Surgical incisions drainage of purulent foci in the neck. Surgical treatment of abscesses and phlegmon of the neck

METHODS OF OPENING OF PHLEGMONS AND ABSCESSES IN THE MAXILLOFACIAL REGION AND ON THE NECK

Surgical intervention for abscesses and phlegmon emanating from the teeth upper jaw (with subperiosteal abscesses, abscesses of the canine fossa, abscesses and phlegmon of the infraorbital region, jaw tubercle), is limited in most cases by an intraoral incision along the transitional fold to the bone within 3-4-5 teeth. If pus is not detected with a sufficiently wide incision to the bone, you should bluntly penetrate higher - to the bottom of the canine (dog) fossa or into the space between the bundles of the square muscle. If such an intervention during the progression of the process is insufficient, an extraoral incision has to be used. In this case, guided by palpation, the abscesses are usually opened with a horizontal skin incision on the face in the place of the greatest accumulation of pus, of course, taking into account the location of the vessels and nerves in this area, and the subsequent drainage of the wound (Fig. 20).

Cellulitis of the zygomatic region are most often opened with a horizontal skin incision at the lower edge zygomatic bone or an arc in the place of the most pronounced fluctuation.

As for the question of opening abscesses and phlegmon of the buccal region, intraoral incisions achieve their goal (evacuation of pus) only when the purulent focus is located between the buccal mucosa and the buccal muscle. Otherwise, it is necessary to operate through the skin in the place of fluctuation or in the area of \u200b\u200bthe most pronounced area of \u200b\u200bpainful infiltration, however, remembering that with any operations on the face, the anatomical features of this area should be taken into account. When the phlegmon is located in the lower part of the buccal region, an opening can be done through an incision in the submandibular region.

During surgical interventions for phlegmon of the temporal region, you should always be guided by the data topographic anatomy this area and determine where the process is localized - superficially (between the skin and the aponeurosis) or between the aponeurosis and the muscle, or between the muscle and the bone. With spilled phlegmons, all parts of this area are involved in the process. In many cases, with phlegmon of the high region good results gives an incision behind the edge of the processus frontosp-henoidalis in the region of the anterior edge of the temporal muscle, under which the upper end of Bish's fat lump is located. In some cases, an incision along the linea temporalis at the border of the attachment of the temporal muscle and its aponeurosis is effective. There are times when you have to make several cuts in this area (Fig. 21).

With certain incision lines, you should always spare the branches of the temporal artery. With deep abscesses, it is better to open the focus vertically or with an incision corresponding to the fan-shaped course of the temporal muscle fibers, and then bluntly penetrate to the scales of this bone with further drainage of the wound.

It is more convenient to open periorbital and orbital phlegmon with a slightly arcuate incision up to 2-2.5 cm long in the region of the lower outer edge of the orbit or in the place where the infiltration is most pronounced. Departing from top to bottom from the edge by 1-1.5 cm, so that the surgical scar does not subsequently twist the eyelids and does not limit their closure, cut through the skin, subcutaneous base, fascia; bluntly penetrate into the orbital tissue behind the inferolateral surface eyeball, after which the wound is washed and drained.

With retrobulbar phlegmon, if other methods of surgery are unsuccessful, it is necessary to create conditions for a good outflow of pus through the perforation in the bottom of the orbit. For this purpose, the maxillary cavity is opened and through it a section of a thin bone plate is removed in the region of the posterior edge of the bottom of the orbit, the periosteum is dissected, after which pus flows from the orbit into the maxillary cavity. The latter is tamponed with iodoform gauze.

I must say that this method has disadvantages. The fact is that in some patients operated on by this method, subsequently there were fistulas that required plastic surgery... It seems to us that it is more convenient and better in such cases to create an anastomosis with the nasal cavity in the lower nasal passage during the operation and to remove the tampon through the nose.

Surgical interventions for phlegmon of the infratemporal and pterygopalatine fossa are reduced to the fact that incisions are made to the bone along the transitional fold in the region of the last two molars of the upper jaw, and in children - in the area of \u200b\u200bthe first large molar, focusing on the zygomatic-alveolar ridge. Then they bluntly penetrate deeply along the jawbone, heading posteriorly, upward and inward to the infratemporal fossa. In many cases, this creates conditions for the outflow of pus. Otherwise, it is necessary to operate extraorally; so, with limited localization of phlegmon in the infratemporal region, an incision is made along the lower edge of the zygomatic arch, and when it spreads from the infratemporal and pterygopalatine fossa to the adjacent areas - pterygo-jaw, buccal, masseteric - it is necessary to open such a diffuse phlegmon through the submandibular and post-vein incisions, not forgetting to use the sub-zygomatic incision.

Surgical interventions for phlegmon of the submandibular triangle are performed much more often than for other peri-maxillary phlegmon. A skin incision with these phlegmon is made parallel to the lower edge lower jaw, departing from the latter downward by 1.5-2 cm. Such an incision is convenient, since, merging topographically with the cervical fold, it leaves a barely noticeable, delicate scar after the wound has healed. In addition, with such an incision, the marginal branch of the facial nerve is relatively rarely damaged. It also has the advantage that, if necessary, it can be extended in one direction or another, it is good to examine the wound and, if the phlegmon spreads to the bottom of the oral cavity, then by crossing in the depth of the wound along the seam of the maxillary-hyoid muscle, you can create access to the bottom of the mouth. The length of the incision when opening the phlegmon of the submandibular triangle is on average 4-7 cm.After layer-by-layer dissection of the skin, subcutaneous base, under the skin muscle and fascia, one should bluntly use a finger (it is better to work with gloves) or a special instrument (Fig. 22) to carefully revise the wound in front and behind the area submandibular salivary gland.

It should be noted that in severe phlegmon, as a result of the presence of an infiltrate that captures a significant area of \u200b\u200btissues, the configuration of this area changes sharply. In this case, it is not possible to palpate the lower edge of the lower jaw, the skin is fused with the underlying tissues, and the tissues deep in the wound (fiber, fascia, muscles, blood vessels and nerves) are fused into a solid mass and it is difficult to distinguish them.

With large infiltrates, the guideline for choosing the direction of the incision is usually a line connecting a point on the border of the middle and upper third of the length of the sternocleidomastoid muscle with the upper edge of the thyroid cartilage.

What should be the length of the incision with such large phlegmon? Some authors justly wrote about this in their time, having in mind, of course, the incisions of infected foci in general: "The incision should be as large as necessary and as small as possible." When opening the phlegmon of the submandibular triangle, one should never forget about the possibility of injury to the vessels - the external jaw artery and the anterior facial vein, located in the path of this incision, if the inflammatory infiltrate prevented the lower edge of the lower jaw from being felt (in the area of \u200b\u200bthe bend of the facial artery) and it was not possible to correctly outline cut line. It is not always easy to stop the bleeding that occurs when they are injured in infiltrated tissues.

If, with phlegmon of the submandibular triangle, the process extends towards the submental region, the incision made to open the phlegmon of the submandibular triangle is lengthened anteriorly, capturing the corresponding half of the submental region, or a typical incision is made here as a counteropening.

With phlegmon, filling only the submental area, it is convenient to make a vertical incision, along the midline of this area; at the same time, the skin, subcutaneous base, superficial fascia are dissected. The cellulose is stupidly revised between the anterior abdomens of the digastric muscles. After that, the wound is drained. With such an incision, there is usually not much bleeding, since there are no large vessels in this area.

When opening abscesses and phlegmon of the parotid-masticatory region and the region of the masticatory muscle, an arcuate incision is made, bordering the corner of the lower jaw, starting behind the edge of the branch 1.5-2 cm above the angle and, going down around the corner, continue it parallel to the lower edge and below it ... The length of the incision is 5-6 cm. Layer-by-layer dissection of the skin, subcutaneous base and fascia, then the chewing muscle is cut off at the place of its attachment and, adhering to the outer surface of the branch, the muscle is exfoliated from the bone in a blunt way until an abscess is detected. Sometimes it is necessary to resort to vertical stratification of muscle fibers through this incision until the abscess is detected. Like other authors, we cannot agree with the recommendation of VF Voino-Yasenetsky to open such phlegmon with an external incision with "a complete transverse transection of this muscle at the level of the angle of the mouth." Such an incision can lead to permanent cicatricial changes in the masseter muscle and contracture of the lower jaw, in addition, it is unacceptable for cosmetic reasons.

We also use a similar incision, as when opening the phlegmons of the chewing area, when opening the phlegmon of the pterygo-maxillary space, with the only difference that after dissecting the soft tissues behind the angle of the lower jaw we go to the place of attachment of the internal pterygoid muscle.

If in this area there is still no tissue melting, the muscle fibers should be stratified, and then bluntly (you can just use your finger) to penetrate into the pterygo-maxillary space, making a revision along the way in the adjacent postero-maxillary fossa adjacent to the incision. This cut can also be used to penetrate upper section pterygoid-jaw space. At the same time, a finger inserted into the wound feels the inner plate of the lower jaw branch and usually easily penetrates upward, heading towards the fossa pterygoidea. The upper part of the pterygo-jaw space can also be penetrated through an incision on the cheek in the interval between the tubercle of the upper jaw and the coronoid process of the lower jaw, slightly displacing the fatty lump.

The intraoral pathway of opening the phlegmon of the pterygomandibular space (in which the incision is made along the plica pterigomandibularis, and after dissection of the mucous membrane and the submucosal layer, they stupidly move between the branch of the lower jaw and the median pterygoid muscle until the pterygoid space is opened) does not always lead to the goal, the exudation does not always provide a reliable exudate ...

The retromandibular and parapharyngeal spaces should be the subject of special attention of the surgeon. The technique of opening the phlegmon of these areas is as follows: with an arcuate incision in the skin fold along the posterior edge of the mandibular branch with a bend around its corner (Fig. 26), the skin, the subcutaneous base, the parotid-chewing fascia are cut and the posterior head of the digastric muscle and the attachment of the stylohyoid muscle are exposed.

The aponeurotic leaf located here, which connects both these muscles, is separated by bluntly and carefully inserted finger into the wound so as not to damage the parotid salivary gland; penetrate, adhering to the median pterygoid muscle, to the tissue of the parapharyngeal space. In this case, the patient usually feels the inserted finger in the pharyngeal region. The wound is drained as usual. VF Voino-Yasenetsky describes the opening of parapharyngeal phlegmon as follows: “Near the corner of the jaw, we make a slightly arcuate skin incision so that it occupies the entire interval from the corner to the point of bend of the external jaw artery across the edge of the jaw, quickly dissect the superficial fascia of the neck and , thus, we open the fascial bed of the submandibular salivary gland in its posterior part, that is, where there is a communication between the bed of the submandibular salivary gland behind the edge of the maxillary-hyoid muscle and bottom parapharyngeal space (the bottom of the mouth). Therefore, without any hindrance, we insert our finger far up, into the parapharyngeal space, empty the pus accumulated there and insert a drainage tube. "

Admittedly, this is a really easy way to access the parapharyngeal space. With this access, it is possible not to damage the vessels, since they are deep in the wound, where we manipulate our finger bluntly.

To open the phlegmon of the floor of the oral cavity, both intraoral and extraoral cuts are shown. Intraoral incisions are made only in cases where pus is localized directly under the mucous membrane of the sublingual space. In all other cases, such a phlegmon should be opened extraorally, through the submental area, in order to ensure a good outflow of pus. As in the case of phlegmon of the submental region, or if the phlegmon of the submental region is combined with the phlegmon of the floor of the oral cavity, a layer-by-layer vertical incision of the soft tissues is performed along the midline of the chin region from the lower edge of the lower jaw to the region of the hyoid bone. With submental phlegmon, access to the purulent focus ends there. In this case, after the front abdomens of the digastric muscles have been bluntly spread apart in both directions, the wound is washed and drained. With phlegmons of the bottom of the oral cavity, after the digestive muscles are pushed apart, the jaw-hypoglossal muscle is dissected in the center of the wound along the seam and bluntly penetrate into the area between the sublingual muscles going to the root of the tongue, creating conditions for the outflow of exudate. With diffuse intermuscular phlegmons of the bottom of the oral cavity in combination with phlegmons of adjacent areas, a so-called collar-shaped incision is shown, that is, an incision from one to another corner of the lower jaw.

If it is necessary to urgently operate on a patient suffering from hemorrhagic diathesis, we prefer to make three horizontal incisions: one in each submandibular region and in the subchin region.

Such incisions are necessary to widen the infected focus.

We would like to dwell on some surgical interventions in the field of language. So, for example, in case of abscesses of the tongue, after the place of its localization has been determined, a test puncture with a syringe with a thick needle, or even better with a narrow double-edged scalpel, should be done at the site of the greatest protrusion. Usually an abscess is found in this place in the thickness of the tongue. It is opened with a relatively wide incision. It should be noted that in some cases this can damage the lingual artery, which runs on the side of the tongue between the chin-lingual and hypoglossal muscles. Such bleeding is usually stopped by tamponade.

In case of phlegmon of the root of the tongue, the operation is performed extraorally according to the following technique: a midline incision from the chin to the region of the hyoid bone, or horizontal along the edge of the jaw (Fig. 29); the anterior abdomens of the digastric muscles are bluntly retracted in both directions.

The jaw-hypoglossal muscle is dissected in the center, after which the incision deepens towards the tongue and a blunt instrument is inserted towards its root to push apart the tissues of the tongue. The operation ends with drainage of the wound.

Finishing the essay on the surgical treatment of phlegmon and abscesses of the maxillofacial region, we would like to note that the proposal of some authors to treat phlegmon and abscesses by sucking purulent exudate from the focus and then injecting antibiotics into it is of great interest. Thus, V.A.Katilene reports that in 72.3% of patients treated by this method, it was possible to do without surgery. It should be noted that this method would be especially useful in facial surgery, where the cosmetic factor is so important.

An interesting method is also proposed by V.A.Lavrov, in which the phlegmon is opened with a small incision, after which the pus is immediately sucked out of the wound with a vacuum pump. The author points out that this method sharply reduces exudation, improves the movement of tissue fluid from the depth of the wound to its surface, which creates unfavorable conditions for the development and life of pathogenic microflora in the wound.Both of these methods are possibly promising, but require further study. In particular, it should be noted that after the publication of the aforementioned works, significant changes took place both in the nature of odontogenic infection and in the characteristics of the reactivity of modern patients.

Therefore, the further development of tempting "non-incision" and "dressing-free" methods for the treatment of phlegmon and abscesses, as well as methods for making small incisions, should be based on the use of even more advanced devices for evacuating pus from the peri-maxillary tissues. It is possible that the creation of two small counterpertures and the provision through them of effective round-the-clock rinsing (dialysis) of purulent cavities against the background of powerful (intensive) general detoxification and antimicrobial therapy is one of the ways to further improve surgical treatment peri-maxillary phlegmon. More details about wound drainage will be discussed below.

Phlegmon of the neck is one of the most dangerous diseases that, if not treated in time, can be fatal. This is a purulent inflammation of the soft tissues of the neck caused by pathogenic bacteria. With phlegmon, a diffuse accumulation of pus develops, which can expand.

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The reasons for the development of phlegmon

Diffuse inflammation of the neck tissues develops secondarily. First bacterial infection occurs in other organs.

Then, with the flow of blood and lymph, bacteria enter soft tissue neck. The reason is Staphylococcus aureus.

The development of phlegmon leads to:

• Diseases of the teeth of the lower jaw, in which there are foci of infection, these are caries, pulpitis, periodontitis, inflammatory diseases of the tissues surrounding the teeth.
• Infectious processes in the throat and trachea, tonsillitis, pharyngitis and laryngitis. The role is played by the chronic course of these diseases, they require frequent treatment antibiotics.

  The body develops resistance to a large number of bacteria, antibiotics are weak, the infection can spread to the neck.

• Inflammatory diseases of the lymph nodes of the neck, which, with an unfavorable course, can move to neighboring areas.
• Furuncles, wounds and scratches on the neck will cause superficial phlegmon.
• Common infectious diseases, measles, scarlet fever, diphtheria. The infection spreads to the neck with blood or lymph.
• The transition of purulent inflammation from the floor of the mouth.

Classification

Depending on the depth of development of the purulent process, the phlegmons of the neck are superficial and deep.

Superficial - located in the subcutaneous tissue, and deep under the muscular fascia of the neck.

Depending on the place of development, phlegmon are distinguished:

• Chin.
• Submandibular. Often occurs as a complication of infectious processes in the lower molars.
• Superficial, running along the front edge of the sternocleidomastoid muscle.
• Interfascial. Formed between the superficial and deep fascia of the neck.
• Superficial phlegmon of the anterior and lateral surface of the neck.
• Phlegmon of the anterior surface of the trachea.
• The posterior surface of the esophagus.
• Fossae of the sternum.
• The lateral cervical triangle, which is bounded by the sternocleidomastoid muscle, the trapezius muscle, and the clavicle.
• The front of the neck.

Phlegmons are:

• One-sided and two-sided;
• Front, side and back of the neck.

They are primary and secondary. The primary ones are those that develop on the neck. Secondary - occur when inflammation passes from other anatomical areas.

Phlegmon, which develops as a complication of diseases of the lower teeth, is called odontogenic.

Clinical manifestations of the disease

Almost always, the course of phlegmon of the neck region is moderate or severe.

Symptoms depend on the place of its localization:

1. Patients complain of neck pain. It can be pain localized on the front of the neck or somewhere deep in the neck, pain in the submandibular region.
2. The patient complains of pain when swallowing, eating and talking.
3. Due to the squeezing of the larynx by the purulent contents of the phlegmon and edema, breathing may be difficult.
4. Suffers general state sick. Often he sits with his head tilted forward.
5. The body temperature rises to 38-39.5 degrees Celsius.
6. Blood pressure may drop.
7. The speech is indistinct, the face lengthens, due to the large amount of purulent exudate.
8. If the phlegmon is superficial, there is reddening of the skin in this area, it cannot be taken into a fold.
9. With a deep location of suppuration, the skin may be of a normal color, fold into a fold, only look shiny.

Local edema is observed, the severity of which depends on the size and depth of the phlegmon. The more superficially it is located, the more pronounced and localized edema.

If the phlegmon is located deep, the edema looks diffuse, the neck is enlarged. When phlegmon is placed in front of the trachea or behind the esophagus, hoarseness of the voice is noted.

When palpating, phlegmon are dense, sharply painful infiltrates.

Video

Necessary investigations and diagnostics

Diagnosis of phlegmon includes a doctor's examination, and, if necessary, the appointment of laboratory and instrumental studies.

On examination, the doctor notes an increase in the patient's neck. With deep phlegmon, the general condition is severe.

The patient is pale, breathing heavily, low blood pressure, high temperature. The position is forced, with the head bent forward. On palpation (palpation) of the neck, there is a sharp soreness and the presence of a dense infiltrate, without fluctuation.

Puncture is the most reliable method for diagnosing phlegmon. Using a special syringe, the doctor aspirates the contents of the purulent focus. If the appearance of a yellowish-greenish fluid is observed, this is a reliable sign of purulent inflammation.

Puncture is impossible with deep placement of phlegmon, due to the possibility of damage to vital organs, blood vessels and nerves.

In the general analysis of blood, there is an acceleration of ESR up to 40-50 mm, an increase in the number of leukocytes. Since a blood test takes some time, in the serious condition of the patient, it is not prescribed.

Disease treatment methods

Treatment of phlegmon of the neck is carried out by a conservative and surgical method.

1. The conservative method is to use antibacterial drugs. Isolated, it is rarely used, with spilled purulent inflammation This is not enough.
2. The main method of treatment is surgical intervention, which is carried out under general anesthesia. The surgeon opens the purulent focus, followed by its drainage with tubular drainage.

   Due to the location in the neck of many vital organs and vessels that feed the main brain, opened phlegmon is accompanied by a number of complications.

   Arrosion may occur - damage to blood vessels, or damage to vital organs located in the neck. Asphyxia (strangulation) often occurs, requiring a tracheotomy.

   For surgical access, incisions are often made along the anterior edge of the sternocleidomastoid muscle or in the region of the jugular fossa.

After stabilization of the patient's condition, drug treatment is prescribed. It is aimed at destroying the bacteria that caused inflammation and the formation of pus, to generally strengthen the body and speed up healing.

On the first day after surgery, the patient may need intramuscular injection pain medications.

What antibiotic to prescribe is decided by the doctor, after determining the causative agent of phlegmon. Antibiotic therapy is continued until the patient's condition is completely normalized.

Effective prevention of phlegmon

Prevention of neck phlegmon is reduced to minimizing the possibility of injury to this area, and if they do occur, they must be urgently treated with an antiseptic solution.

Carious and inflammatory processes must be treated on time. An important role in prevention is played by timely detected and cured inflammatory processes and diseases of internal organs.

What is the Difference Between Phlegmon and Abscess

Inflammatory processes with the release of pus in tissues that are locked in a certain place under the skin are called abscesses. Not localized, inflammation with pus appearing under the skin - phlegmon. Have you heard of cellulite? When mentioned, they mean serous, inflamed processes of adipose tissue, but without pus.

If these diseases cannot be distinguished, a puncture is used for diagnostic purposes, pus and tissue are taken. Bacteriological analysis will help determine the pathogen and its resistance to antibiotics. We determined that cellulitis and abscesses are similar, but different diseases.

The main cause of phlegmon is the division of pathogens. Staphylococci, streptococci, Pseudomonas aeruginosa, Escherichia coli and this is not the whole list.

Diffuse swelling of the neck appears only in the second stage of development. The infection settles in other organs. After it spreads through the blood into soft tissues. Staphylococcus aureus becomes the cause of development.

More precise reasons for the development:

1. Diseases of the teeth in the lower jaw, together with the developed inflammatory process... For example, pulpitis, caries, gum inflammation, periodontitis.
2. Respiratory tract and organ infections, inflammation of the throat and trachea. Especially when such inflammations take on a chronic form, their treatment will require frequent use of antibiotics. The body cannot fight bacteria and they can get into the neck.
3. Inflammation of the lymph nodes in the neck.
4. Various wounds on the neck, possibly boils, will help cause it.
5. Common infectious diseases. The infection is carried by blood to the neck.
6. Purulent inflammation can descend from the mouth below the neck.

The rudiments, which as a result, can transform into phlegmon on the neck - abscesses on the face or inflammation in the mouth, upper respiratory tract, osteomyelitis of the cervical vertebrae, wounds on the neck.

The appearance of tumors on the neck is determined by factors:

• The lymph node network is well developed;
• An individual feature of the structure of the cervical fascia.

Swelling of the lower jaw and chin forms on the neck. The tumor is at first dense, later it takes on a bumpy appearance.

Possible complications and deep forms of phlegmon

The most common infections will cause serious illnesses:

• Lymphadenitis;
• Lymphangitis;
• Erysipelas;
• Thrombophlebitis;
• Sepsis.

Facial swelling may be aggravated by purulent meningitis.

If the inflammation begins to spread to nearby tissues, it may develop:

• Osteomyelitis;
• Purulent pleurisy;
• Tenosynovitis;
• Purulent arthritis.

The latter is the most dangerous complication. As the arterial wall becomes inflamed, then it dissolves and severe arterial hemorrhage occurs.

Deep phlegmon of the extremities is an inflammation with pus, which diverge along the intermuscular spaces. The source of such inflammation will be various wounds on the skin. For example, a bite, scratch, burn, or illness, panaritium, purulent arthritis or osteomyelitis.

The disease is characterized by pain in the extremity, the body temperature increases, there is a general weakness of the body. The disease does not wait long and develops rapidly. As a result, tissue edema is seen, the lymph nodes in the region increase and the limb is greatly enlarged. If the phlegmon is located on the surface, flushing and swollen skin can be observed.

Suppurative mediastinitis. It is a purulent inflammatory process located in the tissue of the mediastinum.

Mediastinitis is often a form of complication of perforation:

• Esophagus and trachea;
• Purulent formations in the mouth;
• In the pulmonary tract;
• Complication of phlegmon of the neck;
• The result of a hematoma;
• Osteomyelitis of the sternum or spinal column.

This problem is developing rapidly, the patient may experience severe pain behind the breastbone, and the body temperature will rise. The pain will move to the back and neck. The neck and chest will swell. To relieve pain, people often sit and tilt their heads forward, which seems to work.

People had increased heart rate, decreased blood pressure, dilated veins in their neck, and complained of pain when swallowing.

Treatment with folk remedies

Let's start with propolis, St. John's wort, and cloves.

First recipe

Ingredients:

• 150 ml of vodka;
• 25 g of propolis;
• 50 g St. John's wort.

Preparation:

• Grind propolis in a mortar;
• Pour vodka into it;
• Chop St. John's wort finely and mix;
• This must be carefully closed and left to infuse for about a week;
• Sometimes you need to shake off the bottle.

After a week, you need to strain the resulting product and rinse the mouth. To do this, dilute 50 drops in a glass of water, rinse about 5 times a day.

Second recipe

Preparation:

• Pour cloves into a glass of water (a tablespoon);
• Boil for about 3 minutes (low heat);
• The resulting product must be insisted for about 1 hour and filtered;

The broth can be used as a compress, or drunk 4 times a day for a tablespoon.

Third recipe

• Pour 3 tablespoons of cloves into 1 liter of boiled water;
• Leave to infuse for about 1 hour, drain.

The broth can be used to compress, apply to the inflamed joint. If taken orally, then you need to drink in small sips in a warm state.

Eucalyptus and birch buds.

Preparation:

• Pour 10 grams of kidneys into a glass of boiled water;
• Boil for 15 minutes (low heat);
• Strain and apply to the problem area;
• Take about 4 times a day for a tablespoon.

Second recipe.

• Take a thermos and pour 2 tablespoons of blue eucalyptus into it;
• Pour 500 ml of boiling water;

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Abscesses and phlegmon of the neck are more often the result of purulent lymphadenitis developing as a result of infection with pritonsillitis, inflammation of the periosteum of the jaws, oral cavity, mucous membrane of the middle ear, nasal cavity and its accessory cavities.

Abscesses and phlegmon of the neck are divided into superficial and deep. In addition to general complications, deep inflammatory foci of the neck are dangerous because they can spread to the cellulose in the anterior and posterior mediastinum. This can cause compression of the trachea or edema of the larynx, involve the walls of large arteries and veins in the process, which can lead to their melting and severe bleeding, which is often fatal.

The main principle of the treatment of abscesses and phlegmon of the neck is a timely incision, which ensures a sufficiently complete opening and drainage of the pathological focus. The incision must be strictly layered. After dissection of the skin, use as blunt instruments as possible (grooved probe, closed Kupffer scissors) so as not to damage the blood vessels altered by the pathological process. Treatment of phlegmon of the neck depends on their location.

Tracheotomy and tracheostomy

Tracheotomy - opening the throat (throat section) - is one of the urgent surgical interventions. Its purpose is to immediately ensure the access of air to the lungs, as well as to remove foreign bodies. Kindsdissection tracheotomy trachea:

longitudinal;

transverse - no more than ½ of the trachea diameter is opened, because the recurrent nerves can be damaged;

cutting out a rectangular flap according to Bjork - the base is in the caudal direction, and the free edge is sutured to the skin to prevent the cannula from falling out;

fenestration - excision of a section of the anterior wall of the trachea.

Tracheostomy - opening the trachea with the introduction of a cannula into its lumen.

There are three types of tracheostomy, depending on the level of tracheal dissection in relation to the isthmus of the thyroid gland:

upper- dissection of the first rings of the trachea above the isthmus;

average- opening of the trachea section covered by the isthmus;

bottom- dissection of the tracheal rings below the isthmus of the thyroid gland.

In children, due to the topographic and anatomical features of the neck, it is more convenient to perform a lower tracheostomy.

Indications:

Mechanical asphyxiation:

foreign bodies of the respiratory tract (if it is impossible to remove them with direct laryngoscopy and tracheobronchoscopy);

impaired airway patency in case of wounds and closed injuries larynx and trachea;

laryngeal stenosis: infectious diseases (diphtheria, influenza, whooping cough), with nonspecific inflammatory diseases (abscessing laryngitis, laryngeal angina, false croup), with malignant and benign tumors (rarely), with allergic edema.

Weakening of breathing - the need for long-term artificial ventilation of the lungs (during operations on the heart, lungs, traumatic brain injury, myasthenia gravis, etc.).

Patient position : on the back, the head is thrown back and is in a strictly sagittal plane. In emergencies, it is possible to operate in a sitting position outside the operating room.

Borders anterior section subhyoid part of the neck (Fig. 84): above - the hyoid bone (os hyoideum) and the back abdomen m. digastricus, below - the edge of the jugular notch of the sternum (incisura jugularis), behind - the front edges of the sternocleidomastoid muscles (m. sternocleidomastoideus).

Fig. 84. Neck muscles: 1 - os hyoideum, 2 - m. thyreohyoideus, 3 - pharyngeal muscles, 4 - m. omohyoideus (venter superior), 5 - m. sternohyoideus, 6 - m. sternothyreoideus, 7 - m. sternocleidomastoideus (cms posterior), 8 - m. sternocleidomastoideus (crus anterior), 9 - m. digastricus (venter posterior), 10 - m. splenius capitis, 11 - m. levator scapulae, 12 - m. scalenus medius, 13 - m. scalenus anterior, 14 - m. omohyoideus (venter inferior)

The subhyoid part of the neck is divided by the median line into two median triangles of the neck (trigonum colli mediale), each of which, in turn, is divided by the anterior abdomen of the scapular-hyoid muscle (m. Omohyoideus) into the scapular-tracheal (trigonum omotracheale) and carotid triangle (trigonum caroticum) (Fig. 84).

Fig. 85. Muscles and fascia of the neck (according to V.N.Shevkunenko): 1 - m. platysma, 2 - t. sternocleidomastoideus, 3 - t. sternohyoideus, 4 - t. sternothyreoideus, 5 - gl. thyroidea, 6 - m. omohyoideus, 7 - oesophagus, 8 - m. scalenus anterior, 9 - m. Trapezius

Layered structure (fig. 85). The skin is thin, mobile. The superficial fascia (the first fascia of the neck according to V.N. Shevkunenko) forms the vagina for the subcutaneous muscle (m. Platysma). Under the muscle and the first fascia are superficial vessels and nerves (v. Jugularis anterior, n. Cutaneus colli) (Fig. 86). Next is the own fascia of the neck (the second fascia according to V.N. Shevkunenko), which is attached at the top to the edge of the lower jaw, below - to the front edge of the sternum handle. In the lateral direction, this fascia forms the vagina for m. sternocleidomastoideus, and then passes into the lateral triangle of the neck and m. trapezius.

Fig. 86. Veins of the neck (according to MG Prives et al.): 1 - a. facialis, 2, 3 - a. facialis, 4 - v. jugularis interna, 5 - v. jugularis externa, 6 - v. jugularis anterior, 7 - arcus venosus juguli, 8 - v. brachiocephalica sinistra, 9 - v. subclavia

The next fascia of the subhyoid region - scapular-hyoid (third fascia according to V.N. Shevkunenko) - has a limited length. At the top, it grows together with the hyoid bone, at the bottom - with the posterior edge of the sternum handle, from the sides - it ends, forming a sheath for the scapular-hyoid muscle (m. Omohyoidei). In the midline, the second and third fascia are fused together to form a "white line." Only at a height of 3-4 cm above the sternum are the fascia sheets separated by a well-defined accumulation of adipose tissue (spatium interaponeuroticam suprasternale). Arcus vetiosus juguli is located directly above the sternum in the tissue of this space. The third fascia forms the vagina for four pairs of muscles: mm. sternohyoidei, sternothyreoidei, thyreohyoidei (located on both sides of the midline of the neck in front of the trachea) and mm. omohyoidei (run in an oblique direction from the large horns of the hyoid bone to the upper edge of the scapula).

The fascia endocervicalis (the fourth fascia according to V.N.Shevkunenko) is located under the named muscles, consisting of parietal and visceral sheets. The latter surrounds the organs of the neck and forms fascial capsules for them. Between the parietal and visceral sheets of the fourth fascia, in front of the trachea, there is a cellular space - spatium previscerale (pretracheale), continuing downward into the tissue of the anterior mediastinum. The parietal leaf of the fourth fascia on the sides of the trachea forms a vagina for the neurovascular bundle of the neck (a. Carotis communis, v. Jugularis interna, n. Vagus), known as spatium vasonervorum. The cellulose contained in this vagina, along the neurovascular bundle, also has a communication with the cellular space of the anterior mediastinum, which predetermines the possibility of the spread of the infectious-inflammatory process into the mediastinum and the development of mediastinitis.

Behind the larynx, trachea and esophagus on the deep long muscles of the neck (mm. Longus colli, longus capitis) is the prevertebral fascia (the fifth fascia according to V.N. Shevkunenko). Between the fourth and fifth fascia behind the esophagus is the posterior visceral cellular space (spatium retroviscerale), which has direct communication with the tissue of the posterior mediastinum.

Thus, in the anterior part of the neck there are interfascial spaces containing accumulations of fiber, in which a purulent-inflammatory process can occur (Fig. 87). These cellular spaces can be divided into two groups: 1) relatively closed and 2) communicating with neighboring areas. The closed cellular space is the suprasternal interaponeurotic space (spatium interaponeuroticum suprasternale). The unclosed cellular spaces include spatium previscerale (communicates with the anterior mediastinum), spatium retroviscerale (communicates above with the periopharyngeal space, below with the posterior mediastinum), and spatium vasonervoram (communicating with the anterior mediastinum).

Fig. 87. Variants of the localization of the purulent-inflammatory process in the anterior subhyoid region of the neck:
1 - in the subcutaneous fatty tissue, 2 - in the suprasternal intergaponeurotic cellular tissue space, 3 - in the pregracheal cellular tissue space, 4 - in the interfascial cellular tissue space of the anterolateral part of the subhyoid part of the neck, 5 - in the tissue of the fascial sheath of the neurovascular bundle of the neck, 6 - , 7 - in the paratracheal space, 8 - in the retrovisceral space

The spread of purulent-infectious processes in the neck can also occur by the lymphogenous pathway (Fig. 88).

Fig. 88. Lymphatic vessels and nodes of the neck (according to MG Prives et al.): 1 - nodi lymphatici submentales, 2 - nodi lymphatici submandibulares, 3 and 6 - nodi lymphatici cervicales profundi, 4 - nodi lymphatici cervicales anteriores superficiales, 5. - nodi lymphatici supraclaviculares

Abscess, phlegmon of subcutaneous fatty tissue of the anterior subhyoid part of the neck

Purulent-inflammatory skin diseases (folliculitis, furuncle, carbuncle), infected wounds, the spread of an infectious-inflammatory process from the subcutaneous fat of adjacent anatomical regions (submental, submandibular, sternocleidomastoid regions).

Typical local signs of an abscess, phlegmon of the skin fatty tissue of the anterior subhyoid part of the neck

Complaints of moderate intensity pain in the anterior part of the neck.

Objectively. Swelling of the tissues of the anterior neck. On palpation, an infiltrate is determined, limited in area, with clear contours (with an abscess), or occupying a significant area, without clear contours (with phlegmon). The skin over the infiltrate is hyperemic, the pressure exerted on the infiltrate during palpation causes pain. Fluctuation can be detected.

Subcutaneous fat of adjacent anatomical regions of the neck and anterior surface chest.

Technique of the operation of opening the abscess, phlegmon of the subcutaneous fatty tissue of the anterior subhyoid part of the neck

1. Anesthesia - local infiltration anesthesia with premedication, anesthesia.

2. For opening the pyoinflammatory foci in the subcutaneous tissue (Fig. 89, A), incisions oriented towards the direction of skin folds are used - horizontal skin incisions passing through the center of the inflammatory infiltrate along its entire length (Fig. 89, B, C).
3. Exfoliating the subcutaneous fatty tissue with a hemostatic clamp, open the pyoinflammatory focus, evacuate pus (Fig. 89, D).
4. After hemostasis, a tape drainage from glove rubber or polyethylene film is introduced into the wound (Fig. 89, D).

Fig. 89. The main stages of the operation of opening the abscess, phlegmon of the subcutaneous fatty tissue of the anterior part of the subhyoid part of the neck

5. Apply an aseptic cotton-gauze bandage with a hypertonic solution, antiseptics.

Abscess, phlegmon of the suprasternal interaponeurotic cellular tissue space(spatium interaponeuroticum suprasternale)

The main sources and routes of infection

Infected wounds, hematoma suppuration, spread of the infectious and inflammatory process along the length from adjacent anatomical areas.

Typical local signs

Complaints of throbbing pain in the lower part of the anterior part of the neck, aggravated by extension of the neck, by swallowing.

Objectively. Swelling of the tissues in the lower part of the anterior neck above the sternum is determined due to an inflammatory infiltrate, palpation of which causes pain. The skin over the inflammatory infiltrate is moderately hyperemic or has a normal color.

Ways of further spread of infection

Due to the relative closure of the suprasternal interaponeurotic space, the spread of the infectious-inflammatory process beyond its limits occurs relatively late, after the purulent fusion of the second or third fascia of the neck occurs. In the first case, when the integrity of the lamina superficialis fasciae colli propriae is violated, the pyoinflammatory process spreads along the superficial fascia of the neck (fascia colli superficialis) along the subcutaneous fat on the anterior surface of the chest. In the second case, in violation of the integrity of the lamina produnda fasciae colli propriae, the purulent-inflammatory process spreads along the fourth fascia of the neck (fascia endocervicalis) behind the sternum, and in violation of the integrity of the parietal leaf of this fascia - into the pretracheal cellular space (spatium pretracheale) and further into the anterior mediastinum.

Technique of the operation of opening the abscess, phlegmon of the suprasternal interaponeurotic cellular tissue space

2. To open the abscess of the suprasternal interaponeurotic space (Fig. 90, A), a skin incision is used, parallel to the upper edge of the sternum handle (Fig. 90, B, C).
3. Cut through the skin, subcutaneous tissue with superficial fascia (fascia colli superficialis) and, spreading the edges of the wound with hooks up and down, expose the surface of the second fascia of the neck (lamina superficialis fasciae coli propriae) (Fig. 90, D).
4. To prevent damage to the veins and the jugular venous arch (arcus venosus juguli) located in the suprasternal interaponeurotic cellular space, a hemostatic forceps is inserted through a small incision up to 0.5 cm under the second fascia of the neck and dissected over the divorced branches of the forceps throughout the inflammatory infiltration (Fig. 90, D).

Fig. 90. The main stages of the operation of opening the abscess, phlegmon of the suprasternal interaponeurotic cellular tissue space

5. Stupidly exfoliating the fiber with a hemostatic clamp (to avoid damage to the jugular venous arch!), Move to the center of the inflammatory focus, open it, evacuate pus (Fig. 90, E).
6. Stupidly stratifying the fiber in the lateral directions, they revise the so-called blind bags (recessus lateralis) located behind the lower end of m. sternodeidomastoideus (Fig. 90, G). Hemostasis.
7. Tape drains made of glove rubber or plastic film are introduced into the purulent-inflammatory focus through the wound (Fig. 90, 3).
8. An aseptic cotton-gauze bandage with a hypertonic solution and antiseptics is applied to the wound.

Abscess, phlegmon of pretracheal cellular tissue space (spatium pretracheale)

The main sources and routes of infection

Infected wounds that penetrate into the pretracheal cellular tissue space, secondary damage as a result of the spread of the infectious and inflammatory process along the length of the adjacent anatomical regions (lateral periopharyngeal space, the vagina of the neurovascular bundle of the neck, the suprasternal interaponeurotic cellular tissue space), as well as by the lymphogenous space (in the tissue) there are lymph nodes).

Typical local signs of abscess, phlegmon of pretracheal cellular space

Complaints of pain in the lower part of the anterior part of the neck, aggravated by swallowing, coughing, turning and throwing the head back.

Objectively... The position of the patient is forced - the head is tilted forward. The jugular cavity is smoothed due to tissue swelling in the lower part of the anterior neck. On palpation, an inflammatory infiltrate over the trachea is determined, the pressure on which causes pain. Lateral displacement of the larynx also causes pain. Due to the deep localization of the purulent-inflammatory process, hyperemia of the skin may be absent. In the event of edema of the subglottic space of the larynx, hoarseness and difficulty breathing may appear.

Ways of further spread of infection

The most probable way of "spreading the infection is to the anterior mediastinum (!). In addition, the spread of the pyoinflammatory process to the periopharyngeal cellular tissue space, and from there to the retropharyngeal space and posterior mediastinum, can be observed.

Technique of the operation of opening the abscess, phlegmon of the pretracheal cellular space

1. Anesthesia - anesthesia (intravenous, inhalation), local infiltration anesthesia against the background of premedication.

Fig. 91. The main stages of the operation of opening the abscess, phlegmon of the pretracheal cellular space

2. With an isolated lesion of spatium pretracheale (Fig. 91, A, B), the abscess is opened, the phlegmon are performed with a median approach. The skin incision is carried out from the middle of the upper edge of the sternum handle along the midline to the cricoid cartilage (Fig. 91, C, D).
3. After dissection of the superficial fascia of the neck (Fig. 91, D, D, E), using a gauze pad, the edges of the wound are peeled off and hooked to the right and left, exposing the surface of the second fascia (lamina superficialis fasciae coli propriae).
4. To prevent damage to the veins and the jugular venous arch (arcus venosus juguli), located in the suprasternal interaponeurotic cellular space, through a small incision up to 0.5 cm long under the second fascia of the neck (lamina superficialis fasciae colli propriae). a hemostatic clamp is brought in and dissected over the divorced jaws of the clamp along the entire length of the wound.
5. With the help of a hemostatic clamp and gauze pad, stupidly exfoliate and exfoliate the tissue with the vessels in it (arcus venosus juguli) from the third fascia of the neck (lamina profunda fasciae colli propriae). Hemostasis is performed.
6. Pushing the fiber back with hooks and finding lamina profunda fasciae colli propriae, dissect it (Fig. 91, F, H). Located under it, the parietal leaf of the fourth fascia of the neck (fascia endocervicalis) is dissected in the same way - over the divorced branches of the hemostatic clamp brought under it (Fig. 91, I, K). Such a layer-by-layer dissection of tissues under the control of vision reduces the likelihood of damage to the vessels located in this cellular space (a. Thyreoidea ima et plexus thyreoideus impar) and the isthmus of the thyroid gland.
7. Stupidly exfoliating the fiber with a hemostatic clamp, they move to the center of the inflammatory infiltrate, open the pyoinflammatory focus, evacuate pus (Fig. 91, L).
8. After the final hemostasis, tape or tubular drainages are introduced into the pyoinflammatory focus through the wound (Fig. 91, M).
9. Aseptic cotton-gauze dressing with hypertonic solution, antiseptics, and when using tubular drains - connecting them to the device (system), which provides the possibility of wound dialysis and vacuum drainage without removing the dressing.

Technique of the operation of opening the phlegmon with a secondary lesion of the pretracheal cellular space associated with the spread of an infectious-inflammatory process from the lateral periopharyngeal space or the vagina of the neurovascular bundle of the neck

1. Anesthesia - anesthesia (intravenous or inhalation).

Fig. 92. The main stages of the operation of opening the phlegmon with secondary lesion of the pretracheal cellular space as a result of the spread of the infectious-inflammatory process from the lateral periopharyngeal space and the fascial sheath of the neurovascular bundle of the neck

The neck incision is made along the anterior edge of the sternocleidomastoid muscle of the corresponding side from the sternoclavicular joint to the lower edge of the thyroid cartilage (Fig. 92, A, B).
3. Layer-by-layer dissect for the entire length of the skin wound subcutaneous tissue, superficial fascia of the neck (fascia colli superficialis). The second and third fascia of the neck, forming the vagina for m. sternocleidomastoideus, m. оmоhyoideus, m. thyreohyoideus, m. sternothyreoideus (Fig, 92, C, D, E).
4. Bluntly stratifying the fiber with a hemostatic clamp and removing it with hooks to the sides, the surface of the parietal leaf of the fourth fascia of the neck (fascia endocervicalis) is exposed (Fig. 92, E).
5. The parietal leaf of the fascia endocervicalis is incised over a length of 4-5 mm, and then, bringing the hemostatic clamp through this incision under it, under the control of vision, the fascial leaf is dissected over the divorced branches of the clamp throughout the wound (Fig. 92, G).
6. Stupidly exfoliating the fiber with a hemostatic clamp, they move to the center of the inflammatory infiltrate in the pretracheal cellular space, open up the purulent-inflammatory focus, evacuate pus (Fig. 92, 3).
7. From the same access, stratifying the fiber with a forceps, they penetrate into the lateral periopharyngeal space, carry out its revision and, if there is a purulent-inflammatory focus in it, open it, evacuate pus.
8. After abduction by hooks m. sternocleidomastoideus laterally expose the surface of the fascial sheath of the neurovascular bundle of the neck, formed by the fascia endocervicalis sheets.
9. In the presence of infiltration of the fiber of the neurovascular bundle of the neck, the wall of the fascial vagina is incised, a hemostatic clamp is inserted under it, thereby pushing back the internal jugular vein, the common carotid artery (v. Jugularis interna, a. Carotis communis), and, under visual control, cut through the wall of the fascial sheath over the slightly divorced jaws of the clamp, throughout the inflammatory infiltrate (Fig. 92, I).
10.To create better conditions for drainage of a purulent-inflammatory focus, it is advisable to complete the operation by cutting off the medial leg m. sternocleidomastoideus from the place of its attachment to the sternoclavicular joint, as recommended by N.A. Gruzdev (Fig. 92, K).
11. After the final hemostasis, tubular drains made of soft-elastic plastic are brought through the wound to the purulent-inflammatory foci (Fig. 92, L).
12. Aseptic cotton-gauze bandage with hypertonic solution. Connecting tubular drains to a device (system) that allows for dialysis of the wound and vacuum drainage without removing the dressing.

Abscess, phlegmon of the carotid triangle of the neck (trigonum caroticum)

The main sources and routes of infection

Secondary damage as a result of the spread of the infectious and inflammatory process through the paravasal tissue from adjacent anatomical regions (submandibular, periopharyngeal, posterior maxillary), as well as by the lymphogenous pathway with a delay in the causative agents of purulent infection in the lymph nodes located on the internal jugular vein (nodus lymphaticus jugulod. 93). Purulent-inflammatory skin diseases, infected wounds of the carotid triangle region.

Typical local signs of abscess, phlegmon of the carotid triangle

Complaints of pain in the region of the carotid triangle of the neck, aggravated by head movements, neck extension.

Objectively. Swelling of tissues in the region of the carotid triangle of the neck. On palpation under the anterior edge of m. sternocleidomastoideus in the area of \u200b\u200bits upper third is determined by a dense infiltrate, pressure on which causes pain. Pulling m. sternocleidomastoideus outwards is also accompanied by the appearance of pain.

Fig. 93. The main stages of the operation of opening the abscess, phlegmon of the region of the carotid triangle of the neck

Ways of further spread of infection

From the carotid triangle, the infectious-inflammatory process along the paravasal tissue can spread to the lower parts of the spatium vasonervorum, then to the anterior mediastinum and to the supraclavicular, and then the subclavian region.

Technique of the operation of opening the abscess, phlegmon of the carotid triangle of the neck

With the localization of a purulent focus in the carotid triangle (Fig. 93, A, B):

1. Anesthesia - anesthesia (intravenous, inhalation), local infiltration anesthesia against the background of premedication.
2. The skin incision is carried out along the front edge of m. sternocleidomastoideus from the level of the angle of the lower jaw to the middle of this muscle (Fig. 93, C, D).
3. Layer-by-layer dissect subcutaneous fatty tissue, superficial fascia of the neck (fascia colli superficialis) with the subcutaneous muscle of the neck (m. Platysma) between its sheets (Fig. 93, D, E).
4. By spreading the edges of the wound with hooks and peeling them with a hemostat from the superficial leaf of the own fascia of the neck (lamina superficialis colli propriae), the anterior edge of m is exposed. sternocleidomastoideus (Fig. 93, G).
5. Near the front edge of m. sternocleidomastoideus is incised for 4-5 mm lamina superficialis fasciae colli propriae, a hemostatic clamp is inserted through this incision, and the fascia is dissected over the divorced jaws of the clamp along the anterior edge of the muscle throughout the entire wound (Fig. 93, H).
6. Layering the underlying tissue with a styptic clamp and removing the hooks m. sternocleidomastoideus up and back, expose the outer wall of the fascial sheath of the neurovascular ray of the neck, formed by the fourth fascia of the neck (fascia endocervicalis).
7. Cut through the outer wall of the fascial sheath of the neurovascular bundle of the neck for 3-4 mm, and then, passing through this incision a hemostatic Billroth forceps between the fascia and the internal jugular vein (v. Jugularis interna), dissect the wall of the fascial sheath.
8. Exfoliating the paravasal tissue with the help of a hemostatic clamp, the purulent-inflammatory focus is opened, pus is evacuated (Fig. 93, I).
9. After the final hemostasis in the spatium vasonervorum enter tape or tubular drainage from glove rubber or polyethylene film (Fig. 93, K).
10. An aseptic cotton-gauze bandage with a hypertonic solution and antiseptics is applied to the wound.

M.M. Soloviev, O. P. Bolshakov
Abscesses, phlegmon of the head and neck

Surgical treatment of superficial abscesses and phlegmon is usually performed under local anesthesia. Skin incisions for opening the phlegmon of the subcutaneous tissue spaces of the neck are carried out over the abscess along the cervical folds and large vessels and continue to its lower border. After dissecting the skin, the tissues are bluntly disconnected with a clamp, the abscess is opened. His cavity is examined with a finger to separate the fascial septa and detect possible leakage of pus into neighboring areas; in the latter case, additional incisions are made. The wound is washed with antiseptic solutions, drained with rubber tubes or rubber gauze tampons.

The operation of opening the deep phlegmon of the neck is performed under general anesthesia. If breathing is disturbed, a tracheostomy is applied to carry out anesthesia and prevent asphyxia in the postoperative period.

Patient position:on the back, a roller is placed under the shoulders, the head is thrown back and turned to the side opposite to the side of the operation.

Operation technique(Figure 13.15). When performing the operation, it is necessary to separate the tissues in layers, widely spread the edges of the wound with hooks and ensure thorough hemostasis. This is important for the prevention of accidental damage to large vessels and nerves, a detailed examination of the cellular spaces in order to identify additional leaks of pus.

Fig. Incisions for opening and draining superficial ulcers of the neck (from: Ostroverkhov G.E., 1964)

Surgical intervention in case of purulent-inflammatory processes of odontogenic nature begins by opening the phlegmon of the floor of the oral cavity, the periopharyngeal space through incisions in the submandibular triangles, the submental region or through a collar-shaped incision.

Then a skin incision is made along the inner edge of the sternocleidomastoid muscle, starting above the angle of the lower jaw and continuing to the jugular notch of the sternum. The incision may be shorter if the abscess does not extend into the lower neck.

The skin, subcutaneous tissue, superficial fascia and superficial muscle are dissected. An external jugular vein is found in the upper corner of the wound, it must be displaced laterally or crossed between two ligatures. The outer leaf of the fascial sheath of the sternocleidomastoid muscle is dissected, its inner edge is separated, and it is pulled back with a blunt hook outward (Figure 13.16).

A deep leaf of the sternocleidomastoid muscle is carefully incised, exfoliated from the underlying tissues with a grooved probe and dissected through it. For orientation in the topographic relationship in the wound, it is advisable to feel the pulsation of the total carotid artery and determine the position of the vascular bundle of the neck. The fascia and fiber above it are stratified with a hemostatic clamp, the bundle is exposed.

When the leakage spreads along the course of the beam, pus is released at this moment. Further, the cellulose with purulent-necrotic changes in a blunt way is widely stratified to healthy tissues, the purulent cavity is examined with a finger to detect possible leaks, which are widely opened. The internal jugular and facial veins are examined visually and by palpation. If thrombi are found in them, then the vessels are ligated above and below the boundaries of the thrombosed areas and excised.

If it is necessary to open abscesses in the pre- and posterior-visceral spaces in the lower half of the wound, the scapular-hyoid muscle is found and crossed, which runs in the direction from the back to the front and from the bottom up. The transection of the muscle facilitates access to the trachea and esophagus. The common carotid artery and trachea are preliminarily groped, then fiber is stratified between them, the neurovascular bundle is removed with a blunt hook outward.

In front of the trachea, below the thyroid gland, an abscess is opened in the pretracheal cellular space using a clamp or a finger. Continuing to pull the vascular bundle outward, the assistant displaces the trachea with a blunt hook in the medial direction. Between the bundle and the esophagus, tissues are stratified in the direction of the cervical vertebrae to the prevertebral fascia and an abscess is opened in the lateral part of the paraesophageal cellular tissue space. The common carotid artery is located near the esophagus: on the right by 1-1.5 cm, on the left by 0.5 cm from its walls. Behind the common carotid artery and the internal jugular vein are the lower thyroid artery and veins, which at the level of the VI cervical vertebra make an arc and go to the lower pole of the thyroid gland. To prevent injury to these vessels, the tissues in the circumference of the esophagus are severed only in a blunt way. Pulling the esophagus in the medial direction, an abscess in the tissue of the posterior visceral space is opened with a clamp between it and the prevertebral fascia.

Fig.

With purulent flow in the supraclavicular region and the suprasternal interaponeurotic space, along with the vertical, a second wide horizontal incision of the tissues above the clavicle is made. The horizontal incisions in the submandibular triangle and above the clavicle, combined with the vertical incisions, form a Z-shaped wound. In case of putrefactive necrotic phlegmon, skin and fat flaps at the corners of the wound are separated, turned away and fixed with a suture to the skin of the neck. The wide exposure of the inflamed tissues creates conditions for their aeration, ultraviolet irradiation, and washing with antiseptic solutions. The operation ends with the washing of the purulent cavities and their drainage. It is dangerous to bring tubular drains to the vascular bundle because of the possibility of a pressure ulcer of the vessel wall and arrosive bleeding.

With common phlegmon surgical intervention perform on both sides of the neck.