Phlegmon

Phlegmon is a spreading diffuse inflammatory process with formation of suppurative/purulent exudate or pus.

Phlegmon affecting the spine is known as spondylodiskitis and is associated with loss of disk height and endplate destruction. In adults, the bone marrow is affected first, while in children, the disease starts in the disc itself and spreads rapidly to the adjacent vertebral bodies. Phlegmon in the spine can be a diffuse enhancement, or localized abscess, (peripheral enhancement) in the epidural, subligamentous or paraspinous spaces. Under MRI examination, phlegmon will show dark with T1, and high signal (bright) with T2.

Etiology

Commonly by bacteria - streptococci, spore and non-spore forming anaerobes, etc.

Factors affecting the development of phlegmons are virulence of bacteria and immunity strength.

Classifications

1. By clinical course:
   • acute
   • subacute
2. By severity of condition:
   • mild
   • average
   • severe (with spreading to other location(s))
3. By location:
   • Superficial
     • cutaneous
     • subcutaneous
     • interstitial tissue
     • intramuscular
   • Deep
     • mediastinal
     • retroperitoneal
4. By etiology:
   • single
   • mix (eg:spore and non-spore forming anaerobes)
5. By pathogenesis:
   • per continuitatem (through neighbouring tissues)
   • hematogenous (through non-valvular veins like venous plexus of face eg: v. pterygoideus plexus → inflammation of veins (phlebitis) → thrombus formation in veins → embolization of thrombus into sinus venousus systems)
   • odontogenous
6. By exudative character:
   • purulent phlegmon
   • purulent-hemorrhagic phlegmon
   • putrefactive phlegmon
7. By presence of complications:
   • with complications (disturbance of mastication, ingestion, speech, cardiovascular and respiratory system, peritonitis, lymphadenitis, loss of conscious if very severe, etc)
   • without complication

Clinical pictures

1. Systemic features of infection such as increased body temperature (up to 38-40 °C), general fatigue, chills, sweatings, headache, loss of appetite).
2. Inflammatory signs - dolor (localized pain), calor (increase local tissue temperature), rubor (skin redness/hyperemia), tumor (either clear or non-clear bordered tissue swelling), functio laesa (diminish affected function).

NB: severity of patient condition with phlegmons is directly proportional to the degree of intoxication level i.e the severe the condition, the higher degree of intoxication level.

Diagnostics

1. Complaints and clinical appearances
2. Anamnesis
3. Visual and Palpations
4. Blood test - leukocytosis (up to 10-12×10⁹/L), decrease or absence eosinophils level, shift of white count differential to the left (neutrophilia), increase ESR (up to 35–40 mm/hr).
5. Urine test - presence of bacteria in urine, increase urinary leucocyte counts.
6. X-ray test
7. Ultrasound test

Treatments

The main goal treatment remove the cause of phlegmonous process in order to achieve effective treatment and prevention of residives.

If the patient's condition is mild and the signs of inflammatory process is presence without signs of infiltrates, then conservative treatment with antibiotics is sufficient.

In a severe condition, immediate operation is necessary with application of drainage system. All of these are done under general anaesthesia. During operation, the cavity or place of phlegmonous process are washed with antiseptic, antibiotic solutions and proteolyic ferments.

In post-operative period, i/v drips of detoxification, antibiotics, haemosorbtion, vitaminotherapy. Additionally, the use of i/v or i/m antistaphylococci γ-globulin or anatoxin can be taken as immunotherapy.

During operation of phlegmon dissection at any location, it is important:

1. to avoid spreading of pus during operation
2. take into account the cosmetic value of operating site especially phlegmmonous process of face.
3. during dissection, avoid damaging nerves especially facial nerves. Use the correct incision line.

See also

• Cellulitiscs:Flegmóna