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Surgical Team Manages Head and Neck Infection
EDITORIAL J Oral Maxillofac Surg 67:1-2, 2009
A Clash of Cultures: The Medical/Surgical Team Manages Head and Neck Infection “He has trismus and needs an awake fiberoptic intubation”: an anesthesiologist Using their Malampati Score assessment, anesthesiologists are used to assessing airway but do not always distinguish between mandibular hypomobility from fibroankylosis and other chronic pathology from the acute changes in upper airway produced by infection or trauma. The anesthesiologist culture is to follow algorithms that will maintain airway and oxygenation CT assessment of the airway, preoperative administration of local anesthesia, and a ratchet mouth prop can relieve the anesthesiologist of their upper airway concerns in some cases and permit direct laryngoscopy and endotracheal intubation. Adequate communication and trust between the anesthesia and surgical team will support improved decisions in this regard. “He has a carious molar and a bit of swelling in his cheek. I ordered a CT . . .”: an ER physician The ER physician culture is to order tests and imaging. In the era of CT, examination of the head and neck patient is becoming a diminishing art. Systemic signs of infection, handling of oral secretions, trismus, changes in phonation, using accessory muscles to support the airway, and simple palpation techniques offer the greatest guide to treatment. CT is being used for even obvious oral vestibular swellings. “The CT showed an abscess in the buccal space but don’t worry, we needle aspirated it under ultrasound guidance”: a radiologist While it is unlikely that there is an actual cabal of radiologists plotting to eliminate the need for those arcane and messy incisions associated with surgery, it just feels that way. It is certain that therapeutic interventional radiology is making great strides and that radiologists are anxious to use those skills to the extent that some patients return from the radiology suite with their abscesses drained with minimally invasive interventional radiology techniques. While it hurts surgeons’ pride and sensibilities to see these techniques emerge, the radiologist culture supports this and outcome studies of aspiration and aggressive medical management offer some support to this method. “Clindamycin and penicillin are of only historical interest in the treatment of head and neck infection”: an infectious disease specialist
In some parts of our land, patients still seek care (and perhaps develop symptoms) based upon the signs of the moon. When the moon is new, the “sign is in the feet,” and when the full moon shines brightly, “the sign is in the head.” When the sign is in the head, toothache, sinusitis, headache, facial injuries, family strife, gluttony, and drunkenness prevail. During the full moon, the ERs seem to fill with pus from head and neck infection and maxillofacial injuries. When the sign is in the feet, the ER calls pass to the orthopedists while the OMS clinic fills with those patients who now believe it safe to have those asymptomatic infected roots removed. Recently (though in reality only the clouds and the rain covered Portland), the sign must have been in the head. Every aphorism, every clinical cliché, regarding head and neck infection was evident in the numerous patients with acute abscesses presenting for care. The events surrounding their treatment reveal a clash of cultures that is occurring with greater frequency among the ER physicians, infectious disease specialists, radiologists, laboratories, anesthesiologists, and surgeons who care for these patients. They bring up important teaching points and controversies that remain in the care of patients with head and neck infection. Each is revealed in a short quotation derived from discussions pertaining to the recent care of these patients: “Remove the source of the infection. Drain the abscess from the source of the infection to the external environment through the shortest dependent route”: a surgeon Inadequate drainage often leads to acceleration and extension of deep space infection. Those without skills in oral and maxillofacial surgery do not have the detailed awareness of the pathways of odontogenic infection. For example, a patient with a submandibular abscess with a drain through the platysma and in the submandibular triangle but not on the lingual surface of the mandible adjacent to the source of the infection, an infected second molar still remaining, will do as much to exacerbate infection as to relieve it. Removal of the tooth and draining the neck using the principles in the quote above will address this cliché that can guide success. 1
2 The culture of infectious disease specialists is to look for something new. The specialist in the above quote chose ceftriaxone and took the patient off clindamycin. Fortunately ceftriaxone is inexpensive and effective but as pointed out in many investigations, penicillin remains the drug of choice for odontogenic infection. While clindamycin, Flagyl, other penicillins, and the cephalosporins, among others, offer useful roles, they should not be empirically used to supplant the proven utility of penicillin. “The cultures grew normal oral florae”: a clinical laboratory pathologist The educated surgeon deciding whether to alter an antibiotic regimen knows the above information is of no clinical use. The culture of the clinical laboratories is to control costs. Despite the protestation of head and neck infection aficionados, laboratories are increasingly hesitant to spend money on kits to identify actual species, thus providing meaningless information to guide therapy. With the emergence of resistant species of anaerobes in the head and neck, greater communication between oral and maxillofacial surgery and the clinical laboratories is needed to ensure that only infections that need culturing are cultured but for those that are cultured, meaningful information is obtained. “The pathology report shows osteomyelitis. She needs to go home on 6 weeks of IV therapy”: a pathologist The culture of the pathologist is to make a clinical diagnosis based upon microscopic findings. In the case of biopsies of the jaws often associated with the
EDITORIAL
removal of teeth, they can erroneously lead to a diagnosis of osteomyelitis when only the normally seen sequelae of odontogenic infection are present. Unfortunately, the pathology report of “osteomyelitis” is in black and white and offers little room for interpretation. Carefully written information on the pathology request form might help in eliminating some cases of over-interpretation of histopathologic findings. “Never let the sun set on undrained pus”: a surgeon The uninitiated colleagues who do not see head and neck infection with any frequency do not know how fast it can evolve. Many disastrous outcomes in head and neck infection begin with inadequate treatment in dentists’ and physicians’ offices with days of oral antibiotics and no drainage or in ERs where over periods as short as a few hours sepsis ensues or an airway is lost. Deep space infection of the head and neck is a surgical emergency that sadly is sometimes only revealed to the clinical team after the catastrophe. How should patients with head and neck infection be prioritized for emergency surgery? Only contemporaneous examination and imaging with the surgical anesthesia team can make that individualized assessment. In the head or in the feet, the surgeons’ culture does not vary. Our culture is to operate. LEON A. ASSAEL, DMD
© 2009 American Association of Oral and Maxillofacial Surgeons doi:10.1016/j.joms.2008.11.001
A Clash of Cultures: The Medical/Surgical Team Manages Head and Neck Infection “He has trismus and needs an awake fiberoptic intubation”: an anesthesiologist Using their Malampati Score assessment, anesthesiologists are used to assessing airway but do not always distinguish between mandibular hypomobility from fibroankylosis and other chronic pathology from the acute changes in upper airway produced by infection or trauma. The anesthesiologist culture is to follow algorithms that will maintain airway and oxygenation CT assessment of the airway, preoperative administration of local anesthesia, and a ratchet mouth prop can relieve the anesthesiologist of their upper airway concerns in some cases and permit direct laryngoscopy and endotracheal intubation. Adequate communication and trust between the anesthesia and surgical team will support improved decisions in this regard. “He has a carious molar and a bit of swelling in his cheek. I ordered a CT . . .”: an ER physician The ER physician culture is to order tests and imaging. In the era of CT, examination of the head and neck patient is becoming a diminishing art. Systemic signs of infection, handling of oral secretions, trismus, changes in phonation, using accessory muscles to support the airway, and simple palpation techniques offer the greatest guide to treatment. CT is being used for even obvious oral vestibular swellings. “The CT showed an abscess in the buccal space but don’t worry, we needle aspirated it under ultrasound guidance”: a radiologist While it is unlikely that there is an actual cabal of radiologists plotting to eliminate the need for those arcane and messy incisions associated with surgery, it just feels that way. It is certain that therapeutic interventional radiology is making great strides and that radiologists are anxious to use those skills to the extent that some patients return from the radiology suite with their abscesses drained with minimally invasive interventional radiology techniques. While it hurts surgeons’ pride and sensibilities to see these techniques emerge, the radiologist culture supports this and outcome studies of aspiration and aggressive medical management offer some support to this method. “Clindamycin and penicillin are of only historical interest in the treatment of head and neck infection”: an infectious disease specialist
In some parts of our land, patients still seek care (and perhaps develop symptoms) based upon the signs of the moon. When the moon is new, the “sign is in the feet,” and when the full moon shines brightly, “the sign is in the head.” When the sign is in the head, toothache, sinusitis, headache, facial injuries, family strife, gluttony, and drunkenness prevail. During the full moon, the ERs seem to fill with pus from head and neck infection and maxillofacial injuries. When the sign is in the feet, the ER calls pass to the orthopedists while the OMS clinic fills with those patients who now believe it safe to have those asymptomatic infected roots removed. Recently (though in reality only the clouds and the rain covered Portland), the sign must have been in the head. Every aphorism, every clinical cliché, regarding head and neck infection was evident in the numerous patients with acute abscesses presenting for care. The events surrounding their treatment reveal a clash of cultures that is occurring with greater frequency among the ER physicians, infectious disease specialists, radiologists, laboratories, anesthesiologists, and surgeons who care for these patients. They bring up important teaching points and controversies that remain in the care of patients with head and neck infection. Each is revealed in a short quotation derived from discussions pertaining to the recent care of these patients: “Remove the source of the infection. Drain the abscess from the source of the infection to the external environment through the shortest dependent route”: a surgeon Inadequate drainage often leads to acceleration and extension of deep space infection. Those without skills in oral and maxillofacial surgery do not have the detailed awareness of the pathways of odontogenic infection. For example, a patient with a submandibular abscess with a drain through the platysma and in the submandibular triangle but not on the lingual surface of the mandible adjacent to the source of the infection, an infected second molar still remaining, will do as much to exacerbate infection as to relieve it. Removal of the tooth and draining the neck using the principles in the quote above will address this cliché that can guide success. 1
2 The culture of infectious disease specialists is to look for something new. The specialist in the above quote chose ceftriaxone and took the patient off clindamycin. Fortunately ceftriaxone is inexpensive and effective but as pointed out in many investigations, penicillin remains the drug of choice for odontogenic infection. While clindamycin, Flagyl, other penicillins, and the cephalosporins, among others, offer useful roles, they should not be empirically used to supplant the proven utility of penicillin. “The cultures grew normal oral florae”: a clinical laboratory pathologist The educated surgeon deciding whether to alter an antibiotic regimen knows the above information is of no clinical use. The culture of the clinical laboratories is to control costs. Despite the protestation of head and neck infection aficionados, laboratories are increasingly hesitant to spend money on kits to identify actual species, thus providing meaningless information to guide therapy. With the emergence of resistant species of anaerobes in the head and neck, greater communication between oral and maxillofacial surgery and the clinical laboratories is needed to ensure that only infections that need culturing are cultured but for those that are cultured, meaningful information is obtained. “The pathology report shows osteomyelitis. She needs to go home on 6 weeks of IV therapy”: a pathologist The culture of the pathologist is to make a clinical diagnosis based upon microscopic findings. In the case of biopsies of the jaws often associated with the
EDITORIAL
removal of teeth, they can erroneously lead to a diagnosis of osteomyelitis when only the normally seen sequelae of odontogenic infection are present. Unfortunately, the pathology report of “osteomyelitis” is in black and white and offers little room for interpretation. Carefully written information on the pathology request form might help in eliminating some cases of over-interpretation of histopathologic findings. “Never let the sun set on undrained pus”: a surgeon The uninitiated colleagues who do not see head and neck infection with any frequency do not know how fast it can evolve. Many disastrous outcomes in head and neck infection begin with inadequate treatment in dentists’ and physicians’ offices with days of oral antibiotics and no drainage or in ERs where over periods as short as a few hours sepsis ensues or an airway is lost. Deep space infection of the head and neck is a surgical emergency that sadly is sometimes only revealed to the clinical team after the catastrophe. How should patients with head and neck infection be prioritized for emergency surgery? Only contemporaneous examination and imaging with the surgical anesthesia team can make that individualized assessment. In the head or in the feet, the surgeons’ culture does not vary. Our culture is to operate. LEON A. ASSAEL, DMD
© 2009 American Association of Oral and Maxillofacial Surgeons doi:10.1016/j.joms.2008.11.001