Larry J. Peterson

Contemporary management of deep infections of the neck

Odontogenic infections rarely lead to involvement of the lateral and retropharyngeal spaces. When this does occur, the microbiology of the infection is similar to the typical odontogenic infection, ie, Streptococcus and oral anaerobes including Peptostreptococcus, Bacteroides, and Fusobacterium. There is an increased incidence of Fusobacterium seen in the more severe infections, as well as a higher incidence of Streptococcus milleri. Many patients who have deep cervical infections also have some compromise in their host defense mechanism, such as diabetes. The signs and symptoms of deep cervical space infections are similar to those of the severe submandibular space infection, but also includes sialorrhea, respiratory distress, odynophagia, and dysphagia. Lateral soft-tissue radiographs of the neck are useful in assisting with the diagnosis of retropharyngeal infections, and CT scans can provide definitive information regarding lateral pharyngeal space involvement. Treatment includes the use of high-dose intravenous bacteriocidal antibiotics. The recommended antibiotics are penicillin-metronidazole, ampicillin-sulbactam, or clindamycin. Certain cephalosporins may also be useful in selected patients. Early surgical intervention is also indicated. Aggressive incision and drainage of all of the involved spaces is necessary to assure early resolution of the infection. Continual airway monitoring and the establishment of surgical airways is the final portion of the treatment triad.

Effect of Prophylactic Amoxicillin on Endodontic Flare-Up in Asymptomatic, Necrotic Teeth

The purpose of this prospective, randomized, double-blind, placebo-controlled study was to determine the effect of prophylactic amoxicillin on the occurrence of endodontic flare-up in asymptomatic, necrotic teeth. Seventy patients participated and had a clinical diagnosis of an asymptomatic, necrotic tooth with associated periapical radiolucency. One hour before endodontic treatment, patients randomly received either 3 g of amoxicillin or 3 g of a placebo control in a double-blind manner. After endodontic treatment, each patient received: ibuprofen; acetaminophen with codeine (30 mg); and a 5 1/2-day diary to record pain, swelling, percussion pain, and number and type of pain medication taken. The results demonstrated 10% of the 70 patients had a flare-up characterized by moderate-to-severe postoperative pain or swelling that began approximately 30 h after endodontic treatment and persisted for an average of 74 h. Of the seven patients who had flare-ups, 4 were in the amoxicillin group and 3 were not. Prophylactic amoxicillin did not significantly (p = 0.80) influence the endodontic flare-up. We concluded that a prophylactic dose of amoxicillin before endodontic treatment of asymptomatic, necrotic teeth had no effect on the endodontic flare-up.

A systematic approach to management of high-flow vascular malformations of the mandible

High-flow vascular malformations of the mandible are associated with significant morbidity and mortality. As these lesions are rare, the experience that a clinician has with treatment may be limited. To facilitate understanding and treatment of such lesions in a controlled and efficient manner, a treatment protocol is presented that includes careful preoperative planning, embolization, and surgery.

Early soft tissue ingrowth into porous block hydroxyapatite.

A dog model was used to determine the rate of soft tissue infiltration into porous block hydroxyapatite (PBHA) in order to provide a scientific basis for treatment of exposed implants. Ten mongrel dogs underwent alveolar ridge augmentation with PBHA and were killed at various times up to 21 days. Significant soft tissue ingrowth had occurred by 14 days and was complete by day 21. Bone formation was also seen as early as 14 days.

Augmentation of the mandibular residual ridge by a modified visor osteotomy

Augmentation procedures for the atrophic mandibular residual ridge have undergone rapid and dramatic changes since Harle’ proposed in 1975 that a vital, pedicled bone flap be elevated for this purpose, in contradistinction to the now classic free onlay bone graft procedure described by Davis et al3 in 1970. Since Harle’s publication, several moditications of the operation have been proposed,4-‘3 all of which have in common a soft tissue vascular pedicle, which presumably maintains the viability of the elevated segment. The purpose of this report is to present the longer-term results of a modified visor osteotomy procedure presented in 1977,’ changes in the procedure now recommended, and problems occasionally encountered.

Prevention of the misdirected sagittal split

If a misdirected split occurs and is recognized, additional surgery is necessary for correction. Two methods may be used. The original medial osteotomy may be extended to the posterior border of the ramus, or, alternatively, a more inferiorly placed osteotomy can be made. Both of these methods result in added tissue trauma and require additional time. The purpose of this paper is to present an explanation for the occurrence of the misdirected sagittal split and to suggest an approach for its prevention.

Use of cricothyroidostomy in oral and maxillofacial surgery.

Surgical entry into the upper airway is not only important in emergency situations but also in the treatment of certain elective maxillofacial procedures. The procedure of choice by which surgical access is gained has traditionally been a tracheostomy. Although a cricothyroidostomy is easier and quicker to perform, with a higher degree of safety, it has generally been relegated to only emergency situations. The purpose of this paper is to present the anatomy, indications, and surgical technique of cricothyroidostomy. It is concluded that cricothyroidostomy, and not tracheostomy, is the preferred procedure for surgical establishment of an upper airway, either in elective maxillofacial surgical procedures, or in an emergency situation.

Treatment of skin graft donor sites with a semipermeable polyurethane dressing

The use of a semipermeable dressing for skin graft donor sites has been described. It permits patients with healing donor sites to ambulate, shower, and wear clothing with no pain during the healing phase. Healing is easily monitored, and signs of infection can be detected early and treated promptly, preventing involvement of the full thickness of the wound. Patients can be discharged from the hospital while the donor site is still healing. The dressing can be removed painlessly at home or in the office. The SPD appears superior to any of the more conventional dressings currently in use for treating skin graft donor sites.