Clinical anatomy and operative surgery of the head. Clinical anatomy of the cellular spaces of the face. Abscess and phlegmon of the sublingual region Odontogenic abscess of the maxillo-lingual groove differential diagnosis

Main sources and routes of infection
Foci of odontogenic infection in the area of the lower molars (including pericoronitis with difficult eruption of the lower third molars), infectious and inflammatory lesions and infected wounds mucous membrane of the floor of the mouth. Secondary damage occurs as a result of the spread of purulent inflammatory process from the sublingual area.

Rice. 10-20. The main stages of the operation of opening an abscess of the sublingual region: a - projection of the abscess to the bottom oral cavity, b - topography of the abscess (cross-section), c-f - stages of the operation.

Clinical picture
Complaints of pain in the throat or under the tongue, aggravated by talking, chewing, swallowing and opening the mouth.
Objective examination. The maxillo-lingual groove is smoothed due to the infiltrate occupying the space between the root of the tongue and the lower jaw. The infiltrate extends to the anterior palatine arch and can push the tongue to the opposite side. The mucous membrane over the infiltrate is hyperemic, palpation causes pain. Mouth opening is moderately limited (due to pain).
Ways of further spread of infection
Cellular spaces of the root of the tongue, sublingual, submandibular regions, pterygomaxillary space.
Technique for opening a maxillo-lingual abscess
groove

Anesthesia - local infiltration anesthesia in combination with conduction mandibular, torusal (according to Weisbrem) anesthesia.
An incision is made in the mucous membrane of the floor of the mouth at the level of the molars in the space between the base of the tongue and the alveolar edge lower jaw parallel and closer to the latter.
Layering with a mosquito hemostatic clamp soft fabrics along the inner surface of the mylohyoid muscle (i.e. mylohyoideus), move towards the center of the infiltrate, open the purulent-inflammatory focus, evacuate the pus, and introduce drainage into the wound.

Topographic and anatomical features of the maxillofacial area for practicing anesthesia techniques, surgical approaches for inflammatory diseases and injuries of the maxillofacial area

Of practical importance for dental practice are primarily The lymph nodes(nodi lymphatici, iymphonodi) face, neck (buccal, parotid, submandibular, cervical).

In the parotid region, superficial and deep nodes are distinguished. The first (non-permanent) 1-2 nodes are located in front of the external auditory canal, corresponding to the fossa that is formed against the head of the lower jaw when opening the mouth, directly under the fascia parotideo-masseterica.

Deep nodes(1-2) are located between the lobules of the parotid salivary gland, in front of the auditory canal at the height of the earlobe. In addition, 1-3 nodes, covered by the parotid salivary gland, are located below auricle(behind the angle of the lower jaw). The retroauricular nodes (1-4) are located in the mastoid region.

Buccal lymph nodes . Most of them are fickle, but worthy of attention. A small nodule is located in the sulcus nasolabialis at the height of the nasal openings, at the inner corner of the orbit or near the infraorbital opening. One or two cheek nodes are located in the tissue on the m.buccinator along the line connecting the corner of the mouth with the earlobe (4-5 cm outward from the corner of the mouth).

Supramandibular lymph nodes(1-2) are located in the tissue on the outer surface of the body of the lower jaw at the anterior edge of the masticatory muscle. Normally, on the corpses of adults they are found in the form of a small formation more often oval shape the size of a lentil grain. The buccal and supramillary lymph nodes differ in their typical location, but are not found in all people.

Submandibular lymph nodes 4 in number are located downwards and medially from the angle of the lower jaw, in the bed of the submandibular salivary gland. These nodes are divided into three groups: anterior, middle and posterior. They are distinguished by significant constancy in number and typical location - they lie outside the capsule of the salivary gland. Some authors describe the nodes lying inside. capsules of the submandibular salivary gland.

Submental nodes, usually 2-3, are located in the space between the anterior bellies mm.digastrici, jaw and hyoid bone.

The lymph nodes of the tongue are located deep between the genioglossus muscles and mm.hyoglossus, one on each side.

Numerous superficial and deep lymph nodes of the neck require special description. We only point out that they are defined in the form of chains along the anterior and posterior edges of the m.sternocleidomastoideus, along the jugular veins and other vessels, nerves and muscles.

Topographic anatomy of the infraorbital region.

The infraorbital region is located on the anterior facial surface of the body upper jaw. Its boundaries are: above - the lower edge of the orbit, below - alveolar elevations (jugae alveolarie) corresponding to the arch of the vestibule of the oral cavity, from the inside - the lateral border of the nose, from the outside - the zygomatic-maxillary suture in depth (zygomatic bone).

In the infraorbital region there is the quadratus muscle of the upper lip (m.guadratus labii superioris), the zygomaticus major muscle (m.zygomaticus major), the canine muscle (m.caninus) and the laughter muscle (m.risorius). There are loose layers of fat between the angular, infraorbital and zygomatic bundles of the quadratus muscle and other muscles; they serve as pathways along which it spreads purulent infection. In this regard, no less important is the abundant venous network anastomosing with the main veins (vv.ophthalmicae inferior et superior), as well as the rich innervation of this area from the second branch trigeminal nerve(n.infraorbitalis).

Topographic anatomy of the zygomatic region.

The boundaries of the zygomatic region correspond to the location of the zygomatic bone. In this area, in addition to subcutaneous fat, there are no accumulations of loose connective tissue, since the zygomatic bone serves only as a place for attachment of muscle fibers.

Topographic anatomy of the buccal region.

The buccal region corresponds to the location of the buccal muscle (m.buccinatorius), which fills the space between the upper and lower jaw. The buccal region is limited in front by the m.risorius, in the back by the anterior edge of the masticatory muscle (m.masseter), above by the edge of the zygomatic arch, below by the edge of the lower jaw. The cheek consists of: 1) skin; 2) subcutaneous fat with the subcutaneous muscle of the neck within the borders of the lower jaw and m.risorius at the border with the infraglaenic region; in the same layer passes the external maxillary artery with the anterior facial vein; 3) aponeurosis (fascia buccalies), which is a continuation of the parotid-masticatory muscle; 4) loose fatty tissue with a fatty lump of the cheek located under the aponeurosis, lymph nodes, nerves, duct of the parotid salivary glands (stenon ducts); 5) buccal muscle; 6) submucosal tissue; 7) oral mucosa.

The primary foci of phlegmonous inflammation of the cheek can be subcutaneous fat, buccal and supramandibular lymph nodes, and submucosal tissue. The fatty lump of the cheek (corpus adiposum buccae s.bulba Bichati), which is closely connected with the surrounding tissues both directly and through the lymphatic and blood vessels entwining it, is also important. Its inflammation with the subsequent development of the phlegmonous process can proceed quite violently, since this fatty lump is connected with its branches to the infratemporal and temporal fossa and partly to the pterygomaxillary space.

Topographic anatomy of the infratemporal and pterygopalatine fossae .

The infratemporal fossa is located in the lateral part of the base of the skull. The boundaries of the infratemporal fossa are: above - scallop big wing main bone (crista infratemporalis); in front - tubercle of the upper jaw (tuber maxillae); at the back is the styloid process with muscles extending from it; inside - the pterygoid process of the main bone and the lateral wall of the pharynx; outside - branch of the lower jaw; the lower border is located above the buccal-pharyngeal fascia (fascia buccopharyngea). Inward to the infratemporal fossa is the pterygopalatine fossa, which extends to the body of the main bone. These two fossae are so intimately connected that practically the phegmon of the infratemporal fossa, to one degree or another, captures the pterygopalatine fossa.

In practical terms, the anterior border of the infratemporal space deserves attention, namely the tubercle of the maxilla itself and its section up to the zygomatic-alveolar ridge. Here are the last two molars, over which anesthetics are usually injected to anesthetize the superior posterior alveolar nerves (m. Alveolares superiors posteriores).

The infratemporal fossa connects at the top with the temporal fossa, and through the infraorbital fissure with the orbit. Through the fatty layer coming from fat lump cheeks, the temporal fossa is connected with the buccal region, as well as with the pterygomaxillary space and the retromaxillary fossa.

Located in the infratemporal fossa, the branches of the I and III branches of the trigeminal nerve, the internal maxillary artery and the pterygoid venous plexus (plexus venosus pterygoideus) connect the infratemporal fossa with the adjacent fiber-rich areas of the superficial and deep parts of the face, as well as the cranial cavity.

Topographic anatomy of the temporal region.

The boundaries of the region are determined by the location of the temporalis muscle. The bulk of the muscle is located, as it were, in a case: the outside is covered by fascia, and the periosteum of the bony bottom of the temporal fossa is located below. The temporal muscle, together with the vessels and nerves located here, does not completely fill the temporal fossa; the remaining free spaces are filled with loose fatty tissue, in which the process is concentrated in cases of phlegmonous inflammation. This fiber is in direct connection with the fatty tissue of the subtemporal and buccal region.

There are superficial and deep layers of tissue in the temporal region. The first (superficial) layer is located between the skin and the temporal aponeurosis, and the second ( deep layer together with the muscle)—between the aponeurosis and the bottom of the temporal fossa.

It is noteworthy that the temporal aponeurosis, having reached the zygomatic arch, splits into two plates, one of which is attached to the outer and the other to the inner surface of the arch. The resulting space between the plates of the aponeurosis is filled with fiber, which can also suppurate with phlegmon.

An important anatomical and topographical feature is that the temporal muscle in its lower third outer surface adjoins the inner surface of the upper part of the masticatory muscle, and the inner one borders on the outer surface of the pterygoid muscle: the buccal muscle begins nearby. The spaces between the muscles are filled with fiber.

These anatomical features contribute to the spread of pus under the masticatory muscle and towards the peripharyngeal space and, conversely, from these areas pus can break into the temporal region.

Topographic anatomy of the maxillary lingual groove

The maxillo-lingual groove is a scaphoid-shaped depression 2-2.5 cm long and 1-1.5 cm wide, located in the posterolateral part of the sublingual region, immediately behind the ridge within the boundaries of the second and third, and sometimes the first lower molars, between the inner surface root of tongue

The distal edge of the recess ends at the base of the anterior palatine arch, where it passes from the lateral wall of the pharynx to the root of the tongue. The groove becomes clearly visible if you move the tongue in the opposite direction with a dental mirror or spatula.

Between the mucous membrane of the maxillo-lingual groove and its bottom, which is the diaphragm of the mouth (m.mylohyoideus), there is loose connective tissue tissue. The latter is usually the site of localization of the purulent process. This fiber envelops the lingual nerve passing here, the excretory duct of the submandibular salivary gland, and its process accompanying the duct on the upper surface of the mylohyoid muscle , as well as the hypoglossal nerve and lingual vein. The lingual artery is separated from the above formations by the hyoglossus muscle (m.hyoglossus).

The lingual nerve is located most superficially and closest to the jaw. After emerging from under the anterior edge of the internal pterygoid muscle, the lingual nerve lies on the upper surface of the mylohyoid muscle and, gradually deviating from the jaw, approaches the tongue. Approximately along the midline of the groove, the lingual nerve crosses, bending around from below, the excretory duct of the submandibular salivary gland and then enters the mass of the tongue.

The intersection of the lingual nerve with the excretory duct is most often located corresponding to the second large molar. Before the chiasm, the nerve lies very superficially and is covered only by the mucous membrane and a thin layer of loose connective tissue.

The occurrence of an abscess in the maxillo-lingual groove is associated with the introduction of pyogenic microbes into the tissue of this area, mainly from infected lower molars (with pericementitis) and surrounding tissues.

The routes for the spread of infection can be both the lymphatic system and the venous system, connecting the periodontal tissues with distant areas, in particular with the tissue of the maxillo-lingual groove, where there is a rich venous network. Thrombophlebitis of its individual branches can be the cause of the formation of an abscess in the groove, which was established by research at our clinic (S.V. Lanyuk). Per continuitatem, the inflammatory process in the area of the maxillo-lingual groove can pass with periostitis and ostiomyelitis of the mandible.

Topographic anatomy of the submandibular triangle.

In the center of the submandibular triangle is the submandibular salivary gland with adjacent regional lymph nodes and the external maxillary artery and anterior facial vein passing here. The anatomical boundaries of the triangle are expressed quite clearly. Its outer border is the lower edge of the body of the lower jaw, the other two sides are represented by the anterior and posterior bellies of the m.digastrici. From above, the triangular space is covered with the mylohyoid msiwtq? located below in layers: skin, subcutaneous tissue with m.platysma and superficial

Peripharyngeal cellular space(spatium parapharyngeum)

The space is closed on the outside by the parotid gland with its fascia - the interpterygoid fascia with the medial pterygoid muscle, and on the inside by the visceral fascia enveloping the pharynx with the adjacent mm. tensor et lavator veli palatini. In front, the space is limited as a result of the fusion of its outer and inner walls accordingly raphe pterygomandibulare. At the back, it is separated from the retropharyngeal space by spurs of the visceral fascia (spurs of Charlie), following from. lateral surfaces of the pharynx to the prevertebral fascia. The peripharyngeal space is divided into anterosuperior and posterior lower section s a septum formed by the styloid process with the muscles of the Riolan bundle extending from it (mm. styloglossus, stylohyoigeus, stylopharyngeus), ligaments (lig. stylomandibulare, lig. stylohyoideus) and the aponeurosis surrounding all these elements.

Through the fiber of the anterior section pass a. palatina ascendes and accompanying vein. With tonsillitis, the vein that receives blood from the palatine tonsils can be the site of the onset of thrombophlebitis and the formation of phlegmon. From here the process can spread to the veins of the face and further to the jugular veins. Through the fiber accompanying m. styloglossus, infection from the peripharyngeal space sometimes spreads to the bottom of the mouth. Having destroyed the relatively thin fascial membrane, pus can penetrate from the parotid gland into the adjacent peripharyngeal space.

The internal carotid artery, the internal jugular vein, glossopharyngeal (IX), vagus (X), accessory (XI) and hypoglossal (XII) nerves, borderline trunk of the sympathetic nervous system, represented by the superior ganglion, and lymphatic pathways with nodes that are concentrated along the vein. Along the vascular vagina, the inflammatory process can spread to the neck, which is observed with the development of putrefactive and gas infections.

Retropharyngeal cellular space(spatium retropharyngeum)

The retropharyngeal cellular space is located behind the pharynx, enveloped in visceral fascia. “Behind it is limited by the prevertebral fascia, on the sides by the fascial spurs of Charpy. According to A.V. Chugai, the retropharyngeal space is divided into right and left by a septum running from the pharyngeal suture to the prevertebral fascia. This explains the development of a unilateral retropharyngeal abscess. The space extends upward to the base of the skull. Below, at the height of the VI-VII cervical vertebra, there are often connective tissue constrictions following from the place where the pharynx passes into the esophagus to the prevertebral fascia. This somewhat delays the progression of the inflammatory infiltrate into the tissue behind the esophagus.

Abscess of the sublingual ridge

Complaints. Children complain of pain on one side of the sublingual area, which increases with swallowing and tongue movement.

Clinic. Mouth opening is free. In the middle section of the sublingual region at the level of the incisor, canine and premolar, dense and sharply painful swelling and infiltration of the tissues of the sublingual ridge are detected. The mucous membrane over them is hyperemic and edematous. It is possible that swelling may spread to the tissues of the lateral surface of the tongue and the alveolar process of the lower jaw. An abscess of the sublingual ridge is accompanied by regional lymphadenitis.

Surgery. The abscess is opened from the side of the oral cavity in the projection of the middle section of the sublingual region. Distal to the sublingual ridge, closer to the lingual surface of the jaw, only the mucous membrane is dissected, since the duct of the submandibular salivary gland and the lingual artery pass deeper. Then, using a “mosquito” type clamp, they penetrate deep into the inflammatory focus. The wound must be drained with rubber strips.

Abscess of the maxilloglossal groove

Complaints child - painful limited opening of the mouth, acute pain when swallowing and chewing food, as well as deterioration in health (weakness, decreased appetite, increased body temperature).

Clinic. A pathognomonic sign of an abscess of the maxillo-lingual groove is difficult, painful opening of the mouth (trismus of varying severity). Due to the limited opening of the mouth, it is necessary to carry out Berche anesthesia or put the child under anesthesia, after which it is possible to examine and open the source of inflammation. When examining the maxillofacial

the lingual groove is not defined (smoothed) due to swelling and infiltration of the tissues of this area. The mucous membrane here is swollen and hyperemic. Palpation of tissues is sharply painful. The “causal” tooth is usually discolored or partially or completely destroyed, the mucous membrane around it is hyperemic and painful on palpation. Concomitant is regional lymphadenitis of the submandibular and retromandibular region.

Surgery. Carrying out surgical intervention under local anesthesia for an abscess of the maxillo-lingual groove is possible only if the mouth is opened satisfactorily. The autopsy is usually performed under anesthesia. The mucous membrane is dissected parallel to the body of the lower jaw and closer to it. This is due to the fact that the lingual artery and vein are located medially and rather superficially. Next, using a mosquito-type clamp, they penetrate into the site of inflammation and empty it. In this case, the surgeon’s fingers should press the tissue in the distal part submandibular region up. Opening the abscess of the maxillo-lingual groove does not give desired results in cases where the exudate descends downwards into the pterygomaxillary space, where the focus of inflammation can move, as evidenced by pain and the presence of infiltrate in the projection of the angle of the lower jaw and behind it. This requires an additional tissue incision in this area extraorally along the line of “safe” incisions and prolonged drainage of the wound.

Abscesses of the infraorbital region and canine ovary

Abscess of the infraorbital region

The infraorbital region includes tissues located within the following boundaries: above - the infraorbital margin, below - the projection onto the skin of the transitional fold of the upper vestibule of the mouth, outside - the zygomatic-maxillary suture, inside - the wing of the nose. The causes of the development of an abscess in the infraorbital region are the 14th, 13th, 12th, 22nd, 23rd, 24th teeth.

Complaints children - on sharp pain and the presence of swelling of the tissues of the infraorbital region.

Clinic. Swelling and painful inflammatory infiltration of the tissues of the infraorbital region are determined; the skin over it is hyperemic and does not fold. When swelling spreads to the eyelids, they are tightly closed. There may be symptoms of infraorbital nerve irritation. Mouth opening is free. In the mouth you can see a “causal” discolored or destroyed tooth with a hyperemic, edematous mucous membrane around it. Palpation of the area is painful.

Surgery. The opening of an abscess in the infraorbital region is practically no different from that for an abscess of the canine fossa. The only difference is that to reach the source of inflammation, the clamp is moved closer to the lower orbital edge, which is fixed from the outside with the surgeon’s finger.

Section 3

Canine fossa abscess

Below the infraorbital region is the canine fossa, which is the anterior wall of the maxillary sinus.

The inflammatory process in the canine fossa occurs from temporary or permanent upper canines and first premolars, and less commonly from incisors.

Complaints children - for pain in the affected area and deformation of the tissues of the cheek and nasolabial fold. The clinical course of the process initially resembles acute purulent periostitis of the upper jaw.

Clinic. During the examination, swelling of the infraorbital and medial buccal region, upper lip is determined, passing on the affected side to the lower and sometimes upper eyelid. The nasolabial fold is smoothed, the wing of the nose is slightly raised. The skin is of normal color, palpation of the area, especially bimanual (simultaneously from the skin and vestibule), causes pain. The opening of the mouth is free, the transitional fold of the upper vestibule is smoothed, its mucous membrane (from the side of the cheek and the transitional fold) is hyperemic and swollen. The “causal” tooth (13, 23,53, 63, 14, 24) is usually destroyed or filled, its percussion is painful.

Surgery abscess of the canine fossa consists of a tissue incision made above the transitional fold of the upper vestibule and parallel to it. Next, adhering to the bone, they penetrate into the canine fossa, where the source of inflammation is localized, and drain it with a rubber outlet.

Abscesses and phlegmons of the buccal area

The boundaries of the buccal region correspond to the places of attachment of the buccal muscle: above - the lower edge of the zygomatic bone, below - the lower edge of the lower jaw, in front - the nasolabial fold and its continuation to the edge of the lower jaw, behind - the anterior edge of the masticatory muscle.

The causes of abscesses and phlegmons of the buccal area are the spread of infection from the molars of the upper jaw, as well as from the infraorbital and parotid-masticatory area, post-traumatic festering hematoma or an abscessed form of boil. Cheek abscesses in children can occur against the background of inflammation of the fatty body of the cheek and the lymph node located in it (sometimes these processes are called “bishaites”).

Complaints children with a cheek abscess - for the presence of tissue deformation, pain that increases with touch.

Clinic. During the examination, a rounded, limited, painful infiltrate is revealed in the thickness of the cheek, the swelling of the tissues around it is insignificant, the skin is fused with the infiltrate, is clearly hyperemic, and does not fit well into the fold. A fluctuation can be observed in the center of the lesion. Opening the mouth is somewhat difficult due to pain and infiltration of the cheek tissue. This is why the child limits the opening of his mouth. The mucous membrane of the cheek is hyperemic, edematous, sometimes with teeth marks on it. During the odontogenic process, the tooth is discolored and its crown part is partially or completely destroyed. The surrounding mucous membrane is swollen, hyperemic, and painful on palpation.

Complaints of children with phlegmon cheeks - sharp pain that intensifies when opening the mouth and chewing, as well as significant deformation of the tissues of the cheek, eyelids, upper and sometimes lower lip.

Clinic. The child's general condition worsens significantly - adynamia, lack of appetite, sleep disturbances, and increased body temperature are observed.

During the examination, diffuse swelling of the tissues of the buccal, infraorbital areas, eyelids, nasolabial folds, upper and lower lips is revealed. The skin in these areas is red, shiny, and does not fold. The child's mouth opening is limited and painful. Swelling and hyperemia of the mucous membrane of the cheek, upper and lower vestibule of the mouth are observed; Often, tooth marks are visible on the mucous membrane.

From the buccal area, the purulent process can spread to the parotid-masticatory, temporal area and to the upper lip.

Surgery. For abscesses and phlegmon of the buccal region (regardless of their location - closer to the skin or to the mucous membrane), for aesthetic reasons, an incision is most often made from the side of the oral mucosa in the area of the upper vestibule or below the level of closure of the teeth, taking into account the location of the parotid duct. The wound should be drained using drainage with a border and fixed in the wound with a suture.

Cellulitis of the floor of the mouth

The diaphragm of the floor of the mouth is formed by the mylohyoid muscle, located between the halves of the lower jaw and the hyoid bone. On both sides of the midline above the diaphragm are the geniohyoid and genioglossus muscles, and under the diaphragm are the anterior bellies of the digastric muscles.

The muscles located behind the diaphragm, as well as the above-mentioned muscles and tissue of the mouth, are connected with all the tissue spaces of the maxillofacial region and neck. This is of particular importance in children, since their aponeurotic septa do not tightly separate the boundaries of anatomical and topographical regions. That is why the inflammatory process in one of them (above or below the diaphragm of the floor of the mouth) tends to spread and all Clinical signs phlegmon of the floor of the mouth (Fig. 49).

From the point of view of the onset of the inflammatory process in the area of the floor of the oral cavity, it is important to divide it into two “floors”:

1st “floor” is the tissue located between the mucous membrane and the diaphragm of the mouth;

2nd “floor” - tissues located between the diaphragm and the skin of the submental area.

The clinical and topographic boundaries of the floor of the oral cavity are:

Section 3

Inflammatory diseases of the maxillofacial area

Upper - oral mucosa;

Lower - the skin of the right and left submandibular and submental areas;

Posterior - the root of the tongue and the muscle attached to the styloid process;

Anterior - the inner surface of the body of the lower jaw.

The cause of phlegmon in the floor of the mouth is usually odontogenic. The tops of temporary and permanent teeth the lower jaw from the incisors to the first molar are located above the diaphragm of the floor of the mouth and cause an inflammatory process in this area, and the apices of the roots of the second molars are below the diaphragm. Therefore, depending on which tooth (incisor, premolar, molar) is the cause of the inflammatory process, the latter begins to develop above or below the diaphragm of the mouth. Thus, when the odontogenic inflammatory process spreads from the 35, 45, 75, 85 teeth, the focus is initially localized in the sublingual region, that is, above the diaphragm, and from 36, 46 - under the diaphragm.

Complaints the child or his parents - for the presence of painful swelling of tissues in the bottom of the mouth, difficulty swallowing (inability to eat), increased body temperature, headache, lethargy, weakness.

Clinic. When the source of inflammation is localized above the diaphragm, during examination, the child’s characteristic appearance is: the mouth is half open, saliva flows freely from it, it is felt from the mouth bad smell. Mouth opening is limited due to pain. Changes in skin color, swelling and infiltration of soft tissues of the submental area are not detected. In the oral cavity, you can see the tongue raised upward due to swelling of the tissues of the sublingual area, covered with a grayish coating. The mucous membrane of this area is hyperemic, palpation is sharply painful.

If the source of inflammation is localized under the diaphragm of the floor of the mouth (2nd “floor”), the clinical signs are as follows: the skin of the face is pale, gray in color, the face has a suffering appearance. The mouth is half open, saliva flows out of it due to painful swallowing. The skin of the submandibular and submental areas is tense, shiny, and hyperemic. Palpation reveals a diffuse, dense, painful infiltrate. Regional lymph nodes are enlarged, painful, but not clearly palpable due to the presence of infiltrate. The “causal” tooth is destroyed, percussion is painful. The sublingual ridge is infiltrated and rises above the lower teeth, painful on palpation. The mucous membrane here is hyperemic and covered with fibrinous plaque. Possible respiratory failure, including asphyxia, due to compression of the trachea by swollen and infiltrated tissues of the floor of the mouth, and posterior displacement of the root of the tongue. The inflammatory process can spread to the pterygomaxillary and peripharyngeal spaces, and the anterior mediastinum.

Surgery such a child must be performed only in a hospital setting, and the operation must be performed under general anesthesia.

The size of the incision and its line are determined by the localization of the inflammatory process, its spread and the creation of conditions for effective outflow of exudate.

If the source of inflammation is localized above the diaphragm, it can be opened using intraoral access, but given the rapid spread of the book-

So, it is advisable to make an extraoral incision. The opening of the inflammatory focus, if it is localized on the 2nd “floor,” is carried out along the midline or in the projection of the future upper skin fold (arcuate), or in the submandibular region along the line of “safe” incisions.

When inflammation spreads to the submandibular region, an arcuate tissue incision is made in the projection of the future skin fold parallel to the edge of the lower jaw. This fold is defined as follows: a horizontal line is conventionally drawn, which runs along the conical ligament parallel to the edge of the body of the lower jaw to the anterior poles mastoid processes. That is, along the fold formed when the head is tilted downwards. This line is the upper border of the neck. The tissue is cut along it.

Drug treatment should begin not with antibiotic therapy, but with detoxification, since what younger child, those more dangerous than the investigation intoxication. The criterion for improving the child’s condition in postoperative period is to reduce signs of intoxication.

Anaerobic phlegmon of Zhansul-Ludwig

The course of the disease is due to the participation of anaerobes in its development. (Clr. Perfringens, Act. Hystoliticus, Act. Aedematiens, Clr. Septicum, nonsporogenous anaerobes). With Ludwig's angina, all tissues of the floor of the mouth, as well as the pterygomaxillary and peripharyngeal spaces are involved in the process (Fig. 50). Inflammation develops rapidly. It is extremely rare in children, but is very dangerous. In the clinic of this disease symptoms of intoxication prevail over local manifestations.

Zhansul-Ludwig phlegmon is characterized by the following pathognomonic symptoms:

1. Tissue crepitation.

2. Rapid spread of infiltrate down to the neck and anterior mediastinum.

3. Absence (in case of non-attachment of banal microflora) of pus during
opening of phlegmon.

Treatment It is advisable to carry out Ludwig's tonsillitis in a ward intensive care. First, the focus of inflammation in the tissues of the floor of the mouth is opened using the same access as for phlegmon of this area. The child is given local continuous dialysis of the wound with solutions of oxygen-releasing liquids (peroxide

Section 3

Inflammatory diseases of the maxillofacial area

Hydrogen, potassium permanganate), chlorhexidine and other antiseptics. To speed up wound cleansing, it is washed with proteolytic enzymes. In addition to antibacterial, detoxification, antihistamine, restorative and vitamin therapy, it is mandatory to administer to the child an anti-gangrenous polyvalent serum containing antitoxins against all causative agents of gas gangrene. If the process extends downwards to chest, then a thoracic surgeon takes part in the treatment of such a patient, draining the mediastinum. Antibacterial therapy should include antibiotics of the 4th-5th generations, for example thienam.

Abscesses and phlegmons of the pterygomaxillary space

The pterygomaxillary space is located between the inner surface of the ramus of the lower jaw and both pterygoid muscles; behind it is partially covered by the parotid salivary gland. The pterygomaxillary space has a very limited volume. Filled with loose fiber, it connects with the retromandibular region and the anterior part of the peripharyngeal space, with the temporal, infratemporal and pterygopalatine fossae, with the submandibular triangle, which explains the possibility of the inflammatory process spreading to these areas. The development of abscesses and phlegmons here is caused by inflammatory processes in the 36, 37, 46, 47 teeth, difficult eruption of the lower wisdom teeth in adolescents, as well as hematomas that fester after mandibular anesthesia.

Complaints children with abscesses of the pterygomaxillary space - pain that increases with chewing and (sometimes) swallowing, progressive limitation of mouth opening. Inflammatory phenomena do not increase as quickly as with phlegmon.

Clinic. During examination, facial asymmetry is usually not observed. Palpation can reveal enlarged, painful lymph nodes in the submandibular triangle. Opening the mouth is impossible due to third degree contracture. After Bersche anesthesia, hyperemia and swelling of the mucous membrane along the pterygomaxillary fold are observed in the oral cavity, and on palpation a sharply painful limited infiltrate is observed. The “causal” tooth is destroyed, percussion is painful.

Complaints of children with phlegmon pterygomaxillary space - sharp pain in the area of the jaw angle that intensifies when swallowing and opening the mouth, weakness, headache.

Clinic. Since the symptoms of intoxication in a child increase quickly, pallor occurs skin, body temperature rises significantly. The swelling of the tissues at the angle of the lower jaw is objectively determined, and here you can palpate a dense painful infiltrate and a package of enlarged lymph nodes. Mouth opening is sharply limited due to the involvement of the medial and lateral pterygoid muscles in the inflammatory process and is possible only after the child has been put under anesthesia. During examination in the oral cavity, hyperemia and swelling of the pterygomaxillary fold and palatine arch are observed, sometimes the swelling spreads to the lateral wall of the pharynx. The “causal” tooth is destroyed, percussion is painful.

Surgery. Opening of abscesses of the pterygomandibular space is carried out using an extraoral approach along the lines of “safe” incisions in the submandibular region. The skin, subcutaneous fatty tissue, and superficial fascia of the neck are dissected and, having reached the bone in the area of the angle of the lower jaw, adhering to the inner surface of its branch, they bluntly penetrate into the pterygomaxillary space with a mosquito-type clamp. The wound must be drained deeply and for a long time, and the “causal” tooth is removed.

Abscesses and phlegmons of the temporal region

The boundaries of the temporal region correspond to the line of attachment of the temporal aponeurosis: below and in front is the zygomatic arch, the temporal plane formed by the temporal, parietal and sphenoid bones, the upper and posterior is the temporal line. The temporal muscle divides the region in depth into two sections - superficial (located between the skin and muscle) and deep (located between the muscle and bone).

Inflammatory processes in the temporal region usually occur secondaryly, with the spread of infection from the buccal, parotid-masticatory region, pterygomaxillary and peripharyngeal spaces, from the infratemporal and pterygopalatine fossae. In young children they occur as a result of staphylococcal or streptococcal skin lesions in the temporal region.

The anatomical structure of the tissues of the temporal region, a small amount of subcutaneous fatty tissue, the slope of the temporal bone, and the tight attachment of the aponeurosis to it determine the development of phlegmons more often than abscesses.

Complaints children with superficial phlegmon - for rapidly increasing intense throbbing pain, limited mouth opening, swelling of the tissues of the temporal region. Usually, with phlegmon of the temporal region, parents of sick children seek help immediately - they are frightened by the localization of the process and the dysfunction of mouth opening.

Clinic. The examination reveals mild deformation of the tissues above the zygomatic arch and collateral edema extending to the parietal and frontal regions. The skin over it is hyperemic, shiny, and does not fold. Palpation reveals a dense painful infiltrate of the temporal region. If the application is early, then there is no pus yet, there is no fluctuation. The child's mouth opening is limited. In the oral cavity above the transitional fold in the projection of the tubercle of the upper jaw, tissue soreness is determined by palpation.

Deep phlegmon of the temporal region is rarely observed in children. In such cases, deformation of the soft tissues does not occur, and mouth opening is sharply limited. This is a pathognomonic sign of deep phlegmon of the temporal region. Quite often, in children, phlegmon of the temporal region is the cause of the spread of the inflammatory process to the infratemporal region, while in adults, phlegmon more often develops along its length, from the infratemporal to the temporal region.

Surgery. Opening of superficial abscesses and phlegmons of the temporal region is carried out by making an incision in the skin, subcutaneous fatty tissue in the lower part of the inflammation (above the zygomatic arch parallel to it) in order to create conditions for effective outflow of exudate. The latter is usually serous, which is associated with early surgical intervention at the stage of serous inflammation. The wound must be drained.

Section 3

Inflammatory diseases of the maxillofacial area

With deep phlegmon, an arcuate incision is often made along the temporal line and bluntly penetrated under the temporal muscle with a mosquito-type clamp. Sometimes the described incision is combined with an incision above the zygomatic arch.

Abscesses and phlegmon of the infratemporal fossa

The infratemporal fossa is located near the base of the skull, medial from it is the pterygopalatine fossa, which connects to it. There are no anatomical structures separating the fossa. Through the inferior orbital fissure, the pterygopalatine fossa connects with the orbit, and through the foramen rotundum - with the cranial cavity.

The inflammatory process in this area can develop more often against the background of hematomas resulting from incorrect technique carrying out tuberal anesthesia in older children, as well as when the inflammatory process spreads from the pterygomaxillary and peripharyngeal spaces. The “causal” teeth may be the upper molars.

Phlegmon of this localization is characterized by a discrepancy between the local signs of the disease and its severity general reaction body.

Complaints child - painful opening of the mouth, headache, loss of sleep and appetite, high temperature bodies.

Clinic. The general condition of the child is significantly changed (intoxication phenomena), although external clinical manifestations due to the deep localization of the source of inflammation are not pronounced. Facial asymmetry is observed due to slight swelling of the tissues of the temporal region, slight swelling of the cheek and zygomatic areas, and sometimes of the lower eyelid. The skin over the swelling is of normal color, mobile, mouth opening is limited, painful. When examining the oral cavity, swelling and hyperemia of the mucous membrane of the upper vestibule and a painful palpation infiltrate behind the tubercle of the upper jaw are observed, which is the leading clinical symptom for abscesses and phlegmon of this localization. The “causal” tooth is destroyed, percussion is painful.

Surgery carried out in a hospital setting under general anesthesia. The “causal” tooth is removed. The incision for phlegmon of the infratemporal fossa is made above the transitional fold of the upper vestibule and bluntly penetrates in the direction back-up-deep along the surface of the bone of the tubercle of the upper jaw to the projection of the mandibular notch. Intervention is carried out as soon as possible after diagnosis. It is with this localization of phlegmon that a very important condition is to establish an adequate and prolonged outflow of exudate through the drainage in order to prevent the spread of the process into the pterygopalatine fossa, access to which is much more difficult.

Abscesses and phlegmons of the parotid-masticatory area

The parotid-masticatory region is located between the lower edge of the zygomatic bone and arch, the lower edge of the body of the mandible, the anterior edge of the masseter muscle and the posterior edge of the ramus of the mandible.

In this area, older children more often develop abscesses and phlegmons from the 36, 37, 46, 47 teeth, and younger children - non-odontogenic abscesses and phlegmons associated with the involvement of lymph nodes in the inflammatory process or developing due to the spread of pus as a complication

purulent mumps or Herzenberg's pseudomumps. Isolated phlegmon of the masticatory area is very rare in children.

With non-odontogenic abscesses and phlegmons of this area in children, we usually talk about superficial processes that develop as a result of skin damage or suppuration of hematomas.

Complaints. With an abscess of this localization, children complain of pain, swelling of tissues in the parotid-masticatory area and difficulty opening the mouth, increased body temperature, and headache.

Clinic. The general condition is often disturbed - the face is pale, the child is restless. During the examination, facial asymmetry is detected due to tissue swelling in this area. A dense painful infiltrate is palpated there, the skin over it is tense and hyperemic. Fluctuation may not be observed due to the location of the purulent focus under the fascia and masseter muscle. The opening of the child's mouth is somewhat limited and painful. The mucous membrane of the cheek is edematous. There are teeth marks on it. If the inflammatory process is of odontogenic origin, then in the oral cavity you can usually see the “causal” tooth changed in color, its crown part is completely or partially destroyed; percussion of the tooth is painful, the mucous membrane around it is swollen and hyperemic. The criterion for determining a superficial or deep abscess of the parotid-masticatory region is a violation of the chewing function with deep and the presence of deformation of the contours of the face in this area - with a superficial abscess.

Depending on the cause of the inflammatory process, for example, purulent parotitis, the symptoms of this disease are clinically determined. Complaints. With phlegmon of the parotid-masticatory area, children complain of significant painful swelling of the tissues, the pain intensifies when opening the mouth. This often leads to food refusal. Worried about headache, weakness, increased body temperature.

Clinic. The child's general condition is significantly impaired - he is lethargic, adynamic, and has a pale face. Upon examination, a sharp asymmetry of the face is observed due to widespread swelling of the tissues of the parotid-masticatory area, the skin over it is tense and hyperemic. Palpation reveals a sharply painful infiltrate, in the center of which fluctuation can be detected. Mouth opening is limited due to contracture of the masticatory muscle and is painful. The mucous membrane of the cheek on the affected side is swollen, with imprints of teeth. If the cause of the development of phlegmon is a tooth, then the examination reveals a change in the color of its coronal part to gray; it may be partially or completely destroyed. The mucous membrane around the tooth is hyperemic, its palpation is painful.

In differential diagnosis, a purulent process in the parotid salivary gland, festering preauricular fistulas and festering atheromas should be excluded. The most important thing is to detect changes in the quality and quantity of saliva.

Surgery. If the source of inflammation is located in the lower parts of the parotid-masticatory region, then the incision is made from the submandibular or retromandibular regions, below the angle of the jaw. In this case, there is no need to dissect and (even more so) cut off the lower section of the chewing tooth from the jaw

Section 3

Inflammatory diseases of the maxillofacial area

muscles. When involved in pathological process of the parotid salivary gland, it is advisable to open the lesion from the side of the oral cavity above or below the line of closure of the teeth, so as not to injure the duct gl.parotis. If a salivary fistula forms during treatment, it will open into the oral cavity. If the source of inflammation is located superficially, it is opened along the preauricular fold.

Abscess of the retrobulbar space

The fiber in the retrobulbar space is located evenly around the eyeball and in the distal part connects through the inferior orbital fissure with the fiber of the pterygopalatine fossa. In children, abscess of the retrobulbar space occurs more often with hematogenous and less often with odontogenic osteomyelitis. It's connected with anatomical features the lower orbital margin, the high location of the maxillary sinus and the insignificant height of the space from the lower orbital margin to the canine fossa, as well as the porosity of the bone of the upper jaw in children, a small amount of inorganic substances in their composition, a rich network of collaterals located in the tissue.

Complaints child - for increasing throbbing pain, protrusion of the eye, headache, blurred vision (diplopia, flickering “midges”).

Clinic. Upon examination, inflammatory swelling of the eyelids and a bluish tint of the skin due to congestion are determined; swollen conjunctiva protrudes between the closed eyelids (chemosis). The mucous membrane of the conjunctiva is hyperemic and edematous. Exophthalmos is observed. Pressing on eyeball painful, his mobility is limited. In advanced cases, vision deteriorates and changes appear in the fundus. When examining the latter, dilation of the retinal venules is noted.

An abscess of the retrobulbar space may be complicated by the spread of infection to meninges, sinuses, brain, cause atrophy optic nerve and blindness. An increase in collateral edema of the eyelids with its development on the healthy side, deterioration of the general condition and intoxication can sometimes indicate the development of thrombosis of the cavernous sinus.

Surgery. To open the focus of inflammation in the retrobulbar space, under anesthesia, the skin of the infraorbital region is pulled back so that the scar is hidden under the lower eyelid, the skin and subcutaneous tissue are dissected, retreating to the middle from the marginal edge of the orbit. Then, using a clamp, they bluntly penetrate into the depths of the orbit, adhering to its lower wall, and advance into the retrobulbar space. Prolonged drainage of the wound is mandatory.

When treating abscesses of this localization, consultation with an ophthalmologist is necessary due to possible complications from the organ of vision. If the child’s general condition does not improve, meningeal symptoms predominate, an urgent consultation with a neurosurgeon is necessary.

Abscesses and phlegmons of the parapharyngeal space

The peripharyngeal space has the following boundaries: external - the medial pterygoid muscle and the pharyngeal process of the parotid salivary gland; internal

the front is the lateral wall of the pharynx, the back is the part of the fascia that connects the pre-throat fascia with the muscles of the pharyngeal wall, the front is the interpterygoid fascia, the top is the base of the skull, the bottom is the submandibular salivary gland. The styloglossus, stylohyoid and stylohyoid muscles divide the peripharyngeal space into anterior and posterior sections. It should be recalled that in the posterior section there are the internal carotid artery and jugular vein, lymph nodes, and in the anterior section there is loose tissue, to which the pterygoid venous plexus is adjacent on top. This fiber connects through the infratemporal fossa with the fiber of the temporal and pterygopalatine fossae, the sublingual region, where the inflammatory process from the peripharyngeal space can spread.

Isolated development of the inflammatory process in the peripharyngeal space is rarely observed. It can spread from the submandibular, sublingual areas, pterygomaxillary space during odontogenic infection or occur as a complication of acute or chronic tonsillitis. A complication of the latter may be an abscess of the peritonsillar space.

The inflammatory process from the peripharyngeal space can spread along the pharynx and neurovascular bundle into the anterior mediastinum with the development of anterior mediastinitis.

Complaints of a child with an abscess peripharyngeal space - to unilateral pain when swallowing, and therefore he refuses food. The child's general condition worsens significantly - he is capricious, weak, sleeps poorly, and his body temperature is elevated.

Clinic. Upon careful examination, slight swelling of the tissues at the angle of the lower jaw on the affected side can be detected. Mouth opening is somewhat limited and painful. Hyperemia and swelling of half the soft palate, palatoglossus and palatopharyngeal arches, and protrusion of the lateral wall of the pharynx are observed. If at such clinical picture(that is, with an abscess) if qualified assistance is not provided in a timely manner, the inflammatory process spreads very quickly and phlegmon occurs.

Complaints with phlegmon peripharyngeal space - to unilateral pain that increases during swallowing; depending on the duration of the disease, painful limited opening of the mouth is possible, and sometimes difficulty breathing. The child’s condition is sharply disturbed - weakness, chills, increased body temperature, bad dream, he refuses food, intoxication quickly increases.

Clinic. Upon examination, swelling of the tissues is determined at the angle of the lower jaw from the side of the lesion; palpation reveals a deep painful infiltrate. Examination of the oral cavity is difficult due to limited mouth opening caused by contracture of the medial pterygoid muscle, so it is best performed under general anesthesia, especially in young children. After opening the mouth, significant swelling and hyperemia of the corresponding half of the soft palate and uvula, the pterygomaxillary fold, and infiltration of the lateral wall of the pharynx are observed. Tissue swelling spreads to the mucous membrane of the sublingual area and tongue.

Surgery. Adequate opening of the abscess of the peripharyngeal space is achieved by extraoral access in the submandibular region, although the abscess can also be opened by intraoral access. The latter provides

The mylohyoid muscle is a flat muscular plate located between the lower jaw and this muscle is often called the diaphragm of the oral cavity, since it is what forms the bottom of the cavity. The muscle provides the distinction between the face and neck.

Above the muscle tissue are the salivary gland and the tongue. The origin of the mylohyoid muscle is directed back towards the midline. The posterior bundles of the muscle are attached to the hyoid bone.

general information

The mylohyoid muscle is flat and has the shape of an irregular triangle. On the opposite side there is a similar muscle. When connected, these muscles form a suture.

The exact shape and size of the muscle depends on the characteristics bone structure body. For example, if a person has a longer lower jaw, then the muscle has a small width, but its length is greater than the average. If there is a short jaw bone, the muscle is wider. The paired craniohyoid muscles form the floor of the mouth. Contracting two muscles at the same time allows the jaw to lower.

Structural features

The mylohyoid line is the place where the muscle of the same name begins. Small gaps form between the muscle bundles. Sometimes infections and purulent accumulations from the oral cavity can spread through them. The gaps are most often located directly under the tongue, in the area of the second lower molar.

How does a muscle work?

Innervation of the muscle is provided by which passes through a special depression in the lower jaw (mylohyoid groove). The main task of the organ is to lower the lower jaw. This occurs only with simultaneous contraction of paired muscles. Proper functioning allows a person to speak, swallow, and chew food. These paired muscles are supplied by the craniohyoid arteries, which arise from the larger lingual and facial arteries.

Abscess and other lesions in this area

Sometimes the mylohyoid muscle is involved in the inflammatory process, which often leads to tissue suppuration. The lesion quickly invades new areas, gradually spreading to the entire surface of the muscle. Since all the tissues that form the oral cavity are connected to each other by blood vessels, the infection can spread to the tongue, nerves, salivary glands. In this case, doctors talk about phlegmon.

Phlegmon most often affects the mylohyoid groove, but can also be localized in other areas of the floor of the oral cavity:

the space under the tongue is affected on both sides;
the space under the tongue and under the lower jaw on one side is affected;
areas under the tongue and jaw on both sides are involved in the inflammatory process;
the floor of the mouth is completely infected.

Causes and manifestations

If the mylohyoid muscle hurts due to phlegmon, then the reasons are most likely the following:

tooth infection;
periodontal disease;
periodontitis;
osteomyelitis.

The clinical picture usually looks like this:

pain when trying to swallow or chew food;
general malaise;
painful sensations during conversation;
difficult, rapid breathing.

Patients with phlegmon often tilt their heads forward, open their mouths slightly, and when sitting, rest their chin on a chair, as this relieves discomfort.

Infection leads to general intoxication of the body, an increase in temperature, and a change in the number of leukocytes in the blood. Cellulitis often leads to respiratory acidosis.

If the tissues located below the mylohyoid muscle are infected, small tumors form on both sides. The skin over them is tense and hot to the touch. When trying to touch the affected areas, the patient experiences discomfort and sometimes severe pain. Self-treatment is unacceptable. If symptoms appear, you should immediately make an appointment with a doctor, as lack of treatment can lead to dangerous consequences. The inflammatory process often spreads to other tissues and organs.

Muscle training to preserve a youthful face

The mylohyoid muscle can be trained, ensuring the preservation of the natural oval of the face. There are several simple exercises:

Chin lift is considered effective. Sitting on a chair, tilt your head back, lifting your chin up. Now tense your muscles as if you are trying to reach the ceiling with your chin.
Stay in the same position with your head tilted back. Extend and purse your lips as if you are trying to kiss the ceiling.
Open your eyes and mouth wide, try to reach your chin with your tongue.
Slow tilts of the head forward, backward and to the sides are considered effective.

The key rules for training neck muscles look like this:

breathing must be carefully controlled;
eyes must be open;
it is important to control arterial pressure; the fact is that static muscle tension, aggravated by head movements, leads to a sharp change in this indicator;
sudden movements during training are prohibited; any exercises are performed smoothly, it is unacceptable to burden the chin too much;
to achieve results, the muscles must be constantly tense; Do not allow your neck to relax completely, as this will cause a temporary loss of muscle control.

After finishing the exercises, you can relax.

Regular training of the mylohyoid and other neck muscles allows you to achieve smooth skin and maintain a clear contour of the face and chin. Exercises tone the body, improve local blood circulation and nutrition of the oral cavity.

The effect is noticeable after 2-3 weeks of regular practice. Without the opportunity to visit cosmetologists and massage therapists, you can take care of your muscles at home and even during the working day. To do this, it is enough to regularly perform 2-3 sets of simple exercises: chin lift, head rotation, bending.

Borders The maxillary-lingual groove is: above - the mucous membrane of the floor of the mouth, below - the posterior section of the mylohyoid muscle; outside - the inner surface of the body of the lower jaw at the level of the large molars; inside - the muscles of the root of the tongue;

behind - muscles of the styloid group; in front, the maxillary-lingual groove opens freely into the sublingual region. The maxilloglossal groove is part of the sublingual region

Source of infection there may be affected small and large molars of the lower jaw, difficult eruption of the lower wisdom tooth, infected wounds of the mucous membrane of the floor of the mouth, calculous and non-calculous sialodochitis,

Clinic. The inflammatory process develops quickly and is characterized by a state of moderate severity. The patient experiences pain when swallowing, which intensifies when moving the tongue. Mouth opening is limited. During the examination, swelling of the posterolateral part of the floor of the oral cavity can be detected; the mucous membrane is hyperemic and edematous. The maxillo-lingual groove is smoothed, fluctuation is determined. Further spread of the purulent process to the pterygomandibular, peripharyngeal and submandibular tissue spaces significantly aggravates the clinical course of the disease.

Treatment. Operative access for abscesses of the maxillo-lingual groove of the intraoral cavity. An incision in the mucous membrane is made from the side of the oral cavity along the bottom of the oral cavity parallel to the inner surface of the body of the lower jaw (at the place of greatest protrusion of the mucous membrane). The length of the incision should not be less than 3 cm. After dissection of the mucous membrane, the purulent focus is opened. If this does not happen, then they penetrate the abscess, bluntly exfoliating the underlying soft tissue, and drain the wound. The resulting cavity should be washed daily using a syringe with a blunt needle with a warm antiseptic solution.

90DONTHOGENIC INFLAMMATORY DISEASES SOFT TISSUE

® Abscesses and phlegmons of the tongue

Purulent processes of the tongue can occur both in the own muscles of the moving part of the tongue and in the cellular spaces of its root. Abscesses of the moving part of the tongue most often occur as a result of infection of wounds, as well as when they penetrate into the tongue foreign bodies food nature, most often fish bones. The patient complains of sharp pain when swallowing and moving the tongue. When palpating the tongue, there is a painful infiltrate, which is located more often on the lateral, less often on the dorsal surface. Fluctuation is usually not determined due to the localization of the purulent focus in the muscle layers. Opening of abscesses of the movable part of the tongue is carried out with longitudinal incisions at the place of greatest protrusion

Root boundaries of the tongue are: on top - the own muscles of the tongue; below - mylohyoid muscle; externally - the genioglossus and hypoglossus muscles of the right and left sides. On the pharyngeal surface of the root of the tongue is the lingual tonsil, which is part of the lymphoid ring of the Pirogov-Waldeyer pharynx(palatine, tubal, pharyngeal and lingual tonsils)

The main source of infection there may be infected wounds of the tongue. A purulent-inflammatory process developing in the area of the root of the tongue can spread with lingual tonsil, from the sublingual, submental and submandibular tissue spaces. Less commonly, the source of infection is foci of odontogenic infection located in the area of the large molars of the lower jaw. We should not forget about suppuration of congenital tongue cysts

Clinic With abscesses and phlegmon of the tongue, patients complain of severe pain in the area of its root, which radiates to the ear. Swallowing saliva and liquid is sharply painful, and sometimes even impossible. When you try to take a sip, the liquid enters the respiratory tract and causes a painful cough. Typically, due to swelling of the epiglottis causes breathing problems, sometimes hearing loss occurs as a result of eustachitis

The clinical course of phlegmon of the root of the tongue is severe. The tongue is sharply enlarged in size, does not fit in the oral cavity, its mobility is sharply limited. The mouth is slightly open, thick saliva is released from the mouth, often with an unpleasant odor. Palpation reveals uniform swelling and density of the tongue; pressing on the back of it (in the midline) causes sharp pain. The mucous membrane of the tongue is hyperemic, cyanotic. Fluctuation is usually not determined, since the purulent focus is located between the muscles. The back of the tongue is covered with a dry purulent coating. The infiltration can be felt in the depths. submental area above the hyoid bone

Treatment Surgical access for purulent-inflammatory processes of the root of the tongue, extraoral. An incision 4 cm long is made from the side of the skin along the midline or in the submental area. We consider it more rational to make an incision along the midline. Spreading the edges of the wound with hooks, dissect the mylohyoid muscles along the seam. Stupidly push apart the soft tissue, penetrate to the purulent focus. Drainage of the latter is carried out with active double tubular drainage. Innoda, with increasing hypoxia, there is a need for the formation of a tracheostomy

® Phlegmons of the floor of the mouth

The floor of the mouth should be divided into two floors The boundaries of the upper floor are: above - the mucous membrane of the floor of the mouth, below - the mylohyoid muscle, in front and outside - the inner surface of the lower jaw, behind - the base of the tongue The boundaries of the lower floor are: above - mylohyoid muscle, anterior external -inner surface lower jaw, behind - the muscles attached to the styloid process and the posterior belly of the digastric muscle, below - the skin of the right and left submandibular and submental regions. Essentially, these are phlegmons of the sublingual and submandibular regions, which spread to the same anatomical areas of the opposite side, involving the cellular spaces located between them in the inflammatory process. Cellulitis of the floor of the oral cavity should include inflammatory processes that involve the upper and lower floors of one side.

Foci of infection can be located in the area of the teeth of the lower jaw, as well as on the mucous membrane of the floor of the mouth. The infection can spread from adjacent cellular spaces. The cause may also be inflammatory processes in the lymph nodes that develop with tonsillitis and tonsillitis.

9 4 Abscesses and phlegmons

Clinic The clinical course of phlegmon of the floor of the mouth is severe. The patient complains of pain when swallowing, speaking and moving the tongue. Due to mechanical compression of the larynx by swelling of the surrounding soft tissues or swelling of the epiglottis, difficulty breathing occurs. The disease occurs with severe symptoms of intoxication and is accompanied by high body temperature. The patient’s position is forced - he sits with his head bent forward. Looks pained. Speech is slurred, voice is hoarse. Due to swelling of the soft tissues of the submental and submandibular areas, an elongation of the face occurs. When involved in the inflammatory process. subcutaneous tissue the skin becomes hyperemic, edematous, tense, glossy, does not gather, and is determined to be dense by palpation. sharply painful infiltration Fluctuation may be observed The patient’s mouth is half-open, an unpleasant odor emanates from it The tongue is dry, covered with a dirty gray coating, its movements are limited The tongue protrudes from the oral cavity The mucous membrane of the floor of the oral cavity is hyperemic, swollen There is a sharp swelling of the tissues of the sublingual area

Rice. 9.4.4. Appearance a patient with anaerobic phlegmon of the soft tissues of the floor of the mouth and neck, complicated by sepsis and mediastinitis.

Clinical symptoms anaerobic phlegmon of the floor of the mouth(previously called Zhansul-Ludwig's angina) is particularly severe. General manifestations of the disease include jaundice of the skin and subicteric sclera, significant intoxication of the body, high body temperature, tachycardia, anemia, severe leukocytosis and high ESR K numbers local characteristics anaerobic infections include an abundance of necrotic masses in purulent foci, dirty gray color of purulent contents, the presence of air bubbles and inclusions of fat droplets, a sharp (unpleasant) odor of exudate, muscles have the appearance of boiled meat, tissues can be stained dark brown Use of antibacterial drugs gives a weak effect According to the clinical picture, it is not always possible to distinguish an infection that occurs as a result of the action

90NOTOGENIC INFLAMMATORY DISEASES OF SOFT TISSUE

anaerobic microflora, from putrefactive aerobic infection caused coli, Proteus, hemolytic streptococcus and other microorganisms

Phlegmon of the floor of the mouth is often complicated by sepsis, mediastinitis (Fig. 9 4 4), thrombosis of the veins of the face and cerebral sinuses, pneumonia, brain abscesses and other diseases. These complications are especially often observed in last years

Treatment For phlegmon of the floor of the mouth, incisions are made in the submandibular areas on the right and left, leaving a skin bridge up to 1-2 cm wide between them. If the outflow of purulent contents from under the chin area is difficult, then an additional incision is made along the midline of this area. We consider it more advisable to make a collar-shaped incision, the line of which runs parallel to the upper cervical fold, followed by active drainage of the purulent focus with double perforated tubular drainage and application of primary delayed sutures to the wound

Features of the course of phlegmon maxillofacial area in childhood is that adenophlegmons are more often observed in children and odontogenic phlegmons are somewhat less common. In some cases, phlegmons occur in children against the background of colds and acute otitis. The clinical course of phlegmon in children is due to the peculiarities of the formation of the dental system. The imperfection of the immune system in young children contributes to a more aggressive course of the inflammatory process.

Localization of phlegmon, ways of spreading pus in elderly and senile people the same as in young people. But in the former, phlegmons develop much later from the onset of the development of the previous disease, and the melting of inflammatory infiltrates occurs more slowly, the possibility of their independent resorption is practically excluded, and therefore wait-and-see tactics in the treatment of these diseases are not justified. Adenophlegmons are also a rare complication, they are limited in nature, resembling an encysted abscess. When opening such phlegmons, it is necessary to remove the purulently molten lymphoid tissue of the node

LEARNING CONTROL TESTS "+" correct answer; "- ">!1 " are incorrect answers.

Tests for section S.1. "Diagnostics of purulent-inflammatory diseases of soft tissues"

1. Temperature reaction at acute forms periostitis and osteomyelitis of the jaws:

It differs, i.e. with periostitis it is lower than with osteomyelitis,

Varies, i.e. with periostitis it is higher than with osteomyelitis

Same for both diseases

2. What is the number of segmented granupocytes (neutrophils) in the peripheral blood healthy people?:

"1 0-2 Ox CHO^l,

23-45x10 9 /l,

110-14 Eh Yu^l

3. What is the number of band neutrophils in the peripheral blood of healthy people?:

OL-O^xYu^l, +02-04Х Yu^l,

0.4-0.6 x Yu^l,

4. What percentage of segmented granulocytes (neutrophils) from total number leukocytes in the blood of healthy people?:

36-48%, + 55-58%

5. What is the percentage of band neutrophils from the total number of leukocytes in the blood of healthy people?:

1-2% + 2-5% "5-10% 276

6. Is there a relationship between the occurrence and characteristics of the clinical course of acute odontogenic inflammatory diseases with microbial sensitization of the patient?:

No, not available

Yes, but in rare cases

Yes, available

T-set to section 9.2. "Lymphadenitis"

7. In an adult, the lymphatic system is grouped into:

100-200 lymph nodes

200-400 lymph nodes,

500-1000 lymph nodes,

1000 2000 lymph nodes

8. The lymphatic system makes up:

" "/20 body weight,

- ^bo body weight, + /ωo body weight,

- /2oo body weight,

- /sod body weight

9. The percentage that the lymphatic system makes up of the body weight of an adult:

Matches the move blood vessels

Does not correspond to the course of blood vessels

Corresponds to the course of nerves

Learning Benchmarks