Dental Abscess

Question 1

You are reviewing a 32-year-old male patient, who has been listed for emergency incision and drainage of a dental abscess. He is a smoker and has learning difficulties.

What are your key concerns in the anaesthetic management of this patient?

Answer 1

• Concerns with regard to the dental abscess:
• Possible difficult airway.
• Local or systemic sepsis may affect the patient’s haemodynamic stability under a general anaesthetic.
• Potential for poor dentition secondary to smoking increases the
  risk of a difficult airway.
• Smoker: The patient is likely to have a reactive airway when anaesthetised, as well as the physiological effects of nicotine, carbon monoxide and other toxins contained within cigarettes.
• Learning difficulties: He may present as a challenging patient with limited compliance for treatment and possible consent issues.

Question 2

What are the increased risks associated with smokers in the perioperative period?

Answer 2

• Increased incidence of adverse respiratory events including laryngospasm, bronchospasm, aspiration of gastric contents, type I respiratory failure and pulmonary oedema.
• Increased risk of postoperative pulmonary complications e.g. atelectasis, pneumonia.
• Increased risk of postoperative cardiac events.
• Higher incidence of sepsis and poor wound healing postoperatively.
• Overall increase in duration of hospital stay, morbidity and mortality.

Question 3

What are the complications of an untreated dental abscess?

Answer 3

• Dental cyst.
• Ludwig’s angina.
• Mediastinitis.
• Maxillary sinusitis.
• Complete airway obstruction.
• Orbital cellulitis.
• Cavernous sinus thrombosis.
• Osteomyelitis.
• Systemic sepsis/shock.

Question 4

How would you assess this patient’s airway?

Answer 4

History:
* Duration of symptoms and speed of progression.
* Changes in speech.
* Difficulty swallowing, eating and breathing.

Examination:
* Observations and general appearance for signs of respiratory distress e.g. stridor, hypoxia, drooling.

• Specific airway assessment:
• Mouth opening.
• Mallampati score.
• Jaw protrusion.
• Neck extension.
• Ability to protrude tongue.

Question 5

The patient is calm but becomes distressed on examination due to pain. He is able to open his mouth to 1 finger width, and neck extension is also limited due to severe discomfort.

What is your plan for induction of anaesthesia in this patient?
* no right answer!!

Answer 5

• A multidisciplinary team discussion regarding the concerns about the patient is essential. He is at high risk of a difficult airway. A focused discussion with the senior surgeon and anaesthetic consultant should be undertaken to establish the plan for securing the airway, and the plan in the event of a failed intubation.
• Options for anaesthesia include:
• Intravenous induction with muscle relaxation.
• Gas induction.
• Rapid sequence induction.
• Awake/asleep fibreoptic intubation.
• Awake tracheostomy.
• The main concern in this patient is trismus, which may not relax on induction of anaesthesia. The patient appeared calm and compliant during pre-assessment, so an awake fibreoptic intubation would be a sensible choice of induction, with sedation.
• However, if the severity of learning difficulties is greater (and therefore an awake intubation would be more challenging), it is important to question whether mask ventilation is likely to be easy or difficult. In this case, the plan for intubation could be an attempt with videolaryngoscopy, followed by an asleep fibreoptic intubation as plan B.

Question 6

The patient is calm but becomes distressed on examination due to pain. He is able to open his mouth to 1 finger width, and neck extension is also limited due to severe discomfort.

What is your plan for induction of anaesthesia in this patient?

Continued…

Answer 6

Technique
* Ensure AAGBI monitoring is attached, the difcult airway trolley is present, and the resus trolley and emergency drugs are readily available.
* Have two senior anaesthetists present, a trained assistant and
surgeons present and scrubbed in theatre.
* Ensure early oxygenation with high fow nasal oxygen delivery and
appropriate positioning of the patient (head-up).
* Give sedation with remifentanil (target-controlled infusion titrated to
efect) controlled by a third anaesthetist.
* Topicalise the airway being mindful of the maximum doses of local
anaesthetic for the patient’s weight.
* Perform the fbreoptic intubation and confrm endotracheal tube
placement prior to induction of anaesthesia.