incision and drainage

[3rdmolarslayer]

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can any of the oms residents give me a step by step instruction list of how to do an I&D. i am fairly familiar with the procedure, but have never done one.

 

[toofache32]

Sounds like you may be a new OMS resident. Welcome to our world.

Here's how I do it:

1) Get an xray to identify the offending tooth. This is especially important in people with crap-mouth who have many rotted teeth. You can usually identify a PA lesion on at least one. If there are several rotted teeth in a row, I will often just take them all out while I am there. Don't forget your differential diagnosis...there are lots of other things (non-odontogenic) that can cause facial swelling. Bug bites, infected furuncles/pimples, sinus disease-->periorbital cellulitis, clogged salivary ducts, etc.

2) Anesthesia. Local anesthetics don't work in the acid environment that infections create, so proximal nerve blocks are best when you can do it. For the maxilla, I like going straight up the greater palatine canal to hit V2 in the way back. You can do an extra-oral V3 but you have to know you're anatomy.For neck and mandibular angle anesthesia you can hit Erb's Point about 6cm below the external auditory canal where it wraps around the SCM. If you're fortunate to be in an ER setting where they have an IV, I sometimes supplement with 4-8mg morphine and 25mg phenergan (for morphine-nausea and added sedation). Here's a great article you can look up showing some of these nerve blocks:

How to block and tackle the face. Plast Reconstr Surg. 1998 Mar;101(3):840-51.

3) I learned in dental school to take out the tooth first because you can sometimes establish drainage through the socket. I don't like that because I still think most of these deserve a formal I&D in the soft tissue. If you have a bubble of pus you might "deflate" it by extracting first. Then it's tough to find the infected space when you're dissecting through soft tissue. Therefore I drain the pus first with an incision, then extract the tooth. But this is just personal preference.

For the incision, only incise through mucosa/skin, then put your blade away so you don't chop up the deeper structures. The rest of the dissection should be with a blunt instrument (hemostat) so you minimize risk to nerves/vessels. Push in the hemostat and spread it, then withdraw it while spread. Remember to insert it closed only. If you insert it open and then close it you risk grabbing something important. Keep aiming for the pus-pocket and have the suction ready because it usually gushes out when you find the sweet spot. Abscesses tend to form loculations so make sure you explore the entire pus pocket with you finger or instrument to break them up. Then you irrigate the heck out of it with sterile saline...one old saying is "the solution to pollution is dilution". Make sure you rinse the abscess clean with a blunt plastic-tipped syringe or something. If you put in a drain, push it to the depth of your dissection and put a stitch at the incision to hold it in place. I usually just cut a finger off of a sterile glove to use as a drain because I can never figure out where we keep real drains.

In general, it's not good to incise over the mental nerve between the 2 lower premolars. Watch out for the parotid duct. For the submandibular space, remember that the marginal mandibular branch of the facial nerve runs within 2cm of the inferior border of the mandible. A rule of thumb is 2 finger-breadths below the inferior border will put you in safe terrain. Also, when you're cutting skin, make sure to prep the site with betadine or whatever you have. I also inject local with epinephrine in the skin to minimize bleeding. Once you incise through skin and subQ fat, undermine the skin a little to expose the platysma. I like to puncture through it gently with a hemostat, undermine along my skin incision, then poke the hemostat tips back out. Now you have a strip of platysma overlying your hemostat and you can sharply incise down to your hemostat which is protection deeper structures. Once you're below the platysma, you're in the area you need to be to find your submandibular pus ball.

This is just how I do it. I would be interested how the other OMS guys around here do it differently. Maybe I can learn something.

I hope this helps.

 

[3rdmolarslayer]

wow...thanks for the extremely thorough response...when you are suturing your drain (either the pentose drain or sterile glove) is one interrupted suture through the drain and mucosa all that is needed.
also, at the risk of sounding ignorant, what is the best way to determine whether you will need to do an intraoral or extraoral approach.

 

[toofache32]

wow...thanks for the extremely thorough response...when you are suturing your drain (either the pentose drain or sterile glove) is one interrupted suture through the drain and mucosa all that is needed.
also, at the risk of sounding ignorant, what is the best way to determine whether you will need to do an intraoral or extraoral approach.

I just use one stitch through mucose and the drain. Some people use resorbable gut in case they don't come back...I use non-resorbable silk so they will come back.

Extraoral vs. intraoral approaches are generally determined by the anatomic space involved. You're looking for the most direct path to establish drainage while minimizing risk to important structures. It's also nice for the patient to give them a scar inside their mouth instead of their face when it can be done. In general, intraoral is used for vestibular, palatal, buccal space, & canine space. Extraoral is used for submandibular and submental space. A combination is often used for lateral pharyngeal, deep temporal space, and masticator space (sometimes only intraoral).The really deep neck infections are usually done with neck incisions only. This is just a quick and dirty explanation off the top of my head. There are other spaces to know about. There's a pretty good explanation in Fonseca's 7-volume series that I remember reading a long time ago.

Check your private message thingy.

 

[3rdmolarslayer]

thanks again...can i call you this weekend when i take my first call...you know make a good impression on the chief and attendings
by the way, i didnt recieve a private message

 

[tx oms]

also, at the risk of sounding ignorant, what is the best way to determine whether you will need to do an intraoral or extraoral approach.

I go intraoral for everything except on the face unless it's pointing. I go extraoral for the neck. If it's only one neck space, I do it in the clinic. If it's two or more neck spaces I'm rolling to the OR.

BTW, we've got a necrotizing fascitis case in house right now. Pretty sweet for us and terrible for the patient. She lost all her anterior neck skin and upper chest/breast skin.

 

[omfsres]

.

 

[ISU_Steve]

How to block and tackle the face. Plast Reconstr Surg. 1998 Mar;101(3):840-51.

Is this seriously the name of the article?

 

[toofache32]

Is this seriously the name of the article?

Yep. Search "block and tackle" on Pubmed.

 

[toofache32]

I only go intraoral on TX OMS's mom.

DAAAAAAAAaaaaaaammmmmmmmnnnnn!!!!!!!

 

[tx oms]

I only go intraoral on TX OMS's mom.

I wouldn't go intraoral on your mom with north2south's "instruments".

 

[tx oms]

I've been waiting until I was on call to write much on this thread. My bitch, er, intern is working somewhere while I'm typing.

2) Anesthesia. Local anesthetics don't work in the acid environment that infections create, so proximal nerve blocks are best when you can do it.

I like to use blocks, too. I always supplement with local infiltration. Same for sewing lacs. After I think they're pretty numb I dump about 2/3 of a carpule right into the center of the infection, I try to overwhelm the acidity with the amount of drug used.

Everything else is the same. Remember, you're not going to get reprimanded for opening up too much so explore as much of the tissue as needed.

 

[ISU_Steve]

I have a question (and forgive me for being ignorant enough to ask this) but it stems from a case we have at the hospital at the moment that is in keeping with the topic of this. A 27 y/o meth addict with the most horrendous mouth infection I've ever seen, came in presenting with sepis on Thursday night- she had to be placed on the ventilator hence my involvement with the case- and pockets of infection extending down from her mandible all the way to her cricoid cartilage in the front. Large quantities of pus and necrotic material were recovered at the time of the debridement surgery (which I was lucky enough to get to watch- the case came in at the end of my shift as an RT and the surgeon allowed me to go in and observe because of my interest in this kind of thing). The best way I can describe the procedure was that they fileted her neck to gain access. Of course, as ill as she was, this was all done under general anesthesia, but my question involves less severe cases. If someone with very extensive infection comes in, is it done under procedural sedation and regional blocks (as I am assuming because I don't think most people would hold still regardless of how good the blocks were) and if so, at what point does it get bad enough to warrant general anesthesia? Thanks everyone for your input and assistance.

BTW, our patient died last night as a result of overwhelming sepsis. I know the surgeon took pictures of the case intraoperatively, and I will attempt to get copies to share with everyone if anyone is interested.

 

[toofache32]

BTW, our patient died last night as a result of overwhelming sepsis. I know the surgeon took pictures of the case intraoperatively, and I will attempt to get copies to share with everyone if anyone is interested.

This story sounds a lot like necrotizing fasciitis, except for the pus. You should probably make sure the patient isn't identifiable in the pictures since there are HIPAA issues.

 

[toofache32]

If someone with very extensive infection comes in, is it done under procedural sedation and regional blocks (as I am assuming because I don't think most people would hold still regardless of how good the blocks were) and if so, at what point does it get bad enough to warrant general anesthesia?

This is a good question. I'm sure there's some variability on this depending on your resources and experiences. This is only my experience and opinion: Superficial abscesses in a single space with fairly well-defined borders and no airway concern can be done with local +/- sedation. In contrast, I would go to the OR for deep spaces, multiple spaces, airway concern, and many infections that require a CT scan to identify all the borders.

Like all procedures, you still have to consider each patient individually. Questionable health status, anticoagulation, and patient compliance also sometimes warrant an OR visit. Not to mention you've got a lot more help and all your cool toys in the OR. The laceration trays they give us in our ER are disposable and really crappy...it's like Fisher Price "My First Lac Tray."

 

[ISU_Steve]

As always Toofache, thank you for being patient with me and answering my questions. 🙂

 

[3rdmolarslayer]

when doing an i&d does anyone incise and drain the the tissue but then just leave it open with no drain or suture in the wound.

 

[north2southOMFS]

when doing an i&d does anyone incise and drain the the tissue but then just leave it open with no drain or suture in the wound.

Bout 90% of the time intraorally. Really never extraorally unless you are going to pack the wound with gauze.

 

[toofache32]

I have started leaving drains more often now even though there aren't as helpful in some situations. Nobody can fault you for putting in a drain, but they can always try to put blame on not putting in a drain.

 

[OMFSCardsFan]

I've been waiting until I was on call to write much on this thread. My bitch, er, intern is working somewhere while I'm typing.


I'll keep that in mind, ass. You can kiss that nightly handjob goodbye...

 

[GatorDMD]

I've been waiting until I was on call to write much on this thread. My bitch, er, intern is working somewhere while I'm typing.


I'll keep that in mind, ass. You can kiss that nightly handjob goodbye...

tell UFOMS wassup!