ARTÍCULO CLÍNICO

 

Behaviour of septic processes of the head and neck in patients hospitalized in the department of maxillofacial surgery

Comportamiento de los procesos sépticos cervicofaciales en pacientes hospitalizados en el servicio de cirugía maxilofacial

 

 

A.C. Valdez Borroto¹, L.D. Medina Vega¹, W. Portal Fernández¹, J. Martín Pino², P.L. Gutiérrez Martínez³

1 Especialista de Primer Grado en Cirugía Maxilofacial. Hospital Universitario Arnaldo Milián Castro. Villa Clara. Cuba.
2 Doctora en Estomatología. Clínica Estomatológica: Celia Sánchez Manduley. Santa Clara. Villa Clara. Cuba.
3 Especialista de Primer Grado en Ortopedia y Traumatología. Hospital Universitario Arnaldo Milián Castro. Villa Clara. Cuba.

Correspondence

 

 

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ABSTRACT

A descriptive and prospective study was carried out on 243 patients admitted with the diagnosis of septic cervicofacial processes to the University Hospital "Arnaldo Milián Castro" during 1999 to 2000, in order to establish the epidemiological, clinical, and therapeutic features of this entity in these patients. A septic process was identified in 20.3% of the total number of patients admitted; 53.1% of these were of a non-odontogenic origin. There was a prevalence among males and among the 21-30 age group. The anatomic regions most affected were the genian and submandibular areas. Most patients were hospitalized between one and seven days. A minimal complication rate was reported.

Key words: Focal infection/epidemiology; Focal infection dental; Focal infection/complications; Antibiotics/therapeutic use.

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RESUMEN

Se realizó un estudio descriptivo prospectivo de los 243 pacientes ingresados con procesos sépticos cervicofaciales en el Servicio de Cirugía Maxilofacial del Hospital Provincial Universitario "Arnaldo Milián Castro" de Santa Clara, Villa Clara, en el período de enero de 1999 a diciembre de 2000, con el propósito de mostrar el comportamiento clínico, epidemiológico y terapéutico de los mismos. El 20,3% de los ingresados se identificó como proceso séptico, de los cuales el 53,1% resultó no odontógeno. El grupo de edades más afectado fue el de 20 a 39 años, así como el sexo masculino. Las localizaciones anatómicas mayormente afectadas fueron la geniana y la submandibular. La instauración de un tratamiento antimicrobiano y complementario adecuado favoreció en la mayoría de los pacientes una estadía hospitalaria de 1 a 7 días. En la casi totalidad de los enfermos, la evolución resultó favorable dada la no existencia de complicaciones.

Palabras clave: Infección focal/epidemiología; Infección focal dental; Infección focal/Complicaciones; Antibióticos/uso terapéutico.

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Introduction

Infectious diseases have influenced the evolution of human history intensely. In the medieval era, the pandemic caused by the black plague changed the social structure of Europe at that time. Even the results of many military campaigns were altered as a result of the outbreak of diseases such as dysentery and typhus.¹

Infectious diseases are at this moment the principal cause of mortality and morbidity in the developed world.² Recognizing these, the conformation of their etiology and therapeutic attitudes have motivated the arduous investigation in order to control them.

Head and neck infections represent a disease of great importance, as much for their high incidence as for how potentially serious they can be. They make up approximately 20 to 25% of the patients attended by the departments of Maxillofacial surgery.³

Two etiological aspects in the region can been defined, and individualized clinically and therapeutically: odontogenic and non-odontogenic processes.

Non-odontogenic infections exclude a dental origin and they are secondary to glandular, sinusal, postsurgical, posttraumatic, cutaneous and mucosal infections, extra infections from neoplasms, branchial and dermoid cysts amongst others. ^4-5

Odontogenic infection originates in the structure that forms the tooth and periodontium. It is the most common type of infection in the head and neck region.^6-7

Of note is the high number of patients that attend our on-duty service with this disease, and many require hospitalization. It should be pointed out that inadequate treatment by a health center has led to the perpetuation and exacerbation of the disease in many sufferers.

All this has lead to our interest in studying head and neck disease clinically, epidemiologically and therapeutically with the aim of reporting on its behavior in our area.

 

Material and method

A prospective descriptive study was carried out of 243 patients with septic processes of the head and neck who were admitted into the department of Maxillofacial Surgery of the "Hospital Provincial Universitario Arnaldo Milián Castro" in Santa Clara, Villa Clara, Cuba, between January 1999 and December 2000. The selection was made up of entirely of these patients.

A form was drawn up for data collection (see annex) with the variables of interest. These had been obtained by carrying out a survey based on the clinical observation of the patient and on reviewing the medical records individually. These had been drawn up on admittance and filed in the Statistics Department of the hospital. The variables were: type of septic process, sex, age, anatomic location, type of antimicrobial agent used, stay and complications.

The data was fed into a computer and processed with the Windows SPSS8.0 system and a database was set up. The data were summarized in statistics tables. Absolute frequencies were determined (number of patients) and relative (percentages) in the distribution of adjusted frequencies.

Percentage analysis, arithmetic average and standard deviation were used for the analysis and interpretation of the results, and inferential statistics were applied. In order to determine if a significant link between the variables existed, the Chi-square test was used and the result given was that of the same value of the statistic x² and its associated significance p.

 

Results

The incidence of septic processes is reflected in figue 1. Patients with infectious diseases make up 20.3% of the total number of inpatients, which is a fifth of the total.

On analyzing the septic process with regard to sex and etiology (Table 1), a predominance of non-odontogenic infections can be detected (53.1%), but in general they keep relative equity with odontogenic processes. More than half the processes corresponded to the male sex (54.3%) and most of the patients with non-odontogenic septic processes were males (62.8%). The relationship between sex and etiology in septic processes is highly significant (p = 0.00481), which indicates that sex influences the type of process (x²=7.9496; DF = 1).

 

 

Table 2 shows the distribution of septic processes according to age. In our study the wide age range was taken into account (15-84), but most patients corresponded to the 20- 39 age group (56%), and they also predominated each type of process (61.4% for odontogenic and 51.2% for non-odontogenic). The statistical comparison between age and type of septic process is highly significant (p = 0.00171), and it shows that age influences the appearance of head and neck sepsis (x²=15.13356; DF = 3).

 

 

The most common anatomic locations in septic processes are set out in table 3. As can be appreciated, there was a predominance in the genian and submandibular regions of 45.7% and 43.2% respectively. Thus, the odontogenic processes were greater in the genian region. (48.8%) although here the differences were not significant. There was a highly significant relationship (p < 0,001) between the anatomic locations that were submandibular, masseteric, genian, of the mandibular body and the parotid region with septic processes (x² =28.967; x2 =21.717; x² =22.886; x² =11.155; DF =1).

 

 

Table 4 shows the complications presented by patients according to the type of process. Most of these did not have complications (95.9%), which speaks in favor of the antimicrobial- drainage combination. Of note in the odontogenic processes were the complications as a consequence of the local extension of the disease (because of continuity). In the non-odontogenic processes, distant propagation was responsible for all the complications.

 

 

Hospital strategy evidently leads the professional to be familiar with the effectiveness of the treatment given. Table 5 links both aspects. This shows that staging fluctuated between 1 and 45 days with an average of 7.6 days being necessary for conventional antimicrobial treatment. The greatest average obtained with regard to stay occurred in patients that consumed aminoglycosides with ciprofloxacin, as they reached an average of 22.5 days with a standard deviation of 16.15 days. This explains why one of the patients who was given a combination had a stay of 45 days, which was influenced by the seriousness of the process, and by not having a diagnostic conclusion. This led to three cycles of antimicrobial treatment being given, the last one being the combination previously mentioned.

 

 

This is followed in order of frequency by those that used vancomycin and ketoconazole who were hospitalized between 13.25 and 12 days respectively. The stay of the patients treated with the remaining antimicrobial drugs varied between 5.22 and 8.50 days respectively.

It should be pointed out that drawing up a treatment protocol was not possible on carrying out this study (in order to compare results), as the availability of drugs was very variable and adjustments had to be made because of this. However, penicillin and metronidazole were relatively stable, to the extent that patients with odontogenic processes were treated with this combination, with the exception of those that reported penicillin allergies, in which case this was substituted by cefazolin, an aminoglycoside or another antimicrobial agent.

The choice of antimicrobial agent for treating non-odontogenic sepsis depended on etiology and availability. Antistaphylococcus drugs were reserved for facial cellulitis because of boils, and postsurgical sepsis. Chloramphenicol and sulfaprim were chiefly available. In cases of allergy, or cases that were more serious, cephalosporins or aminoglycosides were chosen. Vancomycin was kept as a last resort. Ketoconazole was administered for treating oropharyngeal candidiasis in two patients (0.8%).

Antimicrobial therapy was complemented with surgical drainage when necessary. It was also complemented with dental extraction or chamber access in processes with a dental origin.

 

Discussion

The high frequency with which these septic processes arise, despite the possibilities regarding diagnosis, control and treatment in primary care, means that considering this a health problem is necessary.

A study with similar results was carried out in the "Hospital General Calixto García" in our capital by Díaz Veliz, which showed that 21.3% of the 286 patients who were hospitalized suffered from infection in the cervicofacial area. Escudes3 claims that they make up 20-25% of patients who are admitted to Maxillofacial Surgery departments, a figure that agrees with the one obtained in our investigation.

Historically, it is processes with an odontogenic origin that have headed septic disease of the head and neck, but this did not occur in our study. For Kimura⁷ this represents 88.9% of the patients.

There are some important reasons that help to explain this discrepancy:

• Non-odontogenic septic processes include a variety of conditions, each with different epidemiological behavior and one, staphylococci facial cellulitis (derived from skin lesions), has experienced a high incidence over the last years, and it has even been the cause of most of the admittances to our department with a non-odontogenic origin. The high rate of staphylococcus sepsis has been demonstrated in the annual reports sent by the Microbiology Laboratory to the Infections Committee for the years that have been studied.

• Moreover, the patients admitted have signs and symptoms that suggest they have the more serious or complicated septic processes, and that they require hospital care. And that, therefore, the existence of large numbers of patients that experience the disease on an outpatient basis and that are not included in our study cannot be excluded.

• Medical personnel at a primary care level (dentists and family doctors) and the population in general are more familiar with the treatment for odontogenic processes and, as a result, they do not attend our department regularly because they believe that they can solve the process themselves.

It should be mentioned that there are criteria⁸ that deny any gender influence in infection susceptibility. However, other authors^9,10 including ourselves, defend that there is a slight male supremacy, as this is a group with special characteristics and with greater risks, because they are more exposed to trauma as a result of accidents and disputes, they have a greater association with dirty jobs either outside or with contaminated medium, and in general because of slacker hygiene. Having a beard and shaving frequency helps to explain the high number of males with non-odontogenic processes, as the risk of boils and folliculitis increases.

The results obtained with regard to age and sex predominance coincide with those obtained by Díaz Veliz and Rodríguez Calzadilla.¹¹ It is precisely this age group which is more active biologically and socially, and therefore more susceptible to this ailment in the study.

A tendency for septic processes to reduce as age increases can be observed together with a greater accentuation on odontogenic processes, easily explained by the natural deterioration of the dental apparatus and the increase in diseases such as parotiditis and extra infections from neoplasms.¹²

Many authors^11-13 also found the submandibular region to be the most affected by sepsis of odontogenic origin.

The references to using a combination of penicillin and metronidazole are far from few, as many of the investigators referred to^14-17 stress the advantages and efficiency of this combination.

Penicillin is the first choice for treating odontogenic infections. In spite of the inconveniences of its administration (method and frequency) penicillin G is still of inestimable value for serious infections, as its action spectrum is reduced, and it coincides satisfactorily in those habitually found in odontogenic infecctions.¹⁶ Metronidazole has been used increasingly over the world due to resistance being unusual, and because of its pharmacological properties that permit penetrating abscesses and repressing bacteria in an anaerobic environment.¹⁸

The non-odontogenic processes did not require the identification of the etiological condition for pharmacological therapy to be started, and the natural evolution of the disease indicated the need for surgical drainage or not.

However, in odontogenic processes, removing the tooth causing the infection is imperative if there is no possibility for conservative treatment in the future. The extraction should only be delayed or postponed because of limited oral aperture or because antimicrobial treatment has not been started, although it is known that changing appropriate antimicrobial therapy for suppression of the tooth causing the infection and/or prompt surgical drainage, favor and accelerate the resolution of the process (Kimura,⁷ Kpemissi,¹⁵ Scheffer,¹⁹ Miconi).²⁰ This is not a common procedure at primary care level. Dentists will nearly always recommend delaying all surgical investigation, including dental extraction, until the acute cellulitis period has disappeared, as it is considered dangerous, either because of a lack of familiarity or fear, and antimicrobial therapy is misused. This leads to the nonresolution and+ the deterioration of the process, which can end with the hospitalization of patients treated incorrectly as outpatients.^11-21

Kimura,⁷ reported that 75% of the 147 patients is his series recovered with parenteral antibiotic therapy and the remainder required drainage or another surgical procedure, and only one patient is mentioned with septic thrombosis complications of the cavernous sinus.

 

Conclusion

Early diagnosis and treatment is essential for infections of the head and neck with regard to reducing the hospitalization of patients that this can lead to. Although these septic processes represent a potentially serious condition, most of these patients will recover with adequate treatment.

 

 

Correspondence:
Luis Daniel Medina Vega
Prolongación de Martha Abreu, 100 entre B y C
Reparto Virginia. Santa Clara. Villa Clara, Cuba
E-mail: Luisdaniel@cubasi.cu

Recibido: 12.04.04
Aceptado: 06.10.06

 

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