Overlying skin is taut and shiny
 Trismus
 Regional lymph nodes are swollen and
tender

4. 07/22/17 M.Zayady
The eight steps in the management of odontogenic
infections:
1.Determine the severity of infection.
2.Evaluate host defenses.
3.Decide on the setting of care.
4.Treat surgically.
5.Support medically.
6.Choose and prescribe antibiotic therapy.
7.Administer the antibiotic properly.
8.Evaluate the patient frequently.

5. 07/22/17 M.Zayady
Step 1:
Determine the Severity of Infection
Three major factors must
be considered in
determining the severity
of an infection of the
head and neck:
Anatomic location,
Rate of progression,
Airway compromise.

6. 07/22/17 M.Zayady
Anatomic Location
The anatomic spaces of the
head and neck can be
graded in severity by the
level to which they threaten
the airway or vital
structures, such as the
heart and mediastinum or
the cranial contents.

7. 07/22/17 M.Zayady
Low severity
Buccal
Infraorbital
Vestibular
Subperiosteal

8. 07/22/17 M.Zayady
Moderate severity
anatomic spaces that can hinder access to the
airway due to swelling or trismus
Masticatory space Submasseteric.
Pterygomandibular.
Superficial and Deep
temporal spaces.
Perimandibular spaces
)Submandibular, Submental, and Sublingual(.

9. 07/22/17 M.Zayady

10. 07/22/17 M.Zayady

11. 07/22/17 M.Zayady
Ludwig’s angina??

12. 07/22/17 M.Zayady
High severity
swelling can directly obstruct or
deviate the airway or
threaten vital structures.
Lateral pharyngeal
Retropharyngeal.
The danger space.
Mediastinum.
Cavernous sinus thrombosis
and other intracranial
infection also have high
severity.

13. 07/22/17 M.Zayady
 Walls of the pharynx and
related structures:
 superior pharyngeal
constrictor (spc)
 middle pharyngeal
pharyngeal constrictor (mpc)
 inferior pharyngeal
constrictor (ipc)
 bodies of cervical vertebrae
(bcv)
 arrows point to the
retropharyngeal space

14. 07/22/17 M.Zayady
Rate of Progression

15. 07/22/17 M.Zayady
Necrotizing Fasciitis
rapidly progressive infection frequently due to
odontogenic sources, that follows the platysma muscle
down the neck and onto the anterior chest wall. Diabetes
and alcoholism have been shown to be significant
predisposing factors, whereas medical compromise,
delay in surgery, and mediastinitis are associated with
increased mortality. It can rapidly result in necrosis of
large amounts of muscle, subcutaneous tissue, and skin,
resulting in severe reconstructive defects. The earliest
signs of necrotizing fasciitis are small vesicles and a
dusky purple discoloration of the involved skin

16. 07/22/17 M.Zayady
Airway Compromise
Complete airway obstruction
- Endotracheal intubation
- Cricothyroidotomy or Tracheotomy
partial airway obstruction
breath sounds special posture

17. 07/22/17 M.Zayady
Trismus???
A maximum interincisal
opening that has
decreased to 20 mm or
less in a patient with acute
pain should be considered
an infection of the
masticator space until
proved otherwise.

18. 07/22/17 M.Zayady

19. 07/22/17 M.Zayady
Assessing the effectiveness
of respiratory efforts
Pulse oximeter: An oxygen saturation of below 94% in an
otherwise healthy patient is indeed an ominous sign
because it indicates insufficient oxygenation of the
tissues due to hypoperfusion or hypooxygenation.
Soft tissue radiographs: of the cervical airway and chest can
be quite valuable in identifying deviation of the airway
laterally on a posteroanterior film or anterior
displacement of the airway on a lateral view.

20. 07/22/17 M.Zayady
Cont.
The newer high-speed
CT scanners: can
obtain a computerized
CT examination within
seconds to minutes,

21. 07/22/17 M.Zayady
Step 2:
Evaluate Host Defenses
The medical conditions that can interfere with proper
function of the immune system:
 Diabetes
 Steroid therapy
 Organ transplants
 Malignancy
 Chemotherapy
 Chronic renal disease
 Malnutrition
 Alcoholism
 End-stage AIDS

22. 07/22/17 M.Zayady
Systemic Reserve
The host response to severe infection can place a
severe physiologic load on the body. Fever can
increase sensible and insensible fluid losses and
caloric requirements. A prolonged fever may
cause dehydration, which can therefore
decrease cardiovascular reserves and deplete
glycogen stores, shifting the body metabolism to
a catabolic state.

23. 07/22/17 M.Zayady
The physiologic stress of a serious
infection can disrupt previously well
established control of systemic diseases.

24. 07/22/17 M.Zayady
Step 3:
Decide on the Setting of Care
Indications for hospital admission of the patient
with a severe odontogenic infection:
 Temperature > 101°F (38.3°C)
 Dehydration
 Threat to the airway or vital structures
 Infection in moderate or high severity anatomic spaces
 Need for general anesthesia
 Need for inpatient control of systemic disease

25. 07/22/17 M.Zayady
Immediateestablishment of airway security and early
aggressivesurgical therapy arethemost
important intervention stepsin themanagement
of severeodontogenic infections.
Indications for an operating room procedure.
 To establish airway security
 Moderate to high anatomic severity
 Multiple space involvement
 Rapidly progressing infection
 Need for general anesthesia
Step 4:
Treat Surgically

26. 07/22/17 M.Zayady
Needle decompression tech.?
 Decompress the surrounding tissues.
 Decrease the risk of abscess rupture through taut,
distended oropharyngeal tissues during
instrumentation of the airway.
 Redirection of pus drainage into the oral cavity or
onto the skin, where it can easily be removed,
 Obtaining an excellent specimen for culture and
sensitivity testing.

27. 07/22/17 M.Zayady
Surgical Drainage

28. 07/22/17 M.Zayady

29. 07/22/17 M.Zayady
Culture and Sensitivity Testing
 When an infection involves anatomic spaces of
moderate or greater severity.
 When there is significant medical or immune
system compromise.
 When the surgeon is dealing with infections that
have been subjected to multiple prior courses of
antibiotic therapy.
 In chronic infections that are resistant to therapy.

30. 07/22/17 M.Zayady

31. 07/22/17 M.Zayady
Step 5:
Support Medically
 Hydration.
 Nutrition. in all patients
 Control of fever.
 Maintenance or reestablishment of electrolyte
balance . some patients
 Control of systemic diseases

32. 07/22/17 M.Zayady
Daily sensiblefluid loss, consisting primarily of sweat, is
increased by 250 mL per degreeof fever. Insensiblefluid
loss, consisting mainly of evaporation from lungsand skin, is
increased by 50 to 75 mL per degreeof fever per day.
Fever also increasesmetabolic demand by 5 to 8% per degree
of fever per day.

33. 07/22/17 M.Zayady
Step 6:
Choose and Prescribe antibiotic Therapy
Severity of Infection Antibiotic of Choice
Outpatient Penicillin
Clindamycin
Cephalexin (only if the penicillin allergy was not the
anaphylactoid type; use caution)
Penicillin allergy:
Clindamycin
Moxifloxacin
Metronidazole alone
Inpatient Clindamycin
Ampicillin + metronidazole
Ampicillin + sulbactam
Penicillin allergy:
Clindamycin
Third-generation cephalosporin IV
(only if the penicillin
allergy was not the anaphylactoid type; use caution)
Moxifloxacin (especially for Eikenella corrodens)
Metronidazole alone (if neither clindamycin nor
cephalosporins can be tolerated)

34. 07/22/17 M.Zayady
Step 7:
Administer the antibiotic Properly
 Dose
 Route
 Duration

35. 07/22/17 M.Zayady
Step 8:
Evaluate the Patient Frequently
 Daily clinical evaluation and wound care.
 By 2 to 3 postoperative days the clinical signs of
improvement should be apparent:
- Decreasing swelling.
- Defervescence.
- Cessation of wound drainage.
- Declining white blood cell count.
- Decreased malaise.
- Decrease in airway swelling

36. 07/22/17 M.Zayady
Causes of Treatment Failure
 Inadequate surgery
 Depressed host defenses
 Foreign body
 Antibiotic problems
Patient noncompliance
Drug not reaching site
Drug dosage too low
Wrong bacterial diagnosis
Wrong antibiotic

37. 07/22/17 M.Zayady