1 Cellulitis: a non-suppurative inflammation of subcutaneous tissue, extending along connective tissue planes and across intercellular spaces.

Spreading inflammation in the tissue planes is called cellulitis. There is wide spread swelling, redness and pain without definite localization.

Caused by Streptococcus pyogenes.. If general condition of the patient is undermined, as in diabetes, cellulitis spreads rapidly and leads to Septicemia (infection in the blood).Redness, itching and stiffness is present in the site of inoculation (where the bacteria enter the skin), local Gangrene (death of the tissue) may occur. The appearance of skin creases or wrinkles, indicates resolution (healing).

Treatment

1. Rest , Appropriate antibiotics.

Cellulitis of the neck: Is a complication of wounds tonsillitis or mastoiditis Ludwig’s angina is the term applied to sub-maxillary cellulitis. The two dangers of cervical cellulitis are:

1. Oedema of glottis - with possible asphyxia (respiratory obstructon )

2. Mediastinitis - In ludwig’s angina the floor of the mouth become oedematous. The tongue can be seen displaced, turned upwards by swelling and oedema. The patient is unable to close the mouth owing to oedema of the tongue and the floor of the mouth. This can also CCC when the tongue is bitten by a wasp.

Ludwig’s angina: Ludwig - characterized by a brawny (non pitting) swelling of the sub-mandibular region, corn with inflammatory oedema of the mouth. It is the combined cervical and intrabuccal signs that constitute the characteristic feature of the lesion. The cause of the condition is virulent, usually streptococcal infection of the cellular tissue surrounding the sub-mandibular salivary gland.

Clinical features

 The swollen tongue is pushed towards the palate and forwards through the open mouth, while the cellulitis extends down the neck.

The most dangerous plane, is deep to the deep fascia.

Ludwig’s angina is an infection of closed fascial space and if .untreated, the inflammatory exudate often passes via, the tunnel occupied by stylohyhoid to the submucosa of glottis, in which event the patient is in immediate danger of death from oedema of the glottis.

Treatment

1. antibiotics on Early Diagnosis

2. In cases where the swelling, both cervical and intrabuccal, does not subside rapidly with such treatment, a curved incision, beneath the jaw is made and this decompresses the closed fascial space. The incision is deepened and after displacing the superficial lobe of the sub-mandibular salivary gland, the mylohyoid muscle are divided. This decompresses the closed fascjal space referred to. The wound is lightly sutured and drained. The operation can be conducted with greatest safety under local anaesthesia.

Bacteraemia and  Septicemia

Bacteraemia and septicaemia means the organisms are present in the blood. Clinical features are those of severe infection and shock: , Pyrexia is intermittent , Rigors ,  Jaundice is due to liver damage,  Acute renal failure may occur , Peripheral circulatory failure,  lntravascular coagulation indicates a fatal outcome

 causative focus found and treated surgically .g., Appendicetomy in perforated appendix

2. Blood culture taken

3. Broad spectrum antibiotic is given

4. Blood transfusion is given.

5. Injection hydrocortisone is given.

Pyaemia

Pyaemia is due to infected emboli circulating in blood stream. Pyaemia is characterized by: -

1. Rigors

2. Intermittent fever

3. Formation of abscess in vital organs like heart or brain.

Treatment

1. Is to prevent emboli reaching the blood stream

2. Broad spectrum antibiotic is given.

3. Abscess are incised and drained

If not treated portal pyaemia with multiple abscesses in liver occur, which is a dangerous condition.

Acute Abscess :  An abscess a collection of pus.

Bacteria which cause pus formation is called pyogenic organisms. Bacteria reach the infected area by:

1. Direct route: eg. Penetrating wound

Local extension: From adjacent focus of infection

2 Lymphatics

4. Blood stream

Pyogenic membrane surrounds the abscess and is infiltration with (leukocytes and bacteria.

Pus: Pus contains dead leukocytes and bacteria. It reaches the surface of the body or is discharged into a hollow viscous.

Symptoms: patient feels ill., Throbbing pain is characteristic of suppuration. Pain becomes more severe in the dependent position. E.g. infected finger,

Classical signs

Temperature is elevated , Rigors, inflammation

Fluctuation: Present in the later stages, and reveals the presence of pus. Prevention

1. An abscess can sometimes be aborted by antibiotics in the early stage.,. Rest,  Elevation of the affected part.

Treatment

Is incision and drainage of abscess

Hilton’s method of opening an abscess:

It is used where important anatomical structures like the blood vessels and nerves are preesnt, as in the neck, axilla and groin. The skin and superficial fascia is incised. A sinus forceps is thrust into the abscess  cavity. The blades are opened and the pus is drained. A gloved finger is introduced and loculi are broken. A ribbon gauze is lightly packed and antibiotics are given. This is done under surface anaesthesia i.e., ethyl chloride spray.

Antibioma

 If antibiotic is given the pus in the abscess frequently becomes sterile and a large brawny edematous swelling remains which takes many weeks to resolve.

Treatment: explore the mass with a wide-bore aspirating needle

 Most antibiornas are due to late, inadequate, and ineffective antibiotics.

CANCRUM ORIS

Is an infective gangrene of cheek and lip.

may occur as a complication of kala azar, enteric fever and  children with poor oral hygiene.

The lesion starts as an acute inflammatory patch on oral mucosa which is seen ulcerated.

The affected part of the cheek or the lip gradually becomes gangrenous.

Focal vascular thrombosis and sepesis occur.

When slough separates, a part of the cheek or lip sloughs out to form a buccal fistula with ugly deformity. The adjacent jaw may be infected too.

Various organisms are found - specially Fusiform bacillus and_Borrellia vincenti.

The foetid odour, gangrenous patch of cheek or lip, purulent discharge from the mouth, fever and toxaemia are the characteristic features. The patient is unable to open the mouth properly.

Treatment

1. Antibiotics, multivitamins and repeated mouth washes

2 Neostibamine in kala-azar. Sequestrectomy in chronic osteomyelitis of the mandible.

4. Plastic reconstruction of the lip or cheek for unsightly deformity undertaken.

CARBUNCLE

Is an infective gangrene of the subcutaneous tissue. It is due to staphylococcal aureus infection. It is uncommon before the age of 40. Males are the usual sufferers. Diabetes may be present. It often occurs on the nape of the neck.

Clinical features

Subcutaneous tissue becomes painful and indurated. Ove skin is red. Unless treated promptly, extension will occur and late softening. The skin gives way and thick pus and slough are discharged.

Usually, there is one central large slough, surrounded by smaller areas of necrosis. Infection extends widely and fresh openings appear

Treatment

1. Many carbuncles are aborted, if penicillin is used adequately in the early stage.

2. Local treatment consists of hygroscopic dressings being given ie. magsulph-glycerin dressing Later the carbuncle is excised with a cruciate incision.

3. If the gap is large and when the granulation tissue comes to the surface, skin grafting is done.

Cricothyroidotomy

Cricothyroidotomy is a surgical procedure that involves making an incision through the skin over the cricothyroid membrane, which is located between the thyroid and cricoid cartilages in the neck. This procedure is performed to establish an emergency airway in situations where intubation is not possible or has failed, such as in cases of severe airway obstruction, facial trauma, or anaphylaxis.

Indications

Cricothyroidotomy is indicated in the following situations:

• Acute Airway Obstruction: When there is a complete blockage of the upper airway due to swelling, foreign body, or trauma.
• Failed Intubation: When attempts to secure an airway via endotracheal intubation have been unsuccessful.
• Facial or Neck Trauma: In cases where traditional airway management is compromised due to injury.
• Severe Anaphylaxis: When rapid airway access is needed and other methods are not feasible.

Anatomy

• Cricothyroid Membrane: The membrane lies between the thyroid and cricoid cartilages and is a key landmark for the procedure.
• Surrounding Structures: Important structures in the vicinity include the carotid arteries, jugular veins, and the recurrent laryngeal nerve, which must be avoided during the procedure.

Procedure

Preparation

1. Positioning: The patient should be in a supine position with the neck extended to improve access to the cricothyroid membrane.
2. Sterilization: The area should be cleaned and sterilized to reduce the risk of infection.
3. Anesthesia: Local anesthesia may be administered, but in emergency situations, this step may be skipped.

Steps

1. Identify the Cricothyroid Membrane: Palpate the thyroid and cricoid cartilages to locate the membrane, which is typically located about 1-2 cm below the thyroid notch.
2. Make the Incision: Using a scalpel, make a vertical incision through the skin over the cricothyroid membrane, approximately 2-3 cm in length.
3. Incise the Membrane: Carefully incise the cricothyroid membrane horizontally to create an opening into the airway.
4. Insert the Airway Device:
   • A tracheostomy tube or a large-bore cannula (e.g., a 14-gauge catheter) is inserted into the opening to establish an airway.
   • Ensure that the device is positioned correctly to allow for ventilation.
5. Secure the Airway: If using a tracheostomy tube, secure it in place to prevent dislodgment.

Post-Procedure Care

• Ventilation: Connect the airway device to a bag-valve-mask (BVM) or ventilator to provide oxygenation and ventilation.
• Monitoring: Continuously monitor the patient for signs of respiratory distress, oxygen saturation, and overall stability.
• Consider Further Intervention: Plan for definitive airway management, such as a formal tracheostomy or endotracheal intubation, once the immediate crisis is resolved.

Complications

While cricothyroidotomy is a life-saving procedure, it can be associated with several complications, including:

• Infection: Risk of infection at the incision site.
• Hemorrhage: Potential bleeding from surrounding vessels.
• Damage to Surrounding Structures: Injury to the recurrent laryngeal nerve, carotid arteries, or jugular veins.
• Subcutaneous Emphysema: Air escaping into the subcutaneous tissue.
• Tracheal Injury: If the incision is not made correctly, there is a risk of damaging the trachea.