Selectedreadings in Oral and Maxillofacial Surgery

SELECTED READINGS

ORAL AND

MAXILLOFACIAL SURGERY

MAXILLOFACIAL INFECTIONS

Andrew Read-Fuller, DDS, MD Andrew Mueller, DMD, MD Richard A. Finn, DDS

Volume 23, Number 3 November, 2015 Maxillofacial Infections A. Read-Fuller, DDS, MD, et al.

MAXILLOFACIAL INFECTIONS

Andrew Read-Fuller, DDS, MD, MS, Andrew Mueller, DMD, MD, Richard Finn, DDS

INTRODUCTION

Oral and maxillofacial infections are among the most common surgical problems faced by oral and maxillofacial surgeons in the United States. Although severe maxillofacial infections requiring inpatient hospitalization are rare,(1) the mortality rate of patients admitted with maxillofacial infections is estimated to be one in 150.(2) Proper management of odontogenic study included traumatic cases (10.7%), im- infections has important economic implica- munosuppression (1.6%), and pathology tions as well. One study demonstrated that (1.6%), while other causes were responsible the average hospital bill for a patient admit- for the remaining 8% of cases.(5) Byers, et ted with an odontogenic infection was over al’s multicenter study found a dental origin in $17,000, with length of stay, time spent in 86% of maxillofacial infections presenting to intensive care, and repeated trips to the op- Scottish hospitals.(6) erating room accounting for 90% of variation in the hospital bill.(3) By definition, odontogenic infections of the head and neck begin in the teeth through In all phases of treating a maxillofacial a variety of disease processes. Caries is the infection, from diagnosis to perioperative most common of these dental diseases, fol- medical evaluation and surgical interven- lowed by periodontal disease and pericoroni- tion, experience and timely intervention is tis.(7) Lower teeth are much more commonly critical to achieving a favorable outcome. An the source of severe odontogenic infections, adequate understanding of the etiology, di- with the mandibular third molar as the origin agnosis, microbiology, and management of in a majority of cases. This is followed by these conditions is, therefore, critical for the other mandibular posterior teeth, while max- oral and maxillofacial surgeon. illary posterior teeth contribute much less frequently to these infections.(7) ETIOLOGY AND PATHOGENESIS Maxillofacial infections have significantly different distribution among children. They Maxillofacial infections are most com- are more likely to occur in the upper face monly caused by odontogenic sources.(4) than the lower face, and these upper face A retrospective review of hospital admis- infections are caused by odontogenic, trau- sions for maxillofacial infections by one oral matic, and other unknown sources at very and maxillofacial surgery graduate program similar rates. In contrast, lower face infec- showed that 79% were for infections of odon- tions, which occur with less frequency, are togenic origin. Other sources identified in the much more commonly due to odontogenic sources.(8)

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PATIENT DEMOGRAPHICS The findings in the Australian study(15) were consistent with other reviews showing that the uninsured and underinsured, as well Infections of the maxillofacial region are as other patients of limited means, compose more likely to occur in certain patient popu- a very high proportion of patients seeking lations. Males, both adult and children, are emergency treatment for maxillofacial in- more likely to present emergently with odon- fections.(17) In one review of patients hos- togenic and other maxillofacial infections, pitalized with odontogenic infections, nearly although there is significant variation in the 62% were unfunded.(3) Of Scottish patients degree of male predominance.(5,8-12) The presenting to hospitals with maxillofacial in- mean age of patients presenting with acute fections, 54% were from the lowest two so- maxillofacial infections ranges from 25-38 cioeconomic quintiles, 36% from the lowest years in various studies.(6,9-12) quintile alone.(6)

Patients with systemic diseases are Routine dental care may be instrumen- more likely to present emergently with sig- tal in preventing severe odontogenic infec- nificant head and neck infections. Huang, et tion. British oral and maxillofacial surgeons al. found that 34.1% of such patients suffer noted a significant increase in emergency from significant medical comorbidities, with room visits, admissions, and surgeries for 88.9% of those patients having diabetes mel- maxillofacial infections after the National litus.(13) Although the association between Health Service changed their reimbursement maxillofacial and systemic disease is undis- system, eliminating fees per tooth extracted, puted, there is a lack of data demonstrating and implemented a single fee for the more a causal relationship.(14) expensive treatment.(18,19) By decreasing access to needed dental extractions, more Socioeconomic status, patient attitudes, severe manifestations of odontogenic infec- and other psychosocial factors correlate with tions are likely to occur. the patients presenting with maxillofacial infections. A survey of Australian patients CLINICAL PRESENTATION showed that only 16% regularly visited the dentist, and the majority had unfavorable AND HISTORY impressions of oral healthcare, reporting not only difficulty paying for dental treatment, Patients presenting with a significant but also phobias and fears of going to the maxillofacial infection report certain common dentist.(15) Additionally, this study found that complaints, particularly when their infection 34% struggled with either mental illness or has an odontogenic source. Rapidly-wors- substance abuse, which was thought to ex- ening swelling, dysphagia, pain, and trismus plain, in part, the poor oral health of those are the most common presenting symptoms. presenting with odontogenic infections. (15) (7,17) In fact, Uluibau, et al. found that 44 % Specifically, an association between drug of patients had trismus when they presented and alcohol abuse and the development of to the emergency room with an odontogenic severe deep space odontogenic infections infection.(15) has been demonstrated.(16)

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Sato, et al. reviewed records from all of the likelihood that the patient will require maxillofacial infections and found trismus substantial surgical interventions, more in- (43%), fever (28%), and dysphagia (25%) tensive care, or a greater length of hospital were the most common presenting symp- stay. toms.(5) Fetid breath and active drainage may also be found, although less often, and Laboratory Values and Vital Signs 26% of patients present with a draining sinus tract.(6) Among patients in the Byers, et al. audit of Scottish medical centers 16% Obtaining a patient’s history of symp- met the criteria for systematic inflammatory toms is the first important step in gauging response syndrome (SIRS) on admission.(6) the probability of severe infection. Patients Byers, et al. also found that 34% of patients with symptoms for a greater length of time reported dental treatment within the previous prior to admission are more likely to have a two weeks, while 6% reported recent trauma. greater number of involved spaces and, sub- (6) Therefore, taking a proper history may sequently, an increased length of hospital help reveal the origin of the infection. stay (LOS).(20)

ANATOMICAL SPACES Certain admission laboratory values have been shown to be important in assess- ing a patient with a maxillofacial infection. Flynn, et al. examined the frequency C-reactive protein (CRP) is perhaps most and distribution of spaces involved in severe predictive of the severity of a clinical course odontogenic infections.(7) They found the (21) and LOS. In fact, every increase in CRP pterygomandibular space most frequently of 100 roughly translates to an additional 24 involved (59% of the time), followed by the hours of admission.(22) submandibular space (54%) and then the lateral pharyngeal space (43%), buccal space WBC count correlates with a difficult (41%), and space of the body of the man- clinical course for children(23) and can be dible (35%). The average number of spaces predictive of an increased length of hospital involved was 3.3 and ranged from 1-8.(7) stay(10) but may not have the same prognos- Other studies have had similar results al- tic value in adults.(24) CRP may be a more though the submandibular space(9) and the accurate predictor of post-operative compli- buccal mandibular space(5,6) were the most cations and infection severity than WBC.(25) commonly involved. Prealbumin, a marker frequently used PREDICTING DISEASE SEVERITY in nutritional assessment of the inpatient, is AND PROGRESSION frequently low in the patient admitted for an odontogenic infection, and when assessed in conjunction with BUN, accurately predicts One of the most important tasks for length of stay 77% of the time.(26) Tempera- the oral and maxillofacial surgeon called to ture may have a bearing on length of stay evaluate a patient presenting with a maxillo- in adults according to some studies(22,24) facial infection is to rapidly assess him or her while others have found no correlation.(27) and determine the severity of the infection. This assessment must include an evaluation

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Children are also more likely to prog- Diabetes mellitus is a common medi- ress favorably if they are younger, have a cal condition that predisposes a patient to lower admission temperature, and present perioperative complications. A retrospective with upper-face infections that are not of study demonstrated that admission blood odontogenic origin.(8,23) Overall, children glucose not only accurately correlated with generally require shorter hospital stays than postoperative complications, but higher glu- adults.(10) Increasing age is associated with cose values were also associated with a lon- greater LOS.(20) ger hospital stays, infections involving more spaces, and surgery requiring more incisions. Surgical Intervention in the Operating (29,30) Christensen, et al. similarly found a Room correlation between hospital LOS and peak blood sugar, but also saw an increased likeli- Undergoing a surgical intervention in hood of ICU admission with higher glucose the operating room has been demonstrated readings. (31) Han, et al. demonstrated in multiple studies to correlate with an in- that diabetic patients have a higher WBC creased LOS for the infected patient.(24,27) and CRP, have a greater complication rate This association is due in large part to the with infections involving more spaces, and fact that patients requiring drainage in the OR are more likely to require tracheostomy.(32) have more severe infections, with abscesses Conversely, dental infections in the diabetic involving multiple anatomical spaces.(9) may precipitate complications of the diabetes itself. Chandu, et al. reported two cases of patients with odontogenic infections that The Role of Pre-existing Systemic caused diabetic ketoacidosis.(33) Diseases HIV-positive patients must also arouse Patients with medical co-morbidities not concerns for the treating oral and maxillofa- only have a greater likelihood of developing cial surgeon. They often present with a lower maxillofacial infections, but are also suscep- WBC and temperature than HIV negative tible to systemic infection and a longer LOS patients with odontogenic infections, which with a higher chance of mortality.(28) In fact, could confuse the surgeon. These patients a pre-existing medical condition is the most are more likely to require ICU care and re- significant of all patient factors in prolonging main longer when admitted for intensive LOS, increasing hospitalization by an aver- care.(34) age of 1.8 days.(24) Delayed-Onset Infections Huang, et al. also found that patients with systemic disease generally have a longer LOS, compared to healthy patients, and A small subset of maxillofacial infec- also had a higher complication rate (31.7% tions known as “delayed-onset infections” versus 8.2%) and required tracheostomy have their own risk factors. These infections more frequently (19% versus 4.9%).(13) In can occur approximately one month or lon- addition, the three deaths in their series were ger after an initial elective dental procedure. all patients with underlying systemic diseas- A Pell and Gregory classification indicating es. greater depth within the jaw, need for tooth sectioning, and bone or soft tissue impac-

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tion are all closely associated with increased The bacteria isolated from odontogenic risk of developing a delayed-onset infection. infections most commonly include viridans (35) Therefore, a patient who underwent a streptococci, peptostreptococci, staphy- challenging extraction several weeks prior to lococci, and Prevotella, among others. presentation with an infection without an ob- (7,12,17) Studies have indicated that the vious source should arouse a surgeon’s sus- bacterial composition of these infections has picion of a possible delayed-onset infection. not changed over time.(40)

Radiologic Evaluation Aerobic and anaerobic bacteria are frequently isolated from odontogenic infections. (11) The most common aerobic bacteria iso- Imaging is critical to proper preopera- lated by far includes various species of gram tive assessment of the extent and severity of positive cocci, while gram positive rods, gram a maxillofacial infection. While maxillofacial negative rods and gram negative cocci were infections are frequently clinically apparent, rarely isolated. Of the gram positive cocci, deeper infections may be difficult to assess alpha hemolytic streptococci were the most without imaging. Computed tomography common (cultured 91 times), followed by S. (CT) is often used in the assessment of these epidermidis (31 times, although the authors patients, and has been shown to accurately assert that this high number reflects sample predict deep maxillofacial infections. One contamination) unspecified species ofStrep - study demonstrated that in 80.6% of cases, tococcus (21 times), beta hemolytic strepo- a CT interpreted by an oral and maxillofacial cocci(15 times) and finally, Staphylococcus surgeon accurately correlated with operative aureus (12 times).(11) findings of an abscess.(36) CT scans can also be useful in identifying the course of cu- The most commonly found anaero- taneous sinus tracts that can develop as a bic species were gram negative rods, with result of these infections.(37) bacteroides (196 times) and fusobacterium (54 times) predominating. Gram positive Ultrasound has also been shown to be a cocci included Peptococcus (82 times) and useful modality when an abscess is present. Peptostreptococcus (62 times), while gram- Jones, et al. showed a 92% correlation be- negative cocci (Veilonella, 19 times) and tween ultrasound and intraoperative clinical gram-positive rods (Eubacterium, 29 times; findings.(38) Actinomyces,19 times; and Propionibacte- rium, 10 times) were less common.(11) Microbiology Bacterial populations likely vary based Odontogenic infections are caused by a on the anatomical location with the facial re- variety of organisms and are typically poly- gion. Biederman and Dodson demonstrated microbial, which reflects the diversity of bac- a greater variety in bacteria found in infec- teria that comprises oral flora. This oral flora tions of the upper face than the lower face. grows on the teeth in the form of a biofilm, (41) which is responsible for the initiation of odontogenic disease processes such as dental caries and, subsequently, head and neck infections.(39)

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Pericoronitis has been similarly demon- frequent systemic manifestations of maxillo- strated to be a largely polymicrobial process, facial infections less surprising. with Streptococcus milleri being the most frequently cultured organism from these infec- Antibiotics tions, present in 78% of cases in one series. (42) Oral and maxillofacial surgeons have Bacteria produce pathogenicity through utilized numerous antibiotic regimens to treat several mechanisms including enzymes, maxillofacial infections. However, differing metabolites and toxins, capsules that pre- treatment philosophies, increases in antibi- vent phagocytosis and facilitate abscess for- otic resistance over time, and development mation, tolerance to air, and synergism with and increased use of more broad-spectrum other bacteria. Anaerobic bacteria most com- antibiotics have made it difficult to gain con- monly produce 1) superoxide dismutase, sensus on a standard antibiotic treatment which aids in bacterial aerotolerance, 2) course. capsular polysaccharides and succinic acid, which have antiphagocytic properties, 3) en- Penicillin has been a mainstay treat- dotoxins (such as lipopolysaccharides) and ment for maxillofacial infections since the hydrogen sulphide to promote cytotoxicity, discovery of its antibiotic properties by Alex- and 4) proteolytic enzymes that aid in tissue ander Flemming in 1928, and its subsequent degradation and promote bacterial invasion. clinical application in 1941. One of the first (43) patients treated with penicillin, a policeman named Albert Alexander, suffered from a fa- Bacterial composition may influence cial infection that developed as the result of a clinical presentation. For example, authors scratch from a rose thorn. Although Alexan- have sought to explain whether certain bac- der ultimately died of his infection, his case teria predispose a patient towards abscess is cited as an early success for antibiotic formation versus cellulitis. Results indicate treatment, since initially his clinical condition that cultures with isolates of peptostrepto- significantly improved once penicillin thera- cocci are more likely to manifest as a celluli- py was initiated, but after the limited supply tis rather than an abscess.(27) of the drug was exhausted he deteriorated again.(48) Systemic influence of oral bacteria is an inevitable consequence of oral surgical in- Today, the clinical effectiveness of peni- tervention. Numerous studies have demon- cillin in treating more advanced maxillofacial strated that transient bacteremia occurs after infections has declined. Flynn, et al. showed dental extractions.(44-47) The incidence of a 21% failure rate of penicillin in the treat- post-extraction bacteremia is high, with rates ment of severe odontogenic infections that upwards of 96.2% 30 seconds after extrac- required hospitalization.(7) Although peni- tion, and may detectable up to one hour af- cillin has been shown to be equally effec- ter extraction.(44) Cultures in these studies tive when compared to clindamycin against grew both aerobic and anaerobic bacteria. bacteria with low penicillin resistance, most (44-47) The pathophysiology of bacteremia anaerobic bacteria have a higher rate of re- in oral and maxillofacial surgery makes the sistance to penicillin than to clindamycin.(49)

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The potential for development of peni- to beta-lactams, clindamycin is the drug of cillin resistance during the treatment of a choice.(53) Clindamycin is also a suitable single odontogenic infection should also be alternative for patients who have previous- considered, although this concept is some- ly failed penicillin treatment.(52) A 3-4 day what controversial. Some evidence suggests course of antibiotics is generally considered that patients treated with penicillin or another adequate for the otherwise healthy outpa- beta lactam during the course of an infection tient.(53) that never fully resolves should be switched to a beta lactamase-stable beta lactam. The Penicillin failure is more likely with more chances that penicillin-resistant bacteria significant and advanced infections. Flynn, et are present are substantially increased in a al. described a “severity score,” for odonto- failed initial penicillin treatment.(50) Howev- genic infections in which each fascial space er, Flynn, et al. found no correlation between involved is assigned a value of 1-3 based on previous antibiotic use and the development the anatomic location and potential danger of penicillin-resistant bacteria.(27) to nearby vital structures. The patient is assigned a total score which sums the values of Another study examining susceptibility each individual space involved.(7) A greater of individual bacterial species showed that severity score has been shown to correlate the effectiveness of penicillin ranged from with penicillin failure and increased length 27.3% in treating staphylococci to 87.1% of stay.(54) Due to the high rate of penicillin for Streptococcus viridans.(12) The author failure in cases of severe odontogenic infec- concluded that, overall, penicillin should still tion, Flynn recommends that the hospitalized be considered the drug of choice in treating patient should be treated with penicillin com- odontogenic infections given that empirical- bined with a beta-lactamase inhibitor such as ly Streptococcus viridans is isolated much ampicillin/sulbactam.(53) more frequently than staphylococci. In general, the choice of antibiotic Yuvaraj, et al. reached similar conclu- should be made empirically based on the sions after they found 81.3% penicillin sen- above recommendations, because routine sitivity in their isolates from odontogenic culturing of maxillofacial infections is rarely abscesses, with the highest rates of resis- clinically useful. The use of culture swabs tance in staphylococci strains.(51) Other au- only help identify bacteria about a quarter of thors have also concluded that penicillin is the time,(55) and it does not lead to changes still effective against most pathogens found in antibiotic regimen in practice.(10) Furth- in odontogenic infections.(52) Based on more, culturing odontogenic infections may this data, however, it is fair to consider that needlessly increase the overall cost of treat- a failed antibiotic treatment may reflect the ment.(56) presence of penicillin-resistant bacterial species. A significant controversy concerns the prophylactic use of antibiotics for certain In a comprehensive review, Flynn rec- procedures in patient populations that pres- ommended that amoxicillin be used as first- ent an increased risk of developing a post- line treatment in the non-allergic patient with operative maxillofacial or systemic infection. an odontogenic infection not requiring hospi- Current guidelines by the American Heart tal admission.(53) For patients with allergies Association and the Academy of Orthopedic

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Surgeons recommend prophylactic antibiot- postoperative pain, fever, and need for anal- ics in specific circumstances for certain car- gesic medications.(67) The overall benefit of diac and orthopedic patients, respectively. prophylactic antibiotics for routine dental pro- These recommendations are controversial, cedures clearly continues to be controversial and providers should employ their own clini- in oral and maxillofacial surgery. cal judgment when using prophylactic antibiotics in these patients.(57) DEVESTATING MANIFESTATIONS OF MAXILLOFACIAL INFECTIONS Good communication between the or- thopedist and the treating oral and maxillofacial surgeon is critical in determining the In rare circumstances, maxillofacial in- appropriate use of antibiotics.(58) Patients fections can spread to neighboring regions of with immuno-compromising conditions may the body, causing potentially life-threatening also benefit from prophylactic antibiotics but, conditions for the patient. The oral and max- again, inadequate data exists to establish illofacial surgeon must be aware of the pos- clear guidelines.(57) sible morbidity and mortality risks associated with maxillofacial infection. Even more controversial is the routine use of prophylactic antibiotics for infection Descending Necrotizing Mediastinitis prevention in otherwise completely healthy patients. Most authors consider this practice Descending necrotizing mediastinitis unsupported by evidence.(57,59-61) How- (DNM) is a particularly dangerous and deadly ever, IV antibiotics administered immediately form of acute mediastinitis that can occur as prior to impacted third molar extraction de- a result of odontogenic infections spreading creases the risk of surgical site infections via the deep fascial spaces into the chest. (SSI).(62,63) Some have recommend peri- DNM can result in cellulitis, abscess, tissue operative intravenous antibiotics combined necrosis and sepsis.(68) It is often lethal,(69) with a postoperative course of oral antibiot- having a mortality rate of 40%.(70) Death oc- ics for all patients undergoing extraction of curs often as a result of delayed recognition impacted mandibular third molars in order to or proper treatment of the condition,(71) and prevent infections.(64) aggressive, multidisciplinary surgical treatment in addition to antibiotics is needed to Data on antibiotics’ effects on other reduce the high risk of mortality.(69,71) postoperative outcome measures has been mixed. Prophylaxis does not appear to improve wound healing, decrease pain or in- Cervicofacial Necrotizing Fasciitis crease mouth opening, or prevent alveolar osteitis or other postoperative inflammatory Cervicofacial necrotizing fasciitis (CNF) conditions.(61,65) However, other studies is a subtype of necrotizing fasciitis in which have demonstrated improved clinical recov- polymicrobial odontogenic infections spread ery with fewer postoperative visits in the pa- through the deep fascial planes of the neck tient treated with antibiotics.(66) Monaco, et causing severe necrosis. This condition clas- al. concluded that antibiotic prophylaxis not sically spares mucous membranes, and pro- only decreased postoperative infection rates gresses downwards from the face towards after third molar surgery, but also decreased

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the neck and chest.(72) Of these infections, ment being common given the associated 79.71% are of odontogenic origin.(73) CNF extensive soft tissue damage.(76) presents a diagnostic challenge because it is indistinguishable from other deep neck infec- Infection of the Orbit tions on contrast CT scans.(74)

It is a highly lethal condition, with a mor- Orbital involvement is another poten- tality rate reported between 7% and 20%, tially morbid consequence of maxillofacial even with proper treatment,(75) but nearly infections. Although uncommon, a maxillary 100% mortality without surgical intervention. odontogenic infection can extend into the or- (76) The condition is frequently associated bit through several pathways. The root tips with immuno-compromised patients such as of an infected maxillary tooth can cause si- those with diabetes mellitus or who are taking nusitis that tracks through the inferior orbital high-dose steroids.(75) However, necrotiz- fissure into the orbit. An infected maxillary ing fasciitis can occur in any type of patient, molar can travel posterolaterally into either and one case report has even described the the pterygopalatine or infratemporal fossae. condition in a 14-year-old boy after elective An infection can also gain entry into the pre- extraction of wisdom teeth.(77) Classic op- septal space through the eyelid, the angular erative findings include necrotic, grey fascia vein, or the inferior ophthalmic vein through with a “dishwater” fluid, little bleeding, and the pterygoid venus plexus.(79) minimal resistance to blunt dissection.(78) Occasionally DNM and CNF occur simulta- Patients with nephrotic syndrome and neously, in which case the mortality rate in- chronic antral inflammation, heroin addicts, creases from 41% to 64%.(75) and pregnant patients with an upper respira- tory infection are all particularly susceptible Predicting CNF is challenging, howev- to these types of infections. Consequences er, the laboratory risk indicator in necrotizing of orbital involvement of an odontogenic in- fasciitis (LRINEC) score is a validated meth- fection include vision loss, blindness, or ex- od to accurately predict the presence of this tension to the cranial cavity causing cavern- condition. Using six laboratory values (CRP, ous sinus thrombosis, meningitis, subdural total WBC, hemoglobin, sodium, creatinine, empyema, brain abscess or death.(80,81) and glucose), a score is assigned. A LRINEC Surgical drainage typically uses an approach score greater than or equal to 6 has a sensi- through the skin, although drainage through tivity of 0.94 and specificity of 0.95 in detect- a nasal antrostomy procedure has also been ing necrotizing fasciitis.(78) described.(82) Signs of orbital involvement, including proptosis or visual changes, should Surgical debridement is key, and the arouse immediate concerns in the oral and standard antimicrobial regimen includes a maxillofacial surgeon and prompt interven- triple-antibiotic therapy including a broad- tion. spectrum penicillin, an aminoglycoside or third-generation cephalosporin, and either Rare Maxillofacial Infections clindamycin or metronidazole.(76) Even with proper therapy morbidity is frequent, with Other exceedingly rare maxillofacial in- scarring, decreased function and disfigure- fections have been reported in the literature,

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including mucormycosis,(83-85) Aerococcus ticularly when presenting to general dentists. viridans,(86) Mycobacterium avium-intracel- (17) However, it is currently recommended lulare,(87) Cryptococcus neoformans ,(88) and that a tooth causing significant odontogen- Salmonella.(89) Often, infections of this na- ic infection should be extracted as soon as ture spread rapidly, require aggressive sur- possible. The longer a necrotic tooth is pres- gical management, and can result in severe ent, the greater the likelihood of developing illness or death. These infections are mostly significant complications and the higher the likely to develop in the severely immunocom- risk of mortality.(90) promised patient so, while rare, these types of infections should be considered as part of The anatomic location of a maxillofacial the differential in the patient taking certain infection is a predictor of the required treat- medications or with conditions that limit nor- ment. Infections of the upper face are likely mal immune response. to be successfully treated with antibiotics alone, while lower face infections are twice TREATMENT as likely to require surgical intervention.(41) Access to deeper spaces, including the parapharyngeal, lateral pharyngeal, peritonsillar, Surgical Management and Timing and retropharyngeal spaces present specific challenges. Rupture of the abscess can occur spontaneously, presenting a risk for aspi- Two important fundamental questions ration. Additionally, airway compromise is a have been raised in the past regarding man- more significant concern in these areas, so agement of the patient who presents emer- the surgeon should always be prepared for gently with an odontogenic infection: 1) if the urgent surgical airway intervention. Finally, patient has cellulitis without clear evidence of erosion of the abscess into major vessels or an abscess, should an incision and drainage direct extension into the mediastinum is pos- be performed? And 2) should the offending sible with the deeper infections.(91) tooth be extracted immediately, or is it pru- dent to wait for swelling to subside before extracting the tooth? Surgical incision and drainage is still the treatment of choice in these spaces. The peritonsillar abscess can be managed In regards to the first question, it is now through needle aspiration alone, and tonsil- accepted that whether or not there is radio- lectomy 6-8 weeks after drainage should be graphic evidence of abscess on CT, or if considered.(91) Lateral pharyngeal abscess- there are no clear clinical signs of abscess, es can be drained intraorally, extraorally, or a patient who presents with an odontogen- through a combination of both approaches. ic infection associated with facial swelling, (92) should have the infection drained surgically. (15) Alternative methods of drainage have also been described in the literature. Palpa- Historically, timing of tooth extraction ble abscesses have been evacuated percu- has also been a source of controversy. Pa- taneously using the modified Seldinger tech- tients presenting with odontogenic infections nique.(93) Yusa, et al. discusses success in are still frequently given a course of antibiotics using Doppler ultrasound in guiding percuta- without definitive surgical management, par- neous drainage of maxillofacial abscesses

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that are difficult to locate by physical ex- cothyrotomy, a technique that has historically amination alone,(94) particularly deep neck been avoided due to concerns of potentially infections.(95) When an abscess begins to causing tracheal stenosis, has been recently track into the mediastinum, CT guided drain- re-examined, and may also provide a safe age is a favored method.(95) and simple alternative to rapid airway access.(100) Use of Drains In certain cases of exceptionally severe infections—including, for example, maxil- Drains are frequently left in place after lofacial sepsis or odontogenic osteomyeli- incision and drainage of the odontogenic tis—long-term intravenous antibiotics may infection. There are several types of drains be indicated. In such an instance, the place- used, including Penrose, closed-suction, and ment of a peripherally inserted central cath- irrigating varieties. Johnson and Krishnan eter (PICC), may be safely used in either the found that silicone drains are easier to place inpatient or outpatient for administration of than Penrose drains, are more comfortable these antibiotics.(101) for the patient and are more easily irrigated. (96) Balloux, et al., however, found that irrigating a drain postoperatively does not de- ADDITIONAL MANAGEMENT CON- crease a patient’s LOS.(97) SIDERATIONS

Postoperative Infections Managing the Airway

Reducing risk of postoperative infection Proper airway management in the pa- is always a concern of the thoughtful oral tient with maxillofacial infections is critical and maxillofacial surgeon who is planning an due to the possibility of compromise in more elective procedure. However, given that oral advanced cases. Patients with severe odon- surgical procedures occur in a non-sterile togenic infections often require the expertise environment (the mouth), different consid- of an experienced anesthesiologist, and fi- erations must be evaluated by the treating beroptic intubation is the most commonly surgeon. For example, evidence suggests used technique in this patient population.(7) that wearing sterile gloves does not reduce Often times, the patient is intubated awake to the risk of postoperative complications, in- avoid further airway compromise, although cluding infection, after routine dental extrac- various sedatives, including dexmedetomi- tions,(102,103) or wisdom teeth.(104) dine (Precedex™), have been shown to be appropriate for helping to relax the patient Interestingly, although diabetes puts pa- while preserving their ability to maintain their tients at greater risk for maxillofacial infec- own airway during intubation.(98) tions, and traditional teaching suggests that poorly controlled diabetics are at greater risk Tracheotomy is rarely required in large for postoperative infections, other studies trauma centers when anesthesiologists are suggest that patients with inadequate diabe- readily available,(10) although it has been tes control may not necessarily be at risk for shown to be a relatively safe procedure delayed healing after extractions, particularly when a surgical airway is required.(99) Cri- if their blood glucose is less than 180 mg/dL.

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(105) without endangering the fetus.(107)

In the event of a delayed-onset infection Pregnant patients with chronic dental (around one month after a tooth extraction), infections are also at higher risk for pre-ec- surgical intervention may not be immediately lampsia, so a woman planning on pregnancy warranted. In fact, in such a case, a 7-day should have her dental disease addressed course of antibiotics should be administered beforehand to avoid complications of preg- before performing debridement of the extrac- nancy.(108) Despite the added perioperative tion site.(106) considerations in the gravid population, the actual surgical management is the same as The Pregnant Patient in the non-pregnant patient.(107)

CONCLUSION Management of the pregnant patient with a maxillofacial infection presents a number of unique concerns and challenges. Giv- Maxillofacial infections present a variety en the significant radiation associated with of challenges to the oral and maxillofacial sur- CT scans, MRI may be the preferred imaging geon. Aside from the difficulties associated modality. Although most antibiotics common- with identifying the source and extent of the ly used in the management of the maxillo- infection, the surgeon must also be aware of facial infection are safe, including penicillins the other host factors, including age, medical and cephalosporins, others, such as tetracy- history, and concurrent pregnancy, that may clines and metronidazole, should be avoided help predict the potential severity of the in- given their deleterious effects on the devel- fection and guide proper perioperative treat- oping fetus. Local anesthetics, including lido- ment. caine, can be used in the pregnant patient, including those containing epinephrine.(107) It is also important for the oral and maxillofacial surgeon to carefully consider proper Intubating the pregnant patient can be antibiotic treatment for a patient with a maxil- challenging. Given the capillary engorge- lofacial infection. Despite the constant evolu- ment and proliferation that normally occurs tion of bacterial defenses and ongoing devel- during pregnancy, bleeding is more likely opment of new antibiotics, this review should during intubation. Awake fiberoptic intubation serve as a reminder that many of the classes is especially favored in this population, given of drugs traditionally used to treat oral and the higher propensity for airway obstruction. maxillofacial infections, namely penicillins, Hyperemesis and superior displacement of remain effective today. the diaphragm also pose a greater risk of aspiration, and lateral decubitus position- ______ing should be used during surgery to allow adequate organ perfusion and allow adequate venous return.(107) Postoperatively, acetaminophen is the analgesic of choice, although opiates can be used safely in the short term to achieve adequate pain control

SROMS 13 VOLUME 23.3 Maxillofacial Infections A. Read-Fuller, DDS, MD, et al.

Dr. Andrew Read-Fuller is a resident Dr. Richard A. Finn received his DDS at Parkland Memorial Hospital / University degree from the University of Illinois College of Texas Southwestern Medical Center in of Dentistry in 1976. He completed his Oral the Division of Oral and Maxillofacial Sur- & Maxillofacial Surgry training from Parkland gery. He received his MD degree in 2014 Memorial Hospital in 1981. His academic ca- from the University of Texas Southwestern reer began at the University of Texas South- Medical School and is a Magna Cum Laude western Medical Center in 1981 and contin- graduate of the UCLA School of Dentistry ues at UTSWMC to date as a Professor in the in the concurrent DDS / MS program. Dr. Departments of Surgery and Cell Biology as Read-Fuller completed his undergraduate well as the Chief of Oral & Maxillofacial Sur- studies at Princeton University, where he gery at Veterans Administration North Texas earned his AB degree in Politics. Currently, Health Care Center. Dr. Finn has a long his- Dr. Read-Fuller is serving as Immediate Past tory of involvement in clinical and laboratory President of the Resident Organization of the based anatomical issues and studies. He American Association of Oral and Maxillofa- has been actively engaged in treating sleep cial Surgeons (ROAAOMS), and previously disordered breathing problems since 1990. served as President of this organization. Dr. Read-Fuller is interested in the broad scope of oral and maxillofacial surgery.

Dr. Andrew Mueller is a private practice surgeon in Wichita Falls, Texas. He trained at Parkland Memorial Hopsital/University of Texas Southwestern Medical Center in Dal- las in the Division of Oral and Maxillofacial Surgery. He received his MD degree from The University of Texas Southwestern Medi- cal School and is a Cum Laude graduate of Southern Illinois University School of Dental Medicine.

SROMS 14 VOLUME 23.3 Maxillofacial Infections A. Read-Fuller, DDS, MD, et al.

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