Oral & maxillofacial infections

1. Preventing
infectious
complications in the
Practice
surgery
of
maxillofacial
Dr Rishi Bali
Professor , OMFS ,
DAV Centenary DC & H

2. 
Three main causes :

Anaesthesia

Hemorrhage

Infection

3. Maxillofacial infections ? Considerations ?
• Proximity to vital organs & siginificant mortality
• Medically compromised patients
• Antibiotic resistant bacteria

4. 
Fascial space infections

Fungal infections

Sepsis & Septic shock

5. Brain abscess, cavernous sinus
thrombosis,Orbital cellulitis
Upward spread
Systemic spread
SPACE INFECTIONS
Septicemia,DIC
Downward spread
Resp.
obstr
,Aspiration
Pneumonia,Pneumothorax,Mediastinitis
Pericarditis,Thoracic Empyema

6. 
Described in
relation to the
hyoid
◦ Suprahyoid
◦ Infrahyoid
◦ Entire length of
the neck

7.  Superior—skull base
 Inferior—hyoid
 Posterior—prevertebral
fascia
 The
stylopharyngeal
aponeurosis
of
Zuckerkandel : barrier
to infection from the
pre to the post styloid
compartment.

8.  Carotid sheath contributions
from all 3 layers of deep fascia
& can be secondarily infected
Airway
obstruction,
pneumothorax, Mediastinitis,
Horner’s
syndrome,
IJV
thrombophlebitis,LeMierre
syndrome
 Communicates
retropharyngeal space
with

10. 
39 yrs pregnant pt Lt Submandibular Pterygomand
peritonsillar & Parapharyngeal infection

Mild airway compromise , TLC 18,500 , BP 92/50
,HR 120 , Temp 102, RR 21/min

Focus removal - I&D

Patient died
?
?

11. TRIAGE : Occult
Obvious distress,
Near total obstruction
Fiberoptic intubation
Tracheotomy under LA If FB/ skilled anaesthetist not available
Needle decompression before airway control
Avoid Blind nasal intubation

12. IMAGING

Lateral neck film (6 at
2 & 22 at 6 )
False negative rate 33%

CECT is the imaging
of choice
12

14. Cavernous Sinus Thrombosis (CST)
•Periorbital edema, headache, photophobia,
proptosis,ptosis , chemosis, 3 to 6 cranial nerve palsies VI
nerve earliest.
•Sluggish pupillary reaction
•Sensory deficits of the opth & max div of the fifth nerve .
•Headache , Nuchal rigidity & Sepsis.

15. Fungal sinusitis
• Reported with increasing frequency
• Invasive form : associated
morbidity & mortality
with
significant

18. 
No propotosis after 3 months of
Voriconazole
therapy

22. 
Reversal of immunocompromised state

Early intervention & antifungals based on micro.

Accurate Assesment of spread : aggressive Surgery

Regular follow up with imaging for minimum of one
year
Singh V ,Bali R. Rhinocerebral mucormycosis : A diagnostic challenge & therapeutic dilemma . JOMS2012 June;70(6):1369

23. 
Facial swelling & Pain

Opthalmoplegia& blurred vision

26. Lt interpositional arthroplasty in 7 yr male
Blood loss approx. 250 ml & Uneventful extubation
Post op. phase hypotension 98/58 mmhg.
• Hemoglobin 10 .4gm %
• Drain & surgical site were evaluated
• Fast NS followed by colloids
• Blood transfusion 1 unit started 10 hrs after the surgery

27. TEMPERATURE
103
102
101
RESPIRATORY RATE
30
25
100
20
99
15
98
10
97
5
96
0

28. WBC
120
25000
100
20000
80
15000
10000
5000
0
60
40
20
0
SYSTOLIC
DIASTOLIC

30. Infection
SIRS
Sepsis
Severe Sepsis
Ref : Bone et al. Chest. 1992;101:1644-1654.

32. 70%
60%
50%
40%
SIRS
30%
SEPSIS
SEVERE SEPSIS
20%
SEPTIC SHOCK
10%
0%
SIRS
SEPSIS
SEVERE
SEPTIC
SEPSIS
SHOCK

33. Altered
Consciousness
Tachypnea
PaO2 250
Liver Enzymes
>2x ULN
Tachycardia
SBP 90 despite
fluids
Urine Output <0.5
mL/kg/hr despite fluids
Creatinine
Platelets
<100,000/mm3
PTT≥60
Low pH with high lactate
(lactate>2mMol)
Balk RA. Crit Care Clin. 2000;16:179-192.

34. ◦ CRP , Blood Glucose
◦ Leukocytosis or Leukopenia
◦ Toxic granulation of neutrophils & band forms
◦ Arterial Blood gases
◦ Cultures : Blood / Pus

http://www.survivingsepsis.org/campaign

35. 
Sound knowledge of
pathophysiology of
infectious processes ,the ability to diagnose
early , anticipate complications & decisively
interrupt them can prevent many morbidities
& mortalities in Maxillofacial surgery