Oral Surgery ISSN 1752-2471

ORIGINAL ARTICLE

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
Correspondence to:
K French
Bristol Dental Hospital
Lower Maudlin Street
Bristol BS1 2LY
UK
Tel.: 07779992148
Fax.: 01173424443
email:kathryn.french99@gmail.com
Accepted: 23 February 2016
doi:10.1111/ors.12212
Background: Extra-oral drainage of odontogenic abscesses is commonly
performed by oral and maxillofacial surgeons. It is a potentially
hazardous and expensive procedure, but in selected cases can be carried
out under local anaesthetic, avoiding some of the risks and costs
associated with general anaesthesia.
Aim: To evaluate the management options for odontogenic abscesses.
Method: A review of the literature with respect to radiological,
anaesthetic and surgical techniques that facilitate extra-oral incision and
drainage under local anaesthetic.
Results: A case series demonstrates the value of imaging, the Vazirani
Akinosi mandibular nerve block, a specific forcep technique and local
anaesthetic extra-oral drainage of the submandibular space.
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 general anaesthesia1 decreases expenditure and

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.
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
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.
Introduction
There were 912 reported emergency admissions to
hospitals in England for management of dental caries
between 2012 and 20132. 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.
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 damage and death3. Although death is
extremely rare (1 in 100,000 general anaesthet-
ics)4, 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 when
averaged across NHS trusts.5 The cost of a GA has
been calculated to be around 2706,7. 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.
Patient assessment
Patient safety is of the utmost importance and not
every patient with a dental abscess will be suitable
for treatment under LA. Extent and speed of
spread810 and origin11 of infection coupled with the
medical status of the patient12,13 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).
Table 1 Patient assessment prior to extra-oral drainage
Issue Indication for LA drainage
Airway Patent
Medical Fit and well
History
Systemic Systemically normal
Progression Slow onset, stable
Site Limited to sublingual, submental, submandibular, buccal spaces
Trismus Access for American pattern forceps
Anxiety Low: readily accepts standard treatment under LA
Setting Access to anaesthetic team in hospital setting
Surgeon Associate Specialist, experienced staff grade/dentist with special interest
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Extra-oral drainage under LA
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
fatal conditions such as mediastinitis, empyema,
pericarditis and pericardial effusion8,9.
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 inform the surgical approach to
abscess drainage14.
A dental panoramic tomogram (DPT) is the plain
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 trismus15. 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 differentiate an abscesses from celluli-
tis14,16. 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 penetration
and bony anatomy14. Bassiony et al. imaged 42 fas-
cial spaces in 16 patients with cervicofacial infection.
Of those, US imaging showed the same 32 spaces,
Unsuitable for LA drainage
Progressive loss
Poorly controlled diabetes, heart condition,
immunocompromised, alcoholics, elderly, COPD,
asthmatics, anticoagulated, antiplatelets
Signs of sepsis: tachycardia (>100 bpm), pyrexia
(>38C)
hypotensive, >20 breaths per minute
Fast, rapidly progressive onset
Spread to or beyond parapharyngeal or
retropharyngeal spaces
Opening limited to less than forceps height
High
Primary care
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 waves do not penetrate the mandible16.
Computed tomography (CT) scans give precise
anatomical information without field-of-view limita-
tions14. 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 is administered14. 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 infection extending to the
skull base16. 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 infection through the neck17.
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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2016 The British Association of Oral Surgeons and John Wiley & Sons Ltd
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 described by Vazirani in 196018 and Akinosi in
197719. This method anaesthetises the inferior alveo-
lar, lingual and long buccal nerves in one injec-
tion20. 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, allowing the operator to retract the cheek
laterally19. The muscles of mastication should be
relaxed, as tension can obstruct the pterygomandibu-
lar space, preventing the anaesthetic reaching the
correct site21.
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 Figure 3 Anatomy for placement of the needle for the VaziraniAki-
medial pterygoid muscle but must be weighed up nosi technique, between the mandibular ramus and the maxillary
against the risk of needle breakage21. If the needle is tuberosity.
bent, this should be done once only to minimise the
risk. A number of studies20,2224 have compared the
3 The needle is positioned at the level of the gingival VaziraniAkinosi technique to a conventional infe-
margins of the maxillary teeth. The syringe is held rior alveolar nerve block. Goldberg et al.20 tested 40
parallel to the maxillary occlusal plane and the nee- participants who received local anaesthetic using a
dle is advanced in a posterior and slightly lateral conventional inferior alveolar nerve block and a
direction into the tissues in the space between the VaziraniAkinsosi technique. They found no statisti-
vertical ramus and maxillary tuberosity19,21. The aim cally significant differences between the pain on
is to place the needle tip between the ramus and the administration, soft tissue anaesthesia or success of
medial pterygoid muscle21. No bone should be con- pulpal anaesthesia between the conventional inferior
tacted during this technique, if the needle contacts alveolar nerve block and the VaziraniAkinosi tech-
bone, it is most likely the coronoid process and the nique. In 80% of cases, the long buccal nerve was
needle should be repositioned more medially21. successfully anaesthetised using the VaziraniAki-
4 Once the needle tip is in the correct location, a nosi, preventing the need for a separate injection.
full cartridge of anaesthetic is deposited into the Aggarwal et al.22 tested 97 patients in a
pterygomandibular space (Figs. 24)21. 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 al.23 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 VaziraniAkinosi nerve blocks.
Sisk24 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 technique, reinforcing
the findings of Goldberg et al.20.
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 and
movement were unaffected.
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 2
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.
Figure 6 Orthopantomogram showing the grossly carious LR6 with
associated periapical radiolucency.
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
A 41-year-old male presented with a large left-sided
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- radiolucency surrounding the crown of the tooth. The
cal 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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