Cellulitis and All Deep Space Infections

Clinical Description

In this category the most important is Ludwig's angina. This is an inflammation of floor of the mouth and other related structures − This is a life−threatening condition, starts as a unilateral swelling of soft tissues around lower mandible usually arising from the lower second or third molars. The infection spreads to other tissues crossing the midline and becomes bilateral swelling.

Signs and Symptoms

• Patients presents with rapid progressive swelling, difficulty in breathing, elevated tongue, drooling, difficulty in swallowing (dysphagia), bilateral facial space involvement, elevated temperature, severe jaw trismus (<10 mm), toxic appearance, compromised host defense, patient is dehydrated, weak and febrile.

Investigations

• FBC
• Culture and sensitivity
• Skull views

Non-pharmacological

• Admit patient
• Assess the patient for vital signs
• Ensure airway patency
• Removal of the cause
• Extraction of the offending tooth or
• Treat the tooth endodontically with root canal therapy
• Sequestrectomy (removal of necrotic bone)
• Keep patient hydrated (2-3L Fluids/24 hours for maintenance)
• Encourage high-calorie food intake

Pharmacological

• Give analgesics for pain relief
• Prescribe appropriate antibiotics for rapidly progressive swelling as follows:
• Give Amoxycillin 250 mg - 500 mg 8 hourly for 7days or Benzylpenicillin 0.5- 2.0 MU IM or IV 6 hourly for 7days plus
• Give Metronidazole 200 mg - 400 mg 8 hourly or 7days or Metronidazole 250 mg- 500 mg IV 8 hourly for 7 days
• If patient is allergic to penicillin
• Give Erythromycin 250 mg - 500 mg 8 hourly (after food) for 7 days or
• Give Clindamycin 150 mg - 300 mg (plus Metronidazole as above)
• If severe difficulty in breathing perform tracheostomy
• If the condition persists after a long time of first line antibiotic, give

Ceftriaxone 2g od for 5 days

Note: Antibiotics are indicated for diffuse swelling, compromised host defenses, involvement of fascial spaces, severe pericoronitis, osteomyelitis

At Health Centre level refer the patient to a district hospital