1. INFLAMMATORY DISEASES
Phlegmon
- Acute, diffuse purulent inflammation of soft tissue
- Characterised by rapid spread and necrosis – can penetrate anatomical orifices
Etiology
- Most commonly due to bacterial infection of soft tissue
- Agents – staphylococcus, streptococcus, bacteroides
- Starts as purulent inflammation process in oral, nasal cavity or maxillary sinuses
Clinical features
- Constant pain in area
- Spreading, swelling
- Fever, chills, weakness, rapid breathing, palpitations
- Hyperaemia of skin – no clear boundaries
Investigations
- History, physical exam
- Bloods – ↑CRP and ESR, leukocytosis
- Microbiology study at puncture site
Treatment
- Antibiotics, detoxification
- Local treatment – start with conservative
- Dissection of phlegmon (take precaution of CN VII) → excision of necrotic tissue → debride wound → drain with solutions of antiseptics → apply flow-rinsing drain
Ludwig’s angina
- Life threatening infection of tissue of the floor of the mouth – spreads to retrosternal space
- Usually after concomitant dental infection
Etiology
- Bacterial infection – actinomyces israelii
- Most common in the submandibular space
- Then enters into submaxillary space and further into retrosternal area
- Piercings of floor of mouth
Clinical features
- Swelling, pain – neck, sublingual and submandibular region
- Malaise, fever, stridor, dysphagia
Treatment
- Antibiotics and monitoring
- Drain and incision
- Maxillofacial surgery
Lymphadenitis
- Inflammation of lymph node – most commonly due to a complication of bacterial infection of a wound
- Can be generalised (affects many nodes) or localised
- Can be accompanied by lymphangitis
Etiology
- Streptococcus and staphylococcus, TB, tularaemia
- Viral, fungi
- Dental abscess, tonsillitis, infected acne
- General lymphadenitis is caused by – mononucleosis, CMV, toxoplasmosis, brucellosis
Clinical features
- Nodal swelling – pain on palpation
- Fever, chills, loss of appetite, rapid pulse, general weakness
- If lymph node is not sore cat scratch disease is likely
Treatment
- Antibiotics for bacterial etiology – penicillin G, nafcillin, cephalosporins, erythromycin
- Supportive care – hot moist compress
Dental abscess
- Inflamed pus filled lump in bone or soft tissue of the jaw
- Cause by tooth decay or injury to tooth
Clinical features
- Pain, red gums, swollen gums and cheeks
- Fever
- Patient unable to close mouth properly
Pericoronitis
- Wisdom teeth (3rd molars) – erupt in late adolescence
- If there is not enough room it can lead to pericoronitis (inflammation of tissue surrounding teeth)
- Good nidus for bacteria
- Prevention – good oral hygiene and removal of flap of gum tissue
Clinical features
- Pain, swollen gums, bad taste/smell, pus discharge
- Swollen side of face and lymph nodes
- Muscle spasms in jaw
Treatment
- Drain and clean area from pus
- Oral antibiotics
- Brushing, flossing, rinsing – several times a day
- Extraction
Arthritis
- Osteoarthritis – aching jaw pain increases with talking/eating, stops with rest
- Crepitus heard over TMJ, enlarged joints, decreased range of motion
- Rheumatoid arthritis – symmetrical pains in all joints and jaw
- Decreased ROM and stiff after inactivity (especially in the morning)
- Myalgia, weight loss, anorexia
Osteomyelitis
- Inflammation of bone (medullary space) and muscles around it
- Commonly affects the mandible
Etiology
- Polymicrobial – G-rods, anaerobes, A.israelii
Clinical features
- Restricted jaw motion, pseudoparalysis
- Hyperaemic , warm, oedematous tissue around infected bone
- Localised swelling
Investigations
- CT, MRI, bone scan with gallium (detects early disease)
- Needle aspiration – sulphur granules seen in A.israelii
Prevention
- Good dental hygiene, prompt treatment of oral/dental inf
Suppurative parotits
- S.aureus infection of the parotid gland
- Abrupt onset jaw pain, high fever, chills, erythema, edema of overlying skin
- Swollen, tender gland and pus at 2nd top molar (Stensen’s ducts)
2. TUMOURS
Face tumours
Hemangioma
- Abnormal build up of blood vessels in the skin or internal organs
- Capillary hemangioma – on the skin
- Cavernous hemangioma – in deeper tissues/viscera
- Present at birth, disappear in some patients
- Course
- Rapid growth phase → rest phase → disappear fully
- Large hemangiomas are prone to bleed and ulcerate – bacterial infection can superimpose
- Clinical features – red/purple raised lesion, massive raised tumour with blood vessels
- Treatment
- Topical beta blockers – timolol
- Corticosteroids
- Laser surgery
Bowen’s disease
- Squamous cell carcinoma in situ
- Etiology – HPV, AIDs, sun damage, arsenic
- Clinical features – slow growing red scaly plaque
- Treatment – if not excised then turns in to squamous cell carcinoma
Squamous cell carcinoma
- Sun exposure is the biggest risk factor
- Clinical features – ulcerated, raised edges, central scab
- Spreads by lymph and local extension
- Treatment – wide excision and radiotherapy
Basal cell carcinoma
- Superficial slow growing malignant tumour, derived from keratinocytes
- Locally destructive, but doesn’t metastasise
- Etiology – sun exposure, most common in Caucasians
- Clinical features
- Metastases are rare but eroding ulcer can be highly destructive
- Scabbing, erosion of nose, eyes and face
- Investigation
- Biopsy – typical appearance is shiny pearly border, lesion alternatively crust and heal
- Treatment – excision and radiotherapy
Melanoma
- Arises from melanocytes – in skin, nail beds, mucosa, conjunctiva
- Highest mortality rate
- Atypical moles can be a sign of malignancy
- Enlargement, darkening, ulceration, bleeding, indistinct borders
- Metastasis correlates with depth of dermal invasion
- Treatment – wide excision, radio/chemo for systemic disease
Jaw tumours
Ameloblastoma
- Benign tumour of odontogenic epth
- Ameloblasts form the outside part of teeth during development
- Clinical features – painless swelling, un-erupted teeth, blocked nasal or airway
- Investigations – XR and biopsy
- Treatment – wide excision and reconstruction
Odontoma
- Dental harmatoma – composed of normal dental tissue
- Most common in young people
- Types
- Complex – unrecognisable as dental tissue
- Compound – composed of 3 dental tissues – enamel, dentin, cementum
Osteosarcoma
- Osteosarcoma of the jaw has different characteristics than osteosarcoma of the long bones
- It presents at older age, has longer survival and metastases is rarer than in the long bones
- Clinical features – swelling (osteosarcoma of long bones presents as pain instead), facial dysesthesia, loosening of the teeth
- Linked to previous tooth extraction
- Treatment – wide resection. Adjuvant chemo/radio