Odontogenic infection & Other infections Flashcards
What are common microorganisms for odontogenic infection
mixed aerobe and anaerobe -60%
aerobe - 7%
anaerobe - 33%
differential diagnosis of cellulitis
inflammation of the derm (dermatitis), fascia (fascitis)
DVT
neoplasm (malignancy)
signs of septic shock
High temperature >38.5C Hypotension Warm peripheries Malaise Altered mental status Dyspnea
What are presentation of cellulitis?
Infection occurring 3-5 days Severe pain Large and diffuse swelling Firm and erythematous on skin Minimal to moderate serosanguinous fluid with or without pus locules
When a ptn presents to you with infection in the head and neck. What is your mx?
- assessment of emergency level - consciousness & airway
- history taking
- chief complaints and assoc sx
- medical and drug hx
- hydration and nutritional status which maybe affected by pain or LOA, trimus, dysphagia - examination
- general ex: appearance of toxic, malaise, high fever, septic looking, dehydration
- vital signs:
tachy and hpt due to pain and anxiety
septic shock causing hypotension and increased respi R
spo2 desat due to airway obstruction
tempt >38.5
- regional assessment for swelling, stage of infection either in cellulitis or abscess.
- regional lymphadenopathy - investigations
- plain films
OPG to identify source of infection
Lat neck to assess obstruction of airway
- CT scan with contrast
to identify extent of infection, involvement of spaces, localziation of pus, airway patency
- Blood labs: CBC to assess leukocytosis, ESR or CRP to indicate inflammation and for baseline to assess treatment response.
- C&S through aspiration if able to locate pus locule or thru pus swab during I&D - Treatment involves
- emergency tx maintaning patent airway thru OPA or Trachy in Ludwigs angina,
- surgical treatment for removal of source of infection, I&D, with rigorous debridement until infection is cleared
- fluid replacement
- nutritional support
- analgesia
- antibiotics
what are indications of hospitalization
Compromised host defense rapid progressing infection involvement of secondary spaces temp >38.5C toxic appearance trismus difficulty breathing difficulty swallowing does not respond to antibiotics
investigations required in spreading infection
OPG to find offending tooth or cause of infection
Lateral neck to see potential airway obstruction
CT scan with contrast to assess extent of infection, localization of pus (shows “ring” enhancing lesion & abscess collection)
what are indications of radiographic imaging (CT with contrast) in infection
rapid increase in swelling
involvement of secondary spaces such as masseteric, pterygomandibular space, parapharyngeal space, canine fossa,
rapid deterioration of general condition despite lacking in increase in swelling
suspecting cavernous sinus thrombosis
able to assess airway patency
What are indications of C&S
rapid spread of infection poor immune system no response to prior antibiotics recurrent infection osteomyelitis Suspecting actinomycoses
when should antibiotics be prescribed
Cellulitis involvement of fascial spaces poor immune system severe pericoronitis osteomyelitis
What is Ludwigs angina
A spreading infection into fascial spaces involving submandibular, sublingual and submental spaces bilaterally, with airway obstruction caused by swelling of all these spaces and extension of infection posteriorly to the epiglottis leading to epiglottis edema.
What is the sequalae of ludwigs angina
Airway obstruction
How would you treat Ludwig angina
ABC. maintenance of airway, ventilation support and preventing circulatory collapse of cardiac arrest.
Airway - OPA intubation; tracheostomy
Once stabilized: Removal of source of infection I&D Antibiotics Medical support - fluid, ventilation Analgesias Nutritional support
What is woody tongue
Presentation of Ludwig angina:
Elevation of the floor of mouth and tongue
Protrusion of tongue
Posterior enlargement of tongue
How do you manage infection cases in the long run?
What should be reevaluated on follow up after treatment?
response to treatment (improvement of pain, swelling and other subjective symptoms)
Subsiding infection or persistent infection
Reccurence
Toxicity of antibiotics or drug allergy
Concomitant secondary infection such as Candida
What are the causes of failure of treatment
Inadequate surgical treatment
Poor host defense
Presence of foreign body
Issues with antibiotics: poor patients compliance, resistance, wrong use of antibiotic
How does cavernous sinus thrombosis occur
Valveless veins
Allowing retrograde flow of infection of face to sinus
Common veins involved:
- Anterior pathway: angular and ophthalmic veins (upper lip, tip of nose, paranal region)
- Posterior pathway: pterygoid plexus & transverse facial vein
Presentations of CST
Signs of CN VI palsy - loss of lateral gaze (earliest symptom) Periorbital edema unilateral Proptosis Pupillary dilation Photophobia Headache
Whats the early signs of CST
Signs of CN VI palsy - loss of lateral gaze
Structures present in the cavernous sinus
CN III, CN IV, CN V1, CN VI
ICA
Cavernous sinus plexus
Diff dx of CST
Orbital cellulitis
Meningitis
Stroke
How do you diagnose CST?
Clinical finding MRI (using flow parameters) - thrombosed vascular sinuses - deformity of ICA within the cavernous sinus Lumbar puncture - TRO meningitis
What is tx of CST
I&D at the source of infection
Antibitotic IV 6-8 weeks (empirically, then specific after c&s)
Anticoagulation
Steroids
Whats the danger of Actinomycoses infection
its an infection by Actinomyces israeli that causes multiple painful abscesses containing sulfur-like granules
In which chronic infection will cause multiple fistuales
Tx requires long term penicillin (6 weeks) & debridement and fistulectomy
How do you manage fascial space infection
- Airway management
- Adequate diagnosis with CT/MRI
- Close monitoring of condition
- Early I&D even in no apparent abscess
- Aggressive A/b IV
- Supportive care with hospitaliztion
- Correct any immunocompromising factors (diabetes, leukopenia etc)
Common fungal infections
Candiadiasis
Mucormycosis
3 clinical types of candidiasis
- Pseudomebranous
- Erythematous (atrophic)
- Hyperplastic
Give the presentation of pseudomembranous candidiasis
White lesion that can be scraped off leaving raw bare surface
Asymptomatic
Features of erythematous candidiasis
Red and painful burning mouth
Angular cheilitis
Median rhomboid glossitis
Denture related stomatitis
Hyperplastic candidiasis presents with
White plaque or white lesion that cannot be scraped off
Diff dx includes leukoplakia, endocrine associated candidiasis (endocrine-candidiasis syndrome), lichen planus (reticular form), verrucous ca
Dx by biopsy. tro malignancy.
What is mucormycosis
Fungal infection. Invades thru blood vessels. Causes thrombosis and necrosis of surr tissues.
Diagnosis is by biopsy - broad nonseptate hyphae with right angle branching
Give 2 common types of mucormycosis
Rhinocerebral
Rhinomaxillary
Usually begins with nasal obstruction, bloody nasal discharge, facial pain, facial swelling (cellulitis), involvement of CN (paralysis, numbness, visual disturbance).
Rhino-cerebral: Spread of infection to cranial vault - blindness, lethargy, seizures
Rhino-maxillary: Spread to maxillary sinus - intraoral maxillary or palatal swelling, ulceration and black necrotic lesions.
Risk factors of mucormycosis
- “Iron-related”
- IDDM & ketoacidotic (ketoacidosis inhibits binding of iron to transferrin leads to increase serum iron)
- iron-chelating agents in thalassemia - Immunocompromised
- AIDS
- BMT patients
- Diabetic
- Steroid therapy
Tx of mucormycosis
IV amphotericin B
Surgical debridement of necrotic tissues with reconstruction once infection resolved
Presentation of Noma
Noma = orofacial gangrene
Caused by multiple bacteria (polymicrobial) opportunistic infections
Leads to painless tissue degradation
Fusobacterium necrophorum
Prevotella intermedia
Risk factors of noma
Immunocompromised Poor oral hygiene Nutritional deficiency Kids <12 African or Asians (underdeveloped countries)
Tx of noma?
IV penicillin
Surgical debridement with reconstruction after infection subsides
Nutrition and hydration
