53. LIFE THREATENING COMPLICATIONS OF ABSCESSES AND CELLULITIS

what are the life threatening conditions of abscesses and cellulitis?

facial vein thrombosis

cavernous sinus thrombosis

mediastinitis

asphyxia

brain abscesses

what is facial vein thrombosis?

blood clot within the facial vein

what is the etiology of facial vein thrombosis?

acute odontogenic lymphadenitis

osteomyelitis

sialadenitis

sinusitis

abscesses

cellulitis

carbuncles

furuncles

what are the features of facial vein thrombosis?

hyperaemia- blue tone of skin

oedema of face

dilated subcutaneous veins

what are the general symptoms of facial vein thrombosis?

intoxication

fever

chills

weakness

what are key blood results in facial vein thrombosis?

increased white blood cells

increased fibrinogen (this is a major sign of a clot)

what is the goal of treatment for facial vein thrombosis?

limit the spread of infection and return the body conditions back to normal

what are the complications of facial vein thrombosis?

can cause sepsis or abscesses on organs

what are the treatment steps for facial vein thrombosis?

1. intensive antibiotics (broad spectrum augmentin + doxycycline)

2. anticoagulation therapy (2500-3000IU heparin every 4-6h)

3. acidum nicotinicum (50mg 1% twice daily decreases the clot risk)

4. incision and drainage of abscess

where is the cavernous sinus?

located in the middle cranial fossa on the lateral surface of the sella turcica

on the upper side, cranial nerves 3 and 4

on the outer side, cranial nerves 5 and 6

what passes through the cavernous sinus?

internal carotid artery and carotid plexus

what is the etiology of cavernous sinus thrombosis?

it is a complication of inflammation in the facial area

- otitis

- mastoiditis

- nasal and maxillary sinus issues

- odontogenic inflammation

- post- tooth extraction

- tonsillitis/pharyngitis

how does infection enter the cavernous sinus?

• infections in the upper lip/eyelids/forehead spread by the orbital veins

• infections on the face/sinuses/tonsils spread by the pterygoid venous plexus

what are the features of cavernous sinus thrombosis?

1. early stages

2. general syndrome

3. circulatory syndrome

4. neurological syndrome

what occurs in the early stages of cavernous sinus thrombosis?

mucous membranes go blue (cyanosis)

there is impaired blood vessel activity

what occurs in general syndrome of cavernous sinus thrombosis?

severe headache, eye pain

general weakness

fever

enlarged spleen

what occurs in circulatory syndrome?

swollen and hyperemic skin forehead and eyelids

swollen eye tissue

exophthalmus

what occurs in neurological syndrome?

cranial nerves 3,4,5,6 are affected

the eyes don't move

there is ptosis of the upper eyelid - levator palpebrae superioris muscles CN III

there is miosis/mydrias of the pupil - iris sphincter CN III

how do we diagnose cavernous sinus thrombosis?

clinical examination

neurology examination- increased cerebrospinal fluid with more proteins in it

what is the differential diagnosis for cavernous sinus thrombosis?

orbital phlegmon

but this does not cause changes in cerebrospinal fluid

what is the treatment for cavernous sinus thrombosis?

refer to hospital

1. sanitation of initial infection

2. antibiotic therapy- combined, use 2-3 antibiotics

3. antipyretics (ibruprofen/aspirin)

4. anticoagulants (heparin)

anticoagulants and antibiotic mortality reduced 15-28%

what are the complications of cavernous sinus thrombosis?

meningitis

cerebral abscess

sepsis

internal carotid artery thrombosis

blindness

what is mediastinitis?

this is inflammation of the mediastinum

where is the mediastinum?

in the central part of the thorax

between the lungs

what is the etiology of mediastinitis?

• a complication of a purulent infection in the floor of the oral cavity, parapharyngeal space or in the neck

• main causative agent staph+strep

• if causative agent enterobacter,klebsiella extremely severe

what are the main features of mediastinitis?

general infection of the body

- fever >40*C

- low BP

- tachycardia (140bpm)

- severe intoxication

what are specific signs of mediastinitis?

• Gerke's sign- when the patient turns their head they have intense pain behind the sternum

• retrosternal pain that worsens when deep breathing and swallowing

• fever 40 degrees

• arrythamtic 140 bpm

• breathing difficult shallow rapid 45-50 ppm

how do we diagnose mediastinitis?

clinical presentation

- the patient will present with their chin down, against their chest and legs because this relieves pain

3 radiographic projections

- shows an enlarged mediastinal shadow

differential diagnosis of mediastinitis

phlgemons of floor of oral cavity or neck

x ray findings show no mediastinum chnages

mediastiniits shows severe retrosternal pain

what is the treatment for mediastinitis?

mediastinotomy

intensive antibiotic treatment

detox therapy

what is asphyxia?

deprivation of oxygen

gas exchange is disturbed which causes choking

how does asphyxia occur?

inflammatory processes of the floor of the oral cavity or root of the tongue spread to cause compression and narrowing of the airways ( so called mechanial stenotic asphyxia )

what are the 5 stages of asphyxia?

1. pre-asphyxial stage

2. blue asphyxia stage

3. white asphyxia stage

4. terminal breath

5. terminal automatic heartbeat stage

what happens in the pre-asphyxia stage?

the oxygen deficiency causes rapid and deep breathing

the patient is still conscious

the patient has a pale skin colour

lasts 2-2.5 minutes

what happens in the blue asphyxia stage?

levels of oxygen decrease/carbonic acid increases lead breahting disorder

lips and nails cyanosis

arterial BP increases heart rate decreases

the patient is still conscious but they are frightened

lasts 30-40 seconds

what happens in the white (transient apnea) stage?

accumulation of cabronic acid leads to the respiratory muscles weaken leading to apnea

the patient is in and out of consciousness

the face turns a livid colour

this can be reversed

what happens in the terminal breath stage?

separate, deep breaths every 1-2 minutes

short inhale, deep exhale

what happens in the terminal automatic heartbeat stage?

the patient is unconscious

they stop breathing

the heart will still beat

this is biological death

what is the treatment for asphyxia?

if there is a severe phlegmon

- rapid treatment

- refer to hospital

- 8-12 L/min of oxygen

emergency tracheostomy under local anaesthesia

extensive opening of the infected area

what is purulent meningitis?

inflammation of the meninges

what is the etiology of purulent meningitis?

cellulitis of the infra temporal fossa after the cavernous sinus walls have been destroyed by purulent infection

- basically it is a severe complication of cavernous sinus thrombosis

what are the general features of purulent meningitis?

acute onset

39-40*C fever

severe headache

nausea

vomitting

what are the specific signs of purulent meningitis?

1. meningeal irritation syndrome

- headache (loud noises cause severe pain)

- neck rigidity

- Kernig's sign (when trying to straighten the legs, there is resistance)

- Brudzinki's sign (the head is abruptly bent forward and the legs flex up to the abdomen)

2. CSF syndrome

- cloudy, purulent CSF

- increase in CSF pressure

- protein in CSF

- less glucose in CSF

how do we diagnose purulent meningitis?

clinical presentation

lab tests- CSF in lumbar puncture

what is the treatment for purulent meningitis?

urgent consultation with a neurologist