Airway management, intensive care requirement, and corticosteroid use in cervicofacial infection. A Maxillofacial Trainee Research Collaborative (MTReC) study.

Cervicofacial infection (CFI) is a frequently encountered presentation to Oral and Maxillofacial Departments (OMFS). The United Kingdom has recently seen cessation of all routine community dental treatment due to the Coronavirus (COVID-19) pandemic and consequently an initial modification of treatment received in secondary care. Subsequent airway difficulties and the need for level 2 High Dependency Unit (HDU) or level 3 Intensive Care Unit (ICU) is a concern to surgeons and anaesthetists alike. The availability of skilled staff and appropriate facilities can be variable. It is imperative to understand the resource implications of CFI with respect to airway management and critical care utilisation. Adequate provision is fundamental for optimal care. A national, multicentre, trainee-led audit was carried out across 17 hospitals in the UK from May to September 2017. Information recorded included demographic features, presentation, airway management, medical and surgical treatment, and steroid administration. One thousand and two presentations (1002) were recorded. Forty-five percent were female, with a mean (range) age of 37.5 years (0-94). Regarding surgical airway management, 63.4% had a standard intubation (oral 42%, nasal 21.4%). Awake fibreoptic intubation (AFOI) was performed in 28% and surgical airway required in 0.9%. Impending airway compromise at the time of presentation was 1.7%. Following surgical incision and drainage, 96.1% of patients returned to a general ward, 2.7% to Level 3, and 1.1% to Level 2 care. The return to theatre was 2.8%, and 0.7% required reintubation. There was an association between corticosteroid administration and duration of intubation. Those who received steroids were more likely to remain intubated postoperatively (p = 0.006), require a higher level of postoperative care (p < 0.001), and require a return to theatre (p = 0.019). Postoperatively, patients who received steroids were less likely to be extubated at the close of the procedure. Intubated patients who received multiple steroid doses postoperatively were extubated with less frequency those that received a single dose. To our knowledge, this dataset is the largest ever recorded for CFI. Our results showed a high requirement for advanced airway management in this cohort. The requirement for surgical airway was low, but the significance of this situation should not be underestimated. The relatively frequent need for care at levels 2 or 3 within this cohort also placed a significant demand on already overburdened resources. Knowledge of care requirements for these patients will inform resource planning.

Did the March 2020 lockdown cause an increase in patients presenting to the emergency department with odontogenic pain and infection? A single centre, retrospective analysis.

On the 25 March 2020 the Chief Dental Officer (CDO) published guidance to restrict the provision of routine dental care in England due to the rapid spread of the severe acute respiratory syndrome Coronavirus 2 (COVID-19). We analysed the impact of the pandemic on the number of patients presenting with odontogenic pain and infection to the emergency department (ED) of an urban-based teaching hospital, the Bristol Royal Infirmary (BRI). Furthermore, we investigated the severity of infection at first presentation to the ED. The study period encompassed three phases that represented the stages of pandemic restrictions: phase 1 prior to lockdown measures, with no restrictions to dental practice; phase 2 during the government lockdown, with the severest restrictions on dental practices; and phase 3 following the ease of lockdown measures, with return to limited dental services. Data were collected retrospectively from electronic patient records (EPR) regarding adult patients presenting to the ED with dental pain. The rate of presentations (per week) was calculated for each timepoint and compared. A severity score was assigned to each patient using a grading system based on signs of clinical infection and treatment modality. Patients' presentations were analysed at each phase of the pandemic. There was a 42.8% increase in attendance with oral facial pain and infection to ED from phases 1 to 3. The COVID-19 pandemic resulted in restrictions to routine primary dental care services, which were deemed necessary to reduce the spread of the virus. However, this increased demand on secondary care services, as patients increasingly struggled to access primary dental care to manage dental pain.

Is antibiotics overuse justified when immediate intervention is not possible? A rapid evidence review

Introduction: This review revisits clinical use of antibiotics for most common acute oro-dental conditions;we aim to provide evidence governing antibiotics use when access to oral healthcare is not available, as during the ongoing outbreak of the severe acute respiratory syndrome coronavirus 2. Materials and methods: In this rapid review, articles were retrieved after conducting a search on PubMed and Google Scholar. Relevant publications were selected and analyzed. Most recent systematic reviews with/without meta-analyses and societal guidelines were selected. Data were extracted, grouped, and synthesized according to the respective subtopic analysis. Results and discussion: There was evidence supporting the use of antibiotics in common oro-dental conditions as temporary measure when immediate care is not accessible, such as in case of localized oral swellings as well as to prevent post-extraction complications. No sufficient evidence could be found in support of antibiotic use for pain resulting from pulpal origin. Conclusion: Antibiotic use may be justified to defer treatment temporarily or reduce risk of complications in case of localized infection and tooth extraction, when no access to immediate dental care is possible. Copyright Ibrahim N et al.

Ludwig's angina in a COVID positive patient-An atypical case report.

The management of odontogenic infections is established and several guidelines have been proposed for its effective treatment. Outbreak of COVID-19 has posed serious challenge in the management of odontogenic infections, further complicated by immunocompromised status of the patient, where adequate evaluation and prompt attention is mandatory to avoid untoward consequences. Ludwig's angina being a life threatening infection by itself, association or simultaneous presentation with COVID-19 infection can add further complexity in the management for a maxillofacial surgeon. Here we present a case report of Ludwig's angina in a patient who tested positive for Coronavirus infection and how we treated her successfully.

Significant rise in neck infections progressing to descending necrotizing mediastinitis during the COVID-19 pandemic quarantine.

To present five patients with DNM, who were treated during the first quarantine for Coronavirus disease 2019 (Covid-19). Five patients with DNM were treated in our department during the first lockdown. The mean age of the patients was 42,2 years and four were male. Two patients were immunocompromised. Repeated surgical drainage was performed in all patients, whereas four were also subjected to elective tracheostomy during their first operation. The mean hospitalization duration was 55,4 days and mortality was 40%. During the first lockdown for the Covid-19, a rise in the ratio of DNM cases to the overall incidence of cervicofacial infections was observed in our department. All patients with DNM were operated on an emergency basis and were subsequently admitted to the ICU. We consider the effect of the quarantine as a decisive factor for this escalation, because according to the department archives, there had not been any cases of DNM originating from a dental infection, for the past 5 years. Additionally, past studies from the same department reported no more than 6 cases over a 10 year period.

The Impact of COVID-19 on the Treatment of Craniomaxillofacial Trauma and Head and Neck Infections.

There is no shortage of news, information, and guidelines with regards to novel coronavirus (COVID-19). However, there is none yet that is specific to the treatment of patients who have sustained trauma or active head and neck infections-frequently encountered from oropharyngeal sources such as peritonsillar abscess or odontogenic infections. The COVID outbreak has not diminished the incidence of these conditions, and in fact has exacerbated access to care by the closing of urgent care treatment centers as well as private dental offices. The purpose of this article is to outline a protocol to protect health care providers in the provision of this care for at-risk patient populations.