One of the most dangerous mistakes anyone in healthcare can make is to misuse the term “dental abscess” when describing a substantial cervicofacial collection. This suggests a fairly minor “gum boil” condition when the reality is a potentially compromised airway in a septic patient.

Cervicofacial abscess

The area needs to be drained and the cause removed. This will often involve drainage from the skin into the fascial spaces of the neck and sometime even into the mouth. In that case the drain must be removed early to prevent a fistula (an epithelial lined tract) from forming.

Ludwig’s angina

The airway must be maintained and secured at an early stage. This will require intubation to allow drainage of the compressed infected region usually by fibre optic intubation. Tracheostomy or cricothyroidotomy should be procedures of last choice as a surgical airway under these conditions creates a high risk of mediastinitis and an approximate 50% mortality. The involved spaces should be decompressed, even though frequently little pus is obtained (see Figure 1). High dose intravenous antibiotics should be given to complement surgical decompression. Any infective focus should be removed.

Figure 1: Ludwig’s angina postoperatively; multiple drains and tracheostomy in place.

Necrotising fasciitis

These patients require aggressive resuscitation and debridement. The initial surgery should be supported by broad spectrum antibiotics (e.g. megadose penicillin, gentamycin and metronidazole). Second look surgery at 24 to 48 hours should be planned with further debridement as required. Hyperbaric oxygen therapy may be helpful for these patients to eradicate the infection and provide a favourable environment for subsequent healing and reconstruction although there are few areas in the world where this is possible in the acute phase.

Infected foreign bodies should be removed early in order to avoid either of the preceding conditions arising.

Infected skin lesions generally don’t put the airway at risk but can give rise to substantial sepsis by creating spreading cellulitis.