ICD 10 phlegmon of the left foot. What kind of disease is phlegmon of the maxillofacial area and how to treat it? Get treatment in Korea, Israel, Germany, USA

Treatment in the initial stages is conservative: baths with potassium permanganate, antiseptics. If pus appears, surgical treatment is required. May be complicated by subungual panaritium.
  Subungual panaritium is an accumulation of pus under the nail plate. Occurs with suppuration of subungual hematomas, foreign bodies, or transition of inflammation from the periungual fold. Severe pain and “swimming” of the nail plate appear. Sometimes pus is released from under the nail plate.
  Surgical treatment - removal of the nail (partial or complete).
  Cutaneous panaritium is an accumulation of pus under the epidermis in the form of a limited bubble. More often occurs due to microtraumas or foreign bodies of the skin. An accumulation of pus is detected under the epidermis, the pain syndrome is not sharp. Removal of the epidermis leads to recovery. After removing the epidermis, it is necessary to carefully examine the base of the abscess; a fistulous tract may open at the bottom, leading to the deeper parts of the finger (skin panaritium can be a manifestation of panaritium “in the form of a cufflink”: the main focus is subcutaneous panaritium).
  Subcutaneous panaritium is a common form of finger suppuration. Severe tugging pain and local tenderness outside the projection of the tendons are noted. More often the process is localized on the nail phalanx: “The first sleepless night” is an indication for surgery; Delaying the operation risks spreading the inflammation to the bone or joint.
  Tendon felon - suppuration of the tendon sheath, more often when the subcutaneous felon spreads deeper. Severe pain and sharp swelling of the affected finger are noted, which, together with the neighboring one, is in a state of palmar flexion. Palpation of the tendon projection with a button probe determines the area of ​​maximum pain. Delay in the operation leads to necrosis of the tendon and loss of function of the finger; the tendon panaritium of the 1st and 5th fingers is especially dangerous - their tendon sheaths communicate; with inflammation, a U-shaped phlegmon of the hand occurs with swelling on the forearm. The prognosis is serious.
  Articular felon - suppuration of the articular capsule of the interphalangeal joint. More often it is a complication of subcutaneous panaritium (late or incorrectly performed surgical intervention). The joint is sharply swollen, painful on palpation, stretching along the axis of the finger is sharply painful. Conservative treatment can be carried out only in the earliest stages (joint puncture with rinsing the cavity with antibiotics). In case of increased pain and late stages - surgical treatment. The prognosis is serious.
  Bone felon is most often localized on the nail phalanx. There is a flask-shaped swelling of the finger in the area of ​​the nail phalanx, pain on palpation, and sometimes bone crepitus is detected. X-ray reveals bone sequestration. Treatment is surgical.

Phlegmon of the leg is an acute purulent inflammation of tissues, usually of an infectious nature. Such an inflammatory process is dangerous because it does not have clear boundaries, unlike an abscess or boil, and involves a large volume of tissue. First of all, adipose tissue is involved in the pathological process, then all the rest. If treatment is not started in time, ligaments and bones suffer.

This is an exclusively surgical pathology; it can only be eliminated with a scalpel.

According to ICD-10, phlegmon of the lower leg is classified in heading L (infections of the skin and subcutaneous tissue) as phlegmon of other parts of the extremities (L03.1). Phlegmon of the foot according to ICD-10 is also classified, only the inflammatory process of the fingers has a separate code.

Classification of phlegmon

Phlegmon of the ankle joint

A diffuse inflammatory process can occur as an independent disease or as a complication of an existing abscess or boil. Accordingly, they distinguish:

• primary phlegmon resulting from direct entry of microorganisms into tissues;
• secondary, as a complication of an already ongoing inflammatory process.

Depending on the course, it is divided into acute and chronic. And according to the type of spread of infection - damage to deep-lying or superficial tissues.

According to the morphological classification of inflammation, 4 forms are distinguished:

• serous;
• purulent;
• necrotic;
• putrid.

The exact localization of the pathological process is also important, because the treatment tactics and the volume of intervention depend on this. Based on localization, phlegmon is classified into subcutaneous, intermuscular, subfascial or diffuse phlegmon.

Types of pathogens

Opening of deep phlegmons of the sole

Despite the fact that phlegmon of the lower leg can be treated surgically, therapy is impossible without prescribing antibacterial therapy. And its choice directly depends on the type of pathogen that caused the disease.

There are two ways of penetration of the pathogen: through damaged skin or “metastatically” from other anatomical areas (retroperitoneal space, foot, thigh).

The first place among the causative agents of phlegmon is Streptococcus aureus, the second is Streptococcus.

In children and adolescents, due to undeveloped immunity, the disease can be triggered by hemophilus influenzae infection. When bitten by animals (especially domestic ones), Pasteurella multocida may enter the tissue.

The chronic course of phlegmon is caused by the proliferation of diphtheria bacillus, pneumococcus or paratyphoid bacillus.

The course of the disease itself and the type of inflammation depend on the type of pathogen.

For staphylo- and streptococci, abundant discharge of purulent contents is more typical, and if the cause of phlegmon is microorganisms of the genus Proteus or E. coli, you should expect putrefactive melting of the tissues.

Clinical picture

Severe inflammation of the skin of the leg

Phlegmon of the leg is characterized by an acute onset, with the overall body temperature rising to febrile levels (39-40 C), weakness, malaise, and symptoms of intoxication increasing.

Cellulitis (see photo) has a characteristic appearance: the skin acquires a red-gray tint, becomes hot and swollen. In this case, the lower leg can significantly increase in size, the skin becomes shiny and shiny.

At the same time, it is not possible to determine clear boundaries of inflammation; it seems to gradually disappear.

If the inflammation is productive, that is, pus is released, a cavity may form, delimited by fascia or synovial muscle sheaths. If the putrefactive process has affected the skin, a tissue defect may appear with pus coming out.

If the inflammatory process develops at lightning speed or if you do not seek medical help in a timely manner, complications may occur:

• inflammation of the lymph nodes and blood vessels;
• thrombophlebitis;
• sepsis;
• erysipelas.

If a large number of tissues are affected and the immune response is significantly weakened, pathogenic microorganisms may spread to other distant organs and tissues through the bloodstream.

Treatment of phlegmon of the leg

Opening the lesion with striped incisions

Before prescribing antibiotic therapy, it is necessary to identify the causative agent of the disease. To do this, a smear or piece of affected tissue is sent to a bacteriological laboratory.

To treat this disease, an integrated approach is used, that is, a combination of surgery and drug therapy.

The patient must be in a hospital setting.

First of all, the focus of inflammation is opened, sanitized and drained. Even in the absence of a cavity with purulent contents or a symptom of fluctuation, surgical treatment is prescribed. This approach makes it possible to reduce the volume of tissue and remove a large array of dead tissue with pathological organisms.

The opening of the lesion is carried out under general anesthesia with wide “lamp-shaped” incisions (photo).
This allows you to visualize the entire volume of damage and not miss “secret” pockets. To do this, it is necessary to cut not only the skin with subcutaneous tissue, but also the deeper lying muscles.

Rubber tubes or glove strips are used as drainage.

To better separate the contents, bandages with a hypertonic solution or antibacterial ointments are applied to the wound. It must be remembered that “heavy” ointments (ichthyol, tetracycline and the like) are not used in the early postoperative period! This is due to the fact that they completely cover the wound surface, significantly complicating the outflow of pus to the outside.

When a large flap of skin is excised, dermoplasty is subsequently performed.

Drug treatment

Drug treatment of phlegmon

Conservative therapy is carried out to achieve several goals simultaneously:

• infection control;
• anti-intoxication therapy;
• increased body reactivity.

Antibiotics are prescribed empirically until an answer or a bacteriological laboratory arrives. Moreover, their effectiveness is assessed after 72 hours. For anaerobic infection, it is necessary to prescribe anti-gangrenous serum.

To improve your general condition, it is necessary to detoxify the body. An intravenous drip of a Rheosorbilact solution with the addition of ascorbic acid and diuretics is used.

To improve heart function, you can add a solution of glucose or sodium thiopental to the dropper.

In the late rehabilitation period, bandages with various creams and ointments are used topically. Fat-based ointments prevent the formation of granulation tissue. Reinfection and the development of a new round of inflammation are prevented by water-based ointments.

If the infiltrate is not formed, only conservative treatment can be used.

Physiotherapeutic procedures (UHF, heating with the addition of ointments) give good results.

Prevention of the development of phlegmon of the lower leg involves preventing injuries and immediately treating even minor cuts and scratches.

RCHR (Republican Center for Health Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Clinical protocols of the Ministry of Health of the Republic of Kazakhstan - 2016

Skin abscess, boil and carbuncle of the face (L02.0), Cellulitis and abscess of the mouth area (K12.2), Cellulitis of the face (L03.2)

Maxillofacial surgery

General information

Brief description

Approved
Joint Commission on Healthcare Quality
Ministry of Health and Social Development of the Republic of Kazakhstan
dated June 9, 2016
Protocol No. 4

Abscess- acute limited purulent-inflammatory disease of subcutaneous fat.
Phlegmon- acute diffuse purulent-inflammatory disease of subcutaneous fat, intermuscular and interfascial tissue. Phlegmon of the mouth area, as well as phlegmon of the face, are diffuse in nature and tend to quickly spread and develop life-threatening complications.

Correlation of ICD-10 and ICD-9 codes:

Date of protocol development/revision: 2016

Protocol users: general practitioners, pediatricians, therapists, surgeons, dentists, maxillofacial surgeons.

Level of evidence scale

Relationship between strength of evidence and type of research

A	A high-quality meta-analysis, systematic review of RCTs, or large RCTs with a very low probability (++) of bias, the results of which can be generalized to an appropriate population.
IN	High-quality (++) systematic review of cohort or case-control studies or High-quality (++) cohort or case-control studies with very low risk of bias or RCTs with low (+) risk of bias, the results of which can be generalized to relevant population.
WITH	Cohort or case-control study or controlled trial without randomization with low risk of bias (+), the results of which can be generalized to the relevant population or RCT with very low or low risk of bias (++ or +), the results of which cannot be directly generalized to the relevant population.
D	Case series or uncontrolled study or expert opinion.

Classification

Classification of abscesses, phlegmons of the face and mouth (anatomical and topographical).
A. Abscesses and phlegmons of the anterior (middle) part of the face.

Surface areas:
1. Eyelid area (regio palpebralis)
2. Infraorbital region (regio infraorbitalis)
3. Nose area (regio nasi)
4. Area of ​​the lips of the mouth (regio labii oris)
5. Chin area (regio mentalis)

Deep areas:
1. Orbital area (regio orbitalis)
2. Nasal cavity (cavum nasi)
3. Oral cavity (cavum oris)
4. Hard palate (palatum durum)
5. Soft palate (palatum molle)
6. Periosteum of the jaws (periostium maxillae et mandibulae)
B. Abscesses and phlegmon of the lateral part of the face

Surface areas:
1. Zygomatic region (regio zygomatica)
2. Buccal region (regio buccalis)
3. Parotid-masticatory region (regio parotideomasseterica):
a) chewing area (regio masseterica)
b) parotid region (regio parotidis)
c) retromandibular fossa (fossa retromandibularis)

Deep areas:
1. Infratemporal fossa (fossa infratemporalis)
2. Pterygomaxillary space (spatium pteiygomandibulare)
3. Periopharyngeal space (spatium parapharyngeum)

Classification of abscesses, phlegmons of the face and mouth area according to the type of inflammatory reaction:
1. Hypoergic type;
2. Normergic type;
3. Hyperergic type

Diagnostics (outpatient clinic)

OUTPATIENT DIAGNOSTICS

Diagnostic criteria:

Table - 1. Complaints and anamnesis

Complaints and anamnesis in patients with abscesses and phlegmon of the oral cavity:		Complaints and anamnesis in patients with abscesses and phlegmons of the face
Periopharyngeal space	Complaints: pain when swallowing, difficulty breathing, deterioration in general health, limited mouth opening.	Submental area	Complaints: spontaneous pain in the affected area, painful chewing and swallowing.
	History: The main source of infection is the pathological process in the teeth of the lower jaw; the inflammatory process can spread from adjacent cellular spaces, as a complication after mandibular anesthesia, and as a result of previous infectious diseases.		History: Foci of odontogenic infection in the area of ​​the lower teeth. Secondary damage as a result of the spread of infection along the extension from the submandibular and sublingual areas, as well as through the lymphogenous route.
	Complaints: significant spontaneous pain in the affected area, intensifying when opening the mouth. Swelling at the angle of the lower jaw. Significant restriction of mouth opening.	Submandibular region	Aching pain, limited mouth opening, pain when swallowing.
			History: Foci of odontogenic infection, infected wounds. Secondary damage as a result of the spread of infection along the sublingual, submental, parotid-masticatory areas, from the pterygo-maxillary space, by lymphogenous route.
	History: the source of infection is a pathological process in the teeth of the lower jaw; the inflammatory process can spread from adjacent cellular spaces, as a complication after conduction anesthesia, and as a result of previous infectious diseases.
Language	Complaints: intense pain in the tongue, radiating to the ear, sharply painful swallowing, slurred speech, difficulty breathing.		Complaints: significant spontaneous pain in the affected area, intensifying when opening the mouth. Swelling in the corresponding half of the face.
			History: odontogenic foci, complication of purulent lymphadenitis. Secondary damage as a result of the spread of infection along the length of the parotid salivary gland, buccal, temporal areas, chewing space, infratemporal fossa
Maxilloglossal groove	Complaints: spontaneous pain in the throat or under the tongue, aggravated by talking, chewing, swallowing, opening the mouth.	Infraorbital region	Complaints: spontaneous pain radiating to the eye and temple. Complaints of swelling in the infraorbital and buccal areas.
			History: Foci of odontogenic infection, infectious-inflammatory lesions, infected wounds of the skin of the infraorbital region. Secondary damage as a result of the spread of infection from the buccal region and the lateral part of the nose, thrombophlebitis of the angular vein of the face.
	History: foci of odontogenic infection in the area of ​​the lower molars, infectious and inflammatory lesions and infected wounds of the mucous membrane of the floor of the mouth. Secondary damage as a result of the spread of a purulent-inflammatory process from the sublingual area.
Floor of the mouth	Complaints: intense pain, inability to swallow, limited mouth opening, difficulty breathing and speech.	Postmaxillary region	Complaints: spontaneous pain in the affected area, intensifying when turning the head, increasing limitation of mouth opening. Swelling behind the ramus of the lower jaw, decreased hearing on the affected side.
	History: The cause is an odontogenic infection of the teeth of the lower jaw. The process can occur when the sublingual space or floor of the mouth is injured, as well as in the case of salivary stone disease, osteomyelitis of the lower jaw.
			History: Odontogenic infection, spread of the inflammatory process from neighboring areas, the infratemporal fossa, lymphogenous route of infection (with conjunctivitis, infected skin wounds in the outer corner of the eye), pathological process in the palatine tonsils.
Sublingual area	Complaints: spontaneous pain in the affected area, pain when swallowing, inability to move the tongue, limited mouth opening.	Periorbital region	Complaints: throbbing pain in the orbital area radiating to the temple, forehead, infraorbital region, sharp headaches.
			History: Foci of odontogenic infection, with thrombophlebitis of the angular vein (v. angularis). Secondary damage as a result of the spread of an infectious-inflammatory process from the maxillary sinus, ethmoid bone, infratemporal, pterygopalatine fossa, infraorbital region, eyelids.
	History: Infected wounds of the tongue. Secondary damage as a result of the spread of infection from the lingual tonsil (tonsilla lingualis).
-	-		Complaints: spontaneous pain radiating to the temple and eye, aggravated by swallowing, headaches, pain in the upper jaw. Limitation of mouth opening.
			History: Foci of odontogenic infection, infection during conduction anesthesia. Secondary damage as a result of the spread of infection from neighboring areas.
-	-	Buccal region	Complaints: spontaneous sharp pain that intensifies when opening the mouth and chewing. Swelling spreading to the lower and upper eyelids.
			History: Foci of odontogenic infection, infectious-inflammatory lesions, infected wounds of the skin and mucous membrane of the cheek. Secondary damage as a result of the spread of infection from neighboring areas.
-	-	Temporal region	Complaints: spontaneous sharp pain that intensifies when opening the mouth, pain when swallowing, difficulty breathing, deterioration in general health.
			History: foci of odontogenic infection, purulent-inflammatory skin diseases (folliculitis, furuncle, carbuncle), infected wounds, hematomas of the temporal region, phlegmon of adjacent areas: infratemporal, frontal, zygomatic, parotid-masticatory.
-	-	Zygomatic region	Complaints: spontaneous pain in the zygomatic region, radiating to the infraorbital and temporal regions, intensifying when opening the mouth.
			History: foci of odontogenic infection, infectious and inflammatory skin lesions, infected wounds of the zygomatic region. Secondary damage as a result of the spread of an infectious-inflammatory process from neighboring areas: infraorbital, buccal, parotid-masticatory, temporal areas.

Table - 2. Physical examination:

Abscesses and phlegmon of the oral cavity	External inspection		Oral examination	Palpation
Periopharyngeal space	The infiltrate is determined at the angle of the lower jaw. In some patients, swelling occurs in the temporal region. Mouth opening is limited due to grade III inflammatory contracture of the medial pterygoid muscle.		On examination, the mucous membrane of the pterygomandibular fold and soft palate is hyperemic and edematous, the uvula is sharply shifted to the healthy side. Infiltration spreads to the side wall of the pharynx, edema - to the mucous membrane of the sublingual fold, tongue, and posterior wall of the pharynx.	There is a deep painful infiltrate at the angle of the lower jaw
Pterygomandibular space	Swelling is detected at the angle of the lower jaw. Mouth opening is sharply limited due to grade III inflammatory contracture of the masticatory muscle.		When examining the oral cavity, hyperemia and swelling of the mucous membrane is noted in the area of ​​the pterygomandibular fold, palatoglossus arch, and pharynx. Sometimes infiltration spreads to the mucous membrane of the lateral wall of the pharynx and the distal sublingual region.	There is a painful infiltrate at the angle of the lower jaw, the skin above it does not fold. Lymph nodes are fused to each other, sometimes swelling appears in the lower part of the temporal region
Language	Mouth opening is limited, and inflammatory contracture of the masticatory muscles is noted. The enlarged tongue does not fit in the oral cavity; the patient keeps his mouth half open.		The tongue is significantly enlarged in size, protrudes forward, covered with a whitish coating, and a putrid odor emanates from the mouth.	Regional lymph nodes are enlarged, painful, fused to each other. A diffuse, painful infiltrate is palpated in the depths of the chin area.
Sublingual area	Swelling in the submental and anterior parts of the submandibular triangle due to collateral edema. The skin over the swelling is unchanged. Mouth half open. Mouth opening is limited. With widespread phlegmon, the contracture of the internal pterygoid muscles is more pronounced.		Increasing swelling in the sublingual area, the tongue is moved to the opposite side. When both sublingual areas are affected, the sublingual folds are infiltrated and smoothed. The mucous membrane on the surface of the sublingual folds is covered with fibinous plaque. The tongue is significantly increased in size.	The infiltrate is dense and painful. The skin above the swelling is not fused and gathers into a fold.
Maxilloglossal groove	Mouth opening is moderately limited (due to pain). Swelling in the posterior part of the submandibular region.		The maxillo-lingual groove is smoothed due to infiltration, the tongue is shifted to the healthy side. The mucous membrane of the oral cavity above the infiltrate is hyperemic, its palpation is painful.	The infiltrate is dense and painful.
Floor of the mouth	The face is puffy. The mouth is half open, the patient is in a forced position with his head fixed. Mouth opening is difficult and limited. Possible breathing problems.		The sublingual folds are infiltrated, the tongue is enlarged due to infiltration, often dry and covered with a dirty brown coating, tooth marks are visible.	Dense, painful diffuse infiltrate located at the level of the teeth to the submandibular and submental areas.
Abscesses and phlegmons of the face
Submental area		A diffuse infiltrate in the submental triangle and pronounced swelling of both submandibular areas are detected. The opening of the mouth is free and only when the purulent process spreads to the surrounding tissues, the lowering of the lower jaw is limited, chewing and swallowing become painful, the skin over the infiltrate is hyperemic.	Upon examination, the mucous membrane of the oral cavity and the sublingual fold itself were not changed.	There is a softening of the infiltrate, the skin over it is soldered, does not gather into a fold, and fluctuation is determined.
Submandibular region		Swelling in the submandibular and adjacent submental and retromandibular areas. Mouth opening is often not limited, free. In cases where the infiltrate spreads into the sublingual region and the pterygomandibular space, there is a significant limitation in the lowering of the lower jaw and pain when swallowing.	On the affected side there is slight swelling and hyperemia of the mucous membrane and sublingual fold.	A dense, painful filtrate is determined in the center.
Parotid-masticatory region		A diffuse infiltrate is detected from the lower part of the temporal region to the submandibular triangle and from the auricle to the nasolabial groove. The contours of the angle and posterior edge of the lower jaw ramus are smoothed. Mouth opening is sharply limited due to grade III inflammatory contracture of the masticatory muscle. The skin over the infiltrate is shiny and purple in color.	On examination, the buccal mucosa is significantly swollen, with infiltration of the anterior edge of the masticatory muscle.	The infiltrate is dense, sharply painful; the skin over it is welded together and does not form a fold.
Infraorbital region		Swelling in the infraorbital and buccal areas, spreading to the zygomatic region, upper lip, lower and sometimes upper eyelid. The tissues along the anterior surface of the body of the upper jaw are infiltrated. The skin over the infiltrate is bright red.	Upon examination, the upper fornix of the vestibule of the mouth is smoothed, the membrane above it is hyperemic and edematous.	Palpation is painful, the skin over the infiltrate is fused into a fold and is difficult to gather.
Postmaxillary region		Swelling behind the ramus of the lower jaw, which smoothes its contours. The skin over it is bright red. The earlobe is raised. Restriction in mouth opening increases.	Upon examination, the mucous membrane of the pterygomandibular fold, soft palate, palatoglossal arch, and pharynx is hyperemic and edematous.	The infiltrate is dense and painful. The skin over the swelling is welded into a fold and does not gather.
Periorbital region		Restricted mobility of the eyeball, usually in one direction. Infiltration of the eyelid, swelling of the conjunctiva, diplopia appears, followed by a progressive decrease in vision. The skin of the eye socket is bluish in color.
Infratemporal and pterygopalatine fossae		An inflammatory swelling in the lower part of the temporal and upper part of the parotid-masticatory region in the form of an “hourglass”, as well as collateral edema in the infraorbital and buccal areas. Inflammatory contracture of the masticatory muscles is pronounced. The skin color is not changed.	Swelling and hyperemia of the mucous membrane of the upper fornix of the vestibule of the mouth; upon palpation in the depths of the tissue, a painful infiltrate is determined, extending to the anterior edge of the coronoid process.	There is infiltration and pain in the lower part of the temporal region, sometimes pain when pressing on the eyeball on the side where the inflammatory process is localized. The skin is difficult to fold into folds.
Buccal region		Significant infiltration in the buccal area, pronounced swelling of the surrounding tissues, spreading to the lower and upper eyelids, narrowing of the palpebral fissure or its complete closure. The skin in the cheek area is red.		Painful palpation, the skin in the cheek area is infiltrated into a fold and does not gather.
Temporal region		Swelling above the zygomatic arch, involving the temporal fossa; collateral edema extends to the parietal and frontal regions. Swelling of the zygomatic region, upper and lower eyelids is often observed.	There is swelling and hyperemia of the mucous membrane of the cheek, upper and lower fornix of the vestibule of the mouth.	Dense and painful infiltration. The skin over it is welded into a fold and does not gather. Fluctuation is determined.
Zygomatic region		The swelling is significant, spreading to the infraorbital, temporal, buccal and parotid-masticatory areas. The skin over the infiltrate is red.	In the vestibule of the mouth, along the upper fornix at the level of the large molars, there is a swollen and hyperemic mucous membrane.	Dense and painful infiltrate in the projection of the zygomatic bone. The skin over it is welded into a fold and does not gather.

Table - 3. Characteristic local manifestations of abscesses, phlegmons of the head in individual localizations
Localization of the inflammatory process	Dysfunction						External manifestations of the inflammatory process
	Breathing	Swallowing	Mouth opening	Closing the mouth	Vision	Speeches	Facial asymmetry (swelling in the area of ​​inflammation	Swelling in the submandibular region. on both sides	Pharynx asymmetry	Increasing the volume of the tongue	Moving the tongue up
Deep:
floor of the mouth	+	+	-	+	-	+	-	+	-	-	+
parapharyngeal space	-	+	-	-	-	+	-	-	+	-	-
tongue (base)	+	+	-	+	-	+	-	-		+	-
pterygomaxillary space	-	+	+	-	-	-	-	-	+	-	-
submandibular space	-	+	-	-	-	-	+	-	-	-	-
chewing space	-	-	+	-	-	-	+	-	-	-	-
infratemporal fossa	-	-	+	-	-	-		-	-	-	-
temporal region (deep localization)	-	-	+	-	-	-	+	-	-	-	-
Eye socket	-	-	-	-	+	-	+	-	-	-	-
Surface:	-	-	-	-	-	-	-	-	-	-	-
fronto-parieto-occipital region	-	-	-	-	-	-	+	-	-	-	-
temporal region (superficial localization)	-	-	-	-	-	-	+	-	-	-	-
Eyelids	-	-	-	-	+	-	+	-	-	-	-
external nose area	+	-	-	-	-	-	+	-	-	-	-
mouth, chin area	-	-	-	-	-	+	+	-	-	-	-
submental area	-	-	+	-	-	-	+	-	-	-	-
infraorbital region	-	-	-	-	-	-	+	-	-	-	-
zygomatic region	-	-	-	-	-	-	+	-	-	-	-
buccal region	-	-	-	-	-	-	+	-	-	-	-
parotid-masticatory region	-	-	-	-	-	-	+	-	-	-	-
postmaxillary region	-	-	-	-	-	-	+	-	-	-	-
sublingual area	-	-	+	-	-	-	-	-	-	-	+

Laboratory research: No.

· radiography of the jaws - determination of the focus of odontogenic infection.

Diagnostic algorithm

Scheme-1. Algorithm for diagnosing phlegmon and abscesses of the mouth area

Diagnostics (hospital)

DIAGNOSTICS AT THE INPATIENT LEVEL:

Diagnostic criteria:
Complaints and anamnesis: see outpatient level

Physical examination: see outpatient level

Laboratory research:
· general blood test - leukocytosis, increased ESR, shift of the leukocyte formula to the left;
· study of exudate for sensitivity to antibiotics - determination of the qualitative and quantitative composition of microflora, identification of sensitivity to antibiotics

Instrumental studies:
· radiography of the jaws - identifying purulent-necrotic lesions of bone tissue;
· Ultrasound of the maxillofacial area (focus of inflammation) - the presence of a cavity with a liquid component of heterogeneous echogenicity (depending on the location and depth of the abscess).

Diagnostic algorithm: see outpatient level.

List of main diagnostic measures:
· UAC (Er, Hb, Le, Tr, Ht, ESR);
· study of exudate for sensitivity to antibiotics;
X-ray of the jaws.

List of additional diagnostic measures:
orthopantomogram - to identify the focus of odontogenic infection.

Differential diagnosis

Diagnosis	Rationale for differential diagnosis	Surveys	Diagnosis exclusion criteria
Surface: Parotid-masticatory region, Submandibular, submental, Maxilloglossal groove. Floor of the mouth (upper floor) Zygomatic, Infraorbital, Buccal, Temporal region.	Abscesses: limited swelling, small infiltrate, clear boundaries of skin hyperemia, no tendency to spread the suppurative process	Orthopantomography (1-2 times, upon admission and over time): foci of odontogenic infection X-ray of the jaws in frontal and/or lateral projections (according to indications)	Data from anamnesis, clinical examination, localization of the inflammatory process.
	Cellulitis: the swelling is diffuse, hyperemia above the swelling without clear boundaries, the skin is taut, shiny, does not fold
Deep: Pterygomandibular, peripharyngeal, base of the tongue root, sublingual, retromaxillary, Floor of the mouth, Infratemporal and pterygopalatine fossa, Postmaxillary, Periorbital region, Phlegmon of the tongue.	Abscesses: no objective signs, symmetrical face, dysfunction of swallowing, chewing, and in some cases breathing, limited mouth opening.		Impaired function depending on the location of the lesion, more pronounced symptoms of intoxication,
	Cellulitis: severe symptoms of intoxication, dysfunction, lymphadenitis, collateral edema, tend to spread the purulent-inflammatory process to neighboring areas

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Treatment

Drugs (active ingredients) used in treatment

Treatment (outpatient clinic)

OUTPATIENT TREATMENT

Treatment tactics:
If there is a causative tooth, it is removed with curettage of the socket, and also if purulent inflammation develops under the periosteum of the jaw, periostotomy is performed, with the parallel use of non-steroidal anti-inflammatory drugs and sent for further inpatient treatment.

Surgical treatment:
· excision of the affected dental area of ​​the jaw (removal of the causative tooth);
· periostotomy (in the presence of inflammation under the periosteum).

Drug treatment:

Drug treatment provided on an outpatient basis (depending on the severity of the disease):

№	Drug, release forms	Single dose	Frequency of administration	UD
	Nonsteroidal anti-inflammatory drugs
1	Ketoprofen 100 mg/2ml 2 ml or orally 150 mg prolonged 100 mg.			B
2	Ibuprofen		No more than 3 days as an antipyretic; no more than 5 days as an analgesic with anti-inflammatory, antipyretic and analgesic purposes.	A
3	Paracetamol 200 mg or 500 mg; for oral administration 120 mg/5 ml or rectally 125 mg, 250 mg, 0.1 g			A

No
Preventive measures: No.

Monitoring the patient's condition:
· referral to hospital for emergency hospitalization.

Indicators of treatment effectiveness:
· pain relief;
· relief of symptoms of intoxication.

Treatment (ambulance)

DIAGNOSIS AND TREATMENT AT THE EMERGENCY CARE STAGE:

Diagnostic measures: clinical examination, history taking, physical examination.

Therapeutic measures: relief of symptoms of intoxication, prevention of complications.

Treatment (inpatient)

INPATIENT TREATMENT

Treatment tactics

Upon admission of the patient to the hospital, surgical treatment is performed (opening the purulent focus with removal of the causative tooth) with adequate drainage under local or general anesthesia. After this, antibacterial, antihistamine, non-steroidal anti-inflammatory drugs are prescribed, and detoxification therapy is carried out.

Surgical intervention

Opening and drainage of abscess and soft tissue phlegmon.

Indications for surgical intervention:
· the presence of an abscess or phlegmon of the maxillofacial area;
· violation of function, aesthetic appearance;
· high risk of surgical complications (location near blood vessels, nerve trunks, on the face);
relapse after surgical treatment;
· anaerobic abscess or phlegmon.

Contraindications:
Pulmonary heart failure of III-IV degree;
· blood clotting disorders, other diseases of the circulatory system;
· myocardial infarction (post-infarction period);
· severe forms of concomitant diseases (decompensated diabetes mellitus, exacerbation of gastric and duodenal ulcers, liver/renal failure, congenital and acquired heart defects with decompensation, alcoholism, etc.);
· acute and chronic diseases of the liver and kidneys with functional failure;
· infectious diseases in the acute stage.

Removal of the causative tooth. Excision of the affected dental area of ​​the jaw:

Indications:
· the tooth is a source of odontogenic infection.

Contraindications:
· cardiovascular diseases (pre-infarction state and time within 3-6 months after myocardial infarction, hypertension of II and III degrees, coronary heart disease with frequent attacks of angina, paroxysm of atrial fibrillation, paroxysmal tachycardia, acute septic endocarditis, etc.) ;
· acute diseases of parenchymal organs (infectious hepatitis, pancreatitis, etc.);
· hemorrhagic diseases (hemophilia, Werlhof's disease, C-avitaminosis, acute leukemia, agranulocytosis);
· acute infectious diseases (influenza, acute respiratory diseases; erysipelas, pneumonia);
· diseases of the central nervous system (cerebrovascular accident, meningitis, encephalitis);
· mental illnesses during exacerbation (schizophrenia, manic-depressive psychosis, epilepsy).

Non-drug treatment:
· prescription of dietary therapy, table No. 15;
· Mode II.

Drug treatment

Table - 6. Drug treatment provided at the inpatient level NB! use one of the following medications depending on the severity of the disease*

List of essential medicines:

№	Drug, release forms	Single dose	Frequency of administration	UD
	*Antibiotic prophylaxis
1	Cefazolin 500 mg and 1000 mg	1 g IV (children at the rate of 50 mg/kg once)	1 time 30-60 minutes before the skin incision; for surgical operations lasting 2 hours or more - an additional 0.5-1 g during surgery and 0.5-1 g every 6-8 hours during the day after surgery to prevent inflammatory reactions	A
2	Cefuroxime 750 mg and 1500 mg +Metronidazole 0.5% - 100 ml	Cefuroxime 1.5-2.5 g, IV (children at the rate of 30 mg/kg once) + Metronidazole (for children at the rate of 20-30 mg/kg once) 500 mg IV	1 hour before the incision. If the operation lasts more than 3 hours, repeat after 6 and 12 hours similar doses, in order to prevent inflammatory reactions	A
	If you are allergic to β-lactam antibiotics
3	Vancomycin 500 mg and 1000 mg	1 g IV (for children at the rate of 10-15 mg/kg once)	1 time 2 hours before the skin incision. No more than 10 mg/min is administered; the duration of infusion should be at least 60 minutes in order to prevent inflammatory reactions	IN
	*Opioid analgesics
4	Tramadol 100mg/2ml 2 ml or 50 mg orally	Adults and children over 12 years of age are administered intravenously (slow drip), intramuscularly at 50-100 mg (1-2 ml of solution). If there is no satisfactory effect, an additional administration of 50 mg (1 ml) of the drug is possible after 30-60 minutes. The frequency of administration is 1-4 times a day, depending on the severity of the pain syndrome and the effectiveness of therapy. The maximum daily dose is 600 mg. Contraindicated for children under 12 years of age.		A
5	Trimeperidine 1% 1 ml	1 ml of 1% solution is administered intravenously, intramuscularly, subcutaneously; if necessary, it can be repeated after 12-24 hours. Dosage for children over 2 years of age is 0.1 - 0.5 mg/kg body weight, if necessary, repeated administration of the drug is possible.	for pain relief in the postoperative period, 1-3 days	D
	*Non-steroidal anti-inflammatory drugs
6	Ketoprofen 100 mg/2ml 2 ml each or orally 150 mg prolonged 100 mg.	the daily dose for intravenous injection is 200-300 mg (should not exceed 300 mg), then oral administration is prolonged orally 150 mg 1 time per day, 100 mg 2 times per day	The duration of treatment with IV should not exceed 48 hours. The duration of general use should not exceed 5-7 days, for anti-inflammatory, antipyretic and analgesic purposes.	B
7	Ibuprofen 100 mg/5 ml100ml or orally 200 mg; orally 600 mg	For adults and children over 12 years of age, ibuprofen is prescribed 200 mg 3-4 times a day. To achieve a rapid therapeutic effect in adults, the dose can be increased to 400 mg 3 times a day. Suspension - a single dose is 5-10 mg/kg of the child’s body weight 3-4 times a day. The maximum daily dose should not exceed 30 mg per kg of body weight of the child per day.	No more than 3 days as an antipyretic No more than 5 days as an anesthetic with anti-inflammatory, antipyretic and analgesic purposes.	A
8	Paracetamol 200 mg or 500 mg; for oral administration 120 mg/5 ml or rectally 125 mg, 250 mg, 0.1 g	Adults and children over 12 years of age weighing more than 40 kg: single dose - 500 mg - 1.0 g up to 4 times a day. The maximum single dose is 1.0 g. The interval between doses is at least 4 hours. The maximum daily dose is 4.0 g. Children from 6 to 12 years: single dose - 250 mg - 500 mg, 250 mg - 500 mg up to 3-4 times a day. The interval between doses is at least 4 hours. The maximum daily dose is 1.5 g - 2.0 g.	The duration of treatment when used as an analgesic and as an antipyretic is no more than 3 days.	A
	Hemostatic agents
9	Etamzilat 12.5% ​​- 2 ml	4-6 ml of 12.5% ​​solution per day. For children, a single dose of 0.5-2 ml is administered intravenously or intramuscularly, taking into account body weight (10-15 mg/kg).	If there is a risk of postoperative bleeding, it is administered for prophylactic purposes.	B
	*Antibacterial drugs
10	Amoxicillin clavulanic acid (drug of choice)	Intravenously Adults: 1.2 g every 6-8 hours. Children: 40-60 mg/kg/day (for amoxicillin) in 3 doses.	The course of treatment is 7-10 days	A
11	Lincomycin (alternative drug)	Use intramuscularly, intravenously (drip only). It cannot be administered intravenously without prior dilution. Adults: 0.6-1.2 every 12 hours. Children: 10-20 mg/kg/day in 2 administrations.	The course of treatment is 7-10 days	B
12	Ceftazidime (for P. aeruginosa isolation)	Intravenously and intramuscularly Adults: 3.0 - 6.0 g/day in 2-3 injections (for Pseudomonas aeruginosa infections - 3 times a day) Children: 30-100 mg/kg/day 2-3 injections;	The course of treatment is 7-10 days	A
13	Ciprofloxacin (for P. aeruginosa isolation)	Intravenously Adults: 0.4-0.6 g every 12 hours. Administer by slow infusion over 1 hour. Contraindicated for children.	The course of treatment is 7-10 days	B

List of additional medicines :

№	Drugs	Single dose	Frequency of administration	UD
	*Desensitizing therapy
1	Diphenhydramine	Adults and children over 14 years of age: 25-50 mg, maximum single dose 100 mg;	1-3 times a day, 10-15 days	WITH
2	Clemastine	Adults and children 12 years and older: 1 mg. Children from 6 to 12 years: 0.5 mg-1 mg	Adults and children from 12 years of age and older: twice a day, morning and evening. Children from 6 to 12 years old before breakfast and at night.	IN
3	Chloropyramine	Orally, adults: 25 mg, if necessary increase to 100 mg. Children from 1 year to 6 years: 6.25 mg or 12.5 mg from 6 to 14 years: 12.5 mg	Orally, adults: 25 mg 3-4 times a day, if necessary increase to 100 mg. Children from 1 year to 6 years: 6.25 mg 3 times a day or 12.5 mg 2 times a day from 6 to 14 years: 12.5 mg 2-3 times a day.	WITH

Other types of treatment: No.

Indications for consultation with specialists:
· consultation with an anesthesiologist - for anesthesia;
· consultation with an otorhinolaryngologist - to exclude involvement of ENT organs in the inflammatory process;
· consultation with an ophthalmologist - for surgical intervention for abscesses and phlegmon of the paraorbital area;
· consultation with a therapist - in the presence of concomitant diseases.

Indications for transfer to the intensive care unit: if complications of concomitant pathology occur, requiring intensive care.

Indicators of treatment effectiveness:
· elimination of purulent-inflammatory focus of infection;
· restoration of skin and damaged anatomical structures;
· restoration of impaired functions.

Further management:
· observation by a dentist - 2 times a year, by a maxillofacial surgeon - according to indications;
· sanitation of the oral cavity.

Medical rehabilitation

Restoration of lost functions of chewing, speech, breathing, swallowing (see CP on medical rehabilitation).

Hospitalization

Indications for planned hospitalization: No.

Indications for emergency hospitalization:
pain and swelling of the soft tissues of the face and neck;
· dysfunction of swallowing, chewing, breathing;
· intoxication syndrome, development of complications, in particular sepsis;
· development of a purulent-inflammatory process against the background of common somatic diseases.

Information

Sources and literature

1. Minutes of meetings of the Joint Commission on the Quality of Medical Services of the Ministry of Health of the Republic of Kazakhstan, 2016
   1. 1) Kharkov L.V., Yakovenko L.N., Chekhova I.L. Surgical dentistry and maxillofacial surgery of children / Under the editorship of L.V. Kharkov. - M.: “Book Plus”. 2005- 470 s; 2) Supiev T.K., Zykeeva S.K. Lectures on pediatric dentistry: textbook. manual - Almaty: Stomlit, 2006. - 616s; 3) Zelensky V.A., Mukhoramov F.S., Pediatric surgical dentistry and maxillofacial surgery: textbook. – M.: GEOTAR-Media, 2009. – 216s; 4) Afanasyev V.V. Surgical dentistry - M., GEOTAR-Media., 2011, P.468-479; 5) Rabukhina N.A., Arzhantsev A.P. “Dentistry and maxillofacial surgery. Atlas of radiographs" - Moscow, "MIA". - 2002 - 302s; 6) Kulakov A.A. Surgical dentistry and maxillofacial surgery. National leadership / ed. A.A. Kulakova, T.G. Robustova, A.I. Nerobeeva. - M.: GEOTAR-Media, 2010. - 928 p.; 7) V.M. Bezrukova, T.G. Robustova, “Guide to surgical dentistry and maxillofacial surgery,” in 2 volumes. – Moscow, “Medicine”. – 2000. – 776s; 8) V.N. Balin N.M. Alexandrov et al. “Clinical operative maxillofacial surgery. – S.Pt., “Special literature. - 1998. – 592 p.; 9) Shargorodsky A.G. Inflammatory diseases of the maxillofacial region and neck // M.: Medicine 1985 - 352 p.; 10) Bernadsky Yu.I. Fundamentals of maxillofacial surgery and surgical dentistry - Vitebsk: Belmedkniga, 1998.-416 p.; 11) A.A. Timofeev Guide to maxillofacial surgery and surgical dentistry “Samizdat” - 2002; 12) Durnovo E.A. Inflammatory diseases of the maxillofacial region: diagnosis and treatment taking into account the immunoreactivity of the body. – N. Novgorod, 2007. – 194s; 13) http://allnice.ru/readingroom/estmedplast/bisf_skl. MM. Soloviev, prof. G.A. Khatskevich, I.G. Trofimov, V.G. Avetikyan, A.V. Finikov./Center for Maxillofacial Surgery and Dentistry. GMPB No. 2. Head of the center - prof. G.A. Khatskevich. Bisphosphonate osteonecrosis of the lower jaw in the practice of a maxillofacial surgeon; 14) Srinivasan D, Shetty S, Ashworth D, Grew N, Millar B. Orofacial pain - a presenting symptom of bisphosphonate associated osteonecrosis of the jaws. Br Dent J. 2007 Jul 28;203(2):91-2. 15) Lockhart PB, Loven B, Brennan MT, Baddour LM, Levinson M. The evidence base for the effectiveness of antibiotic prophylaxis in dental practice. J Am Dent Assoc 2007;138(4):458-74. 16) Lockhart, PB, Hanson, NB, Ristic, H, Menezes, AR, Baddour, L. Acceptance among and impact on dental practitioners and patients of American Heart Association recommendations for antibiotic prophylaxis. J Am Dent Assoc 2013;144(9):1030-5 17) Oral Maxillofac Surg Clin North Am. 2011 Aug;23(3):415-24. doi: 10.1016/j.coms.2011.04.010. Epub 2011 May 23. Dentoalveolar infections.Lypka M1, Hammoudeh J. 18) Impact of antibiotic stewardship on perioperative antimicrobial prophylaxis.Murri R1, de Belvis AG2, Fantoni M1, Tanzariello M2, Parente P3, Marventano S4, Bucci S2, Giovannenze F1, Ricciardi W2, Cauda R1, Sganga G; collaborative SPES Group 19) . Merten HA1, Halling F. Int J Qual Health Care. 2016 Jun 9. 20) Clinical aspects, diagnosis and treatment of the phlegmons of maxillofacial area and deep neck infections. Krautsevich L1, Khorow O. J Orthop Surg Res. 2016 Apr 27;11(1):52. doi: 10.1186/s13018-016-0386-x. Efficacy of vancomycin-releasing biodegradable poly(lactide-co-glycolide) antibiotics beads for treatment of experimental bone infection due to Staphylococcus aureus. Ueng SW1,2,3, Lin SS4, Wang IC5, Yang CY4, Cheng RC6, Liu SJ7, Chan EC8, Lai CF9, Yuan LJ4, Chan SC6 21) http://www.webmd.boots.com/oral-health /guide/dental-abscess 22) Minerva Stomatol. 1988 Dec;37(12):1005-9. . Zoccola GC, Calogiuri PL, Ciotta D, Barbero P. 23) Dental Abscess Topic Guide http: //www.emedicinehealth.com/dental_abscess/topic-guide.htm 24) Clin Ther. 2016 Mar;38(3):431-44. doi: 10.1016/j.clinthera.2016.01.018. Epub 2016 Mar 2. Ceftazidime-Avibactam: A Novel Cephalosporin/β-Lactamase Inhibitor Combination for the Treatment of Resistant Gram-negative Organisms. Sharma R1, Eun Park T2, Moy S3. J Zoo Wildl Med. 2010 Jun;41(2):316-9. Successful treatment of a chronic facial abscess using a prolonged release antibiotic copolymer in a golden lion tamarin (Leontopithecus rosalia). McBride M1, Cullion C. 25) Ann Plast Surg. 2002 Dec;49(6):621-7. Surgical infections of the hand and upper extremity: a county hospital experience. Weinzweig N1, Gonzalez M.

Information

ABBREVIATIONS USED IN THE PROTOCOL:

ACT	aspartate aminotransferase
ALT	alanine aminotransferase
HIV	human immunodeficiency virus
CT	computed tomography
Exercise therapy	physical therapy
MRI	magnetic resonance imaging
UAC	general blood test
OAM	general urine test
SMT	sinusoidal modulated currents
ESR	erythrocyte sedimentation rate
UHF	ultra high frequencies
UD	level of evidence
Ultrasound	ultrasound examination
Ural Federal District	ultraviolet irradiation
ECG	electrocardiogram
EP UHF	ultra high frequency electromagnetic field
Er	red blood cells
Hb	hemoglobin
Ht	hematocry
Le	leukocytes
Tr	platelets

List of protocol developers with qualification information:

Full name	Job title	Signature
Batyrov Tuleubay Uralbaevich	Chief freelance maxillofacial surgeon of the Ministry of Health of the Republic of Kazakhstan, maxillofacial surgeon of the highest category, professor, candidate of medical sciences, head of the department of dentistry and maxillofacial surgery of Astana Medical University JSC
Zhakanov Toleu Vantsetula	Head of the Department of Pediatric Maxillofacial Surgery, doctor of the highest category, City Children's Hospital No. 2, Astana
Tuleutaeva Raikhan Yesenzhanovna	Candidate of Medical Sciences, Head of the Department of Pharmacology and Evidence-Based Medicine, State Medical University. Mr. Semey, member of the Association of Internal Medicine Doctors.

Disclosure of no conflict of interest: No.

List of reviewers: Dauletkhozhaev Nurgali Amangeldievich - Candidate of Medical Sciences, maxillofacial surgeon of the highest category, Associate Professor of the Department of Surgical Dentistry, RSE at the Kazakh National Medical University named after S. D. Asfendiyarov.

Indication of the conditions for reviewing the protocol: Review of the protocol 3 years after its publication and from the date of its entry into force or if new methods with a level of evidence are available.

Attached files

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Cellulitis is one of the most dangerous acute inflammatory diseases. It affects the skin, mucous membranes, internal organs, and does not have clearly defined boundaries.

You cannot expect that with this diagnosis everything will “resolve on its own” - the disease requires antibacterial treatment or surgical intervention. And it’s urgent.

Phlegmon - what is it?

This purulent inflammation poses a threat not only to health, but also to human life.

The processes proceed rapidly - starting with redness and painful swelling on the skin, phlegmon behaves like an aggressive invader and increases the affected area.

Cellulitis can affect the face (eyelid, jaw, cheek), the torso, and the limbs of a person.

The nature of the disease can be idiopathic (independent, not associated with any other diseases) or represent a complication after a purulent-inflammatory disease (for example, sepsis or).

The processes begin with the outer layers of the epidermis, then move to the subcutaneous tissue.

If purulent inflammation of the tissue occurs in the immediate vicinity of any organ, experts designate the problem using the word “para”, which translated from Greek means “near, near” - for example, “paraproctitis” (inflammation in the rectal area), “ paranephritis" (near the kidneys), paraosseous phlegmon (under the trapezius and rhomboid muscles).

The name is used as a general term "paraorgan phlegmon".

The disease “without borders” also has no age restrictions - newborn children and the elderly can suffer from it.

Causes and pathogens

The most common causative agent of the disease is Staphylococcus aureus.

In addition to this, the following may serve in this capacity:

• enterobacteria;
• obligate anaerobes (streptococci), capable of acting in the absence of oxygen;
• Pseudomonas aeruginosa and (less commonly) Escherichia coli.

The reasons for the formation of phlegmon are activity and a sufficient number of harmful microorganisms that “occupy” the soft tissues of the body to give impetus to the onset of the disease.

Related factors are also required:

• problems with human immune defense;
• the state of his circulatory system;
• presence of allergization in the body;
• the ability of microorganisms to be virulent (tissue infection);
• microbial resistance to drugs.

Sometimes the reason for the formation of phlegmon where there are no signs of injury or surgical incisions remains a mystery, even to specialists.

The main provoking factor in this case is the general health of the patient - the danger threatens people who take many medications that have a detrimental effect on the immune system.

Problems also arise with diabetes and HIV-infected people.

The pathogen enters the body and spreads in different ways:

• through damage to the skin and mucous membranes as a result of injury;
• from the source of infection - through the blood;
• as a result of an abscess rupture;
• after the subcutaneous injection of any chemical substances (for example, turpentine, for the treatment of skin diseases);
• as a consequence of the administration of drugs (post-injection phlegmon).

ICD-10 code

In the International Classification of Diseases (ICD-10), phlegmon is listed under code L03.

This is followed by a more detailed classification:

• if fingers or feet are affected - L03.0;
• limbs (other parts) - L03.1;
• maxillofacial region - L03.2;
• body - L03.3.

Codes L03.8 and L03.9 indicate, respectively, phlegmon of localizations other than those listed and unspecified phlegmon.

The causes of the disease, its symptoms, methods of treatment and prevention, and also look in this material.

Instructions for using Belogent cream and ointment are presented in the article.

Symptoms and localization of the disease

Without clear boundaries, phlegmon reveals itself by changes in the skin surface at the site of inflammation– it becomes red, shiny, glossy.

Pain is felt not only when touched, but also as a result of movements that a person makes, for example, when turning the torso.

Unpleasant sensations intensify as the disease progresses. In addition, the redness zone visually expands (over time, the red color changes to yellow).

Without medical assistance, the patient's condition becomes worse, headache, weakness, shortness of breath appear, and normal sleep is disturbed with general drowsiness during the day.

Body temperature rises to 40°C and above. A person is tormented by chills and thirst. Urination becomes a problem. Lymph nodes in the affected area become enlarged. Blood pressure jumps and heart rhythms go astray.

The localization of phlegmon can be very different.

Facial

This zone includes the temporal region, the infratemporal fossa (through which important nerves and vessels pass), the jaws, the parotid-masticatory region (including the masticatory muscles), the infraorbital zone (limited by the edge of the orbit, the side wall of the nose and the upper jaw). The facial category also includes buccal and zygomatic phlegmon.

When the lower jaw is affected, there is bad breath, swelling, and a swollen tongue. There is a feeling as if the neck, tooth or gums hurt (in dentistry, there are often cases when a patient seeks help “at the wrong address”).

The disease was named “odontogenic phlegmon of the maxillofacial region” (MFA).

It becomes difficult for a person with this diagnosis to speak and swallow, as swelling covers the peripharyngeal space.

Breathing problems may occur. The temperature is rising. The face becomes asymmetrical. Treatment is urgent, since there is a high probability of tooth loss, thrombosis of the facial veins, and asphyxia.

The disease also affects the floor of the mouth, larynx, and throat. Moreover, the infection can spread from one “object” to another almost unhindered due to the abundance of blood vessels, salivary glands, and various intermuscular gaps.

Phlegmon of the eyelid, orbit, lacrimal sac

If symptoms of the disease appear in one eyelid, the disease quickly spreads to the second eyelid, as well as to the entire eye. The patient experiences severe headache.

If the tear sac gets into the affected area (which is quite rare), the swollen area becomes so painful that the person cannot open the eyelids.

It is very dangerous when the eye socket is affected by phlegmon(also called the “orbit of the eye”) is the cavity in which the eyeball and its appendages are located.

Delay in treatment can lead to damage to the optic nerve and loss of vision. The risk of infection spreading to the brain cannot be ruled out.

Necks

The impetus for the development of the disease can be inflammation of the pharynx (in the form of laryngitis or pharyngitis) or advanced caries.

The chin and submandibular area are in the zone of inflammation. The person experiences general weakness, his temperature rises, and his head hurts. Purulent meningitis may develop as a complication.

This disease cannot be treated at home; usually the patient requires the help of a surgeon.

Carpal

The infection first concentrates in the center of the palm, on the thumb or wrist. Then it spreads to the entire hand - other parts of the palm and the rest of the fingers.

The person experiences pain, which is preceded by an unpleasant tingling sensation.

If the inflammation covers the interdigital zones, such phlegmon is called “commissural”; the fingers in this form of the disease are practically devoid of mobility, since every movement is very painful.

The y-shaped form of localization is considered especially severe when the lesion affects such an important auxiliary muscle apparatus as the ulnar and radial synovial bursae of the palms.

Subpectoral

Inflammation covers the areas under the pectoral muscles - small and large.

Subpectoral phlegmon can begin to develop due to an abscess under the armpit, after a severe bruise of the chest, due to boils present in this part of the body, wounds, if the mammary gland is infected (as a result of mastitis). We talked about boils on the chest, as well as on other intimate places.

Limbs and hips

The immediate cause for the onset of purulent inflammation is wounds, burns, bites that affected the hands (for example, the forearm) or legs, as well as a number of diseases (for example, purulent arthritis).

The intermuscular tissue and perivascular space serve as a “conductor” for the spread of purulent infection.

Symptoms of the disease develop rapidly. If the hips or lower limb are in the affected area, it becomes difficult for the patient to move. The legs seem to swell and the lymph nodes become enlarged.

Urinary

This type of disease affects the hips, scrotum, perineum, and buttocks. Urinary (gluteal) phlegmon occurs due to damage to the bladder.

Its symptoms are swelling, bloody urine (or lack thereof), pain in the lower abdomen. The course of the disease is severe, sometimes the disease ends in death.

Scrotum (Fournier disease)

This localization of microbes is one of the most dangerous. In addition to the traditional symptoms of the disease (high temperature, chills, tachycardia), severe pain affecting the scrotum and penis is added.

The skin of the scrotum is covered with brown spots and blisters with purulent contents. Fournier's phlegmon requires surgical treatment.

Experts use another way to classify the disease according to its location.

According to him, phlegmon can be:

• subcutaneous - the disease develops in the layer of fatty tissue, directly under the skin;
• subfascial - in connective membranes covering various organs, nerve fibers, blood vessels;
• retroperitoneal – in the abdominal cavity;
• intermuscular;
• perirenal;
• perirectal.

Classification (types, forms, stages)

The classification provides for the difference between diseases according to the depth of impact on healthy tissue, the severity of the processes occurring and possible consequences.

By time of appearance

A disease is considered primary if it began to develop after the penetration of pathogenic microorganisms into the tissue, or secondary if the inflammation “spread” from neighboring, already affected areas.

By development time

There are 2 types of phlegmon. This is acute phlegmon, in which the patient’s condition rapidly deteriorates, and chronic (sometimes called “woody”), for which a sluggish course of the disease is typical.

The second option involves a long process, up to several months, during which the skin at the site of the lesion becomes bluish, and the phlegmon is transformed into an abscess that does not cause pain.

According to the depth of the lesion

In this case, there are also two options. The superficial form of phlegmon means infection of the subcutaneous tissue and does not affect muscle tissue.

Deep spreads its negative impact on the muscles, the intermuscular space, and the fatty tissue surrounding various internal organs.

By nature of distribution

Phlegmon can be limited, if the abscess is local, or progressive, if there is significant tissue damage.

If in the first case the abscess is opened and the damaged area is drained, then in the second case serious surgical treatment is required, a deep incision with removal of pus and excision of necrotic changes in the tissues.

According to the mechanism of occurrence

In this category, independent forms are distinguished, when the disease develops not against the background or as a result of any pathologies, but independently (if, for example, only the hand, foot, lower leg or thigh are infected).

The mechanism of development of phlegmon can also be “triggered” after surgery (if the hernial sac or abdominal wall is injured).

According to the form of influence

There are several of them: serous (it is considered primary), purulent, putrefactive, necrotic, anaerobic.

For serous form fatty tissue is attacked by pathogenic microorganisms. It becomes gelatinous and becomes saturated with cloudy liquid. The boundaries between diseased and healthy areas can be difficult to distinguish.

Serous phases are followed by more dangerous phases. Purulent involves the transformation of damaged tissue into a purulent mass of greenish, yellow or white color.

Ulcers and fistulas may form. This form of the disease affects bones, tendons, and joints.

In putrefactive form disease, the patient experiences severe intoxication. The affected tissues acquire dark colors - brown and green. Their disintegration is observed - they become loose and mushy.

Necrotic form characterized by the formation of necrotic foci. When the body rejects them, a wound surface is formed, an abscess may appear, which will open on its own.

Anaerobic form- the heaviest of all listed. The tissues have a cooked appearance, without any redness, and a gas component can form inside, as evidenced by a slight crunch that appears when pressing on the inflamed surface.

What does phlegmon look like (photo)

Diagnostics

The patient’s subjective feelings play an important role in making a diagnosis. The more accurately they are formulated, the easier it is for the doctor to navigate the location of the disease and its severity, to understand its pathogenesis (the mechanism of the onset and development of the disease).

“Objective” diagnostic methods include:

• body temperature control;
• Ultrasound of areas where the disease may spread;
• radiographs;
• tests (urine, blood, discharge from areas of inflammation);
• puncture (if the source of infection is deep in the tissues).

Differences from abscess and other diseases

Various purulent inflammations may have similar manifestations, but for successful treatment the diagnosis must be absolutely accurate.

If we compare an abscess and phlegmon, then in the first case, the source of inflammation is enclosed in a capsule, isolated from healthy tissue. Phlegmon does not have this.

It is most difficult to distinguish one disease from another at the initial stage, when the capsule has not yet fully formed and the boundaries of infection are blurred, as with phlegmon.

During the development of the disease, when the capsule is overfilled with pus, it may rupture, which will lead to the transformation of the abscess into phlegmon.

If the disease affects the eyelids, phlegmon in the early stages is practically no different from barley. However, in the first case the sensations are much more painful than in the second, and there are also symptoms of intoxication of the body.

Leg disease is sometimes confused with phlegmon "hemostatic dermatitis", but it has a different nature and cause - insufficient blood circulation in the lower extremities.

It can be difficult to distinguish phlegmon from erysipelas. Both diagnoses are characterized by severe throbbing pain, dense infiltration, and changes in skin color. Find out more about the causes, symptoms and treatment of erysipelas of the leg.

It is sometimes possible to understand complex cases only with the help of laboratory tests.

Treatment methods

The doctor prescribes treatment depending on the severity of the patient, and it is usually carried out in a hospital, even with medication.

Antibiotics

These medications are necessary to stop the formation of pus in the body. They are prescribed to the patient in the form of tablets or injections.

Effective against phlegmon:

• Erythromycin;
• Gentomycin;
• Cefuroxime.

Therapy lasts from 3 to 5 days. If the results are disappointing (the swelling persists, the temperature is still high, the pain does not go away), it means that the process of pus formation could not be stopped and surgical intervention will be required.

Other drugs used include representatives of the penicillin group: Trypsin, Terrylitin, Iruksol.

Ointments, compresses

These remedies can give results at the initial stage of the disease.

Compresses are made with alcohol, with Vishnevsky ointment or with herbs (one of the possible options is a decoction of oregano with flax seeds).

It is advisable to apply compresses at night and carry out physiotherapy during the day. Electrophoresis using mumiyo is also useful.

Opening

Surgery for phlegmon is very effective, especially in advanced stages and with extensive lesions.

Removal of pus is necessary so that the internal organs, to which the infection gets dangerously close - the lung, stomach, kidneys, intestines - are not damaged.

How to treat the disease in newborns and older

In newborns, phlegmon can appear on the 5-8th day of life and develops especially severely. The disease is often preceded by diaper rash or mastitis. The causative agent is usually Staphylococcus aureus.

Young children are treated surgically: drainage is introduced into the body to ensure the outflow of exudate and to cleanse the wound of pus. Antiseptic solutions are used in processing.

Older children are given restorative and immunomodulating medications, and, if necessary, antibiotics, antipyretics and painkillers. They use plasmapheresis, hemodialysis, and laser blood irradiation techniques.

With timely initiation of treatment, the prognosis is favorable. Full recovery occurs in 3-4 weeks.

Recovery and rehabilitation

After the patient has undergone surgery, a recovery period begins: the patient is prescribed antibiotics and ointments to cleanse the skin (troxevasin, with rosehip extract, with sea buckthorn oil). Measures are being taken to strengthen the patient's immunity.

In case of severe damage, dermoplasty (skin grafting) is performed.

An important factor that helps the patient’s rehabilitation is adherence to the regimen. A person recovering should spend most of their time in bed, with those parts of the body that have been infected and undergone surgery should be slightly higher than the rest.

After removing the anaerobic phlegmon, the patient is prescribed injections of anti-gangrenous serum. Drugs containing caffeine and adonylene help restore the functioning of the heart muscle.

If you are interested in what causes the disease, what are its main symptoms, and what are its main symptoms, read our publication.

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What complications can there be?

Since serous-purulent fluid can enter the lymph and blood, the infection risks spreading throughout the body and causing diseases such as:

• sepsis;
• purulent lymphadenitis and lymphangitis;
• erysipelas;
• purulent thrombophlebitis;
• purulent arthritis;
• meningitis.

Prevention

To avoid the development of a dangerous disease, you must:

• when receiving abrasions and wounds, treat them with antimicrobial drugs;
• treat boils in a timely manner;
• do not leave caries untreated;
• at the first symptoms resembling phlegmon, consult a doctor;
• take care of strengthening the body's immune defense.