Diagnostic Tests

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3.1. Specimen Collection and Processing

Because most infections that originate from the oral cavity are polymicrobial in nature, care must be taken during specimen collection to avoid contamination by the resident oral flora. Aaerobic and anerobic blood cultures should always be obtained. In selected patients with pyogenic infections of the face and neck, particularly compromised hosts, needle aspiration of the spreading edge of the skin lesion (using a tuberculin syringe containing 0.5 mL nonbactericidal saline and a 23-gauge hypodermic needle) is a worthwhile procedure. For ulcerative oromucosal lesions, scrapings from the ulcer base should be obtained for Gram-stain, potassium hydroxide, and Tzanck preparations, and cytologic examination. The diagnosis of herpes simplex or varicella-zoster is readily confirmed by a positive Tzanck smear (prepared from scrapings of the

Table 1

Comparative Features of Odontogenic Deep Fascial Space Infections of the Head and Neck

Clinical features

Space Infections

Usual site of origin

Pain

Trismus

Swelling

Dysphagia

Dyspnea

Ol CTi

Masticator Masseteric and Pterygoid Temporal Buccal Canine Infratemporal Submental Parotid

Submandibular Sublingual

Lateral pharyngeal Anterior Posterior

Retropharyngeal (and danger) Pretracheal

Molars (especially third)

Posterior maxillary molars Bicuspids, molars Maxillary canines, incisors Posterior maxillary molars Mandibular incisors Masseteric spaces, 2nd, 3rd mandibular molars Mandibular incisors

Masticator spaces, occasional Masticator spaces, severe

Lateral pharyngeal space, distant via lymphatics Retropharyngeal space, anterior esophagus

Present

Present

Minimal

Moderate

Present

Moderate

Intense

Present

Present

Intense Minimal

Prominent May not be evident (deep) Absent

None Face, orbit (late)

Minimal Cheek (marked)

None Upper lip, canine fossa

None Face, orbit (late)

None Chin (firm)

None Angle of jaw (marked)

Minimal Submandibular

Minimal Floor of mouth (tender)

Prominent Angle of jaw Minimal Posterior pharynx

Absent Absent Absent Occasional Absent Absent Absent Present if bilateral

Present Present

Present Minimal Posterior pharynx (midline) Present Present None Hypopharynx Present

Absent

Absent Absent Absent Occasional Absent Absent Absent Present if bilateral

Ocassional Severe

Present

Severe

Reproduced with permission from ref. 25.

ulcer base), which demonstrates the presence of multinucleated giant cells with intranuclear inclusions. Cultures for bacterial, fungal, mycobacterial, and viral pathogens should be obtained where appropriate. Punch biopsy is also valuable for the investigation of chronic mucosal lesions and for the diagnosis of malignant or premalignant conditions. Immunofluorescence staining for antigen detection can also be performed for herpes simplex and varicella-zoster as well as papilloma viruses and other pathogens. Identification of potential pathogens by DNA amplification and hybridization techniques is a powerful tool that is increasingly being utilized to identify etiologic agents in suspected infections that are culture-negative.

3.2. Imaging Techniques

An orthopantomogram may reveal the true extent of advanced periodontitis or the presence of periapical abscess. Ultrasonography, radionuclide scanning, computed tomography (CT), and magnetic resonance imaging (MRI) are particularly useful for the localization of deep fascial space infections of the head and neck. A lateral radiograph of the neck may demonstrate compression or deviation of the tracheal air column or the presence of gas within necrotic soft tissues. In retropharyngeal infections, lateral radiographs of the cervical spine or CT scanning can help determine if the infection is in the retropharyngeal space or the prevertebral space. The former suggests an odontogenic source, whereas the latter suggests involvement of the cervical spine. Technetium bone scanning, used in combination with gallium- or indium-labeled white blood cells, is particularly useful for the diagnosis of acute or chronic osteomyelitis and for the differentiation of infection or trauma from malignancy.

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