At the first signs of the development of inflammatory phenomena in the soft tissues of the maxillofacial region even before the occurrence of severe infiltrate, with a satisfactory condition of the patient, conservative treatment should be carried out.
For this purpose, dry heat, sollux, rinsing the mouth with a warm solution, sulfonamides, 10% calcium chloride solution are prescribed. Such treatment is sometimes sufficient to stop and eliminate inflammation. To prevent a relapse of the disease, it is necessary to identify a bad tooth, which served as a source of infection, and take measures to treat or remove it. In cases where the inflammatory process in the next 1-2 days tends to increase, despite the ongoing treatment, surgical treatment should be performed.
A similar and only correct doctor tactics should be with already developed phlegmon. The use of thermal procedures and the postponement of the operation in such cases can aggravate the process and contribute to the spread of pus. The operation of opening the phlegmon of the maxillofacial region has the following features compared with the opening of the phlegmon of another location: – opening must not only empty the abscess, but also cross and drain the paths of possible spread of pus; – the operation is carried out not only to determine the softening of the infiltrate, but it is mandatory in cases where there is a threat of exudate migration to neighboring departments, especially to the neck (even in the absence of fluctuation); – taking into account the cosmetic features of the face, an incision for opening is performed along the lines of natural folds, under the edge of the lower jaw, sometimes somewhat away from the main focus; – the presence in the operated area of the branches of the facial nerve requires the observance of caution (skin and fiber are sharply dissected, the further approach to the abscess is carried out stupidly). The best type of anesthesia when opening a phlegmon is anesthesia (fluorotan – nitrous oxide – oxygen or nitrous oxide – oxygen, colipsol ).
Anesthesia allows, without injuring the patient mentally and physically, to perform a mandatory digital audit of the abscess cavity, eliminate pockets, lintels and, if necessary, create a counter-opening . After emptying the cavity from pus with a sharp spoon or scalpel, dead tissue is removed, and then tubular drainage or a rubber strip is introduced . If pus does not stand out when opening the infiltrate or the tissues in the wound are reactive , it is recommended that a swab with a 0.9% isotonic sodium chloride solution be administered. A cotton-gauze dressing, held by the bandage moves, is applied from above. Recently, the introduction of widely used on gauze levomekolevoy ointment having the ability to take the wound fluid contents due to the high osmotic activity. This property of the left- ointment ointment is 40 times higher than the similar possibility of a hypertonic solution. Due to this feature of the ointment, wound cleansing is much faster. In some cases, the operation cannot prevent the development of a new inflammatory focus. In such cases, a second operation is needed to eliminate the inflammatory process of a different localization. With strong impregnation of the dressing with pus, it is replaced more often than 1 time per day. The abscess cavity is cleaned of pus and dead tissue on the 2nd-4th day. The skin wound heals by secondary intention. With a pronounced anaerobic nature of phlegmon, the purulent cavity is opened with a wide incision, and sometimes with 2-3 incisions. The wound is repeatedly washed with a 3% solution of hydrogen peroxide, potassium permanganate (1-2%). In this case, anti-anaerobic serum and hyperbarotherapy are necessarily used . The dose of antibiotics increases significantly. Recently, ultrasound has been successfully used. Sounding the abscess cavity, which is pre-filled with a particular solution (furatsilin, 0.9% isotonic sodium chloride solution, “silver water”, etc.), leads to a decrease in the number of bacteria in the wound, cleansing it of necrotic tissue and helps normalize microcirculation. Chronic dialysis of the abscess cavity is used after opening it using an antiseptic solution. The abscess cavity in the wound itself is irradiated with helium-neon laser rays to accelerate the process of cleansing and healing of the wound. Stimulation of phagocytosis is provided by intracorporal blood illumination with laser light. Proteolytic enzymes are used both topically (on tampons), and in the form of intramuscular injections to cleanse the wound of dead tissue. General treatment includes antibiotic therapy (penicillin, zeporin , oleandomycin , novobiocin , kanamycin) However, the different sensitivity of bacteria to certain antibiotics in some cases negates their therapeutic value. In this regard, when opening phlegmon, it is necessary to take pus for laboratory determination of the sensitivity of bacteria to antibiotics. If this is not possible, broad-spectrum preparations or a combination of 2-3 antibiotics should be prescribed to patients. The administration of antibiotics to patients with moderate phlegmon is carried out every 3 hours.
In cases of intolerance to antibiotics, doses of sulfonamides are increased.
Severe forms of phlegmon of the maxillofacial region (especially in the presence of anaerobes) are treated with hyperbarotherapy (3-4 sessions). The effect of increased oxygen content on the area of acute purulent inflammation contributes to a more rapid recovery of patients, preventing the activation of anaerobes, reducing the duration of the phases of the purulent wound.
The regimen of hyperbarotherapy sessions is usual: a pressure of 2 atm , a compression and decompression time of 1 min; saturation time (saturation) 45 min.
Patients are recommended multivitamins, a dairy-vegetable diet, and thorough oral care.
With severe pain, analgin is prescribed, in some cases, injection of a 1-2% solution of promedol .
In severe cases of phlegmon, when the level of intoxication is high, detoxification therapy is carried out using hemosorption , lymphosorption (intravenous administration of 1000-1500 ml of 0.9% isotonic sodium chloride solution).
For immunotherapy, patients are injected intramuscularly with 0.5 ml of staphylococcal toxoid (1 time), as well as 100 mg of a solution of crystalline lysozyme (factory packaging) 3 times a day for 5 days, gamma globulin, etc.
In cases of more severe course phlegmon is additionally injected intravenously or intramuscularly in 4 ml 2 times a day antistaphylococcal gamma globulin (2-3 days), hyperimmune plasma. The inclusion of immunocorrection helps to speed up the recovery of patients and reduces the number of serious complications.
Of great importance in the treatment is nutrition. Since the act of chewing in such patients is disrupted, they need liquid food. In addition, due to sharp pain when trying to make a chewing, swallowing movement, patients eat very little, therefore, the food should be high-calorie (cream, sour cream, egg, cocoa, butter, strong broth, sugar, etc.).
Special hygienic care for the oral cavity consists in washing it 3-4 times with a solution of furatsilin (1: 5000) or a pale pink (0.1%) solution of potassium permanganate with a rubber balloon. The final and mandatory stage of treatment should be the rehabilitation of the oral cavity. During physiotherapy of patients with abscesses and phlegmons of the maxillofacial region in the initial stages, UHF therapy is most often prescribed.
After opening the abscess or phlegmon, conservative treatment is carried out with the inclusion of physiotherapeutic methods. With sluggish healing of the edges of the incision, treatment is carried out in the same way as an infected wound. Laser therapy is also indicated, which is prescribed on the 3rd day after surgery. The exposure is carried out with a helium-neon laser LG-75 or UVL-01 with a wavelength of 0.63 microns. The first 2-3 days in the period of acute inflammation, a power density of about 150-200 mW / cm2 is applied, the exposure time, depending on the wound surface, is 2 minutes per field (for a total of 6-10 minutes), and then to stimulate tissue regeneration and accelerate wound healing apply a power density of 50 to 100 mW / cm2 in the same temporary exposures. On average, a course of treatment consists of 4 to 5 daily procedures.
A positive clinical effect is achieved after the first procedure. Pain, swelling, tissue infiltration, the amount of wound discharge are reduced, and epithelization is accelerated in the future , which allows you to impose delayed stitches. The duration of treatment is reduced by 2-5 days.