Phlegmon - acute extensive purulent process of inflammation in fatty tissue. The abscess is distinguished by the absence of clearly defined boundaries. By localization, phlegmon is distinguished as subfascial, subcutaneous, retroperitoneal, intermuscular, pericarpal, near-rectum. The causative agents phlegmon Staphylococcus are considered, in a larger number; there may also be other pyogenic pathogens; Anaerobic bacteria and rods are much less common. Therefore, the causative agents of the disease are divided into anaerobic purulent and putrefactive groups of microorganisms.
The causative agents phlegmon enter the fatty tissue mainly through the affected skin or from infections localized near the foci ( furunculosis , caries, lymphadenitis, etc.). At times, pathogens can be hematogenically infiltrated from long-persisting foci of infection.
The main cause of phlegmon development is usually microorganisms that enter the cell area directly through the wound cavity or from the lympho- and circulatory system. Most often, the golden staphylococcus is isolated, after it there is streptococcus on its frequency.
The development of phlegmon is also caused by other microorganisms. For example, in children phlegmon can be provoked by a hemophilic infection. When bitten by dogs, the soft tissue penetrates the bacterium Pasturella multocida. It can promote the development of phlegmon with a sufficiently short incubation period (6-20 hours). But such cases, fortunately, are rare.
The characteristic of the phlegmon flow is explained by the functions of the vital activity of the microorganism, which caused a purulent-inflammatory process. So, staphylococci and streptococci cause a purulent-inflammatory process. But when infected with a vulgar proteome, putrefactive streptococcus or E. coli develops a putrid form of phlegmon.
Severe forms of phlegmon can develop in the course of vital activity of anaerobes, which can exist outside of oxygen. These include the peptococcus, bacteroides, clastridia, etc. Such microorganisms have extreme aggressiveness with respect to the high rate of tissue damage and the tendency to a rapid spread of the inflammatory process.
Chronic phlegmon, also called woody, develops as a result of the functioning of microorganisms such as paratyphoid and diphtheria rods, pneumococcus, and the like.
The percentage of appearance of phlegmon increases with a decrease in the immune status, which can be caused by anorexia , hypovitaminosis, immunodeficiencies (HIV, cancer), diabetes, blood diseases, tuberculosis , etc. Basically, in such conditions, the disease progresses more rapidly and rapidly spreads infection.
Phlegmon can be localized in virtually any area of the body. With phlegmon thigh, the nature of the disease can be primary or can be explained by the ingress of purulent contents from the abdominal wall, the hip joint and others located near the areas. A phlegmon of the foot often develops with diabetes, because with it there are violations of the innervation of the foot, with worsening trophism of tissues and impaired blood circulation. Such cumulative pathological changes in the limbs in diabetes mellitus give excellent conditions for the development of a purulent-inflammatory process observed with a phlegmon of the foot.
I would like to note that diabetes mellitus itself affects the condition of the vessels and tissues of the foot, especially in the male sex.
The phlegmon of the jaw, as a rule, occurs with neglected caries, periodontitis, pulpitis, chronic tonsillitis. Rarely, the phlegmon of the jaw appears from the lower parts with a chronic infection.
Phlegmon can be represented as primary, which arose due to the penetration of pathogenic microorganisms through the wound cavity in the skin, and secondary, which develops when the process of inflammation changes to surrounding tissues. It can also take place either in acute form or in chronic; be deep or shallow, limited or progressive.
Depending on the nature of the damage to soft tissues, purulent, serous, putrefactive and necrotic phlegmon form is determined. Considering the area of the lesion, phlegmon is subdivided into phlegmon subfascial, phlegmon subcutaneous, retroperitoneal phlegmon, phlegmon of intermuscular, phlegmon of neck, phlegmon of interorgan, phlegmon of foot, phlegmon of brush, etc.
During purulent inflammation, the development of the disease occurs in the cell spaces in the region of a particular organ. For example: paranephritis (the process of inflammation in the kidney area), paraproctitis (the process of inflammation in the rectum), parametritis (the process of inflammation in the uterus), etc.
With a rapid flow, phlegmon, as a rule, goes beyond one area and goes to neighboring ones, capturing several regions at the same time.
As a rule, for acute phlegmons, there is a rapid onset with a sharp increase in temperature to 40 ° C, sometimes even higher; general intoxication, which is accompanied by thirst, malaise, headache, chills.
With the superficial form of phlegmon in the affected area, edema and hyperemia of the tissues develop. The affected area always increases in volume due to edema and purulent contents, an increase in lymph nodes located in the affected area is detected. When phlegmon is palpated, it is extremely painful, soldered to the skin, to touch with local temperature increase formation, without localized boundaries. Skin over this formation has a characteristic luster. The movements of the patient are painful; Pain can increase with bends or movements of the body, so patients move less.
Later in the zone of inflammation there is a softened area or cavity, which is filled with purulent contents. Pus can break through, forming a fistula, and can spread to neighboring tissues.
For deep forms of phlegmon, an early bright characteristic of general symptoms is typical: weakness, hyperthermia, chills, etc. There may be rapid deterioration of the condition with the addition of dyspnea, lowering of blood pressure, tachycardia, headache, and blue color of the extremities.
With phlegmon thigh, the size of the upper thigh may significantly exceed the norm. In addition, with palpation of the thigh in the place where the musculature is located, the patient feels a strong pain syndrome. Pain with such localization of phlegmon is constantly observed. The movement of the foot is difficult.
The facial phlegmon can be represented in several types. The one that affects the tissues in the lower third of the face and the one that affects the tissues of the upper third and middle of the face. As a rule, these are the premaxillary tissues. When processes occur that affect the surface layers of cells, they are localized in the zone of the chin, as well as in the region of the ears. When processes occur that cover tissues located deeper, their localization is observed at the bottom of the mouth, under the tongue and in the region of the pharynx.
The phlegmon of the jaw has certain signs and symptoms for it. These include: high body temperature up to 40 ° C, putrefactive odor from the mouth, general intoxication of the body, severe edema in the jaw area and sharp pain syndrome during palpation, swallowing, sometimes with respiratory failure. The clinic of the phlegmon of the jaw proceeds rapidly and often, the inflammatory process passes to other areas of the oral cavity.
Also, with phlegmon, the following five basic forms are distinguished:
- The serous form of phlegmon is characterized at its first stage of development. In the affected area, serous exudate accumulates, the cellulose is infiltrated by leukocytes. The tissues of the cellulose become gelatinous, start to become saturated with a watery opaque liquid. The edges between diseased and healthy tissues are washed away.
- In the purulent form of phlegmon, melting of tissues develops with the appearance of purulent contents, with the formation of turbid exudate. Development of fistulas, ulcers and cavities is observed.
- The putrefactive form of phlegmon is characterized by tissue damage with the appearance of fumes with putrefactive odor. Soft tissues acquire a dark green or dirty brown color, the touch becomes loose, slippery and turns into a semi-liquid sticky mass. The putrefactive decomposition of tissues causes severe intoxication.
- For the necrotic form of phlegmon, the development of foci of necrosis is characteristic, later tearing away, leaving behind a wounded cavity. With a good current of phlegmon, the inflammation zone is delimited from healthy tissues by a shaft with a large formation of leukocytes, and subsequently by a granulation barrier. Inflammatory process have a localized area. At the site of phlegmon formation, abscesses can be formed, which can be opened independently, or drained surgically.
- In the anaerobic form of phlegmon, widespread serous inflammation takes place with the formation of large areas of necrosis and evacuation of gas vapors from the affected tissues. Fabrics have a dark gray color with a fetid odor. When probing the affected area, crepitation is detected, due to the presence of gas vapors.
All of the above forms of phlegmon have an acute course and are often malignant in nature. They are rapidly spreading, capturing all new areas with fatty tissue. Phlegmon accompanied by severe intoxication.
The chronic form of phlegmon can appear with reduced virulence of pathogenic microorganisms and increased resistance of the patient's body. It is accompanied by the development of a woody infiltrate, dense to the touch. Skin covers in the inflammatory region have a cyanotic shade.
Phlegmon and abscess
An abscess is a localized purulent-inflammatory process of soft tissues. Phlegmon is a vast purulent-necrotic nature of inflammation of fatty tissue, spaces of interfascial and other soft tissues.
The causative agents of abscesses and phlegmon are staphylococcal infections, streptococcal infections, less often E. coli, Pseudomonas aeruginosa and anaerobes. The development and course of infection occurs by contact with the flow of lymph.
In symptomatology phlegmon and abscesses distinguish acute stage and subacute stage. Acute is characterized by increased local signs of the inflammatory process (hyperemia, edema, pain syndrome, development of infiltrates), expressed by general intoxication reactions of the body. If there is no timely exposure of purulent exudate, the process of inflammation spreads to neighboring areas, which is fraught with the development of sepsis, meningitis, and so forth.
There can be a simultaneous development of phlegmon and abscesses, which brings severe suffering to the patient. His condition can be dramatically worsened. This condition is accompanied by high fever, pain syndrome in the affected area with a pulsating nature of pain, nausea and vomiting, pallor of the skin. The blood determines the increased level of C-reactive protein, leukocytosis, increased increase in ESR, a decreased level of hemoglobin and erythrocytes. Lowering the level of hemoglobin is associated with secondary anemia, which develops against the backdrop of an intoxication process. If you do not assign urgent treatment to such a patient, rapid development of sepsis with a fatal outcome can occur. Therefore, when syndromes of general intoxication of an organism join, it is necessary to immediately call an ambulance team for the hospitalization of a patient with abscesses and phlegmon.
Therapy of this kind of formation consists in a wide opening and drainage of purulent-inflammatory foci. Sometimes it is necessary to make several incisions in the affected area, which leaves a large gaping deep wound cavity. Daily washing of the wound cavity with antiseptic solutions is necessary, the appointment of passive and active immunization, the introduction of hormone therapy and desensitizing therapy, and the introduction of infusion detoxification therapy.
The procedure of surgical intervention brings the patient a good relief. Although an extensive wound forms after the intervention, it does not cause a sharp pain syndrome to the patient. This is due to the emptying of purulent contents from it. The patient can even wiggle the limb (with phlegmon and abscess on the thigh or arm). There is a decrease in body temperature to subfebrile digits. The use of antibacterial drugs during the first few days helps to eliminate the infection and reduce body temperature.
After opening abscesses and phlegmon it is necessary to observe daily the condition of the wound cavity and the general condition of the patient, arterial pressure, diuresis. After the acute inflammatory process subsides, the appointment of physiotherapeutic procedures (electrophoresis, UHF, UFO, UHF, etc.) is advisable.
Phlegmon of the neck
The phlegmon of the neck is defined as a disease with a protracted course, in which there is a lesion of the intercellular and interfascial spaces of the neck. In the presence of phlegmon of the neck, there is also a filling of purulent contents of certain interfascial spaces (subcutaneous phlegmon of the neck, intermuscular phlegmon of the neck and interfascial phlegmon of the neck). Having in mind the complex anatomical structure of the neck, phlegmon can have a different arrangement. Phlegmon, in contrast to abscesses, which develop in the neck, do not have clear elastic walls and at the same time are limited by fascia.
With the phlegmon of the neck, purulent contents spread from one interfascial space to another, contributing to the development of diffuse extensive areas of damage. The causative agents of the purulent-inflammatory process can easily spread through interfascial fiber, damaging muscles, vessels, connective tissue, lymph nodes.
As a rule, the phlegmon of the neck, arises from the complicated course of catarrhal sinus, the dissection of peritonsillar and zaggot abscesses. It can also develop due to alveolitis , periodontitis and osteomyelitis of the lower jaw, otitis, and trauma. Penetration of the phlegmon pathogen into fatty tissue can occur in various ways: hematogenous way, lymphogenous way, when pus penetrates from nearby inflammatory areas. Pathogenic pathogens with phlegmon neck can be various microorganisms: streptococcus hemolytic group A, staphylococcus, E. coli, Clastridia, Pseudomonas aeruginosa.
With small phlegmon or phlegmon deep, external skin manifestations on the neck may be absent. Body temperature, in general, does not increase more than subfebrile. Manifestations of intoxication syndrome are poorly expressed. But the external or extensive phlegmons of the neck to reveal much easier. On the surface of the skin in the neck area there is noticeable hyperemia, swelling and soreness. When performing palpation of the subcutaneous phlegmon on the neck, the fluctuation and pronounced tenderness, accompanied by the intensity of the skin, are determined. The general condition of the patient is presented in the form of a severe or with an average degree of severity.
Also, with phlegmon neck patients complain of difficulty swallowing and breathing, especially when squeezing phlegmon pharynx or esophagus. With the submaxillary form of the phlegmon of the neck, it is difficult to open the mouth and chew food. The mouth is in a semi-open state, a putrid smell comes from it. As the course and course of the disease, the patient's condition can deteriorate significantly. With phlegmon of the neck, only surgical treatment with drainage of purulent foci in hospital conditions is shown.
The phlegmon of the hand is defined as the purulent inflammation of the superficial or deep soft tissues of the hand without limiting the spread of the inflammatory process. The provoking factor of phlegmon development is a nonspecific pyogenic microflora, which falls into the tissues of the hand in various ways.
Primary purulent foci may be located proximal to the tissues of the hand, with pathogenic microorganisms passing through interfascial vaginas into the soft tissue of the hand, developing an inflammatory process in them. The phlegmon of the hand can be a complication of panaritium, as well as various inflammatory diseases of the skin on the arm. Traumatic injury, too, may be the cause of the development of phlegmon.
There are phlegmons of the space of tenar and hypotenar, interdigital, central, preaponeurotic and subaponeurotic.
Subcutaneous phlegmons develop due to the addition of purulent process to the existing callosity. Her traumatization is an excellent entrance gate for a large number of pathogens. In addition, the anatomical structure of the fascia of the hand and subcutaneous tissue contributes to the development of a purulent-inflammatory process.
The phlegmons of interdigital spaces are defined as a consequence of subcutaneous panaricium on the fingers. In the course of subcutaneous fat, the inflammation process spreads to the interdigital space and the base of the finger.
Phlegmon of the spaces of fascial tenar and hypotenar are considered complication of subcutaneous panaricians or tenovaginitis of 1,2 and 4 fingers of the hand. The latter appear with a trauma of the area of tenar and hypotenar. But the phlegmon of the hypotenar are considered rare.
Clinical signs of phlegmon of the hand are: swelling of the tissues and hyperemia of the skin over the inflammatory focus, a strong pain syndrome, which is sharply increased by moving the brush and probing the affected area. Very often, patients experience general malaise, with large phlegmon joins a rise in body temperature to subfebrile digits.
The phlegmon of the hand also requires surgical intervention, the specificity of which may differ in the places of phlegmon localization.
Therapy of the postoperative period is aimed at the prevention of recurrence of phlegmon. Therefore, recommended the appointment of antibacterial drugs, as well as daily dressings of the wound cavity with drainage of their antiseptic solutions and solutions of antibiotics.
Phlegmon of the oral cavity
Oral phlegmon is considered an acute infectious disease of the oral cavity, characterized by extensive purulent inflammation of the subcutaneous fat.
Oral phlegmon may be a complication that occurs when the infection spreads into the oral cavity due to a certain number of diseases. Such diseases include: periodontitis, periodontitis, tooth cyst, osteomyelitis , caries. These same diseases can cause the development of phlegmon of the face. The phlegmon of the oral cavity can also develop as a result of an injury in the hyoid area. As a result of this injury, the introduction of infection into the mucous membrane of the mouth develops.
The phlegmon of the oral cavity can affect the area under the lower jaw, which is accompanied by the development of infection on the chin zone; sublingual area, which is accompanied by the inflammatory process of the root of the tongue; sublingual area and the area of submandibular space from two sides, accompanied by the defeat of the entire area of the oral cavity.
Symptoms that are observed with phlegmon of the mouth include: swelling of the tongue, because of which it does not protrude their oral cavity; limitation of language mobility; appearance of a gray-brown coating on the surface of the tongue; disturbed speech function; violation of swallowing and / or chewing functions; violation of respiratory function; hypersalivation (excessive salivation); fetid smell from the mouth; general intoxication; the appearance of face asymmetry due to soft tissue edema in the area of the lower jaw and chin; swelling of the skin in the area of the chin and neck; pain syndrome in palpation in the neck and chin; fever and chills.
The process of development of the disease passes swiftly, grasping the two sides of the bottom of the oral cavity, spreading to neighboring areas of the oral cavity.
Treatment of phlegmon of the oral cavity is carried out in the form of a complex of measures, whose composition directly depends on the stage and nature of the phlegmon. At an early stage of development of oral phlegmon, treatment is prescribed with the use of general antibiotic therapy with broad-spectrum antibiotics.
Phlegmon of the oral cavity at later stages, as well as phlegmon of the face, requires surgical intervention characterized by excision of necrotic affected soft tissues, drainage of the purulent-inflammatory wound cavity and subsequent open wound therapy with washing with antiseptic solutions. In the future, plastic surgery is possible.
A huge role in the prevention of phlegmon in the oral cavity is carried out by the following measures: adequate sanitation of the oral cavity (treatment of caries, treatment of periodontitis and any professional cleaning of the oral cavity); daily brushing of teeth; regular preventive visits to the dentist; increased immunity; treatment of chronic foci of infection (tonsillitis, pharyngitis, sinusitis, sinusitis , otitis).
Phlegmon is considered a serious, sometimes life-threatening disease patient. With phlegmon, hospitalization of the patient is considered a prerequisite. The tactic of treatment involves a strict rule: if there is purulent content, it is necessary to empty the affected phlegmon area. Therefore, the main treatment measure is defined as surgical intervention, which consists in opening and subsequent drainage of a purulent-inflammatory focus.
An exception may be the initial stage of phlegmon development (before the infiltration appears). In this case, surgery is not performed. Patients with this stage are prescribed procedures with heat (warmers, sallux, warming compresses), UHF or bandages with yellow mercury ointment.
If the patient has a high temperature and there is a formed infiltrate, then they resort to operative treatment of phlegmon, even if there is no pronounced fluctuation in the inflammation focus. Opening and draining of the affected area can reduce the tension of soft tissues, normalize tissue metabolism and form the conditions for the withdrawal of inflammatory fluid.
Surgery is performed under general anesthesia. Surgical opening of phlegmon is carried out with a wide incision. Therefore, to ensure a good outflow of purulent contents, deeply dissect not only surface but also deeper-lying soft tissues. After emptying the purulent exudate, the wound cavity is washed and drained by graduates with rubber, half pipes or tubes.
On the wound surface, compresses are applied with water-soluble ointments (Levomikol) and hypertonic solution. Ointments such as Vishnevsky or Tetracycline in the early stages of recovery are not shown, because they can hinder the outflow of contents from the wound.
To accelerate the rejection of necrotic areas, certain necrolytic agents are used - Terrylitin, Iruksol, Chymotrypsin, Trypsin, Himopsin.
After complete emptying of the wound, ointment dressings are applied. To accelerate the regeneration of tissues, use the Metuluracil and Troxevasin ointments; for immune maintenance of granulation tissue from traumatization - ointment on fat basis; for the prevention of re-infection - ointments on a water basis.
With epithelialization and scarring of tissues, medicinal preparation Troxevasinum, sea buckthorn and rosehip oil are used. With long non-healing wound cavities and deep skin defects, dermoplasty is performed.
In addition to local therapy, conservative treatment of phlegmon is carried out, which is aimed at developing the defenses of the body to fight infection. The inflamed part is given an elevated position. All patients are shown antibiotic therapy with a wide spectrum of action.