SEPTICEMIA (SEPSIS) AND THROMBOPHLEBITIS
CRANIOFACIAL (TPCF)
* CRANIOFACIAL THROMBOPHEBITES *
Craniofacial venous thromboses are divided into facial venous thromboses and cerebral venous thromboses.
Facial venous thrombosis (FVT) is rare and is often of maxillofacial infectious origin; the literature review only mentions 4 cases since 1968 , only one of which was caused by an infected tooth (upper canine or “eye tooth”). Their diagnosis is essentially clinical. Doppler ultrasound of the face allows visualization of a thrombosis frequently located at the level of the facial vein. They are treated with antibiotics and anticoagulants and thrombolytics.
Cerebral venous thrombosis (CVT) represents 0.5% of all strokes. They are generally aseptic . Cerebral magnetic resonance imaging ( MRI ) combined with venous magnetic resonance angiography ( MRA ) allows diagnosis in the majority of cases. Heparin therapy is the standard treatment.
I. DEFINITION
Thrombophlebitis is the inflammation of a vein in which a blood clot forms, leading to its partial or total blockage (embolism).
Phlebitis is the inflammation of a vein.
II. ANATOMY
1. Veins of the face: there are three of them.
* Facial vein : this is a superficial vein. It arises from the union of the supratrochlear and angular veins at the level of the internal angle of the orbit. It drains the face (nasal region, upper lips, etc.) and flows into the internal jugular vein via the thyro-lingo-pharyngo-facial venous trunk. Its path is oblique from top to bottom and from inside to outside.
* Transverse facial vein : it flows into the parotid plexus.
* Superior, middle and inferior ophthalmic veins. The superior ophthalmic vein arises from the angular and frontal veins, it drains the orbital continuum into the cavernous sinus.
2. Cerebral veins: The venous vascularization of the brain includes a rich network of superficial and deep veins draining into sinuses in the dura mater.
3. Venous sinuses: these are incontractile fibrous formations found in the venous system, devoid of valves.
* dural sinuses (of the dura mater)
* sinus of the base of the skull: the cavernous sinus is paired and symmetrical; it extends on either side of the sella turcica, on the lateral walls of the body of the sphenoid. It allows the venous drainage of most of the face and the anterior floor.
* sinus of the cranial vault
III. PHYSIOPATHOLOGY OF CRANIOFACIAL VENOUS THROMBOSIS : venous thrombosis is divided into two main categories
1. Septic venous thrombosis (facial and cerebral)
2. Aseptic venous thromboses (they mainly affect the cerebral veins). They represent 91% of CVTs (cerebral venous thromboses).
Concerning infectious or septic facial and cerebral thrombophlebitis, the locoregional infectious processes involved are grouped into foci:
* oral-dental
* ENT
* integumentary
* intracranial
For oral-dental infectious foci , the mandible is as affected as the maxilla. On the other hand, if all teeth can be incriminated in the maxillary area, only the molars, and more particularly the mandibular wisdom teeth, can be the cause of such venous thromboses. The tooth is then the starting point of cellulitis which can be complicated by facial, craniofacial and even cervical thrombophlebitis.
Pathophysiology of septic venous thrombosis: there are several possible routes of dissemination of the different infectious or thromboembolic pathologies and therefore of their clinical expression. The cavernous sinus is the first to be affected by the extension of a maxillofacial infectious process.
The infectious process is the starting point for parietal anomalies (vein wall), venous stasis and hemostasis disorders which explain the formation of a thrombus or “in situ” thrombi.
The germs found are not specific. They are germs involved in the infection in question.
IV. ANATOMO-CLINICAL STUDY OF FACIAL VEIN THROBOSIS (FVT) OR FACIAL THROMOPHLEBITIS: in our course we will only deal with (septic) thrombophlebitis of the facial vein.
1. Symptoms, signs and clinical manifestations
They concern the superficial venous network with the facial vein or the ophthalmic vein. The diagnosis is clinical. Venous thrombosis of the superficial face combines pain, local heat, induration, and erythema on the venous pathway. The latter is palpable like an indurated cord. The inflammatory reaction persists for 2 to 3 weeks, the palpable induration persists much longer. In the 4 cases reported in the literature since 1968 , a fever is systematically present.
Facial vein thrombophlebitis results in swelling of the nasolabial fold spreading to the inner corner of the eye (inner canthus). Canine involvement is sometimes found. It has therefore been nicknamed “eye tooth” or “Hypocrates tooth”.
Ophthalmic vein thrombophlebitis combines upper eyelid edema, serous chemosis and then exophthalmos.
TVFs can extend to the cavernous sinus and risk the formation of a thrombosis at this level, which is dramatic .
2. Additional examinations
Medical imaging confirms the diagnosis. Doppler ultrasound can visualize the thrombus. Brain MRI looks for cavernous sinus thrombosis.
3. Evolution and prognosis
The evolution and prognosis of TVF are linked to the severity of sepsis and the extension of thrombosis to the cavernous sinus. The association of TVF_TVC of the cavernous sinus is pejorative.
4. Treatment
Preventive treatment is based on rigorous disinfection of any facial wound, early surgical treatment of facial fractures under antibiotic cover and administration of corticosteroids to prevent thrombosis, and maintenance of adequate oral hygiene. Curative treatment of TVF is based on antibiotic therapy and heparin therapy (anticoagulants).
*SEPTICEMIA OR SEPSIS*
SEPSIS: clinical syndrome associating a systemic inflammatory response syndrome with an infection confirmed at least clinically. The infection spreads through the venous route, except for left endocarditis where diffusion occurs through the arterial route (brain; eye, skin, etc.).
SEPTICEMIA: a term formerly used to define a generalized infectious state, due to the dissemination of a pathogenic germ throughout the body, via the blood or lymph.
Unlike bacteremia (transient passage of bacteria into the blood), septicemia corresponds to repeated discharges from a septic focus, for example thrombophlebitis.
This term is now replaced by the notion of sepsis.
SEPTICOPYOHEMIA: This is a generalized infectious condition due to a pyogenic microbe and characterized by the presence of secondary suppurative foci.
Clinically, sepsis is the almost inevitable complication of infectious thrombophlebitis. It is a serious infection of the body, characterized by significant and repeated discharges of pathogenic germs into the blood, originating from an initial focus (cellulitis, thrombophlebitis, etc.) and which can create multiple secondary infectious foci (septico-pyohemia).
Two clinical situations may arise:
1. Acute sepsis: in this case fever is the first sign that appears, it is often very high (40 C and more), accompanied by solemn chills and alteration of the general condition at the time of discharges of bacteria in the blood. Hypothermia is sometimes found. The blood culture is positive and confirms the diagnosis.
Headaches, drowsiness sometimes interspersed with episodes of excitement and tachycardia quickly indicate the progression.
The occurrence of such a state of toxic-infectious shock has a poor prognosis, even currently with various antibiotics.
Pyogenic germs develop from a primary infectious focus and spread through the veins. In some cases, they lead to the formation of a second suppurating infectious focus.
Treatment includes a combination of broad-spectrum, highly bactericidal antibiotics. They are administered intravenously for at least 10 days .
2. Septicopyohemia: it develops from thrombophlebitis (inflammation of small veins in contact with the original infectious focus with the formation of a septic clot or infectious embolus). Secondary foci are located in the areas drained by the inflamed veins, mainly in the liver and lung. The onset is also very sudden. The fever peaks correspond to infectious micro-emboli released into the bloodstream. Secondarily, they are responsible for many systemic and local pathologies:
* Oslerian endocarditis
* rheumatological manifestations
* ophthalmological manifestations
* neurological manifestations
* pulmonary manifestations…
* hepatic manifestations.
SEPTICEMIA (SEPSIS) AND THROMBOPHLEBITIS
TERMINOLOGY
Embolus: An embolus is a small element that migrates through the bloodstream until it becomes blocked in a vessel that is too narrow. It most often consists of a blood clot (thrombus).
Embolism: sudden obstruction of a vessel, by the migration of a foreign body (embolus) carried by the blood circulation.
Thrombosis: pathological phenomenon leading to the formation of blood clots inside the veins and arteries.
END
SEPTICEMIA (SEPSIS) AND THROMBOPHLEBITIS
Wisdom teeth can cause infections if not removed.
Dental crowns restore the function and appearance of damaged teeth.
Swollen gums are often a sign of periodontal disease.
Orthodontic treatments can be performed at any age.
Composite fillings are discreet and durable.
Composite fillings are discreet and durable.
Interdental brushes effectively clean tight spaces.
Visiting the dentist every six months prevents dental problems.