Table Of ContentHead, Neck, and Orofacial
Infections: An Interdisciplinary
Approach
James R. Hupp, DMD, MD, JD, MBA, FACS
Founding Dean and Professor of Oral-Maxillofacial Surgery
School of Dental Medicine
Professor of Surgery
School of Medicine
East Carolina University
Greenville, North Carolina
Elie M. Ferneini, DMD, MD, MHS, MBA, FACS
Assistant Clinical Professor
Oral and Maxillofacial Surgery Division, Department of Craniofacial Sciences
University of Connecticut
Medical Director, Beau Visage Med Spa
Private Practice, Greater Waterbury OMS
Waterbury, Connecticut
3251 Riverport Lane
St. Louis, Missouri 63043
HEAD, NECK, AND OROFACIAL INFECTIONS:
AN INTERDISCIPLINARY APPROACH ISBN: 978-0-323-28945-0
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Contributors
Matthew Anderson, BS R. Bryan Bell, MD, DDS, FACS
School of Medicine Medical Director
University of Connecticut Oral, Head and Neck Cancer Program and Clinic
Storrs, Connecticut Providence Cancer Center
The Earle A. Chiles Research Institute
Amir F. Azari, DMD, MD Providence Portland Medical Center
Department of Oral and Maxillofacial Surgery Attending Surgeon
School of Dentistry Trauma Service/Oral and Maxillofacial Surgery Service
Oregon Health and Science University Legacy Emanuel Medical Center
Portland, Oregon Consultant
Head and Neck Institute
Ali Banki, DO Portland, Oregon
Private Practice
Glastonbury, Connecticut; Jeffrey D. Bennett, DMD
Clinical Associate Professor and Chair
Department of Dermatology Department of Oral Surgery and Hospital Dentistry
University of Connecticut Indiana University
Attending Dermatologist School of Dentistry
Saint Francis Hospital and Medical Center Indianapolis, Indiana
Hartford, Connecticut
Tyler T. Boynton, DMD
Mohammad Banki, MD, DMD, FACS Sonoma Valley Oral Surgery (Private Practice)
Artistic Contours (Private Practice) Sonoma, California
Warwick, Rhode Island;
Clinical Faculty Grishondra Branch-Mays, DDS, MS
Department of Surgery Associate Professor
Warren Alpert Medical School Division of Periodontics
Brown University Department of Developmental and Surgical Sciences
Providence, Rhode Island; School of Dentistry
Clinical Faculty University of Minnesota
Division of Oral and Maxillofacial Surgery Minneapolis, Minnesota
Department of Craniofacial Sciences
School of Dental Medicine Joseph V. Califano, DDS, PhD
University of Connecticut Professor
Farmington, Connecticut Department of Periodontology
School of Dentistry
Lydia Aoun Barakat, MD Oregon Health and Science University
Assistant Professor of Medicine Portland, Oregon
Section of Infectious Disease
Department of Internal Medicine
Yale School of Medicine
Medical Director of the YNHH Nathan Smith Clinic
Program Director of the Yale HIV Primary Care Track
New Haven, Connecticut
v
vi Contributors
Todd Cassese, MD Susan L. Fink, MD, PhD
Director Instructor
Phase 1 of the Clinical Arts and Sciences Course Department of Laboratory Medicine and Immunobiology
Associate Professor Yale School of Medicine
Department of Medical Sciences New Haven, Connecticut
Frank H. Netter MD School of Medicine
Quinnipiac University Thomas R. Flynn, DMD
North Haven, Connecticut Private Practice
Reno, Nevada;
Charles L. Castiglione, MD, MBA, FACS Former Associate Professor of Oral and Maxillofacial
Associate Clinical Professor of Surgery Surgery
School of Medicine Harvard School of Dental Medicine
University of Connecticut Boston, Massachusetts
Chief of Plastic Surgery
Hartford Hospital Ashraf F. Fouad, DDS, MS
Connecticut Children’s Medical Center Professor and Interim Chair of Endodontics, Periodontics
Hartford, Connecticut and Prosthodontics
School of Dentistry
Frank M. Castiglione Jr., MD University of Maryland
Associate Clinical Professor Baltimore, Maryland
Department of Dermatology
Yale School of Medicine Jacob Gady, DMD, MD
Associate Clinical Instructor
Yale New Haven Hospital and West Haven VA Hospital Division of Oral and Maxillofacial Surgery
New Haven, Connecticut; University of Connecticut
Private Practice Private Practice
Hamden, Connecticut West Hartford, Connecticut
Jason A. Chin, MD Morton H. Goldberg, DMD, MD
Section of Vascular Surgery Clinical Professor
Yale School of Medicine Division of Oral and Maxillofacial Surgery
New Haven, Connecticut School of Dental Medicine
University of Connecticut
Scott T. Claiborne, DDS, MD Hartford Hospital
Oncologic and Reconstructive Surgery Hartford, Connecticut
North Memorial Medical Center
Robbinsdale, Minnesota Michael T. Goupil, DDS, MEd, MBA
Associate Dean for Student Affairs
Marc D. Eisen, MD, PhD Associate Professor
Assistant Clinical Professor, Otolaryngology Department of Oral and Maxillofacial Surgery
Department of Surgery School of Dental Medicine
University of Connecticut Medical Center University of Connecticut
Farmington, Connecticut Farmington, Connecticut
Lewis N. Estabrooks, DMD, MS Neil Haycocks, MD
Associate Clinical Professor Community Based Clinical Faculty
Department of Oral and Maxillofacial Surgery Frank H. Netter MD School of Medicine
Tufts University School of Dental Medicine Quinnipiac University
Board of OMSNIC and Fortress Professional Liability Hamden, Connecticut
Companies
Boston, Massachusetts Kyle Johnson, MD
University of Connecticut Health Center
Antoine M. Ferneini, MD, FACS Department of Otolaryngology
Section Chief Head and Neck Surgery
Division of Vascular Surgery Farmington, Connecticut
Yale-New Haven Hospital/St. Raphael Campus
Connecticut Vascular Center, PC
North Haven, Connecticut
Contributors vii
Lewis C. Jones, DMD, MD Luke H. L’Heureux, DMD, MD
Assistant Professor Division of Oral and Maxillofacial Surgery
Department of Oral and Maxillofacial Surgery School of Dental Medicine
School of Dentistry University of Connecticut
University of Louisville Farmington, Connecticut
Louisville, Kentucky
Stuart E. Lieblich, DMD
James A. Katancik, DDS, PhD Clinical Professor
Department of Periodontology Division of Oral and Maxillofacial Surgery
School of Dentistry School of Dental Medicine
Oregon Health and Science University University of Connecticut
Portland, Oregon Farmington, Connecticut;
Avon Oral and Maxillofacial Surgery (Private Practice)
Kristine Kelliher, MD Avon, Connecticut
Department of Surgery, Hartford Hospital
Hartford Healthcare Medical Group Maricar Malinis MD, FACP
Emergency General Surgery Assistant Professor of Medicine
Surgical Critical Care Section of Infectious Diseases
Hartford, Connecticut; Yale University School of Medicine
Instructor New Haven, Connecticut
Department of Surgery
University of Connecticut Michael Miloro, DMD, MD, FACS
Farmington, Connecticut Professor and Head
Department of Oral and Maxillofacial Surgery
Orlando C. Kirton, MD, FACS, MCCM, FCCP University of Illinois
Ludwig J. Pyrtek, MD Chair in Surgery Chicago, Illinois
Chief, Department of Surgery
Chief, Division of General Surgery Thomas S. Murray, MD, PhD
Interim Director, Trauma Service Associate Professor
Hartford Hospital Frank H. Netter MD School of Medicine
Hartford, Connecticut; Quinnipiac University
Professor and Vice Chair Hamden, Connecticut;
Department of Surgery Attending Physician
School of Medicine Pediatric Infectious Diseases
University of Connecticut Connecticut Children’s Medical Center
Farmington, Connecticut Hartford, Connecticut
Antonia Kolokythas, DDS James Naples, MD
Associate Professor School of Medicine
Department of Oral and Maxillofacial Surgery University of Connecticut
University of Illinois at Chicago Farmington, Connecticut
Chicago, Illinois
Timothy O’Brien, MD
Akshay Kumarswamy, BDS, MS Connecticut Ear, Nose & Throat Associates
Clinical Assistant Professor (Private Practice)
School of Dental Medicine Hartford, Connecticut
East Carolina University
Greenville, North Carolina Kourosh Parham, MD, PhD, FACS
Associate Professor
Matthew E. Lawler, DMD, MD Division of Otolaryngology
Harvard School of Dental Medicine Department of Surgery
Harvard Medical School University of Connecticut Health
Massachusetts General Hospital Farmington, Connecticut
Boston, Massachusetts
viii Contributors
Zachary Peacock, DMD, MD, FACS Luis Suarez, MD
Assistant Professor of Oral and Maxillofacial Surgery Vascular Fellow
Harvard School of Dental Medicine Tufts Medical Center
Attending Oral and Maxillofacial Surgeon Boston, Massachusetts
Massachusetts General Hospital
Boston, Massachusetts Stevan H. Thompson, DDS
Clinical Assistant Professor
Robert Piorkowski, MD, FACS Division Director, Oral and Maxillofacial Surgery
Chief School of Dental Medicine
Division of Surgical Oncology East Carolina University
Department of Surgery Staff, Oral and Maxillofacial Pathology
Hartford Hospital Vidant Medical Center
Hartford, Connecticut Greenville, North Carolina
Philip M. Preshaw, BDS, FDS RCSEd, PhD Alison Y. Yeung, DDS, MD
Professor of Periodontology Clinical Assistant Professor
School of Dental Sciences and Institute Division of Oral and Maxillofacial Surgery
of Cellular Medicine School of Dental Medicine
Newcastle University East Carolina University
Newcastle Upon Tyne, United Kingdom Greenville, North Carolina
Thomas Schlieve, DDS, MD Katherine J. Zamecki, MD, FACS
Oral/Head and Neck Oncologic Surgery Fellow Attending Ophthalmologist
The Department of Oral and Maxillofacial Surgery Ophthalmic Plastic and Reconstructive Surgery
University of Tennessee Medical Center Danbury Eye Physicians and Surgeons, PC
Knoxville, Tennessee Danbury, Connecticut
David Shafer, DMD Skye Zeller, PhD
Chair and Associate Professor School of Dental Medicine
Division of Oral and Maxillofacial Surgery University of Connecticut
School of Dental Medicine Farmington, Connecticut
University of Connecticut
Farmington, Connecticut Ryan Zengou, MD
Assistant Professor
Rabie M. Shanti, DMD, MD Division of Neurosurgery
Fellow in Oral, Head and Neck Oncologic Surgery/ School of Medicine
Microvascular Reconstructive Surgery University of Connecticut
Department of Oral and Maxillofacial/Head and Neck Farmington, Connecticut
Surgery
Louisiana State University Health Sciences Center
Shreveport, Louisiana
Julie Ann Smith, DDS, MD
Associate Professor and Predoctoral Program Director
Department of Oral and Maxillofacial Surgery
Oregon Health and Science University
Portland, Oregon
To Carmen, the love of my life, best friend, and wife;
our unbelievably special children, Jamie, Justin,
Joelle, and Jordan (Maime, Joost, Welly, and Jordo);
our wonderfully talented daughters-in-law and son-
in-law, Natacha, Jordan, and Joe; and our delightful
granddaughters, Peyton and Morgan.
JRH
I dedicate this book to my wife Moniek, whose love,
support, and devotion have made completion of this
book possible. I would also like to express my love to
my children Michael, Isabella, and Anthony, who
inspire me and give me the strength and the will to
strive to be the best I can be. Above all, I would like
to thank my parents and brothers, especially Tony,
who have encouraged me and taught me the value of
education and hard work.
EMF
Preface
Head, Neck, and Orofacial Infections: An • S urgeons including general surgeons, head and neck
surgeons, otolaryngologists, oral-maxillofacial surgeons,
Interdisciplinary Approach
plastic surgeons, neurosurgeons, ophthalmologists, der-
matologists, pediatric surgeons, and trauma surgeons
Head, neck, and orofacial infections are commonly seen
• D ental professionals including general dentists, periodon-
in medical and dental offices, and, in severe cases, in hos-
tists, endodontists, pediatric dentists, oral-m axillofacial
pital emergency departments. Head and neck anatomy is
pathologists, and oral-maxillofacial radiologists
complex, with many contiguous spaces, and thus infections
• N ursing professionals including midlevel providers,
in one anatomic region may easily spread to other regions,
those working in hospital infection control, and nurses
including the pharynx, eye, and brain. This can lead to dev-
in emergency care facilities and operating rooms
astating results, including airway obstruction, blindness,
and altered mental status with cranial neuropathies. Early
Key Features
recognition and correct management of severe infections
can be life-saving, especially in medically compromised
• O ver 500 images (including photographs, radiographs,
patients and in those who present late in the infectious dis-
and illustrations) clearly demonstrate pathologies, proce-
ease process. Knowledge of the surgical anatomy and the
dures, and outcomes.
path of spread of infections in the head and neck is funda-
• E xperts in the field provide authoritative, state-of-the art
mental in correct diagnosis and treatment.
Head, Neck, and Orofacial Infections: An Interdisciplinary guidance.
Approach is the first book of its kind to present this level • A variety of topics are covered such as the evolving prin-
ciples of antibiotic therapy; odontogenic infections; the
of in-depth information for those diagnosing and manag-
pathophysiology and management of nasal and paranasal
ing pathology due to infections of the head and neck and
sinus infections; acute ear infections; orbital infections;
orofacial complex. This comprehensive resource provides
the infection issues surrounding dental implants; anes-
both time-tested and cutting-edge approaches to patient
thetic management of the patient with a head and neck
management.
infection; and much more!
This book is designed to be of value to a wide range of
health professionals:
• P hysicians including family physicians, infectious dis-
ease specialists, anesthesiologists, internists, hospitalists,
critical care physicians, pediatricians, radiologists, and
clinical pathologists
x
Acknowledgments
I appreciate the skill and hard work of the publishing team I would like to acknowledge my mentors, colleagues, resi-
at Elsevier who helped make this book possible, including dents, students, and staff who have, over the years, directly
Kathy Falk, Courtney Sprehe, and David Stein. I am also or indirectly, contributed to this work. Their never-ending
deeply grateful to my oral-maxillofacial colleagues at ECU, assistance and constant support have made this book pos-
Drs. Ali Yeung and Stevan Thompson for giving me the sup- sible. For that, I am eternally grateful. I also want to express
port I needed to dedicate time to this endeavor. Finally, I my appreciation for the expertise of the entire publishing
wish to acknowledge and thank Drs. Richard Topazian and team at Elsevier.
Morton Goldberg for the important contributions they
made to my education and for the original concept of a EMF
book dedicated to the topic of maxillofacial infections.
JRH
xi
1
Immunobiology of
Infectious Disease
JOSEPH V. CALIFANO AND PHILIP M. PRESHAW
Introduction within the host, and a productive infection ensues. Once
this occurs, many of the elements of innate immunity are
The human immune system is a biologic marvel designed still active, but an adaptive immune response occurs over
to identify and destroy or alter pathogens, foreign material, time.2 This response may be dominated by a humoral
and abnormal cells that threaten an individual. This chapter response in which opsonizing antibody specific to the
presents a detailed discussion of the immune system as it pathogenic organism facilitates phagocytosis and clear-
relates to infectious pathogens. ance of the microorganism and its toxins (typical for
Throughout our lives we are constantly encountering extracellular pathogens such as bacteria), or it may be
microorganisms capable of causing infectious disease. We dominated by a cellular response in which cytokines,
have, through the evolutionary processes of natural selec- phagocytes, or cytolytic T cells eliminate infected host
tion, developed a complex and highly organized immune cells to clear the pathogen (typical response for intracel-
system composed of molecules, cells, and tissues that protect lular pathogens like viruses and some bacteria, such as
us from agents of infection. Although infections clearly do Mycobacterium tuberculosis). Innate immunity is consti-
occur, most interactions with potentially pathogenic bacte- tutive; it does not require prior exposure to the micro-
ria, viruses, or fungi do not result in a productive infection. organism to respond to it. Adaptive immunity, on initial
For infection to occur, the inoculum and virulence of the exposure to a pathogen, requires 3 to 7 days for a response
organism must be of a magnitude sufficient to overwhelm to occur. With multiple exposures to the pathogen over
the immune system. time, either naturally or through immunization, there is
Our immune system has been divided, based on our a decrease in the lag time and an increase in the magni-
understanding of function, into innate immunity and tude and efficacy of the adaptive immune response.
adaptive immunity (Figure 1-1). It is important to note
that these aspects of immune functioning do not operate Cells of the Immune System
in isolation; indeed, there is close functional integration
between the innate and adaptive arms of the immune The cells of the immune system are derived from pluripo-
response.1 Innate immunity serves to provide the first tent stem cells in the bone marrow. The stem cells then dif-
line of defense in preventing infection. It includes physi- ferentiate into lymphoid and myeloid progenitors.
cal barriers such as the skin and mucosa, phagocytic cells The lymphoid progenitor ultimately differentiates into B
(e.g., neutrophils, macrophages), specialized receptors lymphocytes (produced in the bone marrow), T lympho-
that bind and detect classes of macromolecules associ- cytes (produced in the thymus), and natural killer (NK)
ated with pathogens not found in eukaryotic cells (e.g., cells. NK cells are involved in early immune responses, and
lipopolysaccharide, lipoteichoic acid, single-stranded they recognize virally infected cells and neoplastic cells.
DNA, double-stranded RNA [dsRNA]), and molecules B lymphocytes, when activated further, differentiate into
that promote inflammation, chemotaxis, and opsoniza- memory B cells and antibody-secreting plasma cells. T lym-
tion (e.g., cytokines, complement, acute phase proteins, phocytes further differentiate into helper T cells, cytotoxic T
arachidonic acid metabolites). In most cases, infectious cells, and regulatory T cells. These different subpopulations
agents are eliminated by innate immunity. When the of T cells are distinguished from each other by the types of
innate immunity is not sufficient to prevent infection, cytokines they produce and by the surface molecules that
the invading microorganism is successful in replicating they display (Figure 1-2).
2
