Abscess and phlegmon of the maxillofacial area. Etiology, pathogenesis, clinical manifestations, diagnosis, treatment and prevention.

 

Inflammatory processes of tissue maxillofacial area in all cases are infectious in nature, ie, their origin, development and current leading role of microbial flora. Inflammation is a primary link evolutionarily produced stereotypical reactions that cause the body's ability to resist a variety of damaging environmental factors.

Phlegmon - an acute diffuse inflammation of subcutaneous , intramuscular and mizhfastsialnoyi fiber.

Abscess - purulent inflammation with formation of cavities.

Phlegmon characterized by a tendency to spread rapidly , the process from the very beginning is diffuse in nature. Inflammation is growing so rapidly that the demarcation process is delayed , and separation of the lesion is impossible.

The condition in the hospital maxillofacial surgery takes leading place . In recent years, the number of patients with this disease has increased, deepened gravity flow process , frequently observed complications ( mediastinit , sepsis, thrombosis of the cerebral veins and sinuses of the face ).

 

 

The cell infiltrate in the tissue wounds are rare plasma cells (1), numerous lymphocytes (2), diffuse distribution of large quantities of neutrophils (3), LABROTSYTY (4).

 

Etiology. As the research for the " tying " of local infectious - inflammatory process need some "critical concentration " of disease , individual for each organism. In surgery is recognized that opportunistic microbes, which include representatives of oral microflora , can cause inflammation of the concentration of 105-106 or more microbes in 1 gram of tissue or 1 ml of biological substrate.

Agents of inflammation are usually different types of cocci ( staphylococci, streptococci and other ) in symbiosis with intestinal and other sticks. The most common pathogen prevails as white or Staphylococcus aureus. Occurs anaerobic infection: bacteria dominate nesporohennûe - bacteroides and clostridia . Emphasized the associative participation anaerobes and aerobes .

For etiological basis emit " osteoflehmonu " that develops on the background of osteomyelitis of the jaws and " phlegmonous adenitis " - complicating suppurative lymphadenitis , which may be associated with diseases of the teeth. Provided " odontogenic abscess " in which on the basis of periodontitis and there suppurative periostitis process, but changes in bone are reversible . Most scholars distinguish another form of inflammation of the soft tissues - " cellulite " and mean by this name form of inflammation of serous tissue.

Depending on the source of infection of inflammatory processes of the maxillofacial region can be divided into:

• odontogenic ( cause of - gangrenous teeth and their roots );

• yntraossalnûe (as odontogenic kind , including as a result of traumatic peryostytov , osteomyelytov , pericoronitis , sinusitis , cysts and other diseases );

• hynhyvalnûe (development associated with gingivitis and periodontitis );

• mukostomatohennûe ( due to the presence stomatitis and hlossytov );

• salyvatornûe (resulting syalodohytov and sialadenitiv );

• tonzyllyarno - pharyngeal ;

• rynohennûe ;

• Otogenic .

 

 

ROZVOLOKNENNYA edema and subcutaneous tissue (1), hyperemic vessels ( 2) and small cell infiltrates (3) in the tissues of the wound.

 

A clear separation inflammatory in origin is important because it allows you to avoid tactical mistakes in diagnosis and treatment.

Depending on the type and severity of inflammation of the soft tissues of the process may be serous, purulent, hemorrhagic , hnoynûm and putrid .

CLASSIFICATION. We consider it appropriate to distinguish between cellulitis and abscess following maxillofacial region and neck:

Phlegmon and abscesses face and neck.

I. Abscesses and cellulitis in the vicinity of the upper jaw :

• • infraorbital region;

• • orbital area (including eyelids );

• • temporal region ;

• • infratemporal and pterygopalatine fossa.

II. Abscesses and cellulitis in the vicinity of the mandible :

• • pidnyzhnoschelepovoyi area;

• • pozadychelyustnoy area;

• • parotid- masticatory area;

• • pterygoid - mandibular space;

• • navkolohlotkovoho space.

III. Abscesses and cellulitis, located both near the upper and lower jaw :

• • Jaw area;

• • zygomatic area.

IV. Abscesses and cellulitis floor of the mouth :

• • upper ( sublingual area );

• • lower division (area pidpidboriddya ).

V. Abscesses and cellulitis tongue :

• • own tongue ;

• • root of the tongue.

VI. Abscesses and phlegmon of the neck:

• • surface ;

• • deep :

1) neurovascular bundle ;

2) around the trachea and esophagus;

3) peredhrebetnoho space.

 

On the severity of illness of patients conventionally divided into 3 groups:

• patients with cellulitis, localized in the same anatomical region;

• patients with cellulitis, localized in two or more anatomical regions;

• seriously ill with phlegmon temporal region , infratemporal and pterygopalatine fossa, floor of the mouth , tongue and neck.

Granulation tissue wounds

 Fibroblasts (1) vessels ( 2).

 

 

Pathogenesis. Most okolochelyustnûe abscesses and cellulitis occur in persons aged 20-30 years. This is probably due to the highest intensity of caries teeth and difficult prorezûvanyem wisdom teeth. There is seasonality in the development of abscesses and abscesses , with the largest number of diseases observed in spring- summer and summer- autumn periods.

The development and course of acute purulent inflammation of the maxillofacial area and neck depends on the microflora, total local nonspecific and specific protective factors reliance various organs and body systems and anatomic and topographic features of the maxillofacial region . The inflammatory response may be normerhycheskoho , hypererhycheskoho and hypoerhycheskoho type.

The clinical picture consists of local symptoms and general symptoms of intoxication. The clinical course of abscesses in the head and neck differs significantly varied. Depending on how many anatomical regions is purulent- necrotic process , what are its tendency to spread and are life- threatening complications can occur , this will be the clinical picture .

Complaints of patients with pain at the site of affected tissue , significant swelling of a particular anatomical region , painful swallowing, if the process is localized in the hyoid region, pterygoid - mandibular , navkolohlotkovomu spaces , limiting opening your mouth and chewing violation , with phlegmon localized near the masticatory ' muscles . Typically, the growing signs of intoxication: malaise , fatigue , loss of appetite (patients refuse a meal and liquid) , poor sleep . Some patients with irritable, more sluggish, retarded , are reluctant to come into contact. Violated physiological downward daily urine output ( oliguria ), there are locks. Body temperature varies between 38-39 ° C.

From history can be defined as the first manifestation of clinical signs of odontogenic abscesses and abscesses maxillofacial region fit into the clinical picture of acute or exacerbated chronic periodontitis. Then growing signs that indicate the distribution process beyond the jaws of defeat of one or more adjacent anatomical spaces. The patient should be developed to clarify the cause of odontogenic cellulitis, determine whether preceded periodontitis , pericoronitis , abstsedyruyuschaya form of periodontitis , abscess or osteomyelitis of the jaw or disease preceded neodontohenna lesions lymphadenitis , carbuncle or furuncle, traumatic osteomyelitis specific processes in the maxillofacial region .

OBJECTIVE: local manifestations are characterized by five classic signs of inflammation: swelling or infiltration (tumor), pain (dolor), redness or flushing (rubor), an increase in local temperature (calor) and dysfunction (functio lesae). Expression of each of these signs of inflammation depends on the anatomical location of cellulitis . Since the localization of abscess in subcutaneous adipose tissue is particularly pronounced swelling , redness and increased local temperature . While in deep abscess location , such as pterygium , mandibular , navkolohlotkovomu space , these symptoms are less pronounced . In this case, are more pronounced pain and dysfunction often seen chewing, swallowing , speech and respiration . The combination of these symptoms creates a peculiar clinical picture characteristic of infectious inflammation of a location.

 

 

ROZVOLOKNENNYA edema and subcutaneous tissue (1), hyperemic vessels ( 2) and small cell infiltrates (3) in the tissues of the wound.

 

Locally defined tight, painful and spreads quickly infiltrates . At the bottom it is flyuktuatsyya palpation .

There are acute and subacute stages of the disease .

In the acute stage is characterized by the growth of local manifestations of inflammation with characteristic signs of intoxication: hyperthermia , weakness, change in function. In blood marked leukocytosis (from 12-15 .109 / .109 L to 20 / l), leukocyte left shift , increased ESR (30 to 60 mm / h), ýozynopenyya , proteynohrammû change the appearance of serum C- reactive protein , increased leukocyte index of intoxication , increased IgG, increased total proteolytic activity of blood. Found in urine protein.

Subacute stage following the opening of abscesses and abscesses , provided that no complications arise . Thus there is subsiding acute inflammation : local - reduced infiltration of tissues , decreases the number of wound discharge, granulation tissue grows , there is scarring and wound epithelization . At the same time decreases the severity of common reactions , improving the health of the patient, recovering broken functions of breathing, swallowing, chewing.

DIAGNOSIS .

Provides clarifying the localization and nature of the inflammatory process , evaluating the virulence of the infectious agent and the type of response reactions ( normerhycheskaya , hypererhycheskaya , hypoerhycheskaya ) and early detection of complications. Topicheskaya diagnosis of odontogenic abscesses maxillofacial area based on 4 local attributes:

I. Attribute ' causal tooth . " In the mouth is peryodontytnûy or parodontytnûy tooth, periodontium which is " generator " infection spreads and impressive surrounding soft tissue. He turns on the basis of patient complaints , reviews and radiography.

II. Symptom severity of inflammatory infiltrates soft tissues. He pronounced in superficial phlegmon and absent or weakly detected in the deep. In this case the measured visible signs of infiltration and as a criterion for its violation , the configuration of individual or absence of asymmetry. As an example in cheek phlegmon ( abscess superficial location ) face asymmetry is evident , while phlegmon pterygoid - mandibular space ( deep location of the abscess ) find asymmetries in the external review of the patient's face is not possible. Flushing of the skin and mucous membranes of the inflammation causes a local increase in temperature. You can find direct contact thermometry or by thermography using liquid crystals or holesterycheskyh teplovyzora .

III. Signs of motor function of the lower jaw. It is known that any inflammatory process localized in the area of ​​at least one of masticatory muscles in one way or another gives motor function of the lower jaw. The functions of the masticatory muscles will be opening and closing the mouth , and lateral movement of the jaw and nominate it forward. Knowing when examining the patient's degree of impairment of the lower jaw can be assumed with sufficient certainty foci of inflammation.

IV. Sign difficulty swallowing. There is the localization of inflammatory infiltrates in the muscle lateral pharyngeal wall , thus resulting in compression or muscle contractures occur pain when swallowing.

 

In clinical diagnosis of superficial abscesses usually does not cause difficulties. This infraorbital such as cellulitis , jaw , zygomatic , orbital , pidnyzhnoschelepova , pidpidboriddya and hyoid . However, with a deep location in the diagnosis of abscess may be some difficulties. This podmasseteryalnoho cellulitis , winged - mandibular and navkolohlotkovoho spaces, floor of the mouth , infratemporal and pterygopalatine fossa, temporal region .

Virulence early infection largely determines the scope and depth of tissue damage and the likelihood of complications. Virulence depends on the number and characteristics of pathogens cellulitis . Assessment of virulence conducted considering the severity of the local inflammatory response and general reactions. A patient with an average level of immunological reactivity there is a direct proportional relationship between the virulence of infection and the magnitude of the early response reactions (fever , leukocytosis , increased ESR , change proteynohrammû , increasing the total proteolytic activity of the blood , and increased levels of IgG). Reduced immune responsiveness case with endocrine disorders ( diabetes) , blood diseases in old age , the people who continued receiving hormones , cytostatics . It must be remembered that an increase in body temperature by 1 ° C is accompanied by increased heart rate by 10 beats per minute. In these patients there is a marked tachycardia or subfebrile at normal temperature.

To implement targeted immunosuppressive therapy an evaluation of the response of an organism to action early infection . Thus, when the reaction is carried out hypererhycheskom type hyposensybylyzyruyuschaya therapy in hypoerhycheskom - therapy directed at improving the patient's immune responsiveness . Slow growth involving inflammation in the inflammatory process of new tissue structures against the background of moderately expressed general reactions typical reactions hypoerhycheskoho type. The reaction hypererhycheskoho type fast growing signs of inflammation, early formed cellulitis and abscesses.

Pathological anatomy. Purulent necrotic process develops mainly in the loose connective tissue - subcutaneous , intramuscular , mezhfastsyalnoy tissue and muscles. Microbes in penetrating tissue skoplyuyutsya around and around blood vessels. In the inflammatory tissue reactions , identify the following stages:

edema ;

infiltration ;

purulent fusion of tissues;

necrosis ;

limit foci formation of granulation shaft;

If an abscess a clear serous , sero -purulent exudation of tissue and subsequent separation of purulent inflammation in a cavity whose walls are formed granulation tissue . Necrotic processes in septic foci expressed a bit.

When phlegmon stage edema, serous, purulent inflammation alter in varying degrees of severity of the necrotic process : in some cases the dominant diffuse serous , sero- purulent inflammation , in others, especially in septic necrotic phlegmon - alteration phenomena with significant hemodynamic violation tissue necrosis of tissue, muscle fascia .

Acute inflammation are on the decline after spontaneous or surgical discharge purulent or purulent necrotic lesions. Separation of necrosis is due to leukocyte infiltration , and granulation tissue develops on the edge of necrotic tissue. Gradually exposed to rejection and partial resorption of necrotic tissue. Connective tissue growing, replacing the lost land, formed connective tissue scar.

In septic necrotic phlegmon driving in the movie inflammation is necrotic changes in the form of drainage areas of necrosis tissue, fascia and even muscles. There are multiple foci krovoyzlyyanyy . Harsh tissue swelling accompanied by mild cellular infiltration.

Formulation of diagnosis . Originally indicated causes of cellulitis, such as odontogenic osteoflehmona , then anatomical region, eg pidnyzhnoschelepovoyi area on the right. Fully diagnosis is : odontogenic osteoflehmona pidnyzhnoschelepoviy field matter if the character is diagnosed fluid , it is possible a diagnosis of purulent necrotic abscess floor of the mouth . Allowed a diagnosis of phlegmonous adenitis neck left.

Anesthesia. The best requirements for anesthesia during surgery opening abscesses and abscesses of the face and the neck meets the anesthesia that has made ​​physician- anesthetist . But he chooses the method of anesthesia. It uses familiar anestetetyky , used in anesthesiology . However, the general rule is superficial level of anesthesia with rapid awakening after surgery. If ýndotrahealnoho anesthesia ekstubatsiyu performed only after the cessation of bleeding from the surgical field in the mouth and in the restored consciousness of the patient.

When opening abscesses chosen method of anesthesia should provide :

1) Safety for the patient and ease of manipulation for the surgeon ;

2) maintaining the airway ;

3 ) rapid awakening of the patient from the recovery pharyngeal , throat and tracheal reflexes immediately after surgery.

 

Since the surgery performed in an emergency , drugs for premedication should be administered intravenously. With tranquilizers can be successfully used Seduxen (5-10 mg) of neyroleptykov - talamonal (0,5-2,0 ml). The dose of atropine intravenously may be reduced to 0.1 - 0.3 mg, and an average of 0,5-0,7 ml. It pyam'yataty that after premedication the patient should not get out of bed .

Evaluating the effectiveness of premedication produced or counting rate and blood pressure , as the autonomic nervous system is sensitive to inadequate premedication , tachycardia, hypertension, pallor and damp skin.

 

While difficult, opening his mouth and swallowing - when abscess localized in the parotid- masticatory area pterygoid - mandibular , navkolohlotkovomu spaces with phlegmon floor of the mouth and tongue , and phlegmon temporal region , the use of barbiturates in intravenous anesthesia is undesirable because of possible respiratory depression . In the presence of respiratory failure caused by inflammation of the larynx , the additional inhibition of barbiturates can create a very dangerous situation . Endotracheal anesthesia is also dangerous because of great difficulties during tracheal intubation . If intubation is successful , then ýndotrahealnaya tube contributes to edema of the larynx and can lead to tracheitis in the postoperative period . In such cases, appropriate personal approach with a combination of local anesthesia combined with intravenous drugs or anesthesia because of traheostomu .

 

Schematic representation of a horizontal fascia neck cut (by VI Shevkunenko )

Acceptable use of local anesthesia. As an anesthetic used novocaine, lidocaine , trimekaina (0.25 %, 0.5 %, 1 %). Pain relief is as follows : first performed anesthesia with 2% solution of a local anestetikov of up to 5,0 ml., Then 0.25% or 0.5 % solution of anesthetic anestezuyut layers future line cut ( skin, fat , muscle ). Start infiltration of the skin with necessary peripheral infiltrates in the unlit tissue. Care should be taken that the solution did not get in the abscess cavity . Infiltration of tissues by the intended line of cut made ​​in the form of creeping infiltrates , clinically manifested pobelenyem skin, then the same is done by infiltration of the deeper layers. It is advisable to carry out infiltration of 4 injections at the ends of two perpendicular diameters. After waiting for 8 to 10 minutes, checking the needle sensitivity of the patient, proceed to cut.

Formulation of diagnosis . Originally indicated reason caused such odontogenic phlegmon osteoflehmona , then anatomical region, eg pidnyzhnoschelepovoyi area on the right. Fully diagnosis is : odontogenic osteoflehmona pidnyzhnoschelepoviy field matter if the character is diagnosed fluid is a possible diagnosis of purulent necrotic abscess floor of the mouth . Permissible a diagnosis of phlegmonous adenitis neck left.

Treatment.

The goal of treatment of patients with abscesses and phlegmon of maxillofacial localization - as soon as possible the elimination of infection early with full restoration of disturbed functions. This goal is achieved by carrying out a comprehensive therapy. When choosing a medical doctor measures into account the localization of the lesion , the virulence of infection early , stage of disease , the nature of the inflammatory process , the type of the response body, comorbidities and age of the patient.

Construction of pathogenetic treatment should reflect :

1) effect on the pathogen ;

2) increasing immunological properties of the organism ( restorative effect on the body );

3) correction of the functions of organs and systems.

Active local treatment of the wound is carried out taking into account the phases of inflammation. so

in the I phase ( inflammation) performed mechanical and physico -chemical antiseptic

in phase II ( proliferation and regeneration) - Chemical and biological and biochemical reorganization of wounds

in phase III (reorganization and formation of scar) therapeutic measures aimed at stimulating reparative regeneration in the wound .

In the acute stage of the disease the main problem is to limit the spread of infection zone and restore the balance between cell chronic odontogenic infection and the patient's body . The nature of the inflammatory process ( serous, purulent or purulent- necrotic ) largely determines the therapeutic approach. In serous tissue inflammation ( cellulitis ) possible regression of the process in a timely opening and drainage of infective foci in the jaw (tooth extraction ) and carrying out the relevant causal and pathogenetic therapy. When purulent and necrotic suppurative inflammation than described interventions jaw requiring urgent surgical intervention okolochelyustnûh soft tissues. Reduced virulence provides drainage of purulent foci through dissection of the soft tissues over the place of accumulation of pus and drainage of the primary focus of infection in the jaw (tooth extraction ). This , together with manure removed part of microorganisms, their toxins and products of tissue disintegration that is damaged by endogenous factors , mediators of inflammation. the earlier evacuation of pus made ​​better prognosis , the lower the likelihood of complications ( thrombosis of the sinuses of the dura mater , meningoencephalitis, medyastenyt , sepsis ).

In carrying out surgery on abscesses and abscesses of the face and neck choice of anesthesia depends on the localization of infection beginning of training anesthesiologist and the appropriate equipment.

When surgery is necessary to carefully treat tissue , avoiding their excessive compression, hyperextension , undesirable extensive delamination periosteum. Length of cuts on the skin and in the mouth is determined length infiltrates . In no case moves to create a funnel with a significant cut surface tissues and a small entrance in the purulent cavity. Skin , mucosa , muscle and subcutaneous fascia towards infectious focus should be cut and hlybokolezhachi tissue along kletchatochnûh spaces stupid flake . In patients with septic -necrotic phlegmon shown necrectomy ( excision areas of necrosis ). This is done to reduce toxicity, necrotic tissue serve as a good breeding ground for microorganisms and a source of endogenous intoxication.

Draining wounds made:

I. All sorts of drains ( rubber strips, tubes, polyethylene alumni , cotton strips , etc.) introduced into the wound. Use gauze graduates inappropriate because they 6 hours become purulent plug , which makes content flow from the wound. For a better outflow of fluid from the wound above superimposed aseptic cotton - gauze bandage impregnated with hypertonic solution ( 10% solution of NaCL, 25 % solution MgSO4). Change dressings made ​​daily to reduce the appearance of exudation and wound granulation. With the advent of granulation impose mazevûe dressing.

II.Dializ wounds ( wound lavage to remove microbes and their toxins and products of tissue destruction ). How dyalyzyruyuschyh solutions solutions used antibiotics, antiseptics ( dimeksid , ýtonyy , ýkterytsyd , furatsilin ), surfactants ( slfanol , katamyn AB, hlrheksydyn biglyukonata , rokkal ), proteolytic enzymes ( trypsin, hemopsyn etc.), brine 4-8 % solution of soda, acids , etc. Dialysis is:

continuous (during entry solutions in wound through the blood by gravity or by creating a vacuum in the wound by jet or elektrovidsmoktuvannya . Dyalyzat However , that vidsysayetsya , when the bandage is removed in napivzamkneniy system or after passing through the filters again enters the wound with circular dialysis in a closed system ).

fractional dialysis (through puncture catheter and tissue installed every 4 hours dyalyzyruyuschye solution is injected into the wound with a syringe ).

III.Pereryvyste or continuous suction of fluid through the catheter , introduced into the infectious focus through the surgical wound or an optional cut - puncture. In this way, by vacuum drainage. Its duration depends on the phase of exudation.

As a general treatment is targeted antibiotic therapy. Antibiotics are used considering planting flora of suppurative focus and sensitivity to them. The choice of dose and route of administration are carried out by the general principles of antibiotic therapy. During the introduction of the patient to obtain antibiotikogrammy prescribe a broad spectrum antibiotic or combination thereof including synergy effects. It is usually combined with antibiotic therapy appointment sulfanylamydnûh drugs, analgesics.

In patients with septic -necrotic phlegmon advisable to appoint a mixture of sera against the main types of anaerobic bacteria , as well as to hyperbaric oxygenation ( space in barokameu , 5-10 sessions) or administered through a catheter into the wound ynsufflyatsyy oxygen. Patients with anaerobic microflora prescribe metronidazole ( trihopol ) at a dose of 0.25-0.5 2 times a day.

It is advisable to carry out activities to improve the rheological properties of blood hypercoagulability and correction .

For excretion of degradation products and toxic substances monitoring the adequate intake of fluids. At night the patient should get about 3-5 liters. If fluid intake naturally difficult ( painful and difficult swallowing ), it is shown or intravenous drip solutions through the rectum.

The severity of inflammation of the intensity hyposensybylyzyruyuschey therapy and the choice of drugs. Of course prescribed calcium supplements derived salicylic acid and pyrazolona , protyvohystamynnûe product. When hypererhycheskom inflammation when rapid development of the local manifestations of the disease combined with severe general reaction of the organism using drugs adrenal and their synthetic analogues: hydrocortisone , prednisone , dexamethasone .

To enhance nonspecific and specific immunoreactivity body , especially when purulent necrotic phlegmon use adaptogens ( 0,005 dibazol 2 times a day for 5-10 days). In patients with hypererhycheskoy reaction to it provides hyposensybylyzyruyuschyy pronounced effect in patients with hypoerhycheskoy reaction - activates immunological processes .

To clean the wound from the remnants of necrosis topically applied proteolytic enzymes. When the granulation tissue and its stimulation by an electric field UHF. Microwave, radiation of helium- neon laser , UV oblucheniyem .

In the subacute stage of the disease the main objective in the shortest possible time to ensure healing of the wound with the elimination of the infectious focus and full restoration of disturbed functions . This is achieved by the use of drugs stimulating tissue metabolism, fyzyo and diet therapy .

After the cessation of suppuration , cleaning the wound of necrotic tissue may be imposed secondary seams:

• prevychno - delayed ( 2-3 days after surgery, the appearance of the wound granulation tissue );

• Secondary (for granulating wound ).

Contraindications to the imposition of secondary joints:

common causes : the presence of fever and severity of acute inflammation , chronic comorbidities (diabetes , rheumatism , infectious arthritis, nephritis, malignancy, cardiovascular failure in violation of the peripheral circulation , chronic radiation sickness );

local causes: signs of osteomyelitis (mobility of teeth with suppuration from the gums, positive symptom Vincent , the X-ray - bone resorption , etc.) is stored infiltration of the wound edges , which does not tend to decrease in dynamics.

It should refrain from imposing secondary sutures in children and the elderly. Near these patients after treatment of wound necrosis produced seamless convergence of its edges by strips of sticky plaster. Draining wounds this period the strips of rubber gloves.

Surgical technique .

Skin around the wound treated with a solution of iodine , alcohol , and then conduct a local infiltration anesthesia . Then the wound copiously washed with antiseptic solution ( furatsilinom , 3 % hydrogen peroxide solution ). Since the depth of the wound at a distance of 0.5-1.0 cm apart impose a material that does not resolve , the seams . Only in the presence of excessive granulation vyskribayut or excised . Between the sutures in the wound injected rubber graduates. The skin patch of hypertonic solution. Let's use an active vacuum drainage or dialysis.

With the stabilization of inflammation around infectious foci formed soedynytelnotkannaya capsule. It is on the one hand helps limit the spread of infection , and on the other - delays penetration into infectious focus antibiotics, cellular and humoral factors of immunity , prevents complete destruction of microorganisms. Therefore, at this stage of the disease to delay the excessive development soedynytelnotkannoy capsule and increase its permeability through the use of ultrasound, elektroforez potassium iodide lydazû . Displaying purpose exercise that helps restore facial function and masticatory muscles.

Patients should receive full power. While difficult, opening his mouth and swallowing painful jaw assigned diet. Food is ground to kashepodibnoho condition diluted broth or milk and introduced into the stomach naturally or through poyilnyka or probe. Power supply such patients should be high to have enough vitamins and be balanced in proteins, fats and carbohydrates .

Forecast. Generally favorable with timely and proper treatment of abscesses and phlegmon of maxillofacial area and neck.