Phlegmon of the peri-rectal space and the floor of the oral cavity: causes, symptoms, diagnosis, treatment

Phlegmon near-minute space with periamigdalite lingual tonsil usually develops within 6-8 days, and against the background of antibiotic therapy, maturation of the abscess can be delayed up to 2 weeks, after which it is independently opened and all signs of periamigdalita of the lingual tonsil pass for 4-5 days.

Diagnosis in typical cases with acute onset, obvious signs of catarrhal inflammation and the development of a unilateral infiltrate with the subsequent formation of an abscess does not cause much difficulty. With sluggish flow, mild pain syndrome and fuzzy, inflammatory symptoms, the final diagnosis is not always possible from the first day of the disease. In this case, the periamigdalitis of the lingual tonsil should be differentiated from sarcoma and gum of the lingual tonsil, interstitial glossitis, and also from phlegmon of the sublingual-shchotonadgortan space.

Treatment in most cases is nonoperative (sulfonamides, antibiotics), which, with an early appointment, can provide the reverse development of the inflammatory process without suppuration. This is facilitated by physiotherapeutic procedures (UHF, laser therapy), as well as UV of blood, polymicrobial vaccination and other immunomodulating methods. In some cases, with increasing choking, a tracheotomy may be indicated.

Opening of the abscess (phlegmon) is made when the spontaneous emptying is delayed, and the clinical signs increase. After opening the abscess, antibacterial treatment is continued for another 3 days.

Phlegmon of the bottom of the mouth (angina Ludwig) - putrefactive necrotic phlegmonous process, the etiological factors of which are anaerobic streptococci,

Bacteria fusospirochetnoy association (B. Fusiformis, Spirochaeta buccalis), as well as staphylococcus, E. Coli, etc. A number of authors do not exclude a definite role in the occurrence of this disease and anaerobic clostridial microbiota. The source of occurrence of angina Ludwig in the overwhelming majority of cases are the lower carious teeth, gangrenous pulpitis, periodontitis; less often the infection can enter the cellulose of the bottom of the oral cavity from the crypt of the palatine tonsils or arise as a complication in the removal of a pathologically altered tooth.

Pathological anatomy. The pathoanatomical picture is characterized by extensive necrosis of the cellulitis, marked edema of the surrounding tissues and an increase in regional lymph nodes, often necrosis of the muscles located here (mm. Hyoglossus, mylohyoideus, venter anterior m. Digastrici), gas bubbles in them and a sharp putrefactive odor. The remaining tissues at the site of the cut are dry, dense, slightly bleeding. Instead of pus there is only a small accumulation of chorious liquid of the color of meat slops. As AIEvdokimov (1950) notes, the lack of propensity to purulent fusion of the affected tissues is an essential feature of Ludwig's angina, as a nosological form that distinguishes it from the banal phlegmon of the bottom of the mouth, which is characterized by profuse pus formation and which is incorrectly attributed to Ludwig's angina .

Symptoms and clinical course. The onset of the disease is manifested by chills, malaise, headache, pain in the bottom of the mouth with swallowing, loss of appetite, insomnia due to the growing rash pain in the inflammatory focus. The body temperature rises slowly and reaches 39 ° C or more only by the third day. The course of bolezii is usually severe and only in some cases it is of moderate severity.

A typical early manifestation of Ludwig's angina is a swelling in the submandibular salivary gland, characterized by a woody density. Hence the inflammatory process in severe cases quickly passes to the entire region of the bottom of the oral cavity and, descending on the neck, concentrates in the subcutaneous tissue. On the neck, the swelling extends to the clavicles, upward it covers the lower half of the face first, then spreads over the entire face and eyelids. The skin over the hearth in the first 2-3 days is not changed, then it becomes pale, then redness and individual bluish purple and bronze spots appear, typical for anaerobic infection.

Swelling of the tissues of the bottom of the mouth causes narrowing of the entrance to the pharynx, the voice becomes hoarse, speech is indistinct, swallowing is painful and difficult. Fabrics in the sublingual region swell and rise (symptom of the second tongue), the mucous membrane over them is covered with fibrinous coating. The tongue is enlarged, dry, covered with a dark brown touch, is inactive, located between the teeth. The mouth is half open, from it there is a putrid smell. The face is pale with a cyanotic or earthy tinge, expresses fear, the pupils are dilated. Breathing is intermittent, rapid, the patient feels a shortage of air. The position of the patient is compulsory, half sitting.

The general condition of the patient is progressively worse every day, there are tremendous chills and heavy sweats, darkened consciousness, delirium. At the same time, the hemoglobin content falls, with pronounced leukopenia marked by a sharp shift in the leukocyte formula to the left. With increasing general weakness, decreased cardiac activity and a picture of total sepsis, death may often occur at the end of the first, less often the second week.

Complications: pneumonia and abscess of the lung, asphyxia, mediastinitis, etc.

Forecast. In the pre-antibiotic period, mortality was 40-60%, the prognosis was serious. Currently, the forecast can be considered favorable.

Treatment. They produce early wide and deep intraoral cuts of lesions, opening of submaxillary spaces with infiltration of the whole space of the bottom of the oral cavity and other surgical interventions on the front surface of the neck. Wounds are carefully drained with thin rubber strips. During dressings, they are washed with solutions of antiseptics and appropriate antibiotics. The use of anti-gangrenous sera (Antiperfringens, Antiocdematiens, Antivibrionseptic), broad-spectrum antibiotics, especially active against anaerobes, sulfonamides. Intravenous appoint a transfusion of UV-irradiated blood, the administration of urotropine, calcium chloride; with severe leukopenia - leukocyte mass. Also used drugs that increase immunity, multivitamins, increased doses of ascorbic acid. Of great importance is oral care. The diet is predominantly vegetable-milk, plentiful drink. Bed rest should be observed until the complete rejection of necrotic tissues and the normalization of body temperature.