Airway management and outcomes in surgical drainage
of severe odontogenic infections: a retrospective
cohort study

Karam Azem; Adham Kashkush; Benjamin Zribi; Eitan Mangoubi; Shai Fein; Roussana Aranbitski; Sharon Orbach-Zinger; Esmat Najjar; Philip Heesen; Gal Avishai; Dror Bar Hai; Gavriel Chaushu; Daya Masri

doi:10.1016/j.bjane.2026.844756

Original Investigation

Airway management and outcomes in surgical drainage of severe odontogenic infections: a retrospective cohort study

Manejo das vias aéreas e desfechos na drenagem cirúrgica de infecções odontogênicas graves: estudo retrospectivo de coorte

Karam Azem, Adham Kashkush, Benjamin Zribi, Eitan Mangoubi, Shai Fein, Roussana Aranbitski, Sharon Orbach-Zinger, Esmat Najjar, Philip Heesen, Gal Avishai, Dror Bar Hai, Gavriel Chaushu, Daya Masri

http://dx.doi.org/10.1016/j.bjane.2026.844756 Braz J Anesthesiol, vol.76, n3, 844756, 2026

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Abstract

Background

Severe odontogenic infections requiring surgical drainage pose significant airway management challenges. This study aimed to compare perioperative characteristics and clinical outcomes between patients managed with conventional laryngoscopy versus awake fiberoptic intubation, to identify factors associated with the selection of airway management technique, and to determine predictors of hospital length of stay.

Methods

This single-center retrospective study included 85 adult patients who underwent surgical drainage of severe odontogenic infections under general anesthesia between 2015 and 2024. The primary objective was to identify factors associated with awake fiberoptic intubation selection. Secondary objectives included comparison of perioperative outcomes and identification of predictors of hospital discharge. Multivariable logistic regression and Cox proportional hazards modeling were used.

Results

Of 85 patients, 60% were managed with AFOI. Multivariable analysis identified trismus (OR = 6.67, 95% CI 1.53, 39.53, p = 0.010) and higher BMI (OR = 1.15, 95% CI 1.03, 1.33, p = 0.013) as independent predictors of AFOI selection. AFOI patients experienced more complex postoperative courses, with intraoperative tracheostomy, ICU admission, and septic shock occurring exclusively in this group. Spontaneous ventilation postoperatively was associated with earlier discharge (HR = 2.14, 95% CI 1.23, 3.73, p = 0.007), while septic shock (HR = 0.26, 95% CI 0.07, 0.91, p = 0.036) and lower BMI (HR = 0.95, 95% CI 0.90, 1.00, p = 0.040) were associated with delayed discharge.

Conclusion

AFOI was preferentially selected for anatomically complex odontogenic infections based on objective criteria, particularly trismus and elevated BMI. The ability to achieve spontaneous ventilation postoperatively serves as a key prognostic indicator, while septic shock is strongly associated with prolonged recovery. These findings support evidence-based airway management protocols and early identification of high-risk patients to optimize outcomes in this challenging population.

Keywords

Abscess; Airway Management; Focal Infection: Dental; Laryngoscopy; Sepsis; Trismus

Resumo

Introdução

Infecções odontogênicas graves que requerem drenagem cirúrgica representam desafios significativos para o manejo das vias aéreas. Este estudo teve como objetivo comparar características perioperatórias e desfechos clínicos entre pacientes manejados com laringoscopia convencional versus intubação fibroóptica acordada, identificar fatores associados à seleção da técnica de manejo das vias aéreas e determinar preditores do tempo de internação hospitalar.

Métodos

Este estudo retrospectivo unicêntrico incluiu 85 pacientes adultos submetidos à drenagem cirúrgica de infecções odontogênicas graves sob anestesia geral entre 2015 e 2024. O objetivo primário foi identificar fatores associados à escolha da intubação fibróptica acordada. Os objetivos secundários incluíram comparação dos desfechos perioperatórios e identificação de preditores de alta hospitalar. Foram utilizados regressão logística multivariável e modelo de riscos proporcionais de Cox.

Resultados

Dos 85 pacientes, 60% foram manejados com intubação fibróptica acordada (AFOI). A análise multivariável identificou trismo (OR = 6,67; IC 95% 1,53–39,53; p = 0,010) e maior índice de massa corporal (OR = 1,15; IC 95% 1,03–1,33; p = 0,013) como preditores independentes da escolha de AFOI. Pacientes submetidos à AFOI apresentaram cursos pós-operatórios mais complexos, com traqueostomia intraoperatória, admissão em UTI e choque séptico ocorrendo exclusivamente nesse grupo. Ventilação espontânea no pós-operatório esteve associada à alta hospitalar mais precoce (HR = 2,14; IC 95% 1,23–3,73; p = 0,007), enquanto choque séptico (HR = 0,26; IC 95% 0,07–0,91; p = 0,036) e menor índice de massa corporal (HR = 0,95; IC 95% 0,90–1,00; p = 0,040) estiveram associados à alta tardia.

Conclusão

A AFOI foi preferencialmente escolhida para infecções odontogênicas anatomicamente complexas com base em critérios objetivos, particularmente trismo e índice de massa corporal elevado. A capacidade de alcançar ventilação espontânea no pós-operatório mostrou-se um importante indicador prognóstico, enquanto choque séptico esteve fortemente associado à recuperação prolongada. Esses achados sustentam protocolos de manejo das vias aéreas baseados em evidências e a identificação precoce de pacientes de alto risco para otimizar desfechos nessa população desafiadora.

Palavras-chave

Abscesso; Manejo das vias aéreas; Infecção focal dentária; Laringoscopia; Sepse; Trismo

References

1. Bali RK, Sharma P, Gaba S, Kaur A, Ghanghas P. A review of com- plications of odontogenic infections. Natl J Maxillofac Surg. 2015;6:136−43.

2. Balatsouras DG, Kloutsos GM, Protopapas D, Korres S, Economou C. Submasseteric abscess. J Laryngol Otol. 2001;115:68−70.

3. Green AW, Flower EA, New NE. Mortality associated with odon- togenic infection!. Br Dent J. 2001;190(10):529−30.

4. Sakkas A, Weiß C, Zink W, et al. Airway management of orofa- cial infections originating in the mandible. J Pers Med. 2023;13:950.

5. Schumann M, Biesler I, Börgers A, Pförtner R, Mohr C, Groeben H. Tracheal intubation in patients with odentogenous abscesses and reduced mouth opening. Br J Anaesth. 2014;112:348−54.

6. Ovassapian A, Tuncbilek M, Weitzel EK, Joshi CW. Airway manage- ment in adult patients with deep neck infections: a case series and review of the literature. Anesth Analg. 2005;100:585−9.

7. Apfelbaum JL, Hagberg CA, Caplan RA, et al. Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology. 2013;118:251−70.

8. Apfelbaum JL, Hagberg CA, Connis RT, et al. 2022 American Society of Anesthesiologists Practice Guidelines for Manage- ment of the Difficult Airway. Anesthesiology. 2022;136:31−81.

9. Ahmad I, El-Boghdadly K, Bhagrath R, et al. Difficult Airway Society guidelines for awake tracheal intubation (ATI) in adults. Anaesthesia. 2020;75:509−28.

10. Opitz D, Camerer C, Camerer DM, et al. Incidence and manage- ment of severe odontogenic infections-a retrospective analysis from 2004 to 2011. J Craniomaxillofac Surg. 2015;43:285−9.

11. Weise H, Naros A, Weise C, Reinert S, Hoefert S. Severe odonto- genic infections with septic progress - a constant and increasing challenge: a retrospective analysis. BMC Oral Health. 2019;19:173.

12. Flynn TR, Shanti RM, Levi MH, Adamo AK, Kraut RA, Trieger N. Severe odontogenic infections, part 1: prospective report. J Oral Maxillofac Surg. 2006;64:1093−103.

13. Christensen B, Han M, Dillon JK. The cause of cost in the man- agement of odontogenic infections 1: a demographic survey and multivariate analysis. J Oral Maxillofac Surg. 2013;71:2058−67.

14. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies ‒ PubMed [Internet]. [cited 2024 Jan 1]. Available from: https://pubmed.ncbi.nlm.nih.gov/18313558/.

15. Riekert M, Kreppel M, Zöller JE, Zirk M, Annecke T, Schick VC. Severe odontogenic deep neck space infections: risk factors for difficult airways and ICU admissions. Oral Maxillofac Surg. 2019;23:331−6.

16. De Jong A, Molinari N, Pouzeratte Y, et al. Difficult intubation in obese patients: incidence, risk factors, and complications in the operating theatre and in intensive care units. Br J Anaesth. 2015;114:297−306.

17. Dobner J, Kaser S. Body mass index and the risk of infection - from underweight to obesity. Clin Microbiol Infect. 2018;24:24−8.

18. Abugroun A, Nayyar A, Abdel-Rahman M, Patel P. Impact of mal- nutrition on hospitalization outcomes for older adults admitted for sepsis. Am J Med. 2021;134:221−226.e1.

19. Schneider SM, Veyres P, Pivot X, et al. Malnutrition is an inde- pendent factor associated with nosocomial infections. Br J Nutr. 2004;92:105−11.

20. Boscolo-Rizzo P, Da Mosto MC. Submandibular space infection: a potentially lethal infection. Int J Infect Dis. 2009;13:327−33.

21. Bakir S, Tanriverdi MH, Gün R, et al. Deep neck space infections: a retrospective review of 173 cases. Am J Otolaryngol. 2012;33:56−63.

22. Alotaibi N, Cloutier L, Khaldoun E, Bois E, Chirat M, Salvan D. Criteria for admission of odontogenic infections at high risk o deep neck space infection. Eur Ann Otorhinolaryngol Head Neck Dis. 2015;132:261−4.

23. Moghimi M, Baart JA, Karagozoglu KH, Forouzanfar T. Spread of odontogenic infections: a retrospective analysis and review of the literature. Quintessence Int. 2013;44(4):351−61.

24. Fu B, McGowan K, Sun H, Batstone M. Increasing use of intensive care unit for odontogenic infection over one decade: incidence and predictors. J Oral Maxillofac Surg. 2018;76:2340−7.

25. Fu B, McGowan K, Sun JH, Batstone M. Increasing frequency and severity of odontogenic infection requiring hospital admission and surgical management. Br J Oral Maxillofac Surg. 2020;58:409−15.

26. Bergese SD, Candiotti KA, Bokesch PM, et al. A Phase IIIb, ran- domized, double-blind, placebo-controlled, multicenter study evaluating the safety and efficacy of dexmedetomidine for sedation during awake fiberoptic intubation. Am J Ther. 2010;17:586−95.

27. Boyd BC, Sutter SJ. Dexmedetomidine sedation for awake fiber- optic intubation of patients with difficult airways due to severe odontogenic cervicofacial infections. J Oral Maxillofac Surg. 2011;69:1608−12.

28. Pertzov B, Krasulya B, Azem K, et al. Dexmedetomidine versus propofol sedation in flexible bronchoscopy: a randomized con- trolled trial. BMC Pulm Med. 2022;22:87.

Submitted date:
11/21/2025

Accepted date:
04/04/2026