Odontogenic phlegmon and abscesses of the upper jaw. Phlegmon of the floor of the mouth: photos, symptoms and treatment Removal of phlegmon on the jaw

Phlegmon means purulent inflammatory process adipose tissue. At the site of phlegmon formation, the skin initially swells slightly, acquires a red tint, and unpleasant sensations (pain) appear when touched, weakness and headache (if it is phlegmon of the maxillofacial area).

In contact with

If the inflammatory process increases, then a rise in temperature and an increase in lymph nodes near the diseased skin area is possible. This inflammatory process changes the structure of the tissue deeply enough when compared with impetigo.

Cellulitis is mainly caused by bacteria, most commonly Staphylococcus aureus.

In second place is the bacterium - streptococcus, in children (up to the age of six), hemophilic bacteria can provoke the development of phlegmon.

This inflammatory process occurs more in people with reduced immunity and people who suffer diabetes mellitus.

Phlegmon can form both in areas where a wound or injury has formed, and in other places where there is no damage to the skin. If inflammation spreads very quickly, then this indicates that the body is depleted or has severe chronic diseases.

Phlegmon is not contagious, and it is impossible to get infected with it by being in contact with a sick person, because the deep layers of tissue are affected, and the epidermis, that is, the upper layer does not allow the infection to spread.

If we talk about phlegmon of the maxillofacial region, then, most likely, these are complications after infection has entered the oral cavity.

The reasons that can provoke the development of phlegmon of the maxillofacial region:

• Diseased teeth that infect the mouth (wisdom teeth, molars).
• Formation of injury to the hyoid space.

Areas that are most often affected by phlegmon:

• If inflammation of the root of the tongue occurs, then phlegmon is formed under the tongue (both sides).
• Region lower jaw, the inflammation spreads to the chin.
• If the entire area of \u200b\u200bthe floor of the mouth is affected, then inflammation forms both under the tongue and under the jaw (lower).

Gum cellulitis is an inflammation that has formed on the gums

With weakened immunity, the process of development of phlegmon is significantly accelerated and everything starts with not healthy tooth, which was not cured in time.

First it begins, then it collapses bone and the periosteum becomes inflamed. Following is formed, and then or phlegmon.

Phlegmon is very dangerous, can lead to serious diseases (meningitis, sepsis, mediastinitis, meningoencephalitis, etc.) and consequences such as disability or even death. Therefore, it is extremely important to determine the symptoms and seek medical help in a timely manner.

The most important signs of phlegmon of the oral cavity:

Phlegmon treatment

A specialist can easily identify this disease. As a last resort, for complete confidence, the doctor will prescribe you to pass the necessary tests.

Treatment will be prescribed depending on the stage of the inflammation. If you see a doctor on time, then you will be prescribed anti-inflammatory therapy, that is, antibiotics.

If the patient consults a doctor at a late stage, then most likely surgery, excision of the affected tissue and treatment of an already open wound will be required.

You may also need plastic surgery... If the phlegmon has led to the fact that the patient has difficulty breathing, then before using any measures, a tracheostomy is applied, which will ensure normal breathing for the patient.

To avoid the appearance of phlegmon, use preventive measures, that is, treat your teeth on time, observe hygiene oral cavity and don't forget to go to your dentist for routine check-ups. Be healthy!

Abscess and phlegmon of the buccal region. The boundaries of the buccal region are: top-bottom edge zygomatic bone; front-line connecting the zygomatic-jaw suture with the angle of the mouth; below - the lower edge of the lower jaw; behind - the anterior edge of the masseter muscle. Through Bisha's fatty lump, the buccal region communicates with many cellular spaces (pterygo-maxillary, deep parotid-masticatory region, infratemporal, temporal and pterygopalatine fossae, infraorbital region).

In the buccal region are the buccal the lymph nodesthat take lymph from the skin of the cheeks, nose and eyelids. With inflammation of the lymph nodes, lymphadenitis, periadenitis and adenophlegmon may occur.

The main sources of buccal infection are pathological processes that have arisen in the premolars and molars of the upper and lower jaws. On the cheek, the inflammatory process can spread from the infraorbital, parotid-masticatory areas and infratemporal fossa.

Distinguish between superficial abscesses and phlegmon of this area, which are located between the buccal aponeurosis and the buccal muscle, as well as deep, located between the submucosal layer and the buccal muscle.

The disease begins with a throbbing pain in this area, aggravated by opening the mouth. With superficially located inflammatory processes, pronounced infiltration is observed, which extends to the entire cheek and even the eyelids, as a result of which the palpebral fissure narrows or closes completely. The skin over the infiltrate is tense, hyperemic, does not fold into a fold, fluctuation is often determined. The pain at rest is moderate, there is a restriction in opening the mouth. With a deep localization of the inflammatory process (under the buccal muscle), the symptoms of inflammation from the skin are less pronounced. On the eve of the oral cavity, a painful infiltrate is palpated, there is hyperemia and swelling of the buccal mucosa, smooth transitional folds, and difficulty opening the mouth. According to N.A. Gruzdev, the involvement of Bish's fatty lump in the inflammatory process is a harbinger of the generalization of infection. At the same time, there is a sharp deterioration in the general condition of the patient's body and an increase in clinical symptoms.

Superficial abscesses and phlegmon are opened with external access. The skin incision is made above the center of the infiltrate or near its lower edge parallel to the course of the branches facial nerve, in the submandibular region or along the nasolabial fold. Deep abscesses and phlegmon of the cheeks are opened from the side on the eve of the oral cavity along the line of closing the teeth or parallel to the course of the excretory duct parotid gland... The length of the incision should not be less than the length of the infiltrate. Wound drainage is carried out with elastic perforated tubular drainage (from the side of the oral cavity), followed by washing (2-3 times a day) with antiseptic solutions. Extraoral purulent wounds of the cheek are drained with double tubular drainage and the focus is actively washed.

Abscess and phlegmon of the buccal region (cellular spaces of the cheek).The cause of purulent diseases of the buccal region is the spread of infection from the upper or lower large or, less often, small molars. Sometimes an abscess or phlegmon of the buccal region develops as a complication of acute purulent periostitis of the upper or lower jaw, as well as as a result of the spread of infection from the infraorbital, parotid-masticatory areas and infratemporal fossa.

The boundaries of the buccal region are: upper - the lower edge of the zygomatic bone, lower - the lower edge of the body of the lower jaw, anterior - the circular muscle of the mouth, the posterior - the anterior edge of the chewing muscle. Fiber is located between the muscle of laughter, the subcutaneous muscle of the neck on the outside and the body of the lower jaw, the buccal muscle on the inside. The buccal muscle is covered with fascia. Outside, subcutaneous fatty tissue is adjacent to it, inside is the submucosa. Together they form superficial and deep cellular spaces. In the buccal region there are subcutaneous fatty tissue, zygomaticus muscle, muscular plexus of the corner of the mouth, muscles lowering the corner of the mouth and lower lip, buccal lymph nodes, submucosa, and also the facial vein, artery, and parotid duct. The buccal region includes a fatty lump of the cheek, which is enclosed in a fascial sheath and communicates with the parotid region, infratemporal fossa, pterygo-mandibular space.

The fatty body of the cheek, being limited by the fascial sheath, has processes penetrating into the parotid-chewing, infratemporal, temporal, pterygo-mandibular and other adjacent spaces. These processes serve as pathways through which the infection enters both from these spaces into the buccal region and in the opposite direction.

Patients with an abscess of the buccal region complain of minor local pain, aggravated by palpation. A purulent focus can form in the superficial cellular space between the skin and the buccal muscle. In such cases, the presence of a limited, often rounded form of infiltration is characteristic, located, depending on the tooth that served as the source of infection, in the upper or lower part of the buccal region. Edema is slightly expressed in the tissues adjacent to the focus. Quite quickly, the infiltrate is soldered to the skin, which becomes intensely pink or red. On palpation, fluctuation is clearly noted. Often, the purulent process is slow and sluggish. The formation of an abscess can last 1-2 weeks or more. After opening the abscess, the discharge is scanty, the abscess cavity is filled with flaccid granulations. The location of the abscess in the deep cellular space between the buccal muscle and the mucous membrane is characterized by edema of the tissues of the buccal region. When palpating in the thickness of the cheek, a dense infiltrate is determined, often fused with the alveolar process of the upper jaw. The mucous membrane of the cheek is sharply hyperemic, edematous, teeth imprints are visible on it, soreness is noted. After 2-3 days from the onset of the disease, softening appears in central departments infiltration and fluctuation. Sometimes several interconnecting foci of softening are formed.

With phlegmon of the buccal region, patients complain of sharp spontaneous pains, aggravated by opening the mouth and chewing. There is a considerable length of infiltration in the buccal region, pronounced edema of the surrounding tissues, extending to the lower and upper eyelids, as a result of which the palpebral fissure narrows or closes completely. Edema captures the upper, sometimes lower lip, submandibular triangle. The skin in the buccal region is red, infiltrated, does not fold into a fold. There are edema and hyperemia of the mucous membrane of the cheek, upper and lower fornix of the vestibule of the mouth. Often, the mucous membrane bulges out and imprints of the outer surfaces of the upper and lower teeth are visible.

A superficially located abscess of the buccal region is opened in the place of the greatest fluctuation from the side of the skin. When the abscess is located closer to the mucous membrane or in the thickness of the cheek, the incision is made in the oral cavity from the upper, less often the lower fornix of the vestibule of the mouth, as well as in the place of greatest pain and fluctuations parallel to the parotid salivary gland duct and bluntly pass into the abscess cavity. For aesthetic reasons, with phlegmon, they also try to create an outflow of exudate from the side of the oral cavity, making an incision in the vestibule of the mouth, and, stratifying the cellulose, they penetrate to the center of the purulent focus. In case of insufficient outflow of discharge from such a wound, an operative approach from the skin is shown, taking into account the direction of the branches of the facial nerve, in the infraorbital region or the nasolabial groove. The cellulose is stratified and sometimes they resort to bilateral emptying of purulent foci with intraoral and extraoral cuts.

A purulent process from the buccal region can spread to the zygomatic and parotid-masticatory regions, infratemporal fossa, pterygo-mandibular space.

Abscess of the infratemporal fossa, phlegmon of the infratemporal and pterygo-palatine fossa. The cause of inflammatory processes in the infratemporal and pterygo-palatine fossa is the upper wisdom tooth, less often the second or first upper large molar. The infection penetrates into the tissues adjacent to the tubercle of the upper jaw, and from here it can go into the infratemporal and pterygo-palatine fossa. Inflammation in the infratemporal fossa is possible with infection during tuberal anesthesia, in particular with improper technique of its implementation and injuries of the pterygoid venous plexus, as a result of which a hematoma and its suppuration occur. In addition, purulent diseases of the infratemporal and pterygo-palatine fossae develop as a result of the spread of the process from the pterygo-mandibular and periopharyngeal spaces. The close anatomical connection between cellular formations in the infratemporal and pterygo-palatine fossa often does not make it possible to accurately determine the localization of purulent inflammatory processes.

The infratemporal fossa is located at the base of the skull and the infratemporal ridge is delimited from the temporal region located above and outside of it. Its boundaries: upper - temporal surface big wing the sphenoid bone, the inner one is the lateral plate of the pterygoid process of the sphenoid bone and the posterior part of the buccal muscle, the anterior one is the tubercle of the upper jaw, the outer one is the branch of the lower jaw and bottom part temporal muscle. The infratemporal fossa is adjacent to the temporo-pterygoid space, which is bounded from the outside by the lower part of the temporal muscle and from the inside by the lateral pterygoid muscle. In these spaces are the pterygoid venous plexus, the maxillary artery and branches extending from it, and the mandibular nerve. Posteriorly and downward from the infratemporal fossa, there is an inter-pterygoid space, which is limited by the lateral and medial pterygoid muscles extending in this area. Above, the infratemporal fossa communicates with the temporal region, behind and outside - with the posterior maxillary region, below and outside - with the pterygo-mandibular and periopharyngeal spaces.

Inside of the infratemporal fossa there is a pterygo-palatine fossa communicating with it. Its boundaries are: anterior - infratemporal surface of the upper jaw body; posterior - the maxillary and orbital surface of the large wing of the sphenoid bone, the lower - the mouth of the pterygoid canal, the inner - the maxillary surface of the perpendicular plate of the palatine bone. The pterygo-palatine fossa is filled with cellulose, which contains the maxillary artery, the maxillary nerve, the pterygopalatine node of the maxillary nerve. Through the lower orbital fissure, it communicates with the orbit, through a round opening - with the cranial cavity, which causes the spread of infection through the venous system, including into the medullary cavity.

There are abscess of the infratemporal fossa, phlegmon of the infratemporal fossa and phlegmon of the infratemporal and pterygo-palatine fossa.

With an abscess of the infratemporal fossa, in most cases, the abscess is located in the tissue at the infratemporal surface of the upper jaw body and between the lateral and medial pterygoid muscles. Characterized by spontaneous pain, limitation of opening the mouth. With this localization, there are no external changes in the face configuration. Sometimes there is a slight inflammatory edema of the buccal region. As a result of the proximity of the pterygoid muscles, the opening of the mouth is limited, sometimes significantly. When examining the vestibule of the mouth (the cheek is somewhat pulled outward), edema and hyperemia of the mucous membrane of the upper fornix of the vestibule of the mouth are found at the level of the large molars. By palpation, it is possible to establish an infiltrate in the region of the upper fornix, and often in the area between the upper jaw and the middle edge of the branch of the lower jaw. However, often only pain in a limited area is determined here.

In patients with phlegmon of the infratemporal fossa, the pain increases (often when swallowing), radiating to the temple and eye.

On external examination, there is an inflammatory swelling in the lower part of the temporal and upper section hourglass-shaped parotid-masticatory region, as well as collateral edema in the infraorbital and buccal regions. The tissues are soft, painful, the skin folds into a fold with difficulty, its color is not changed. Inflammatory contracture of the masticatory muscles is significantly pronounced ( III degree). In the oral cavity, the same changes are noted as with an abscess, but sometimes only edema and hyperemia of the mucous membrane and soreness along the upper fornix of the vestibule of the mouth.

Phlegmon, developing in the infratemporal and pterygoid-palatine fossa, is characterized by significant headache, pain in the upper jaw, radiating to the eye and temple. There is a swelling in the buccal, lower temporal, upper parotid-masticatory regions, extending to the eyelids. With phlegmon of the infratemporal and pterygo-palatine fossae, the condition of patients is severe or moderate, body temperature rises to 40 0C, chills occur. On palpation of the swollen tissues, infiltration and soreness are noted in the lower part of the temporal region, sometimes soreness when pressing on the eyeball on the side of the inflammatory process. The opening of the mouth is limited. The mucous membrane of the upper fornix of the vestibule of the mouth is hyperemic and edematous; palpation in the depths of the tissues reveals a painful infiltrate extending to the anterior edge of the coronoid process. In some patients, the initial manifestations of phlegmon of the infratemporal and pterygo-palatine fossa may go unnoticed. It is possible to suspect a lesion of the infratemporal and pterygo-palatine fossa with an increasing deterioration in the general condition of the patient, an increase in edema and the appearance of an infiltrate in the lower temporal region, edema of the eyelids of the eye on the affected side.

Surgical intervention for the abscess of the infratemporal fossa is performed from the side of the upper fornix of the vestibule of the mouth, corresponding to the molars, making an incision 2-3 cm long.After cutting the mucous membrane in a blunt way, using a grooved probe or a curved hemostat, pass up and inward, thus bypassing the tubercle of the upper jaw , and open the abscess.

The phlegmon of the infratemporal fossa is sometimes opened with the same incision with the separation of tissues, including bundles of the external pterygoid muscle, and bluntly reach the lateral plate of the pterygoid process of the sphenoid bone. In other cases, the operative access may depend on concomitant purulent lesions of the cellular spaces adjacent to the infratemporal and pterygo-palatine fossa. In case of damage to the temporal region, an incision is made through the skin, corresponding to the anterior edge of the temporal muscle. The skin and subcutaneous fatty tissue, the temporal fascia are dissected, the fibers of the temporal muscle are moved apart, and they penetrate to the scaly part temporal bone and, bending around the infratemporal crest with a curved instrument, enter the infratemporal fossa. V.P. Ipolitov and A.T. Tokstunov A991) consider it expedient to combine such an operative approach with an intraoral incision along the upper-posterior fornix of the vestibule of the oral cavity. When an incision is made along the zygomatic arch, its section is resected and the coronoid process of the lower jaw is crossed, then bluntly passes into the infratemporal fossa. The phlegmon of the infratemporal and pterygoid-palatine fossa can be opened with an external incision made in the submandibular region. Separating the attachment of the medial pterygoid muscle from the pterygoid tuberosity of the branch of the lower jaw, they bluntly penetrate upward and forward and, pushing the tissues between the tubercle of the upper jaw and the branch of the lower jaw, open the abscess.

Often, the results of surgery (obtaining an inflammatory exudate, areas of necrotic tissue from the infratemporal and pterygo-palatine fossae) are the basis for the final topical diagnosis of phlegmon.

From the infratemporal and pterygo-palatine fossa, a purulent inflammatory process can spread to the temporal, parotid-masticatory regions, the pterygo-mandibular and periopharyngeal spaces. Cellulitis of the infratemporal and pterygo-palatine fossa can also be complicated by the spread of infection to the tissue of the orbit, facial veins and thrombosis of the sinuses of the dura mater.

Cellulitis of the temporal region. The inflammatory process in the temporal region occurs a second time. The complaints of patients about the usual pains and pains of a general nature associated with intoxication are increasing. A swelling appears above the zygomatic arch, involving the temporal fossa. Collateral edema extends to the parietal and frontal regions. It is often possible to observe swelling of the zygomatic region, the upper and less often the lower eyelid. With purulent processes developing under the temporal muscle or between the bundles of this muscle, the restriction of opening the mouth increases, a dense, painful infiltrate is palpated, usually spreading from the lower or anterior parts of the temporal region upwards. The skin above it is soldered to the underlying tissues, does not fold into a fold, but it is not always changed in color. A site of significant pain is determined, fluctuation occurs later. Superficial fusion of tissues is characterized by an increase in edema of adjacent areas, cohesion and bright red color of the skin, and the appearance of fluctuations.

With abscesses and phlegmon of the temporal region, first of all, surgical interventions are performed to ensure a free outflow of pus from the foci in the cellular spaces of the head and neck. Phlegmon of the temporal region with the focus of inflammation in the subgaleal space is opened from the side of the skin of the temporal region with a radial incision parallel to the course of the branches of the superficial temporal arteries and veins, ligating them. If necessary, you can make a vertical cut [Fedyaev IM, 1990]. The temporal aponeurosis is dissected and bluntly penetrate into space. Sometimes several fan-shaped incisions are made, placing them parallel to the course of the arterial trunks. With a deep accumulation of exudate in the interaponeurotic space, a wide arcuate incision is made along the edge of the temporal muscle, the aponeurosis and the edge of the temporal muscle are dissected and bluntly penetrate under the temporal muscle. This operative approach can be combined with an incision over the zygomatic arch.

Phlegmon of the temporal region, especially with damage to the tissue deeply located under the muscle, can be complicated by secondary cortical osteomyelitis of the scaly part of the temporal bone, as well as the penetration of infection into meninges and the brain (meningitis, meningoencephalitis, brain abscess), which makes the prognosis for such complications life-threatening.

Abscess and phlegmon of the zygomatic region (zygomatic space). These processes develop a second time with the spread of purulent exudate from the adjacent areas of the face - infraorbital and buccal.

The boundaries of the zygomatic region correspond to the location of the zygomatic bone: the upper one is the antero-lower part of the temporal region and the lower edge of the orbit, the lower one is the anteroposterior part of the buccal region, the anterior one is the zygomatic-maxillary suture, the posterior one is the zygomatic suture. Between the zygomatic bone and the superficial layer of the temporal fascia is the cellular space of the zygomatic region. It continues the interaponeurotic cellular space of the temporal region. More often phlegmon are observed here, less often abscesses.

Patients with an abscess complain of moderate pain in the affected area. The limited inflammatory infiltrate that appears in the zygomatic region softens rather quickly. The skin above it is soldered to the underlying tissues, acquires a bright red color.

Patients with phlegmon are disturbed by spontaneous pain in the zygomatic region, radiating to the infraorbital and temporal regions. They enhance painassociated with primary purulent foci in neighboring areas. Inflammatory edema is pronounced significantly, spreads to the infraorbital, temporal, buccal and parotid-chewing regions. On palpation, according to the location of the zygomatic bone, a dense infiltrate of varying length is determined. The opening of the mouth is somewhat limited as a result of the involvement of the upper part of the masseter muscle in the inflammatory process. Often, when opening the mouth, the soreness increases. On the eve of the mouth, along the upper arch at the level of the large molars, an edematous and hyperemic mucous membrane is found. Gradually, the infiltrate softens, thinning of soft tissues sets in, purulent exudate comes out under the skin or can spread to the outer corner of the palpebral fissure, where spontaneous opening of the purulent focus occurs.

Surgical intervention for abscesses and phlegmon of the zygomatic region is performed in the place of the most pronounced fluctuation, making a skin incision parallel to the course of the branches of the facial nerve. A purulent process from the zygomatic region can spread to the parotid-chewing area. With a prolonged course of abscesses and phlegmon, secondary cortical osteomyelitis develops.

Abscess and phlegmon of the orbit. A purulent inflammatory process develops in the tissue of the orbit with the spread of odontogenic purulent diseases from the areas adjacent to the upper or, less often, the lower jaw. With phlegmon of the infraorbital region and infratemporal, pterygo-palatine fossa, less often with acute osteomyelitis of the upper jaw, acute inflammation of the maxillary sinus, the transition of the purulent process into the orbit is observed. The inflammatory process in the orbit can also occur as a result of purulent thrombophlebitis, spreading from the infraorbital region along the angular vein, from the areas adjacent to the lower jaw, through the pterygoid venous plexus and optic veins.

The borders of the orbit correspond to its walls. Fiber is evenly distributed in a circle eyeball... The orbital septum in the form of a dense fascia divides the orbital region into the superficial region, or eyelid region, and the deep region - the orbital region itself. The latter contains the eyeball, optic nerve, orbital artery. In the distal part of the orbit there is the greatest accumulation of tissue, communicating through the lower orbital fissure with the fiber of the pterygo-palatine and infratemporal fossa, through the maxillary - with the middle cranial fossa, through the upper wall of the orbit - with the anterior cranial fossa and frontal airway sinus, through the lower - with the sphenoid sinus and cells of the ethmoid labyrinth.

An abscess in the orbit is accompanied by increased pain of a pulsating nature in the area of \u200b\u200bthe eyeball, headache and complaints associated with visual impairment. Inflammatory swelling appears in the eyelids. Skin color may not be changed; sometimes the skin of the eyelids is bluish in color due to congestion. Palpation of the eyelids is painless, they are not infiltrated, soft. The mucous membrane of the conjunctiva is hyperemic, edematous, often bluish in color. The pressure on the eyeball is painful, exophthalmos, visual impairment (appearance of "flies", double vision) are noted.

Complaints with phlegmon of the orbit are intense. There are pulsating pains in the orbital region with irradiation to the temple, forehead, infraorbital region, a sharp headache. The mobility of the eyeball is limited, often in one direction. Inflammatory phenomena increase, the infiltration of the eyelids intensifies, the conjunctiva swells and bulges between the half-closed eyelids (chemosis), diplopia appears, and subsequently the decrease in vision progresses. Examination of the fundus reveals expansion of retinal venules, severe visual impairment.

The development of thrombosis of the cavernous sinus of the dura mater is characterized by an increase in collateral edema of the eyelids, the development of these phenomena in the area of \u200b\u200bthe eyelids of the other orbit, a deterioration in the general condition and an increase in signs of intoxication.

When inflammatory diseases in the orbit area immediately produce surgery... A purulent focus in the upper part of the orbit is opened with a 2 cm long incision in the skin and subcutaneous fatty tissue in the upper external or upper internal edge of the orbit. Bluntly pass along the bone wall until the accumulation of exudate. With the localization of a purulent process in the lower part of the orbit, the skin and subcutaneous fatty tissue are similarly dissected along the lower outer or

the lower inner edge of the orbit, retreating downward from it by 0.7 cm. After dissection of the orbital septum along the lower wall of the orbit in a blunt way, fiber is stratified and the abscess is emptied.

A prompt approach is possible through maxillary sinus by trepanation of the lower wall of the orbit. This access makes it possible to penetrate into the lower, lateral and distal parts of the orbit and is advisable in case of primary damage to the maxillary sinus. With diffuse lesion of the orbit, the abscess is opened prompt access at the top and bottom walls orbital sockets, and sometimes two external incisions are also made by approaching through the maxillary sinus, creating the best outflow of exudate (Fig. 9.1, b). Some authors recommend that in cases of complications with panophthalmitis, exenteration of the orbit (removal of the contents). This allows you to ensure a good outflow of purulent exudate and prevent the development of purulent meningitis.

Phlegmon of the orbit may be complicated by further spread of infection to the meninges, sinuses of the dura mater, and the brain. Frequent complications are atrophy optic nerve and blindness.
Abscesses and phlegmon of the tissues adjacent to the lower jaw
Abscess and phlegmon of the submandibular region (submandibular space). Odontogenic inflammatory processes in the submandibular region occur more often than in other parts of the maxillofacial region. They develop as a result of inflammatory processes spreading from the lower small and large molars, less often from the pterygo-mandibular space, the sublingual region, including the maxillofacial groove, and the submental triangle. Possible lymphogenous pathway for the spread of infection and damage to the lymph nodes of the submandibular triangle with the subsequent involvement of fiber in the inflammatory process.

The boundaries of the submandibular region (submandibular triangle, submandibular space): upper-inner - maxillary-hyoid muscle, a leaf of the own fascia of the neck, postero-lower - the posterior abdomen of the digastric muscle and the superficial leaf of the own fascia of the neck, outer - the inner surface of the body of the lower jaw - anterior , superficial layer of the own fascia of the neck.

In the submandibular triangle, the submandibular salivary gland, lymph nodes are localized, the facial artery and vein, the regional and cervical branches of the facial nerve, the hypoglossal nerve, the lingual vein and the nerve pass. It contains a significant amount of loose fiber; in anterior section there is much more of it than in the back [Gusev EP, 1969]. Fiber is located in three successive layers: between the skin and the subcutaneous muscle of the neck, between this muscle and the leaf of the superficial fascia of the neck and above the superficial leaf of the own fascia of the neck; even deeper is the submandibular tissue space itself, in which the salivary gland is localized. Its size varies depending on the shape of the lower jaw. If the lower jaw is high and wide, then the transverse size of the gland is maximal, and the longitudinal one is minimal. On the contrary, with a narrow and long lower jaw, the gland has the greatest length and the smallest width. Accordingly, the adjacent fiber is located. At the bottom of the triangle there are three sagittal slits: median, medial and lateral, which allows communication with the sublingual, parapharyngeal spaces and tissue of the face [Smirnov VG, 1990]. In the distal region, on the surface of the hyoid-lingual muscle, there is a Pirogov triangle. Accordingly, the purulent process can develop superficially in the subcutaneous fatty tissue, the middle space under the subcutaneous muscle of the neck and deep tissues - the submandibular tissue space itself.

To spread infection from teeth to soft tissue, adjacent to the lower jaw, have the meaning of communication between the submandibular triangle and other cellular spaces. So, behind the posterior edge of the maxillofacial muscle is the submandibular duct. Through the tissue surrounding it, the infection penetrates the hyoid region. In this way, inflammatory processes from the sublingual region spread to the submandibular triangle. The posterior regions of the region communicate with the pterygo-mandibular and anterior regions of the periopharyngeal space. The subcutaneous fatty tissue of the submandibular region is intimately associated with the tissue of the submental triangle.

Distinguish between abscesses of the anterior and posterior parts of the submandibular region, phlegmon of this area [Vasiliev GA, Robustova TG, 1981]. With an abscess, patients complain of spontaneous aching pains.

An external examination reveals a limited infiltration in the anterior or posterior part of the submandibular triangle, anterior or posterior to the submandibular salivary gland. On palpation, the infiltrate is dense, the skin above it is fused with the underlying tissues, changed in color (from bright pink to red), and thinned. In its center, a fluctuation site can be noted, especially with tissue damage in the anterior part of the submandibular triangle. Opening the mouth is free. There are no changes in the oral cavity.

Cellulitis of the submandibular triangle are accompanied by more intense pain. Characterized by diffuse swelling, which, within 2-3 days from the onset of the disease, spreads to the tissues of the submandibular triangle and the adjacent submental and posterior regions. The skin over the swelling is infiltrated, does not fold, sometimes reddens. A dense painful infiltrate is palpable in the center. Edema is noted in the buccal and parotid-masticatory areas. Opening the mouth is often not limited. If the process spreads to the submandibular triangle from the maxillofacial groove, mouth opening may be limited due to infiltration of the internal pterygoid muscle at its attachment point at the inner corner of the mandible (grade I inflammatory contracture). In cases of deep location of the abscess and its spread into the sublingual region and the pterygo-mandibular space, the lowering of the lower jaw is significantly limited and pain appears when swallowing.

In the actual oral cavity with phlegmon of the submandibular triangle, a slight edema and hyperemia of the mucous membrane of the sublingual fold on the corresponding side can be found on the affected side.

Surgical intervention consists in making an incision from the side of the skin in the submandibular triangle, 2 cm below the edge of the lower jaw in order to avoid injury to the marginal branch of the facial nerve and parallel to it. With an abscess in the place of greatest fluctuation, an incision is made 1.5-2 cm long, pushing the tissue apart with a pean. In case of phlegmon, the incision should be 5-7 cm long. In case of phlegmon, the skin, subcutaneous tissue, subcutaneous muscle of the neck, superficial and own fascia of the neck are dissected layer by layer; submandibular salivary gland, penetrate into all parts of the affected area, especially behind and above the gland. By exfoliating tissues, the facial artery and vein are found, and they are ligated. Pus is evacuated, necrotomy and antiseptic and antibacterial wound treatment, as well as its drainage.

Phlegmon of the submandibular triangle can be complicated by the spread of infection in the pterygo-mandibular and periopharyngeal spaces, the sublingual region, the submental triangle and other areas of the neck, including the neurovascular vagina. Particularly dangerous are the involvement of the deep parts of the neck and the descending spread of the infection into the anterior mediastinum, which can pose a threat to the patient's life.

Every day to the branches maxillofacial surgery city \u200b\u200bhospitals are hospitalized at least one person in serious condition with a diagnosis of phlegmon of the maxillofacial region. Is this disease dangerous to health and what precedes its development?

Periomandibular phlegmon is an acute, purulent, diffuse inflammation of the subcutaneous fat in the neck, floor of the mouth, jaws and face, caused by the penetration of pathogenic microflora from the affected areas. Most often it develops as a complication of diseases of the oral cavity: either, or in case of infection with injuries or ENT diseases.

The disease develops under the influence of a number of microorganisms, which, entering the tissues, cause the development of a pathological process:

Most often, the flora is mixed, with a predominance of anaerobic microorganisms that do not need oxygen. If microorganisms enter through the tissues of the teeth, then the pathological process is called odontogenic.

The structural features of the lymphatic and circulatory systems predispose to the development of purulent diseases of the subcutaneous fat. In case of availability allergic diseasessuch as hay fever, eczema and atopic dermatitis, the likelihood of developing phlegmon increases.

There are 5 main sources of infection that cause the development of phlegmon of the pterygo-jaw space:

• and affected roots;
• inflamed periodontal tissues;
• inflammatory processes of the oral cavity:,;
• inflammation of the ENT organs.

The pathogenesis of this disease is due to the ingress of a virulent microorganism that releases toxins and causes the development of inflammation with characteristic signs: redness, pain, swelling, fever, dysfunction of the jaw joint.

There is a delay in the formation of soft tissues, limited by the neutrophilic shaft, and massive death of leukocytes with the onset of purulent inflammation.

Clinical features and symptoms

The disease begins quickly with a short period of precursors. Initially, patients note the presence of headache, increased fatigue, weakness.

With phlegmon of the maxillofacial region, the pathological process is unlimited from healthy tissues, which becomes the cause of the development of intoxication of the body. Intoxication syndrome is characterized by fever up to 38.5-40 C, headache, nausea, vomiting.

Subsequently, a dense diffuse edema forms, accompanied by sharp unbearable pain. In the place of inflammation, a sharp asymmetry of the face is formed, depending on the localization of the pathological process, the breathing process is difficult with the formation of shortness of breath.

The skin over the inflamed area is hyperemic with characteristic symptom fluctuations: when you press on the site of inflammation, fluid fluctuations are felt. Saliva production increases during food intake.

Modern classification

Currently, the most modern is the topographic - anatomical classification, taking into account that the maxillofacial phlegmon can be localized:

• in the upper jaw;
• on the lower jaw;
• in the area of \u200b\u200bthe bottom of the mouth;
• on the soft tissues of the tongue and neck.

Due to the occurrence, odontogenic (dental provoking factor) and non-odontogenic phlegmon are distinguished.

According to the severity of the condition, patients are divided into 3 groups:

• easy severity - the pathological process is within the same anatomical region;
• average severity - pathology is localized in several anatomical areas;
• heavy severity - the process captures the entire maxillofacial region and neck.

Maxillary region

Cellulitis of the upper jaw is the most dangerous for the health and life of a sick person, inflammation of the infraorbital region and the orbit of the eye is especially dangerous. This is due to the anatomical location blood vessels and the possibility of introducing infection with further development inflammation in the cavernous sinuses and meninges.

All this leads to the progression of pathology and the development of meningitis and thrombosis of the cavernous sinus of the brain. The disease usually begins with swelling of the upper lip, which subsequently spreads to the upper jaw.

The nasolabial fold above the lip is smoothed out. The skin of the infraorbital region is sharply hyperemic; when trying to fold it into a fold, a sharp soreness appears. Opening of the mouth is not disturbed, during the tapping of the tooth, which caused the pathological process, moderate pain appears, the folds of the oral cavity are smoothed.

Treatment of maxillary phlegmon is carried out only by surgical intervention by opening the focus and conducting active drainage with the application of Vishnevsky ointment.

Zygomatic region and eye sockets

The cause of the development of phlegmon of the zygomatic region is also the carious teeth of the upper jaw. Also, it is not excluded that an infection gets in with suppuration of hematomas, an insect bite, the development of boils.

Symptoms do not differ from phlegmon of other localization: swelling of the cheekbones appears with possible spread to the orbit area, the skin turns red, soreness develops, mouth opening is not disturbed.

Purulent inflammation located in the orbit most often develops as an exacerbation chronic sinusitis... In the course of the process, one of the most severe pathologies. It is characterized by severe intoxication, headache, high temperature... It is accompanied by intense pain in the orbit area.

There is a pronounced edema and bluish color of the eyelids. In the case of involvement of the optic nerve, various visual impairments are possible:

The main method of treatment is surgical dissection in order to penetrate the inflammatory focus, active drainage is performed using a PVC tube and washed with antiseptic solutions in order to prevent the multiplication of microorganisms and remove purulent exudate from the focus.

Localization in the pterygo-palatine fossa

When located in the pterygo-palatine fossa, the main source of the disease is the carious teeth of the upper jaw, in particular the second and third molars. The course is extremely difficult:

1. Painful sensations are pronounced. Most often, irradiation occurs in the temporal, parietal, infraorbital regions.
2. The temperature rises to 39C, a severe headache appears. Lack of treatment is detrimental to general state the patient.
3. There is edema of the temporal, zygomatic and infraorbital regions.
4. Opening the mouth and chewing food is difficult.

Treatment is only surgical, the patient is admitted to the Department of Maxillofacial Surgery. The operation is performed urgently in order to prevent the development of complications. Active drainage of the inflammatory focus and rinsing with antiseptic solutions are mandatory.

Buccal region

Phlegmon of the soft tissues of the cheek according to the anatomical location is:

• superficial;
• deep.

The reason, as in all cases described above, is carious processes in the molars and premolars of the upper and lower jaw. Symptoms characteristic of this pathology:

• throbbing pain that tends to get worse when opening the mouth;
• swelling of the cheek, a pronounced symptom of fluctuation;
• the skin of the inflamed focus is hyperemic and tense;
• opening the mouth is difficult.

Treatment is only surgical with active drainage of the focus and rinsing with antiseptic solutions at least 3 times a day.

Cellulitis of the lower jaws

Among all the anatomical regions, the most dangerous are phlegmon developing in the submandibular (see photo below), pterygo-mandibular and periopharyngeal space, leading to the development of serious complications: asphyxia, phlegmon of the neck.

The main source of such purulent inflammation is carious damage to the mandibular wisdom teeth. Most often, the pathological process develops in persons with weakened immunity after 25 years.

Patients complain of swelling of the lower jaw. There is no opportunity to make any movement with the jaw. The main complaints are pain when moving, eating, talking and swallowing. The skin in this place is reddened.

Treatment is carried out by wide opening of the lesion by means of an incision up to 6 cm. The skin and all subsequent layers are dissected in layers. Next, drainage is installed, most often it is a vinyl chloride tube, followed by rinsing with antiseptics.

Lesion of the floor of the mouth

The bottom of the oral cavity is much less likely to become the site of the development of purulent inflammation of the subcutaneous fat. The most common reason for the development of phlegmon of this localization is carious teeth and other inflammations of the oral cavity, such as.

The clinical manifestations are very diverse. A feature is the close location of the larynx, as a result of which mechanical suffocation may develop due to the development of edema. Therefore, the person is in sitting position with the head bent forward.

Patient status medium severity or severe due to the following signs:

• temperature increase;
• swelling of the chin and lower jaw;
• tongue covered;

The treatment is exclusively surgical and has no peculiarities.

Neck area

Phlegmon of the neck develops as a complication of most dental diseases. A sedentary infiltrate is determined.

The patient complains of weakness, a strong increase in temperature, hoarseness of the voice, shortness of breath appears. With the localization of phlegmon in the esophagus, difficulties in eating are possible.

Treatment is only surgical, with numerous incisions on the surface of the neck and the installation of many drains. It is necessary to constantly wash the focus at least 4 times a day.

Prevention consists in premature treatment and. The visit to the dentist should be at least once a year.

At the first symptoms of the disease, you should immediately contact a maxillofacial surgeon for timely treatment.

Phlegmon of the maxillofacial area in dentistry is called an acute inflammatory process of a purulent nature, which spreads to soft tissues, affecting vessels and organs on its way. The main reason for the development of pathology is diseases of the teeth and gums of an acute or chronic nature. A purulent abscess in the face, jaw or neck area is very dangerous and requires immediate surgical intervention.

Causes

The impetus to the beginning of the development of the pathological process is the activation of pathogenic bacteria, which, when they enter the tissues, cause their inflammation. Most often, the appearance of acute diffuse inflammation of adipose tissue is provoked by:

1. staphyllcocci;
2. streptococci;
3. pseudomonas aeruginosa;
4. dental spirochete;
5. escherichia coli.

In most cases, the flora is mixed, it is dominated by anaerobic microorganismsthat do not need oxygen. If pathogenic bacteria penetrate the tissues of the teeth, phlegmon is called odontogenic.

Due to the structural features of the lymphatic and circulatory systems subcutaneous fat is especially susceptible to the development of inflammatory processes. The presence of allergic diseases increases the risk of developing maxillofacial abscesses.

Symptoms

Dentists differentiate phlegmon by topographic and anatomical criteria. Based on this, infectious infiltrates are conditionally divided into two main types:

• localized in the upper jaw;
• located next to the lower jaw.

Also, phlegmon of the maxillofacial region can develop in the upper and lower parts of the oral cavity, in the region of the tongue and neck. Most often clinical manifestations diseases arise from the presence of a diseased tooth, less often the lymph nodes are the source of infection.

The rapid course of the disease leads to a rapid rise in temperature, pulsation is felt at the site of inflammation. The patient has headaches, chills appear, the skin turns pale. The general well-being of the patient is rapidly deteriorating.

With a shallow localization of the inflammatory infiltrate, the face becomes asymmetric. Due to swelling, the skin in the area of \u200b\u200binflammation is stretched, a characteristic shine appears. If suppuration occurs near the pharyngeal region, problems arise with food intake, it becomes difficult for a person to swallow saliva and it is difficult to breathe.

For phlegmon, the following symptoms are characteristic:

• swelling and limitation of the mobility of the tongue, the accumulation of a gray or brown plaque on it;
• disruption of the speech and chewing apparatus;
• difficulty breathing, increased salivation;
• intoxication of the body caused by the mass death of microorganisms with the release of toxins;
• cutting bad smell from the oral cavity, due to the activation of causative agents of putrefactive processes;
• spread of puffiness to nearby tissues;
• soreness to touch;
• increased body temperature.

Classification

In medicine, this disease is classified according to many characteristics. Phlegmon can be anaerobic, purulent, or putrid. Also, odontogenic infiltration is subdivided according to the type of pathogen that provoked inflammation of the hypodermis.

According to the mechanism of development, the disease can occur:

• independently, as a rule, inflammation is localized in the region of the upper and lower extremities;
• due to surgical complications;
• if the skin is damaged in certain areas of the body.

In addition, there is a topographic and anatomical classification, which indicates the area of \u200b\u200blocalization of phlegmon (neck, cheeks, eyelid, orbit, lacrimal sac). Fournier's gangrene sometimes develops.

According to the severity of the disease, it is divided into 3 groups:

• a state of mild severity (inflammation affects one anatomical region);
• a condition of moderate severity (the infection spreads to neighboring areas);
• a state of severe severity (the infectious and inflammatory process covers the entire maxillofacial region with the transition to the neck).

Phlegmon of the upper jaw: description and methods of treatment

A particular danger to human health is the inflammation of the hypodermis in the upper jaw. The proximity of large blood vessels increases the risk of infection of the cavernous sinuses and meninges.

The disease progresses rapidly, which often leads to such serious consequences as meningitis and thrombosis of the cavernous sinus of the dura mater of the brain. Initially, the disease is manifested by swelling of the upper lip, followed by the transition to the maxillary skull.

Due to swelling with phlegmon of the jaw, the nasolabial fold is smoothed out (look at the photo). The areas of the skin located below the infraorbital edge of the orbit are sharply hyperemic and painful. Touching a sore spot causes severe pain... In this case, the patient can open his mouth, this function is not impaired. When tapping on a problem tooth, moderate pain occurs. The folds of the oral mucosa are smoothed.

Such symptoms involve surgical intervention. The inflammatory focus of the maxillary phlegmon is opened, drainage is performed. The wound is treated with Vishnevsky ointment.

Cellulitis of the zygomatic regions

The impetus for the development of odontogenic abscess of the zygomatic region is the upper teeth affected by caries. Sometimes tissue infection occurs due to an insect bite, the formation of boils, and suppuration of hematomas. The symptoms of this disease are similar to other phlegmons of the maxillofacial region.

The patient's cheekbone swells with the subsequent transition to the infraorbital region. Skin acquire a reddish tint, the inflamed area becomes painful. The patient is able to freely open and close the oral cavity.

A frequent complication of this pathology is purulent inflammation in the eye socket. The human body fights against severe intoxication, his body temperature rises, he suffers from headaches. The swollen eyelid becomes bluish.

If the inflammatory process affects the optic nerve, then the person exhibits the following symptoms:

• diplopia;
• reduced visual acuity;
• the outer mucous membranes of the eye swell;
• the eye protrudes from the side of the lesion;
• a compressed nerve leads to a loss of the ability to see.

Pathology is treated exclusively surgically... The doctor gets to the site of inflammation by opening the tissue abscess. Then active drainage is carried out. The infected areas are washed with antiseptic solutions.

The defeat of the pterygo-palatine fossa

Phlegmon of the pterygo-palatine and infratemporal fossa can develop in the head of the lower jaw or in the region of the medial pterygoid muscle. A common reason the development of pathology becomes infected wisdom teeth. Sometimes inflammation occurs after removal of the 7th and 8th molars, when a hematoma occurs due to incorrect administration of anesthesia.

When an infectious infiltrate appears, the patient experiences stiffness of movements when opening the mouth. It hurts him to swallow. Lips and chin partially lose sensitivity; the mucous membranes of the oral cavity turn red and swell, become painful.

Phlegmon is treated surgically. The doctor makes an incision in the oral mucosa and, with the help of additional instruments, opens access to the infratemporal and pterygo-palatine fossa. After removing the pus, the wound is drained.

Cheeks

A buccal abscess can be superficial or deep. The most common cause of inflammation is the teeth of the upper and lower jaw, damaged by caries.

With this disease, a person has a throbbing pain in the inflamed area; pain sensations increase when opening the mouth. The cheek swells due to the accumulation of fluid in the pathological focus. The skin is hyperemic and tense; the patient has difficulty opening his mouth.

It is possible to remove inflammation and remove pus only by surgery. After surgery, the wound is drained. Washing with antiseptics is carried out 3 times a day or more often.

Cellulitis of the lower jaws

Odontogenic phlegmon of the submandibular region often leads to serious consequences. Often, the inflammation spreads to the tissues of the neck, which often causes asthma attacks in patients.

Pathology is again caused by untreated mandibular molars. According to statistics, a mandibular abscess is more common in people over the age of 25. As a rule, such patients have reduced immunity.

The disease begins with the appearance of swelling of the gums and tissues in the mandibular region, and develops rapidly. A person is not able to open his mouth wide and cannot move his jaw. Eating, swallowing liquids and making sounds are accompanied by excruciating pain. The skin becomes crimson.

The treatment is carried out by a surgeon, he opens the purulent focus, making a 6 cm incision. Then drainage is placed, antiseptic treatment is carried out.

Floor of the mouth

The infection penetrates into soft tissues due to carious processes in the teeth, burns or wounds of the mucous membranes of the floor of the mouth. Phlegmon of the floor of the mouth leads to a general deterioration in the patient's health. He feels pain when swallowing and talking. In addition, breathing problems appear. Due to unbearable pain, a person is forced to take a sitting posture with the head tilted forward. The mucous membranes with phlegmon of the floor of the mouth are hyperemic, the tongue is covered with a characteristic coating, an unpleasant odor appears from the mouth. Due to tissue edema, the tongue rises, speech becomes slurred.

Body temperature with phlegmon of the oral cavity can rise above 40 degrees. In blood tests, a sharp rise in the number of leukocytes is noted.

In the absence of proper treatment, the infection can spread to the submandibular, parotid-chewing and buccal regions, and can also affect the periopharyngeal space and mediastinum. Often this pathology leads to the development of sepsis.

Phlegmon of the oral cavity requires an integrated approach to treatment. Measures are being taken to reduce the virulence of the infectious focus and the regulation of immunological reactions. The surgeon removes the causative tooth, carries out drainage and antiseptic treatment of the infected tissues of the floor of the mouth.

Neck

Cervical abscesses are characterized by an unpredictable course. The disease often leads to serious, life-threatening complications. Pathology develops against the background of pharyngitis, laryngitis, chronic caries, etc.

Superficial phlegmon (see photo) do not pose a particular danger and are easy to treat. Most often, the infectious infiltrate is localized in the chin and submandibular region.

The infectious and inflammatory process leads to intoxication of the body: a rise in body temperature, headaches, weakness and malaise. Blood tests indicate increased content leukocytes.

In case of untimely treatment of phlegmons of the maxillofacial region, the infection can spread to other tissues: large facial veins, meninges, etc. Treatment is exclusively operative.