General surgical tactics
The majority of acute inflammatory processes in the maxillofacial region are managed conservatively in the early stages, focusing on the phase and localization of inflammation. If conservative therapy fails, active measures are initiated: the infiltrate is infiltrated with antibiotics and a surgical incision is performed.
Prior to making the incision, the surgeon must confirm the presence of pus. For this purpose, a diagnostic puncture is mandatory. The needle is inserted into the zone of greatest fluctuation. The incision itself is usually made directly over this center.
Depending on the localization and etiology of the abscess, one of the following approaches is chosen:
- Intraoral approach: through the oral mucosa. This route is preferred for perimaxillary phlegmons of odontogenic (tooth-related) origin.
- External approach: through the facial skin.
Surgery for acute purulent parotitis
Surgical intervention for purulent inflammation of the parotid salivary gland is performed under general anesthesia. The primary objective of the surgeon is to open the focus of purulent-necrotic breakdown and ensure adequate wound drainage until complete sloughing of necrotic tissues occurs.
The surgeon layer-by-layer dissects the skin, subcutaneous adipose tissue, and the parotidomasseteric fascia (fascia parotideomasseterica). It is critical to select the direction of the incision taking into account the course of the facial nerve branches:
- When the abscess is localized on the outer surface of the masseter muscle, the incision is made radially from the external acoustic meatus (strictly parallel to the course of the nerve branches).
- When the focus is localized in the retromandibular portion of the gland, a vertical incision is performed, running parallel to the posterior border of the mandibular ramus. This direction corresponds to the projection of the trunk, as well as the upper and lower branches of the facial nerve.
To guarantee the safety of the nerve structures, the gland tissue overlying the abscess is not dissected with a scalpel, but is carefully separated by blunt dissection. At the end of the operation, a strip of glove rubber is placed at the focus for drainage.
Opening of abscesses in the parotid region and nasolabial fold
When purulent processes are localized in these zones, external skin incisions are used. A strict tissue-traversal algorithm exists:
- Depth of dissection: The scalpel is used to dissect exclusively the skin along with the subcutaneous tissue. The branches of the facial nerve lie deeper than this incision plane, so they remain undamaged when this rule is followed.
- Traversing deep layers: Through the deep layers of adipose tissue and mimic musculature, the surgeon proceeds strictly by blunt dissection. The tissues are gently separated using closed scissor blades or an anatomical forceps.
- Drainage: After opening the abscess cavity, a drain—a strip of glove rubber—is placed into the wound. It is left in the tissues until the discharge of purulent contents completely ceases.
Briefly: answers to topical questions
Which branches form the pes anserinus major of the facial nerve within the thickness of the parotid salivary gland?
The pes anserinus major within the thickness of the parotid salivary gland is formed by the five main motor branches of the facial nerve.
- Temporal branch (r. temporalis) — projects vertically upward toward the middle of the zygomatic arch.
- Zygomatic branch (r. zygomaticus) — runs toward the outer corner of the eye.
- Buccal branches (rr. buccales) — run above the upper lip toward the midpoint between the alar base of the nose and the corner of the mouth.
- Marginal mandibular branch (r. marginalis mandibulae) — runs along the lower border of the mandible.
- Cervical branch (r. colli) — descends vertically down the neck.
Which facial fascial spaces are most frequently involved in odontogenic phlegmons?
The provided sources do not specify which facial fascial spaces are involved most frequently. The involvement of the following regions and spaces is described:
- Submandibular region — inflammation can spread to adjacent fascial spaces.
- Submental region — described as a separate fascial space bounded by the mylohyoid and digastric muscles.
- Infraorbital region — the infiltrate can spread to the buccal and zygomatic regions.
- Zygomatic region — described in relation to abscesses and phlegmons of this area.
- Temporal region — its fascial spaces communicate with the deep regions of the face and neck, determining the pathways of spread for odontogenic phlegmons.
The safe facial incision rule: "Skin with a scalpel, depth with a blunt instrument." This helps remember that deep tissues superficial to the facial nerve are separated only with a closed instrument to avoid transecting its branches.
Class and exam questions
What anesthesia method is used when opening purulent parotitis?
Intervention for acute purulent parotitis requires adequate pain control, therefore the operation is performed under general anesthesia.
What must be done immediately before making the incision?
Prior to tissue dissection, a diagnostic puncture at the center of fluctuation must be performed to confirm the localization of the abscess.
How should the incision be directed during purulent parotitis on the outer surface of the masseter muscle?
The incision is made radially from the external acoustic meatus. This direction allows passage strictly parallel to the course of the facial nerve branches, avoiding injury to them.
Why must deep layers not be cut with a scalpel in nasolabial fold abscesses?
Deep to the subcutaneous tissue lie the branches of the facial nerve. To avoid transecting them, the deep layers of adipose tissue and mimic muscles are traversed by blunt dissection (using closed scissors).
What else to study on this topic
- Topography of facial nerve branches and projection lines on the face
- Surgical anatomy of the parotidomasseteric fascia (fascia parotideomasseterica)
- Topographic anatomy of the retromandibular fossa
- Features and technique of intraoral approaches in odontogenic phlegmons
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