Clinical features and differentiation in maxillofacial surgery
In inflammatory processes of the maxillofacial region, it is important to accurately determine the boundaries of the lesion. For example, in abscesses and phlegmons of the infraorbital region, induration, smoothing of the nasolabial fold, and eyelid edema are observed, while mouth opening remains unrestricted. Unlike purulent periostitis of the maxilla, such phlegmons do not present with pronounced smoothing of the mucosa along the mucobuccal fold.
The zygomatic region is involved in pathology of the upper premolars and first molars. The infection can spread to the temporal, buccal, and parotid-masseteric regions, as well as into the orbit.
Distinguishing phlegmon from erysipelas
In practice, it is often necessary to differentiate deep purulent processes from superficial skin infections. The main rules for differentiation from erysipelas:
- Erysipelas is characterized by prominent systemic toxicity preceding the appearance of dermal erythema, whereas phlegmon is accompanied by marked purulent tissue melting.
- In men, an erroneously diagnosed "upper extremity erysipelas" is in almost 100% of cases a purulent process (phlegmon or abscess).
- The absence of positive dynamics and a response to antibiotics during the first week indicates an initially erroneous diagnosis or the development of purulent complications.
- Persistence of alterations in the complete blood count (leukocytosis, elevated ESR) serves as a laboratory marker of phlegmon development.
Surgical treatment and drainage
Management for confirmed phlegmon is exclusively active:
- A surgical approach is performed (e.g., an intraoral incision along the mucobuccal fold when localized in the canine fossa fossa canina).
- Blunt separation of the muscles is performed using a hemostatic clamp to access the interfascial/intermuscular spaces.
- An obligatory step is adequate wound drainage using double drains (a gauze strip with Vishnevsky ointment and a rubber drain).
Phlegmon differs from periostitis by the fold: in periostitis, the mucobuccal fold is markedly smoothed, whereas in infraorbital phlegmon, it is not.
Class and exam questions
What is the main difference between infraorbital phlegmon and purulent periostitis of the maxilla?
The main difference lies in the state of the mucobuccal fold: in infraorbital phlegmon, there is no pronounced smoothing of the mucosa along the mucobuccal fold.
Which pathologies are primarily included in the differential diagnosis of erysipelas?
First of all, urgent surgical pathology must be excluded: abscess, phlegmon, suppurated hematoma, and thrombophlebitis.
What does the lack of response to antibacterial therapy for erysipelas within a week indicate?
This indicates the development of purulent complications (abscesses or phlegmons) or an initially erroneous diagnosis.
What else to study on this topic
- Anatomical boundaries and pathways of infection spread in zygomatic region phlegmons
- Diagnostic criteria for necrotizing anaerobic fasciitis
- Features of complete blood and urine tests in purulent and inflammatory processes
- Symptoms and differential diagnosis of agranulocytosis and monocytosis
- Local and systemic complications of erysipelas
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