27. Maxillofacial inflammation and tumours

1. Definition

• Inflammatory processes of the maxillofacial area → infections of the teeth, jaws, soft tissues of the face and neck, and salivary glands
• Tumours of the maxillofacial area → benign and malignant neoplasms of the lips, oral cavity, jaws and salivary glands

2. Inflammatory diseases

A. Odontogenic infections

• Source → dental caries, periapical abscess, pericoronitis (wisdom tooth), periodontitis
• Organisms → mixed oral flora: streptococci, anaerobes (Peptostreptococcus, Prevotella, Fusobacterium)
• Spread from the tooth apex:
  • Periosteum → subperiosteal abscess
  • Soft tissues of the face → abscess, phlegmon
  • Fascial spaces → submandibular, sublingual, submental, masticator, parapharyngeal, retropharyngeal
  • Mediastinum → descending necrotising mediastinitis
• Treatment → drain the abscess, remove the cause (extraction, root canal), antibiotics (penicillin + metronidazole)

B. Ludwig's angina

• Bilateral cellulitis of the submandibular, sublingual and submental spaces
• Source → lower molars (second and third)
• Signs:
  • Brawny, board-like swelling of the floor of the mouth and upper neck
  • Elevated, protruding tongue
  • Drooling, dysphagia, trismus
  • Stridor → airway threat
• Treatment:
  • Secure the airway → awake fibreoptic intubation or tracheostomy
  • Intravenous antibiotics
  • Surgical decompression and drainage
  • Extract the source tooth

C. Osteomyelitis of the jaws

• Mandible far more often than maxilla
• Causes → odontogenic infection, fracture, radiotherapy (osteoradionecrosis), bisphosphonates (medication-related osteonecrosis)
• Signs → pain, swelling, fistula, loose teeth, lower lip numbness (Vincent's sign)
• Treatment → antibiotics, sequestrectomy, debridement

D. Salivary gland inflammation

• Acute suppurative parotitis → elderly, dehydrated, postoperative; Staphylococcus aureus
  • Painful parotid swelling, pus from Stensen's duct
  • Treatment → hydration, oral hygiene, sialogogues, antibiotics; drain if abscess
• Sialolithiasis → 80% in the submandibular gland (Wharton's duct)
  • Pain and swelling on eating (mealtime syndrome)
  • Treatment → stone removal through the mouth, sialendoscopy, gland excision
• Viral parotitis → mumps
• Chronic sialadenitis, Sjögren's syndrome

E. Soft tissue infections of the face

• Furuncle of the upper lip and nose → danger triangle; spread through facial and ophthalmic veins → cavernous sinus thrombosis
• Erysipelas, cellulitis

3. Tumours

A. Benign

• Odontogenic → ameloblastoma, odontoma, odontogenic keratocyst
• Haemangioma, lymphangioma
• Fibroma, papilloma, lipoma
• Salivary gland tumours → 80% in the parotid; 80% of parotid tumours are benign
  • Pleomorphic adenoma → most common; slow, painless; recurs if enucleated; risk of malignant change (carcinoma ex pleomorphic adenoma)
  • Warthin's tumour → second most common; older male smokers; bilateral in 10%
• Rule of 80s → 80% parotid, 80% benign, 80% pleomorphic adenoma

B. Precancerous lesions

• Leukoplakia → white patch that cannot be rubbed off
• Erythroplakia → red patch; highest malignant risk
• Oral submucous fibrosis → betel nut chewing
• Lichen planus (erosive)
• Actinic cheilitis → lower lip, sun exposure

C. Malignant

• Squamous cell carcinoma (SCC) → > 90% of oral cancers
• Sites → lower lip, lateral border of the tongue, floor of the mouth
• Risk factors:
  • Tobacco and alcohol (synergistic)
  • Betel nut
  • Human papillomavirus (HPV) → oropharynx
  • Poor oral hygiene, sharp teeth, ill-fitting dentures
  • Ultraviolet light → lip
• Signs → non-healing ulcer with raised everted edges, induration, bleeding, pain referred to the ear, loose teeth, neck lymph nodes
• Salivary malignancy → mucoepidermoid carcinoma (most common), adenoid cystic carcinoma (perineural spread)
• Facial nerve palsy with a parotid mass → malignant until proven otherwise
• Jaw sarcomas → osteosarcoma

4. Diagnosis

• Clinical examination, palpation of neck nodes
• Orthopantomogram (OPG) → dental and jaw lesions
• Ultrasound → salivary glands, neck nodes
• CT or MRI → extent, bone invasion, deep spaces
• Fine-needle aspiration (FNA) → salivary masses, neck nodes
• Incisional biopsy → oral lesions
• Never incisional biopsy of a parotid mass → tumour spillage

5. Treatment of tumours

• Benign parotid tumour → superficial parotidectomy with facial nerve preservation
• Submandibular tumour → excision of the gland
• Oral SCC:
  • Wide local excision with 1 cm margin
  • Neck dissection → nodal disease or high risk (depth of invasion > 4 mm)
  • Reconstruction → local or free flaps (radial forearm, fibula)
  • Adjuvant radiotherapy or chemoradiotherapy → advanced stage, positive margins, extranodal spread
• Lip cancer → wedge excision

6. Complications

• Airway obstruction, mediastinitis, sepsis (infections)
• Cavernous sinus thrombosis
• Facial nerve palsy, Frey's syndrome (gustatory sweating) after parotidectomy
• Salivary fistula
• Recurrence, osteoradionecrosis after radiotherapy