Oral Surgery ISSN 1752-2471

O R I G I N ALAR TI C LE

Extra-oral drainage of submandibular abscess under local

anaesthetic: review of the literature and case series
K. French, E. Brown, J. Collin & C. Bell
Bristol Dental Hospital, Bristol, UK

Key words: Abstract

anatomy, assessment, co-morbidities,
infection, odontogenic, radiology Background: Extra-oral drainage of odontogenic abscesses is commonly performed
by oral and maxillofacial surgeons. It is a potentially hazardous and expensive
Correspondence to: procedure, but in selected cases can be carried out under local anaesthetic, avoiding
K French some of the risks and costs associated with general anaesthesia.
Bristol Dental Hospital
Lower Maudlin Street
Bristol BS1 2LY Aim: To evaluate the management options for odontogenic abscesses. Method: A
UK review of the literature with respect to radiological, anaesthetic and surgical
Tel.: 07779992148 techniques that facilitate extra-oral incision and drainage under local anaesthetic.
Fax.: 01173424443
email:kathryn.french99@gmail.com Results: A case series demonstrates the value of imaging, the Vazirani Akinosi
mandibular nerve block, a specific forcep technique and local anaesthetic extra-oral
Accepted: 23 February 2016
drainage of the submandibular space.
doi:10.1111/ors.12212 Conclusions: Oral surgeons can utilise their specialist knowledge of head and neck
anatomy, local anaesthetic technique, surgical skills and specialist equipment to
deliver quick and definitive treatment for odontogenic abscesses. To our knowledge,
extra-oral incision and drainage of dental abscesses is not regularly carried out under
local anaesthetic. However, if removal of the causative tooth and abscess drainage can
be undertaken under local anaesthetic, the risks and costs of general anaesthesia can
be avoided.

Clinical relevance
Scientific rationale for study
To demonstrate a useful technique taught to and by
experienced oral surgeons at Bristol Dental Hospital that
could benefit patients in other units.
1
general anaesthesia decreases expenditure and improves
patient care. We believe that with an appropriate
environment and patient selection crite-ria, extra-oral
drainage of cervicofacial abscesses under local anaesthesia
can be performed with mini-mal risk to the patient.

Principle findings
Following accurate patient assessment, drainage of a
submandibular abscess can be carried out safely under local
anaesthetic in the correct setting.
Practical implications
Avoiding delays associated with fasting, theatre availability
and hospital admission required for
Introduction
There were 912 reported emergency admissions to
hospitals in England for management of dental caries
2
between 2012 and 2013 . The sequelae of untreated
odontogenic infection can be severe and sometimes fatal.
Cervicofacial abscesses can lead to airway obstruction,
septic emboli, cavernous sinus thrombo-sis and intracranial
abscess. Dental abscesses requir-ing extra-oral drainage are
often associated with trismus and are most commonly
treated under

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2016 The British Association of Oral Surgeons and John Wiley & Sons Ltd
French et al. Extra-oral drainage under LA

general anaesthetic (GA), necessitating an awake fibre-
optic nasal intubation.
General anaesthesia is associated with risk of
complications such as sore throat, nausea and vomiting,
respiratory infection, anaphylaxis, periph-eral nerve
3 fatal conditions such as mediastinitis, empyema,
damage and death . Although death is extremely rare (1 in
4
100,000 general anaesthet-ics) , negating this risk is
attractive. The cost of a non-elective inpatient short and
long stay com-bined (excluding excess bed days) is 1,489
5
when averaged across NHS trusts. The cost of a GA has
6,7
been calculated to be around 270 . Similar equipment is
required for abscess drainage whether performed under
local anaesthetic (LA) or GA therefore a saving of around
1,750 per patient is possible if the procedure can be
performed without GA.
Muscle and fascial attachments of the head and neck
direct movement of infection into the submandibular,
sublingual, submental or parapha-ryngeal spaces depending
on the causative tooth. Uncontrolled infection can spread to
the medi-astinum or pleural spaces, resulting in potentially
8,9
pericarditis and pericardial effusion .
Radiology
Appropriate medical imaging will help distinguish between
an abscess requiring drainage and cellulitis. It can also aid
in monitoring the progression of neck space infection and
14
inform the surgical approach to abscess drainage .

A dental panoramic tomogram (DPT) is the plain

Patient assessment
Patient safety is of the utmost importance and not every
patient with a dental abscess will be suitable for treatment
810 11
under LA. Extent and speed of spread and origin of
12,13
infection coupled with the medical status of the patient
influence suitability for treatment either with or without
GA. The table below shows factors that must be considered
before planning the procedure (Table 1).
There are well-recognised patterns for spread of dental
infection via fascial planes that also form the boundaries of
potential spaces for abscess formation. Individual
anatomical variation in root morphology and muscle
attachments will affect case selection and approach to
incision and drainage. In this article, we discuss the spread
of infection from the mandibular premolars and molars
(Fig. 1).
radiograph of choice as it can identify the source of
infection and show the position of a tooth in relation to
surrounding structures. It also shows the general condition
of the patients dentition and can be taken despite
15
trismus . A DPT will only provide an image in two
dimensions and does not show soft tissue swelling or fluid
collection.
Ultrasonography is rapidly becoming the imaging
modality of choice for neck space infections. It is a non-
invasive technique useful in showing superficial soft tissue
oedema and abscess formation. It is the best way to
14,16
differentiate an abscesses from celluli-tis . Ultrasound
(US)-guided needle aspiration can be used to drain small,
uncomplicated collec-tions. Although quick and well-
tolerated, US scans are limited by depth of the sound-wave
14
penetration and bony anatomy . Bassiony et al. imaged
42 fas-cial spaces in 16 patients with cervicofacial
infection. Of those, US imaging showed the same 32
spaces,

Table 1 Patient assessment prior to extra-oral drainage

Issue Indication for LA drainage Unsuitable for LA drainage

Airway Patent Progressive loss
Medical Fit and well Poorly controlled diabetes, heart condition,
History immunocompromised, alcoholics, elderly, COPD,
asthmatics, anticoagulated, antiplatelets
Systemic Systemically normal Signs of sepsis: tachycardia (>100 bpm), pyrexia
(>38C) hypotensive, >20 breaths per minute
Progression Slow onset, stable Fast, rapidly progressive onset
Site Limited to sublingual, submental, submandibular, buccal spaces Spread to or beyond parapharyngeal or
retropharyngeal spaces
Trismus Access for American pattern forceps Opening limited to less than forceps height
Anxiety Low: readily accepts standard treatment under LA High
Setting Access to anaesthetic team in hospital setting Primary care
Surgeon Associate Specialist, experienced staff grade/dentist with special interest Inexperienced/ unsupported practitioner

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Extra-oral drainage under LA
Figure 1 Potential fascial spaces of the head and neck. Transverse section cut at an oblique angle.
but could not detect involvement of masticator,
parapharyngeal or lingual spaces. Lingual space
involvement can be difficult to image as the ultra-sound
16
waves do not penetrate the mandible .
Computed tomography (CT) scans give precise
anatomical information without field-of-view limita-
14
tions . Thus, they show in more detail the deep and often
multiple cervicofacial spaces involved in a com-plex
infection. Mediastinal and intracranial involve-ment can
also be shown clearly on CT scans. Abscess formation can
be differentiated from cellulitis when intravenous contrast
14
is administered . However, there are drawbacks of CT
imaging including artefacts caused by amalgam fillings,
radiation exposure and adverse reaction to intravenous
contrast.
Magnetic resonance imaging (MRI) produces bet-ter soft
tissue detail then CT. In 2001, Munoz et al. compared MRI
versus CT in the initial evaluation of
22
French et al.
acute infections involving the neck in 47 patients. They
found MRI superior when looking at lesion conspicuity,
number of spaces involved, extension and source of
infection. In complex cases, MRI with gadolinium contrast
can be used to assess epidural space involvement and
16
infection extending to the skull base . However, MRI
remains expensive and is not easily available in the UK,
particularly on an emergency basis. It can be difficult for
claustrophobic or anxious patients to tolerate, which has
implica-tions where timely treatment influences their
recov-ery. Ariji et al. found that CT and MRI could both
clearly demonstrate the different pathways of odon-togenic
17
infection through the neck .
Ultrasonography is useful to evaluate the initial
superficial lesion that may be amenable to image-guided
aspiration. If deep fascial spaces are involved, MRI should
be considered, especially if intracranial
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French et al. Extra-oral drainage under LA

or intraspinal involvement is suspected. However, due to

ease of access in a time-constrained situation, a CT is
generally sufficient to assess odontogenic infection
involving the neck.

Extra-oral incision and drainage

After careful examination and investigation, patients with
an odontogenic neck space abscess may be suit-able for
incision and drainage under local anaesthe-sia. The
following section describes the techniques that help
facilitate this approach.

Local anaesthetic techniques

The VaziraniAkinosi technique Figure 2 Final needle position for the VaziraniAkinosi technique,
showing the needle tip in the pterygomandibular space.
The closed mouth mandibular nerve block technique was
18 19
described by Vazirani in 1960 and Akinosi in 1977 .
This method anaesthetises the inferior alveo-lar, lingual
20
and long buccal nerves in one injec-tion . It has the
advantage over conventional techniques, as the patients
mouth remains closed during administration of the
anaesthetic; therefore, it is ideal for patients who have
trismus related to odontogenic infection.

1 The patients mouth is closed with the teeth in occlusion,

19
allowing the operator to retract the cheek laterally . The
muscles of mastication should be relaxed, as tension can
obstruct the pterygomandibu-lar space, preventing the
21
anaesthetic reaching the correct site .

2 A decision is made by the clinician whether to bend the

needle. A bend of 15 to 30 towards the ramus can prevent
the needle penetrating the medial pterygoid muscle but
21
must be weighed up against the risk of needle breakage .
If the needle is bent, this should be done once only to
minimise the risk.
3 The needle is positioned at the level of the gingival
margins of the maxillary teeth. The syringe is held parallel
to the maxillary occlusal plane and the nee-dle is advanced
in a posterior and slightly lateral
direction into the tissues in the space between the vertical
19,21
ramus and maxillary tuberosity . The aim
is to place the needle tip between the ramus and the medial
21
pterygoid muscle . No bone should be con-tacted during
this technique, if the needle contacts bone, it is most likely
the coronoid process and the needle should be repositioned
21
more medially .
4 Once the needle tip is in the correct location, a full
cartridge of anaesthetic is deposited into the
21
pterygomandibular space (Figs. 24) .
Figure 3 Anatomy for placement of the needle for the VaziraniAki-
nosi technique, between the mandibular ramus and the maxillary
tuberosity.
A number of studies20,2224 have compared the
VaziraniAkinosi technique to a conventional infe-rior
20
alveolar nerve block. Goldberg et al. tested 40
participants who received local anaesthetic using a
conventional inferior alveolar nerve block and a Vazirani
Akinsosi technique. They found no statisti-cally significant
differences between the pain on administration, soft tissue
anaesthesia or success of
pulpal anaesthesia between the conventional inferior
alveolar nerve block and the VaziraniAkinosi tech-
nique. In 80% of cases, the long buccal nerve was
successfully anaesthetised using the VaziraniAki-
nosi, preventing the need for a separate injection. Aggarwal
22
et al. tested 97 patients in a
randomised, double-blind study. They found no

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2016 The British Association of Oral Surgeons and John Wiley & Sons Ltd
Extra-oral drainage under LA
Figure 4 Point of needle insertion for the VaziraniAkinosi technique,
at gingival margin of the maxillary molars, parallel to the occlusal
plane.
statistically significant differences in achieving suc-cessful
anaesthesia between conventional inferior alveolar nerve
block and the VaziraniAkinosi tech-nique. Todorovic et
23
al. studied 90 patients under-going routine tooth
extraction. They found no statistically significant
differences between pain on injection, soft tissue
anaesthesia, onset of anaesthesia or duration of anaesthesia
between conventional inferior alveolar and Vazirani
Akinosi nerve blocks.
24
Sisk found no significant difference in quality of
anaesthesia or intraoperative bleeding when compar-ing the
VaziraniAkinosi technique on one side and a conventional
inferior alveolar nerve block on the other side. They also
found that in 80% of cases, the long buccal nerve was
successfully anaesthetised using the VaziraniAkinosi
20
technique, reinforcing the findings of Goldberg et al. .
Overall, we can conclude that the VaziraniAkinosi
technique is successful in anaesthetising the inferior
alveolar, lingual and long buccal nerves and provides a
depth and quality of anaesthesia comparable to that of a
conventional inferior alveolar nerve block.
Anaesthetising the extra-oral soft tissues
Local infiltration of anaesthetic agent is used to
anaesthetise the soft tissues in the submandibular region.
The skin and superficial fascia are anaes-thetised prior to
incision, and the platysma and deep cervical fascia are
anaesthetised further as the dissec-tion continues deeper
towards the submandibular space. The tissues of the floor
of mouth, including
24
French et al.
Figure 5 American pattern forceps: Beaks angled to allow
application onto a tooth with the handle projecting anteriorly out of
the mouth. Allows tooth removal in patients with severe trismus.
the mylohyoid muscle are already anaesthetised by the
VaziraniAkinosi mandibular nerve block.
Surgical approach
Exodontia
American pattern dental extraction forceps are par-ticularly
useful in situations where patients have severe trismus. The
beaks are angled such that they can be placed over a
mandibular molar tooth with the handles projecting out of
the patients mouth anteriorly. This is in contrast to English
pattern for-ceps more commonly used in the UK that need
the handles to project from the patients mouth laterally.
The use of American pattern forceps allows the infected
tooth to be removed successfully even with limited mouth
opening (Fig. 5).
Incision and drainage
After adequate anaesthesia is obtained, extra-oral incision
and drainage of the submandibular space is carried out in
the usual way, as illustrated by the cases below.
Case series
We present a case series of seven patients who pre-sented
with odontogenic abscess involving the sub-mandibular
space, who were managed by dental extraction and extra-
oral incision and drainage under local anaesthesia. They
were all treated in a 12-month period and account for 30%
of all patients
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French et al. Extra-oral drainage under LA

seen during this time who required extra-oral inci-sion and

drainage of a submandibular swelling. The incision and
drainage technique was the same for all patients.

Case 1
A previously well 35-year-old female presented as an
emergency to Bristol Dental Hospital with a 5-day history
of increasing pain and swelling associ-ated with the lower
right first molar. Examination revealed an extensive right
submandibular swelling that was tender, firm and
erythematous. Trismus limited mouth opening to
approximately 2 cm inter-incisal distance. There were no
signs or symptoms of imminent airway compromise and
she was afebrile. The lower right first molar was grossly
carious, the floor of mouth was soft and tongue position
Figure 6 Orthopantomogram showing the grossly carious LR6 with
and movement were unaffected. associated periapical radiolucency.

A sectional DPT radiograph confirmed the extent of

caries and periapical abscess associated with the lower
right first molar (Fig. 6). A diagnosis was made of
submandibular space infection associated with acute
periapical abscess of the lower right first molar. After
appropriate consent was obtained, the patient underwent
extraction of the lower right first molar and extra-oral
incision and drainage under local anaesthetic (Table 2).
At post-operative day 2, the pain and swelling had
reduced, but pus continued to drain extra-orally. A new
dressing was applied. At post-operative day 5, the pain and
swelling had significantly improved; there was no more
pus draining and therefore the drain was removed. The
patient continued to make a full recovery without the need
for a hospital admis-sion or GA.
Case 3
A 50-year-old male presented with a large left sub-
mandibular swelling. He was apyrexial, with mouth
opening limited to 2 cm inter-incisal distance. The patient
was a smoker with no medical problems. Clinical and
radiographic examination confirmed the diagnosis of
periapical abscess associated with the carious roots of
lower left third molar. The roots were removed with
elevators and extra-oral incision and drainage was carried
out under LA. The patient was discharged with oral co-
amoxiclav and at day 2 post-operative review, he had
greatly improved and the drain was removed.
Case 4

Case 2 A 41-year-old male presented with a large left-sided

A 31-year-old female presented with large left-sided
submandibular swelling, temperature of 37.7C and inter-
incisal opening of 1 cm. She was penicillin allergic and had
taken a course of erythromycin pre-scribed from her
general medical practitioner prior to presentation; however,
the swelling had not improved. Clinical and radiographic
examination confirmed the diagnosis of acute periapical
abscess associated with lower left second molar. The tooth
was extracted with American pattern forceps and extra-oral
incision and drainage carried out under LA. She was
discharged with a course of oral metronidazole and at 2-
day review, the swelling had improved and the drain was
removed.
submandibular swelling. He had the lower left sec-ond
molar extracted one day previously with his general dental
practitioner and the swelling had significantly increased in
size since. The swelling was drained extra-orally under
local anaesthetic and he was discharged with oral
amoxicillin and metronidazole. The patient failed to attend
his 2-day review but was seen 7 days post-operatively
when the swelling had resolved and the drain was removed.
Case 5
A 58-year-old male presented with large left sub-
mandibular swelling. The patient was afebrile. Medically

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Extra-oral drainage under LA French et al.

Table 2 Demonstration of extra-oral incision and drainage of right sided submandibular swelling

1. Right-sided submandibular swelling associated with periapical abscess of LR6.

2. Incision site marked at two fingerbreadths inferior to the lower border

of the mandible to preserve the marginal mandibular branch of the facial
nerve. Skin prepped with betadine and sterile drapes are placed over patient.

3. After successful anaesthesia using the VaziraniAkinosi technique, the LR6

was removed using American pattern forceps. Note the handles projecting
anteriorly from the patients mouth.

4. After local anaesthetic infiltration, an incision is made through the skin in

the submandibular region as previously marked.

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French et al. Extra-oral drainage under LA

Table 2 (Continued )

5. Blunt dissection down to and through the platysma muscle, then up to the
lower border of the mandible to access the submandibular space.

6. Copious pus drained from the submandibular space.

7. A corrugated drain was placed to keep the space open for further drainage.

8. Drain secured with black silk sutures and an absorbent dressing is

placed over the wound.

the patient had a history of a cerebrovascular event unerupted lower left third molar with a unilocular
10 years ago, but no lasting neurological deficit. Clini-cal radiolucency surrounding the crown of the tooth. The
and radiographical examination revealed an diagnosis was that of an infected dentigerous cyst

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2016 The British Association of Oral Surgeons and John Wiley & Sons Ltd
Extra-oral drainage under LA
associated with lower left third molar. The sub-mandibular
swelling was drained extra-orally under LA and the patient
booked for a cone beam CT scan and follow-up for
enucleation of the cyst.
Case 6
A fit and well 26-year-old male presented with an extensive
left submandibular swelling, temperature of 38C, and
mouth opening of 1 cm. Clinical and radio-graphic
examination revealed periapical abscess asso-ciated with
carious lower left second molar. US scan confirmed a 3 cm
collection in the left submandibular space. The patient
underwent extraction of tooth and extra-oral incision and
drainage under LA. Due to his pyrexia, he was admitted for
24 h of IV antibiotics. At review 2 days post-operatively, he
had improved sig-nificantly and the drain was removed.
Case 7
A 38-year-old female presented with a 4-day history of left
submandibular swelling. The lower left second molar had
been extracted 2 days previously but the swelling had
continued to increase in size. Her tem-perature was 38C
and mouth opening limited to 2 cm inter-incisal distance.
Clinical and radiographic examination revealed no retained
roots in the extraction socket and no other source of
infection. US scan ruled out superficial collection but could
not exclude a deeper collection. Therefore, extra-oral
incision and drainage was carried out under LA. The
patient was admitted for 24 h of IV antibiotics due to her
pyrexia. At 5-day review, the swelling had greatly
improved.
Conclusion
These cases demonstrate that in carefully assessed patients
presenting with submandibular space infec-tions, dental
extraction and extra-oral incision and drainage can be
carried out successfully under local anaesthetic. This may
avoid the need for a costly hospital admission and a GA
with conscious fibre-optic endotracheal intubation, which is
both risky and uncomfortable for the patient. The treatment
must be carried out at a specialist secondary care unit with
appropriately trained staff and access to anaesthetic support
if deterioration occurs. A thor-ough assessment with
appropriate imaging should be carried out prior to
treatment. Case selection is crucial, as some patients who
present with advanced neck space infections will require
urgent
28
French et al.
hospital admission, especially if there is any danger of
airway compromise. Hospital admission may still be
prudent post-operatively if there are signs of sepsis.
We have not investigated how patients tolerate extra-oral
incision and drainage under LA. So far we have always
completed treatment under LA success-fully and not had to
abandon the procedure due to patient discomfort. Formal
assessment of patient experience is an area for further
research.
Evidence, experience and patient factors have influenced
the development and use of this tech-nique. The authors
conclude that DPT and CT imag-ing are the most readily
available forms of imaging and adequate to assess
odontogenic neck space infec-tions. The VaziraniAkinosi
technique is a simple and effective technique for achieving
good anaesthe-sia in cases where there is significant
trismus. Ameri-can pattern forceps facilitate molar
extractions and with adequate anaesthesia extra-oral
drainage can be carried out as effectively as if the patient
was under a GA.
Conflict of Interest
The authors confirm that there are no conflicts of interest.
Ethical Approval
None required.
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