*99362*

K.B.Djusupov, V.O.Kenbayev

Diagnostics and treatment odontogenic mediastinitis

Shymkensky city hospital of the first help

Introduction.

Sharp odontogenic the infection is one of actual problems of modern surgical stomatology.

Last years the increase in number sick sharp odontogenic is marked by inflammatory diseases, the heavy, progressing current, becoming complicated by sharp respiratory insufficiency, mediastinitis, meningoentsifalitom and other intracranial inflammatory processes, a sepsis, septic shock (1,2) is quite often observed.

Despite the certain successes reached in treatment sharp odontogenic of inflammatory diseases and their complications, a lethality continues to remain high that testifies to necessity of early diagnostics, forecasting of a current and effective treatment.

Change of a clinical picture of disease, especially in the beginning of its development that creates diagnostic difficulties (3) is quite often noticed.

Abundantly clear that increase and increase in weight of a current of inflammatory diseases have led to considerable growth of time invalidity, and in some cases to physical inability of an analyzed category of patients.

Thus, the considered problem has not only medical, but also important social value.

According to different authors, frequency of lifetime diagnostics mediastinitis makes 20,5% - 50%, and now disease diagnostics continues to remain one of difficult solved problems (4).

Complexity of early diagnostics odontogenic mediastinitis speaks absence of symptoms, pathognomonic for mediastinitis early stages of its development, complicated differential diagnostics of phlegmons of maxillofacial area, a neck and odontogenic mediastinitis and its treatments.

The purpose of this study was to examine pathognomonic signs in odontogenic mediastinitis, the effect of systemic enzyme therapy on the course of the inflammatory process.

Materials and Methods.

We archive the data analyzed SHGBSMP over the past 10 years. It was found in 12 patients with odontogenic mediastinitis, at the age of 31 to 52 years.

All patients, depending on the type of treatment were divided into 2 groups.

Group 1 consisted of 5 patients who were treated with traditional methods without the use of systemic enzyme therapy.

Group 2 consisted of 7 patients treated with systemic enzyme.

In particular, "Wobenzym" was used for oral administration of 30 tablets per day. For local application of the enzyme was used the following technique: after surgical drainage of purulent focus and source of necrotic tissue, wound treated with antiseptics (hydrogen peroxide, chlorhexidine, etc.), then watered it with a solution of this enzyme. Enzyme solution was prepared at the rate of 25-50 mg "Vobenzima" to 5-8 ml of isotonic solution. In the purulent wound initially injected solution from the syringe. This irrigation enables better contact with the enzyme tissue.For large wounds, irrigation was carried out with solutions of the enzymes were injected simultaneously gauze sponges soaked in solutions of the same enzymes. Superimposed on the wound aseptic bandage with hypertonic saline.

Results.

For odontogenic mediastinitis in late diagnosis is characterized by its progressive course with lightning-like spread of purulent-necrotic process in the background of impaired immunity to all parts of the mediastinum to the development of polyorganic and hemodynamic disorders, mental disorders,which is typical for the clinic of infectious-toxic shock.

In recent decades, the development of techniques of cultivation under anaerobic conditions in the etiology of odontogenic mediastinitis clarify the role of obligate anaerobic microorganisms inhabiting the oral mucosa (5).That anaerobic bacteria are nesporogennye etiologic agent of odontogenic mediastinitis. Synergy aerobes and anaerobes leads to increased virulence of microorganisms and promotes an aggressive course of the inflammatory process, the rapid melting of the tissue and severe intoxication, aggravated by the lack of timely laboratory confirmation.

In 16% of cases the disease has developed against a background of relative physical health, 84% of process took place in the presence of any underlying disease.

Most other diseases encountered chronic alcoholism (12% of cases), cardiovascular failure (11%), diabetes (9%), renal-hepatic failure (8.1%), etc.

Risk of developing acute inflammatory process in the mediastinum consisted of patients with lung diseases (asthma, tuberculosis, chronic obstructive bronchitis), gastrointestinal tract (chronic gastritis, gastric ulcer and duodenal ulcer) blood (iron deficiency anemia,chronic lymphocytic leukemia).

Mediastinitis is characterized by a syndrome comprising the triad, each of which is due to an independent pathogenetic mechanism.

The first symptom - pain involves a group of symptoms characterized by increasing pain in the retrosternal space, which is enhanced by crowding the head (symptom Gerke), palpation, stroking upwards or delaying neurovascular neck (a symptom of Smith),swallowing and cough.

Coughing symptom characteristic of odontogenic mediastinitis as a consequence of edema floor of the mouth, soft palate and peripharyngeal space in the development of phlegmon of the locations, which is always accompanied by irritation of the tongue.

With the development of acute inflammation in the mediastinum appear symptom-Shcherbo Ravitch, characterized by retraction of the skin in the area of the jugular depression during inspiration, and paravertebral symptom Steinberg - the appearance of rigidity of muscles.

On the possibility of acute inflammation in the mediastinum shows symptom-Rutenburga Revutskiy characterized by the appearance of pain in the chest with displacement of the trachea.

In the later stages of development of mediastinitis, if the total defeat of the mediastinum, there may be a symptom of compression Popov - strengthening of chest pain and the appearance of cough reflex with effleurage of the calcaneus with extended lower limbs in the patient lying down.

In addition, there may be a positive phrenic symptom - pain in the hypochondrium and muscle tension anterior abdominal wall.

At the rear of mediastinitis note of pain in the interscapular irradiation or epigastralnuto field and gain the slightest strain, and with pressure on the spinous processes of the vertebrae, especially the 5th baby.

All patients had mediastinitis is defined sharp pain in the sternum and ribs. If the subcutaneous tissue of the neck or chest is accumulation of gas, revealed crepitations symptom. The development of pain determines the forced position of the patient in bed, as an attempt to straighten causes increased pain in the back, chest and in the throat.

The second group of symptoms is determined by increasing intoxication.

The patient is disturbed consciousness, somnolence, areactivity, apathy, delirium. Sometimes, in severe cases, delirium develops intoxication, which is showing signs of aggression.

Less commonly observed euphoria, quickly giving way to loss of consciousness manifestation of the terminal state.

The third group of symptoms is determined by the compression of blood vessels and nerves. In many patients the superior vena cava syndrome, manifested by swelling of the upper torso, neck and face, increased subcutaneous veins. This is accompanied by increased headache, increasing tinnitus, cyanosis of the facial skin.

Compression of large vessels and nerves, leading to dysfunction of internal organs, and compression and irritation of the purulent exudate of the vagus nerves causes heart rhythm disturbances, bradycardia, bronchospasm. A number of patients we observed sinus tachycardia, atrial fibrillation. As the relief of the inflammatory process in the mediastinum state infarction improved.

On the involvement of an acute inflammatory process of sympathetic trunk shows symptom Horner.

Symptoms of irritation of the phrenic nerve is a hiccup. Due to compression of the phrenic nerve arises diaphragmatic paralysis, which can lead to respiratory failure.

Among the very important and severe symptoms can include effects of compression of the trachea, main bronchi and esophagus.

In such cases, the clinical picture becomes very severe mediastinitis.In addition to the compression of these organs, their displacement occurs, and the destruction of their walls.

Compression of large vessels and nerves, causing resorption of toxins and decomposition products of tissue, which, according to clinicians, enhances cardiovascular function disorders and respiratory systems.

Clinical analysis of results of treatment of the second group showed that the most pronounced therapeutic effect was obtained with local application "Vobenzima" and administered orally in large doses.

Thus, patients with the first group, where we used the traditional method of treatment of the stabilization process of advancing to 7-8 per day. Share of the mortality was 41.6%. Whereas in group 2, the stabilization process took place for 4-5 days, the percentage of mortality was 14.2%.

To illustrate typical observations give the following extract from the history of the disease:

Patient M.D, 34 years old. Case history number 8960, was admitted to hospital on the third day 20/10/09 from onset.

Complaints of general weakness, headache, fever, sleep, appetite, dry mouth, difficulty swallowing, breathing.

Locally defined abrupt swelling of the bottom of the mouth, skin hyperemic and edematous.On palpation determined sharply painful infiltrate without sharp boundaries in the submental and submandibular regions on the left and right. Mouth opening is limited to 1.5 cm due to an inflammatory contracture. Language is increased, overlaid with a purulent coating.

On admission the patient was determined in blood leukocytosis 28.9 x 10⁹ / l, neutrophilia, toxic granulation of neutrophils, leukocyte shift to the left, accelerated erythrocyte sedimentation rate 30 mm / h. The urine was observed proteinuria, leukocyturia, cylindruria.

In the analysis of biochemical parameters established hypoproteinemia 48 ± 1,8 g / l, hyperglycemia, 6,84 ± 0,76 mmol / liter.

Chest radiography in frontal projection possible to determine the extension of the median shadow, blurring its outlines (Fig. 1).

Figure 1. X-ray study. Patient ID number Mukhamedova history 9980.

However, we found that expanding the boundaries of the mediastinum and the retropharyngeal space is far from the neck in all patients. It depends on the mechanism of inflammation in the tissue of the mediastinum (Fig. 2).

Figure 2. X-ray study.

Of radiographic methods of investigation the most common X-ray of neck and mediastinum in two projections, which must be done in the dynamics of every 2-3 days (Fig. 3).

For the diagnosis of odontogenic mediastinitis performed X-ray examination of the neck and lateral projections, which identifies the expansion of the shadow of retropharyngeal space, the presence of gas in soft tissues and in retrofaringealnom space.

Figure 3. X-ray study of the dynamics. Patient ID number Mukhamedova history 9980.

Clinical diagnosis: "odontogenic phlegmons floor of the mouth. Odontogenic mediastinitis. "

Under general anesthesia, the incision is made on the angle of the mandible to the angle. Then the wound bluntly extended covered in submaxillary bolast left and right submental region, received up to 15 gnynogo discharge with bad odor. Wound washed with antiseptic solutions (hydrogen peroxide, potassium permanganate). After that, the wound irrigated with a solution from the syringe by the enzyme "Wobenzym", and the wound was introduced rubber tube, which is around zatamponirovana gauze, saturated solution of the enzyme "Vobenzima." On the surface of the wound dressing was applied antiseptic with hypertonic saline.

Cervical access to the mediastinum, the proposed VI Razumovsky in 1899, is convenient and malotravmatichen, allows for adequate disclosure of deep phlegmon of the neck kletchatochnyh spaces, particularly retropharyngeal space.

Appointed general medication. A similar purulent wound dressing, the patient was carried out on a daily basis.

After 4-5 days the patient's condition improved and pain decreased.

In good condition the patient was discharged from the hospital (02.11.09g) for outpatient treatment.

The basis of treatment of odontogenic mediastinitis is prompt surgical intervention, consisting in the disclosure under general anesthesia phlegmon kletchatochnyh deep space neck and active drainage and sanitation foci of chronic odontogenic infectionwhich caused inflammation. Severe condition of the patient with mediastinitis can not be regarded as a contraindication to surgery.

Active surgical treatment of purulent diseases pathogenetically substantiated and practically justified, because in reducing treatment time, achieving good functional results and lower mortality rates (Figure 4).

Figure 4. Patient ID number Mukhamedova history 9980.

Comprehensive treatment program phlegmon deep neck spaces kletchatochnyh complicated by mediastinitis contact, is to implement a pathogenetically based measures aimed at suppressing the pathogen, the correction of hemodynamic and metabolic disordersfight against intoxicationincrease of nonspecific resistance and immunological reactivity. Remedial measures already after 3-4 days ensure reduction of toxicity, body temperature, the patient feel better.

If not, there is reason to believe that the outflow of pus is not enough, or you can think about the possibility of any infectious and inflammatory complications.

The outcome of odontogenic mediastinitis is in direct proportion to the length of hospitalization. According to our observations in the delivery of patient care within 3-4 days after the onset of primary tumor mortality from mediastinitis was 31.3% at admission in a period of 4 to 6 nights - 41.2% in the period from 7 to 9 days - 51.7%.

On admission patients at a later date adverse outcomes reported in 100% of cases.

In all cases, adverse events were detected in sections of diffuse purulent or septic mediastinitis, purulent pericarditis, pleurisy and pneumonia. With the development of mediastinitis seen against the background of sepsis venous plethora of parenchymal organs: liver, spleen, and kidneys.

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