DEEP PHLEGMONS OF THE MFA: DIFFERENCES FROM SURFACE. A PARAPHARYNGEAL SPACE PHLEGMON AND PTERYGOPALATINE-JAW SPACE INFECTION: ETIOLOGY, PATHOGENESIS, CLINICAL FEATURES, DIFFERENTIAL DIAGNOSIS, TREATMENT, COMPLICATIONS, PREVENTION. PHLEGMON OF PTERYGOPALATINE AND INFRATEMPORAL FOSSAE: CHARACTERISTICS OF APPEARENCE, LOCALIZATION, CLINICAL COURSE, DIFFERENTIAL DIAGNOSIS, SURGICAL TREATMENT.
Parapharyngeal Abscess
A parapharyngeal abscess is a deep neck abscess. Symptoms include fever, sore throat, odynophagia, and swelling in the neck down to the hyoid bone. Diagnosis is by CT. Treatment is antibiotics and surgical drainage.
The parapharyngeal (pharyngomaxillary) space is lateral to the superior pharyngeal constrictor and medial to the masseter muscle. This space connects to every other major fascial neck space and is divided into anterior and posterior compartments by the styloid process. The posterior compartment contains the carotid artery, internal jugular vein, and numerous nerves. Infections in the parapharyngeal space usually originate in the tonsils or pharynx, although local spread from odontogenic sources and lymph nodes may occur.
Abscess swelling can compromise the airway. Posterior space abscess can erode into the carotid artery or cause septic thrombophlebitis of the internal jugular vein (Lemierre syndrome).
Most patients have fever, sore throat, odynophagia, and swelling in the neck down to the hyoid bone. Anterior space abscesses cause trismus and induration along the angle of the mandible, with medial bulging of the tonsil and lateral pharyngeal wall. Posterior space abscesses cause swelling that is more prominent in the posterior pharyngeal wall. Trismus is minimal. Posterior abscesses may involve structures within the carotid sheath, possibly causing rigors, high fever, bacteremia, neurologic deficits, and massive hemorrhage caused by carotid artery rupture.
Diagnosis
- CT
Diagnosis is suspected in patients with poorly defined deep neck infection or other typical symptoms and is confirmed by using contrast-enhanced CT.
- Broad-spectrum antibiotics (eg, ceftriaxone , clindamycin)
- Surgical drainage
Treatment may require airway control. Parenteral broad-spectrum antibiotics (eg, ceftriaxone, clindamycin) and surgical drainage are generally needed. Posterior abscesses are drained externally through the submaxillary fossa. Anterior abscesses can often be drained through an intra-oral incision. Several days of parenteral culture-determined antibiotics are required after drainage, followed by 10 to 14 days of oral antibiotics. Occasionally, small abscesses can be treated with IV antibiotics alone.
LATERAL PHARYNGEAL (PARAPHARYNGEAL) ABSCESS
The lateral pharyngeal (pharyngomaxillary) space is divided into two compartments by the styloid process of the mastoid bone. The anterior portion is close to the tonsillar fossa medially and to the internal pterygoid muscle laterally. The posterior compartment contains the carotid sheath. Involvement of these structures determines the clinical manifestations and complications of infections in these spaces.[20] Lateral pharyngeal abscess now ranks as the third most common supraglottic infection, after peritonsillar and retropharyngeal infections. Infection of the compartments of the lateral pharyngeal space may be the result of extension of suppurative local tonsillopharyngitis, retropharyngeal abscess, mastoiditis (Bezold abscess), parotitis, or dental abscess.
Clinical Manifestations
The hallmarks of infection in the anterior compartment are tender swelling below the angle of the mandible, induration and erythema of the side of the neck, and trismus. Most patients are febrile, appear to be acutely ill, and complain of severe odynophagia and neck pain. A bulge in the lateral pharyngeal wall can be observed, but the tonsil is normal in size and relatively uninflamed, thus distinguishing this infection from a peritonsillar abscess. Torticollis, with head tilted toward the side of involvement, is often present, along with impressive cervical lymphadenitis. The classic triad that indicates pharyngomaxillary abscess, an anterior compartment syndrome, includes (1) tonsillar and tonsillar fossa prolapse, (2) trismus, and (3) swelling of the parotid area or lateral neck, or both. Infection in the posterior compartment is ill-defined clinically, and characterized by signs of septicemia, with minimal pain or trismus. Swelling can often be missed when it is deep to the palatopharyngeal arch. A tender, high cervical mass, with ill-defined boundaries initially, can be palpated during the phlegmon or frank abscess stages. CT scan or magnetic resonance imaging (MRI) is necessary for opportune diagnosis and management. These imaging modalities delineate involvement of critical fascial planes, vital structures, and complications.
Treatment
Treatment of the posterior compartment of a pharyngeal abscess requires drainage of the lateral neck in conjunction with high dosages of appropriate antimicrobial therapy, administered intravenously. An external excision below the angle of the jaw is preferred because it provides access to the carotid artery, which should be ligated in cases of arterial erosion. Surgical drainage is best performed after localization of infection and during the course of intravenous antibiotic therapy (using agents as for retropharyngeal infection) unless hemorrhage or respiratory obstruction necessitates earlier intervention. The progress of disease must be monitored closely; establishment of an artificial airway may be required preemptively because airway obstruction can develop abruptly.
Complications
Complications occur frequently, especially from infection in the hidden posterior compartment of the lateral pharyngeal space, and may include respiratory embarrassment, laryngeal edema, airway obstruction, septicemia, pneumonia, septic thrombosis of the internal jugular vein (Lemierre syndrome), suppurative intracranial complications (meningitis, brain abscess, and thrombosis of the cavernous and lateral sinus), and erosion of the carotid artery. Erosion into the carotid artery sheath can cause life-threatening hemorrhage or thrombosis. Extension of infection inferiorly along the carotid sheath or posteriorly into the retropharyngeal space may lead to mediastinitis.
Pterygomandibular Abscess,Anatomic Location,Etiology, Clinical presentation and Treatment
Anatomic Location.
This space is bounded laterally by the medial surface of the ramus of the mandible, medially by the medial pterygoid muscle, superiorly by the lateral pterygoid muscle, anteriorly by the pterygomandibular raphe, and posteriorly by the parotid gland. The pterygomandibular space contains the mandibular neurovascular bundle, lingual nerve, and part of the buccal fat pad. It communicates with the pterygopalatal, infratemporal, submandibular, and lateral pharyngeal spaces.
Etiology
An abscess of this space is causedmainly by infection of mandibular third molars or the result of an inferior alveolar nerve block, if the penetration site of the needle is infected (pericoronitis).
Clinical Presentation
Severe trismus and slight extraoral edema beneath the angle of the mandible are observed. Intraorally, edema of the soft palate of the affected side is present, as is displacement of the uvula and lateral pharyngeal wall, while there is difficulty in swallowing.
Treatment
The incision for drainage is performed on themucosa of the oral cavity and, more specifically, along the mesial temporal crest. The incision must be 1.5 cm long and 3–4 mm deep. A curved hemostat is then inserted, which proceeds posteriorly and laterally until it comes into contact with the medial surface of the ramus. The abscess is drained, permitting the evacuation of pus along the shaft of the instrument.
Diagrammatic illustration showing the spread of a dentoalveolar abscess into contiguous fascial spaces. (1 Submandibular abscess, 2 pterygomandibular abscess, 3 parapharyngeal abscess, 4 retropharyngeal abscess)
Incision for drainage of a pterygomandibular abscess
THE INFRATEMPORAL AND PTERYGOPALATINE FOSSAE
I. Review of Osteology
Before beginning your consideration of this region, it is vitally important that you review the bones of the skull and mandible. This will orient you to the region and help make understanding this very compact space more clear. To complete the review which follows, you should read with skull in hand and have pipe cleaners, dental floss threaders, cellophane tape, and string available.
View the skull from the side; the so-called Norma lateralis. Identify the bones which make up the lateral projection of the braincase. These include the frontal, parietal, temporal, zygomatic, spheroid, and occipital bones (fig. 1). On the lateral sides of the frontal, parietal, and temporal bones are two curved lines, the temporal lined. These mark the attachments of the components of the temporalis muscle to the skull. Anteriorly note that the lines end at a vertical projection of the zygomatic bone, the frontal process. Posteriorly the lower temporal line becomes continuous with the zygomatic arch or cheer: bone . The space bounded by the temporal lines, the zygomatic arch, and the frontal process of the zygomatic bone is the temporal fossa. The main occupant of the temporal fossa is the temporalis muscle. In addition to its attachment to the skull, the temporaTis muscle attaches to the coronoid process of the mandible. Identify the coronoid and condylar processes of the mandible. Try to imagine how the large, semicircular temporalis muscle converges onto its tendon of insertion on the coronoid process. Palpate your own temporalis muscle, both at the posterior border of the frontal process of the zygomaiic bone and just in front of your ear. By clenching your teeth you can observe the jaw-closing functions of the different parts of this muscle.
The temporal fossa opens inferiorly into the infratemporal fossa. To determine the extent and boundaries of the infratemporal fossa, a more detailed analysis of the spheroid bone is required. The sphenoid is an extraordinary bone which contains a body and, on each side of the body, two wings and two pterygoid processes. The body can best be seen in the interior of the cranium, where it houses the pituitary gland and is the center of the middle cranial fossa (fig. 2). The lesser wings of the spheroid are also seen there where they form most of the border between the middle and anterior cranial fossae. The greater wings form part of the lateral wall of the middle cranial fossa (fig. 2), and also part of the temporal fossa (fig. I ). Projecting inferiorly from the greater wings into the infratemporal fossa are the two pterv~oid processes. These two processes can be most easily seen if the skull is viewed from beneath after the mandible is removed (fig. 3). The large and flat lateral pterygoid process or plate lies just posterior to the maxilla and is roughly in line with the maxillary tooth row. The more slender medial pterygoid process lies more medial and contains a small, medially directed hook at its inferior extreme. the pterygoid hamulus. Identify the foremen lacerum. Recall that in life, most of this foremen is covered with fibrocartilage to form the carotid canal, which marks the passage of the internal carotid artery into the skull. Note the close relationship between the foremen and the pterygoid plates.
Just anterior to the lateral pterygoid plate, between it and the maxilla, is the pterygomaxillary fissure (fig. 4). Look into the depths of this fissure, either by holding the skull up to the light, or by using a penlight, and observe that at its base is a fossa, the pterygopalatine fossa, ana an opening, the sphenopalatine
foremen. Place a dental floss threader into the pterygomaxillary fissure and guide it through the sphenopalatine foremen. Note that the floss threader now lies in the nasal cavity. Between the two pterygoid plates is a small depression, the scaphoid fossa, and at its anterior end is an opening to a bony canal, the pterygoid canal. Pass a dental floss threader into this canal and look into the pterygomaxillary fissure to confirm that the threader passes into the sphenopalatine foremen. Find the greater palatine foremen on the surface of the hard palate ( fig. 3). By passing a floss threader into this foremen, confirm that it too communicates with the sphenopalatine foremen. Find the foremen rotundum in the middle cranial fossa. Pass a pipe cleaner through it and, turning the skull over, push the pipe cleaner through the inferior orbital fissure into the orbit. Note that the pipe cleaner, which follows the course of the maxillary nerve, passes directly over the pterygopalatine fossa. If these observations are viewed another way, the pterygopalatine fossa is a place where several pathways converge. The sphenopalatine foremen, the pterygoid canal, greater palatine foremen, and the inferior orbital fissure all communicate with it directly.
Once all of these bony landmarks have been found, the boundaries of the infratemporal fossa can be easily delineated. Replace the mandible and follow the description of the boundaries. The lateral wall is formed by the ramus of the mandible. Near the center of this ramus note the mandibular foremen. At the anterior end of the fossa the maxilla forms the boundary. At the top of this anterior wall is the inferior orbital fissure. At the medial extreme of the anterior wall is the pterygomaxillary fissure. The medial wall of the infratemporal fossa is formed by the lateral pterygoid plate. The roof of the fossa is mainly the temporal fossa, but note that the infratemporal fossa is somewhat deeper than the temporal fossa so that a small bony roof, formed mainly by the spheroid, can be identified. Two important foramina lie m this roof: the foremen ovate and the foremen spinosum.
II. Contents of the Infratemporal Fossa
By now you should have a pretty good idea of the bony landmarks surrounding and forming the infratemporal fossa and of the foramina opening into it. Before proceeding to a dissection of the region, it will be useful to review the contents of the infratemporal fossa, so that you can develop an idea of what you should expect to find. The infratemporal fossa contains the pterygoid muscles, the maxillary artery and its branches, the pterygoid venous plexus, and branches of the mandibular division of the trigeminal nerve. In addition, the maxillary division of the trigeminal nerve courses in the roof of the fossa.
Pterygoid muscles
The pterygoid muscles are muscles of mastication. They arise from the two sides of the lateral pterygoid plate and insert onto the mandible (fig. 5). The deeper and larger medial pterygoid muscle courses from the medial side of the plate to the angle of the mandible. It acts to pull the mandible up and forward during chewing. The lateral pterygoid courses from the lateral side of the plate to the condylar process of the mandible. It has two heads. The larger oblique head acts much as the medial pterygoid muscle. The smaller horizontal head pulls the mandibular condyle forward during jaw opening.
Maxillary Artery
The main arterial supply to the infratemporal fossa is the maxillary artery (fig. 6). This is the largest terminal branch of the external carotid artery (the other terminal branch is the superficial temporal artery, which supplies the contents of the temporal fossa). The maxillary artery arises just posterior to the neck of the mandible in the substance of the parotid gland and courses somewhat obliquely through the fossa to end in the pterygomaxillary fissure. Through its course It usually lies lateral (superficially to the lateral pterygoid muscle, but it can sometimes lie on the deep side of the muscle. It has an impressive number of branches, but the important ones can be learned with careful attention to the course of the artery. Two early branches are the middle meningeal and the inferior alveolar. The middle meningeal artery courses superiorly from the maxillary and leaves the infratemporal fossa through the foremen spinosum, thereby entering the middle cranial fossa, where it supplies the meninges. The inferior alveolar artery courses inferiorly from the maxillary, enters the mandibular foremen, and courses in the body of the mandible, supplying the mandibular teeth. Numerous muscular branches leave the maxillary artery during its course. Especially important among these are the deep temporal artery which courses on the deep surface of the temporalis muscle, and the buccal artery which supplies the cheek region. The terminal branch of the maxillary artery is the sphenopalatine artery. It enters the pterygomaxillary fissure and will penetrate the sphenopalatine foremen to supply the soft palate and nasal regions. However, before leaving the infratemporal fossa, it gives off branches to the upper molar teeth (posterior superior alveolar), palate (descending palatine) and orbit (infraorbital).
Pterygoid Plexus
The veins corresponding to the branches of the maxillary artery form a plexus on the lateral and medial surfaces of the lateral pterygoid muscle called the pterygoid plexus (fig. 7). The pterygoid plexus communicates directly with the internal jugular venous system, via the retromandibular vein, but also with the facial vein, via a deep facial vein, with the cavernous sinus of the skull via a small tributary coursing through the foremen ovate, and with a plexus of veins on the pharynx via the sphenopalatine foremen. You should keep in mind that all of these veins are valveless, so that blood can flow in either direction in them, depending on the prevailing pressure gradients.
Any time spent mastering the distribution of the maxillary artery will be time well spent, since the distribution of the branches of the mandibular division of the trigeminal nerve will be similar.
The mandibular division of the trigeminal nerve enters the infratemporal fossa through the foremen ovate (fig. 8). Unlike the other divisions of the trigeminal nerve, the mandibular division contains motor axons which supply skeletal muscle. Branches of this division innervate the muscles of mastication: the medial and lateral pterygoid muscles, the temporalis, and the masseter, all via branches in the infratemporal fossa. In addition the mandibular nerve innervates the mylohyoid muscle and the anterior belly of the digastric muscle outside of the fossa.
Upon entering the infratemporal fossa, the mandibular nerve usually forms anterior and posterior branches. The anterior branches include muscle branches and the buccal nerve, an important source of SENSORY innervation to the skin of the cheek. (Remember that the buccinator muscle receives its motor innervation from buccal branches of the facial nerve.)
The posterior division of the mandibular nerve is chiefly sensory. There are three main branches.
1. The auriculotemporal nerve arises as two roots that encircle the middle meningeal artery. It courses posteriorly! in the infratemporal fossa, deep to the lateral pterygoid muscle, and ascends just in front of the ear, in the company of the superficial temporal artery. It provides mainly sensory innervation to the scalp, although it also receives autonomic axons from the otic ganglion destined for the parotid gland.
The otic ganglion lies at the top of the infratemporal fossa, just below the foremen ovate, behind the medial pterygoid muscle, and just anterior to the middle meningeal artery (fig. 9). Parasympathetic preganglionic axons course to the otic ganglion from their source in the glossopharyngeal nerve via the lesser petrosal nerve. The lesser petrosal nerve passes through a canal in the temporal bone and emerges in the infratemporal fossa in or near the foremen ovate. These axons synapse in the ganglion and postganglionic axons join the auriculotemporal nerve to supply the parotid grand. In addition, sympathetic postganglionic axons derived from the cells of the superior cervical ganglion enter the otic ganglion from a plexus on the middle meningeal artery. They course through the ganglion without synapsing, join the auriculotemporal nerve’ and supply blood vessels in the parotid gland.
2. The lingual nerve descends on the deep surface of the lateral pterygoid muscle where it receives a small branch, the chorda tympani nerve (fig. 8). The chorda tympani nerve arises as a branch of the facial nerve in the petrous portion of the temporal bone. Instead of coursing through the facial canal with the main part of the nerve, it courses through a small canal in the temporal bone, through the middle ear cavity (hence its name), and emerges from the skull at the posterior extreme of the infratemporal fossa. It carries special sensory fibers associated with taste and parasympathetic preganglionic axons destined for the submandibular ganglion. After receiving this branch, the lingual nerve courses deep to the mucosa of the floor of the mouth, passes beneath the duct of the submandibular gland and supplies mainly sensory innervation to the anterior V3 of the tongue. These include general sensation and special sensation associated with taste buds. In addition, axons from the lingual nerve supply the submandibular ganglion. Some of the parasympathetic postganglionic axons from submandibular ganglion cells join the lingual nerve to supply glands in the mucous membrane of the floor of the mouth.
3. The inferior alveolar nerve courses with the inferior alveolar artery, enters the mandibular foremen and courses forward in the mandibular canal, ending as it emerges anteriorly from the mental foremen as the mental nerve. It supplies sensory innervation to the mandibular (lower) teeth and gums and to the skin of the chin region. Just before entering the mandibular foremen, the inferior alveolar nerve gives off a mylohyoid branch. This branch courses inferiorly, along the inner-side of the mandible and supplies the mylohyoid muscle and the anterior belly of the digastric muscle.
The maxillary division of the trigeminal nerve makes only a cameo appearance in the infratemporal fossa. It courses through the roof of the fossa, leaving the skull via the foremen rotundum and then entering the orbit through the inferior orbital fissure. It terminates anteriorly as the infraorbital nerve. Thus the maxillary nerve courses over the pterygopalatine fossa, and communicates with it. The maxillary nerve has numerous sensory branches to the face (infraorbital and zygomatic branches) and maxillary (upper) teeth (anterior and posterior superior alveolar branches). It also contains axons of sensory and autonomic neurons the lacrimal gland and the mucosa of the palate and pharynx. These latter are not originally part of the trigeminal nerve, but simply “hitch a ride” with it so that they deserve special consideration.
Parasympathetic preganglionic axons derived from the facial nerve leave the main trunk of the nerve and course in a special canal in the temporal bone as the greater petrosal nerve (fig. 10). Sympathetic postganClionic axons derived from cell bodies in the superior cervical ganglion course on the surface of the internal carotid artery and enter the skull with the artery at the carotid canal. Just before the internal carotid artery enters the cavernous sinus. some of these axons leave to form the deep petrosal nerve, course a short distance in the temporal bone, and join with the greater petrosal nerve to form the nerve of the ptervgoid canal. (Recall the proximity of the carotid canal and the opening of the pterygoid canal from your examination of the base of the skull.) This mixed nerve courses through the pterygoid canal to end in the sphenopalatine foremen. The sympathetic axons course through the adjacent pterygopalatine ganglion without synapsing and are distributed with the nerve and arterial branches emanating from it, to the mucosa of the nasal and pharyngeal regions. The parasympathetic fibers entering the pterygopalatine ganglion synapse there and distribute to glands in the same mucous membranes. In addition, some of the postganglionic axons pass to the lacrimal gland by way of first the maxillary nerve, then one of its branches, the zygomatic nerve, and finally by way of one of the branches of the ophthalmic division of the trigeminal nerve, the lacrimal nerve (fig. 10). Sensory axons of the maxillary division of the trigeminal nerve from the nasal, palatine, orbital, and lacrimal regions take courses similar to these autonomic neurons (but in the opposite direction) and pass through the pterygopalatine ganglion without synapsing. Their cell bodies (equivalent to those found In the dorsal root ganglia) lie in the trigeminal ganglion.
Plan for Dissection
By now you should be familiar with the boundaries and contents of the infratemporal fossa, so that a detailed dissection plan will seem somewhat silly. Your individual dissection plan should, as always, keep in mind the structures that you wish to see as well as those structures you want to preserve for your demonstration of the region. The instructions which follow are only designed to be very general ones.
First, you will want to orient yourself to the region on your cadaver. Find the palpable bony boundaries of the fossa: the zygomatic arch the frontal process of the zygomatic bone, the angle of the mandible, and the external acoustic meatus (alveolar), palate (descending palatine) and orbit (infraorbital).
Identify the masseter and temporalis muscles and the coronoid and condylar processes of the mandible. In order for you to expose the infratemporal fossa, you will have to remove its lateral wall, the ramus of the mandible, and the zygomatic arch. However, you will want to be especially careful in doing so, as you will not want to destroy the contents of the fossa in the process. The best way to insure success is to recall the superficial structures of the fossa and to move them out of the way before you remove the bone. The procedure described in your dissector is a good starting point. Removal of the zygomatic arch, temporalis muscle, and the coronoid process of the mandible should be done first. In removing the rest of the mandibular ramus, don’t spend too much time looking for the “lingula“. Your objective will be to make your saw cut above the level of the mandibular foremen, so that the important inferior alveolar vessels and nerves will be preserved. To do this, run the tip of a probe down the inside of the mandible until you feel it catch in the mandibular foremen. Note the length of the probe to the tip from the mandibular notch. Mark this distance on the outside of the mandible and make the third saw cut above this line. The third saw cut should be done especially carefully to preserve the lateral pterygoid muscle and maxillary artery, both of which course close to the suggested area. Once the infratemporal fossa is opened, identify the two heads of the lateral pterygoid muscle and then cut its posterior connections and reflect it forward. If this is not possible, then remove the lateral pterygoid muscle in pieces, taking care not to damage arteries branching off of the maxillary artery. Follow a similar procedure for removing or reflecting the medial pterygoid muscle, so that the mandibular nerve can be seen entering the infratemporal fossa through the foremen ovate. You should now have a good idea of how and where to find most of the important structures you want. If you are confused by what you see, review the contents of the fossa with your dried skull, and try to relate what you see to what you have learned on the skull.
Infratemporal Space Infection Following Maxillary Third Molar Extraction in an Uncontrolled Diabetic Patient
Abstract
Infratemporal space infection is a rare but serious sequel of odontogenic infection. The diagnosis is difficult due to non spe-cific signs and symptoms. Diabetes mellitus as a definitive risk factor for odontogenic infections needs more consideration during clinical procedures. We report a case of an undiagnosed diabetic patient with isolated infratemporal space infection after tooth extraction with presentation of similar signs and symptoms of temporomandibular joint and muscle problem.
Keywords: Diabetes mellitus, infratemporal space, odontogenic infection
Introduction
The infratemporal fossa is an anatomic space of great importance in the head. Abscesses of this space are rare but potentially life threatening. With regard to the proximity to some important anatomical areas of the head, dealing with infratemporal space infectioeeds great consideration both in examination and surgical practice. The infection might spread through the pterygoid plexus to the cavernous sinus or through the valveless ophthalmic veins into the orbit. Isolated infection of the infratemporal space is rare and difficult to diagnose. Clinical symptoms of pain, trismus, and fever are more likely to be diagnosed as a joint or muscle disorder.
To the best of our knowledge, a few cases of the diagnostic dilemma have been reported in the literature. Therefore, we aimed to report a case of isolated infratemporal space infection after extraction of a maxillary third molar in an uncontrolled diabetic patient that had been misdiagnosed as a temporomandibular joint (TMJ) disorder.
Case report
A 40-year-old male with the chief complaint of pain on the right side of the face and slight swelling in condylar area following a complicated maxillary right third molar extraction 24 days before, was referred to the Department of Oral and Maxillofacial Surgery, Tabriz University of Medical Sciences. Trismus and tenderness was observed in the right condylar area. Symptoms of pain and trismus had started five days after extraction. Other presentations were dysphagia, odynophagia, chills, and fever (39ºC).
The condition had been diagnosed and treated as a dry socket initially. However, prescription of amoxicillin 500 mg three times a day for a week had not improved the symptoms. Therefore, treatment of TMJ dysfunction syndrome by moist heat pack, muscle relaxant and NSAIDS was started. Pain, click and trismus had gradually risen.
Past medical history showed no systemic diseases; however, the patient complained of polyuria and sudden weight-gaining since six months ago. The history of chronic myofacial pain and TMJ dysfunction syndrome and long-term appliance therapy was remarkable with the complaint of recurrent periods of trismus and tenderness on the right condylar area and facial muscles since two years ago. The patient was using a night guard appliance in periods of recurrent and uncontrollable pain due to bruxism and clenching.
Extraoral examination indicated slight swelling and tenderness on the right side of the face with non-pitting appearance on palpation of the jaw. Right parotid gland was non-tender. No cervical lymphadenopathy was noted. Otologic and rhinoscopic examinations were unremarkable.
Slight tenderness without purulent discharge was observed around the extraction socket of right third molar. Posterior open bite was remarkable on the right side of centric occlusion. Trismus with maximum interincisal distance less than 15 mm was observed. Needle aspiration of the area was non-productive.
An axial and coronal spiral computed tomography (CT) scan with 5 mm sections on the condyle and infratemporal fossa revealed right infratemporal space cellulitis with accumulation of the fluid in right TMJ (Figure 1).
Figure 1. Coronal CT scan shows right infratemporal space celullitis (A); axial view (B).
A
The patient was admitted to the hospital immediately and empirical intravenous antibiotic therapy with penicillin and metronidazole was started. Serum fasting blood sugar (FBS) was checked twice, which the results were more than 196 mg/dl and glucose tolerance test (GTT) was 250 mg/dl. Consulting with the internal medicine service, insulin therapy was started to control blood glucose level. Empirical antibiotic therapy improved trismus, and maximum interincisal distance reached to 25 mm.
The patient was taken to the operating room for intraoral incision and drainage. Under endoscopic nasal intubation and general anesthesia, intra-oral incision over the anterior aspect of the ascending ramus was carried out and dissection was continued to the condylar and infratemporal area. As soon as the hemostat reached to the infratemporal space pus began to flow. Opening the hemostat along with moving mandible caused further drainage. Drain was placed in the site. The result of microbiological culture was unremarkable.
The patient complained of severe headache and vomiting after surgery, however, previous signs and symptoms were improved. Consulting with neurosurgery service, CT scan of brain ruled out brain abscess formation. Drain removed three days after surgery. Post operative CT scan showed normal tissue structure (Figure 2). The patient was discharged from hospital with oral antibiotics for further 7 days.
Discussion
Infratemporal fossa infection occurs secondary to odontogenic infections with the common origin of mandibular molars. Abscesses are rare and potentially dangerous complications. Besides, clinical diagnosis tends to be challenging as a result of non-specific signs and symptoms. Different manifestations might be observed depending on the specific anatomical feature involved in the infection including pain, fever, trismus in acute infection and trismus with swelling in chronic infection and even neurosensory deficit. Trismus can be the diagnostic hallmark to distinguish infratemporal space infection from other conditions with facial swelling.
The differential diagnosis may include parotitis and temporomandibular joint disorder. Considering past medical and dental history, clinicians should perform an accurate intra- and extra-oral examination in order to get to a proper diagnosis. Furthermore, the precise information of imaging modalities especially CT scan will allow for timelier and targeted diagnosis and treatment. CT scan is known as the only way to detect characteristic signs such as lucency and gas bubbles definitively.
In agreement with most reported cases, microbial culturing showed no particular organism isolation. In addition to the polymicrobial nature of odontogenic infections, the reason might be several antibiotic prescriptions before final diagnosis.
Clinical management of the patient with serious infectioeeds complete information about the systemic condition. In immunocompromised patients, such as uncontrolled diabetes mellitus (DM), proper diagnosis as well as prompt surgical intervention is critical in emergency situations. Before the surgical procedure, standard antibiotic prophylaxis and medical supervision are essential for these patients. It is necessary to consider that empirical antibiotic therapy should cover Klebsiella pneumonia in diabetic patients. The treatment should focus on prevention of spreading infection with possible life-threatening complications.
Fascial Space Infections
Four Anatomic Groups
1. Mandible and below
2. Cheek and Lateral Face
3. Pharyngeal & Cervical
4. Midface
Mandible and below
1. Buccal vestibule BBBMSS
2. Body of the Mandible
3. Mental space
4. Submental space
5. Sublingual space
6. Submandibular space
Cheek and Lateral Face
1. Buccal vestibule of the maxilla BBST
2. Buccal space
3. Submasseteric Space
4. Temporal space
Pharyngeal & Cervical
1. Pterygomandibular Space PPC
2. Parapharyngeal Space
3. Cervical Spaces
Midface
1. Palate PBCP
2. Base of Upper Lip
3. Canine Spaces
4. Periorbital Spaces
The mandibular buccal vestibule is the anatomic area located between the buccal cortical plate, overlying alveolar mucosa and the buccinator muscle in the posterior (mentalis) muscle in the anterior. In this case the source of infection is a mandibular posterior or anterior tooth in which the purulent exudate breaks through the buccal cortical plate, and the apex or apices of the involved tooth lie above the attachment of the buccinator or mentalis muscle, respectively.
The mandibular buccal vestibule is the anatomic area located between the buccal cortical plate, overlying alveolar mucosa and the buccinator muscle in the posterior (mentalis) muscle in the anterior. In this case the source of infection is a mandibular posterior or anterior tooth in which the purulent exudate breaks through the buccal cortical plate, and the apex or apices of the involved tooth lie above the attachment of the buccinator or mentalis muscle, respectively.
The space of the body of the mandible is that potential anatomic area that is located between the buccal or lingual cortical plate and its overlying periosteum. The source of infection is a mandibular tooth in which the purulent exudate has broken through the overlying cortical plate, but not yet perforated the overlying periosteum. Involvement of this space can also occur as a result of a postsurgical infection.
The mental space (Fig. 13-5) is the potential bilateral, anatomic area of the chin that lies between the mentalis muscle superiorly and the platysma muscle inferiorly. The source of the infection is an anterior tooth in which the purulent exudate breaks through the buccal cortical plate, and the apex of the tooth lies below the attachment of the mentalis muscle.
The submental space (Fig. 13-6) is that potential anatomic area that lies between the mylohyoid muscle superiorly and the platysma muscle inferiorly. The source of the infection is an anterior tooth in which the purulent exudate breaks through the lingual cortical plate, and the apex of the tooth lies below the attachment of the mylohyoid muscle.
The sublingual space (Fig. 13-7) is that potential anatomic area that lies between the oral mucosa of the floor of the mouth superiorly and the mylohyoid muscle inferiorly. The lateral boundaries of the space are the lingual surfaces of the mandible. The source of infection is any mandibular tooth in which the purulent exudate breaks through the lingual cortical plate and the apex or apices of the tooth lie above the attachment of the mylohyoid muscle.
The submandibular space (Fig. 13-8) is the potential space that lies between the mylohyoid muscle superiorly and the platysma muscle inferiorly.The source of infection is a posterior tooth, usually a molar, in which the purulent exudate breaks through the lingual cortical plate, and the apices of the tooth lie below the attachment of the mylohyoid muscle. If the submental, sublingual and submandibular spaces are involved at the same time, a dignosis of Ludwig’s Angina is made. This life threatening cellulitis can advance into the pharyngeal and cervical spaces, resulting in airway obstruction.
Cheek and Lateral Face
Buccal vestibule of the maxilla
Anatomically, the buccal vestibular space (Fig. 13-9) is located between the buccal cortical plate, the overlying mucosa, and the buccinator muscle. The superior extent of the space is the attachment of the buccinator muscle to the zygomatic process. The source of infection is a maxillary posterior tooth in which the purulent exudate breaks through the buccal cortical plate, and the apex of the tooth lies below the attachment of the buccinator muscle.
Buccal space
The buccal space (Fig. 13-10) is the potential space located between the lateral surface of the buccinator muscle and the medial surface of the skin of the cheek, extent of the space is the attachment of the buccinator muscle to the zygomatic arch, whereas the inferior boundaries are the attachment of the buccinator to the inferior border of the mandible and the anterior margin of the masseter muscle, respectively. The source of can be either a posterior mandibular or maxillary tooth in which the purulent exudate breaks through the buccal cortical plate, and the apex or apices of the tooth lie above the attachment of the buccinator muscle (i.e., maxilla) or below the attachment of the buccinator muscle (i.e., mandible)
Submasseteric Space
As the name implies, the submasseteric space (13-11) is the potential space that lies between the lateral surface of the ramus of the mandible and the medial surface of the masseter muscle. The source of the infection is usually an impacted third molar in which the purulent exudate breaks through the lingual cortical plate. The apices of the tooth lie very close to or within the space.
The Temporal Space
The Temporal space is divided into two compartments by the temporalis muscle. The deep temporal space is the potential space that lie between the lateral surface of the skull and medial surface of the temporalis muscle. Whereas the superficial temporal space lies between the temporalis muscle and its overlying fascia. The deep and superficial temporal spaces are involved indirectly as a result of an infection spreading superiorly from the inferior pterygomandibular and submasseteric spaces, respectively.
Pharyngeal & Cervical
Pterygomandibular Space
The pterygomandibular space (Fig. 13-13) is the potential space that lies between the lateral surface of the medial pterygoid muscle and the medial surface of the ramus of the mandible. The superior extent of the space is the lateral pterygoid muscle. The source of the infection is mandibular second or third molars in which the purulent exudate drains directly into the space. In addition, contaminated inferior alveolar nerve injections can lead to infection of the space.
Parapharyngeal Space
The parapharyngeal spaces are comprised of the lateral pharyngeal and retropharyngeal spaces (Fig. 13-14). The lateral pharyngeal space is bilateral and lies between the lateral surface of the medial pterygoid muscle and the posterior surface of the superior constrictor muscle. The superior and inferior margins of the space are the base of the skull and the hyoid bone, respectively, whereas the posterior margin is the carotid space, or sheath, which contains the common carotid artery, internal jugular vein, and the vagus nerve. Anatomically, the retropharyngeal space lies between the anterior surface of the prevertebral fascia and the posterior surface of the superior constrictor muscle and extends inferiorly into the retroesophageal space, which extends into the posterior compartment of the mediastinum. The pharyngeal spaces usually become involved as a result of the secondary spread of infection form other fascial spaces or directly from a peritonsillar abscess
Cervical Spaces
The cervical spaces are comprised of the pretracheal, retrovisceral, danger, and prevertebral spaces (Fig. 13-15). The pretracheal space is the potential space surrounding the trachea. It extends from the thyroid cartilage inferiorly into the superior portion of the anterior compartment of the mediastinum to the level of the arch of the aorta. Because of its anatomic location, odontogenic infections do not spread to the pretracheal space. The retrovisceral space is comprised of the retropharyngeal space superiorly and the retroe-sophageal space inferiorly. The space extends from the base of the skull into the posterior compartment of the mediastinum to a level between vertebrae C-6 andT-4. The danger space (i.e., space 4), as originally described by Grodinsky and
Midface
Palate
The source of infection of the palate is any of the maxillary teeth in which the apex of the involved tooth lies close to the palate.
Base of Upper Lip
The source of infection of the base of the upper lip is a maxillary central incisor in which the apex lies close to the buccal cortical plate and above the attachment of the orbicularis oris muscle.
Canine Spaces
The canine, or infraorbital space, (Fig. 13-16) is the potential space that lies between the levator anguli oris muscle inferiorly and the levator labii superioris muscle superiorly. The source of infection is the maxillary canine or first premolar in which the purulent exudate breaks through the buccal cortical plate and the apex of the tooth lies above the attachment of the levator anguli oris muscle.
Periorbital Spaces
The periorbital space (see Fig. 13-16) is the potential space that lies deep to the orbicularis oculi muscle. The source of infection is the spread of infection from the canine or buccal spaces. Infections of the midface can be very dangerous because they can result in cavernous sinus throbosis– a life-threatening infection in which a thrombus formed in the cavernous sinus breaks free, resulting in blockage of an artery or spread of infection. Under normal conditions, the angular and ophthalmic veins and the pterygoid plexus of veins flow into the facial and external jugular veins If an infection has spread into the midfacial area, however edema and resultant increased pressure from the inflammatory response causes the blood to back up into the cavernous sinus. Once in the sinus, the blood stagnates and clots The resultant infected thrombi remain in the cavernous sinus or escape into the circulation.
CERVICO-FASCIAL INFECTIONS & LUDWIG’S ANGINA
Cervico-Fascial Space Infections / Cervico-Facial Cellulitis /
Peri-Mandibular Infections
Due to the strategic position of the wisdom tooth (3rd molar) at the junction of a
number of different fascial spaces, any infection in this area must be taken
seriously as an infection here can easily spread along the fascial planes and
compromise the airway.
The head and neck (cervical) region has a large number of fascial spaces. These
‘spaces’ are bounded by the fascia, which may stretch or be perforated by the
purulent exudates (pus), facilitating the spread of infection. These ‘spaces’ are
potential areas and do not exist in healthy individuals. There are a number of them
including the:
- buccal space
- buccinator space
- para-pharyngeal space
- sub-mandibular space
- sub-lingual space
- lateral pharyngeal and
- pterygoid space
Infections in the buccal space and buccinator space are usually localised on the
lateral side of the mandible.
Sub-masseteric infections occupy the potential space between the lateral border of
the mandible and the masseter muscle. This is not a fascial-lined space; infection
in this area is in direct contact with the masseter muscle and usually induces
intense spasm in the muscle, resulting in a profound limitation in mouth opening
(trismus).
Internal pterygoid space infections occupy the fascia-lined space between the
internal pterygoid muscle and the medial aspect of the mandible. Infections in this
area cause a less profound trismus but can result in airway embarrassment. They
can also result from Inferior Alveolar Nerve block.
The sub-mandibular space consists of a splitting of the investing fascia of the neck
to enclose the submandibular salivary gland and is in continuity with the internal
pterygoid and para-pharyngeal spaces. Infections in this region can cause airway
embarrassment and, when bilateral with associated cellulitis, is termed Ludwigs
Angina. This is very serious and potentially life-threatening.
Infections occur between the pharyngeal mucosa and superior constrictor muscle.
Infections in this region are also potentially life-threatening and require urgent
attention.
Fascial Space Infections – key features
• Potentially life-threatening infections due to spread of bacteria into peri-oral
fascial spaces
• Infection usually arises from lower second or third molars (wisdom teeth).
• Affected tissues are swollen and of ‘board-like’ hardness
• Severe systemic upset
• Glottic œdema (swelling) or spread into the mediastinum may be fatal
The main principles of treatment remain surgical with (dependent) drainage of pus
augmented by antibiotic therapy. The infective organisms are normal oral flora and
the penicillin family of antibiotics remains the antibiotics of first choice.
With the increasing recognition of the role of anærobic oral bacteria in these
infections, clindamycin can be substituted for penicillin in severe infections or
metronidazole added to the penicillin. Studies show an average of four bacterial
species in any oral infection with anærobic species outnumbering ærobic species,
although streptococci remain the largest single group of organisms.
Ludwig’s Angina
Ludwig’s Angina is a severe form of cervico-fascial infection / cellulitis which
usually arises from the lower second or third molars (wisdom teeth).
Deep fascial space infections cause gross inflammatory exudates (a fluid with a
high content of protein and cellular debris which has escaped from blood vessels
and has been deposited in tissues or on tissue surfaces, usually as a result of
inflammation. It may be septic or non-septic) and tissue œdema (swelling),
associated with fever and toxæmia (blood poisoning). Before the advent of
antibiotics, the mortality was high and the disease is still life-threatening if
treatment is delayed.
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Photos of varying severities of Ludwig’s Angina |
The main fascial spaces involved in Ludwig’s Angina are the sublingual,
submandibular and para-pharyngeal. Normally, the spaces both side of the
midline (ie bilateral) are effected.
The characteristic features are:
• diffuse swelling, pain, fever and malaise.
• The swelling is tense and tender, with a characteristic ‘board-like’ firmness.
• The overlying skin is taut and shiny.
• Pain and œdema (swelling) that limit opening the mouth and often cause
dysphagia (difficulties in swallowing)
• Systemic upset is severe, with worsening fever, toxæmia (blood poisoning)
and leucocytosis
.
• The regional lymph nodes are swollen and tender.
• In Ludwig’s Angina particularly, airway obstruction can quickly result in
asphyxia.
Anærobic bacteria are primarily responsible and infection mainly spreads from
mandibular third molars (lower jaw wisdom teeth) whose apices (root tips) are
closely related to several fascial spaces. Fasciæ, covering muscles and other
structures are normally adherent but can be spread apart by inflammatory exudate.
Spaces created in this way are almost avascular (do not have a blood supply) and
inflammatory exudate carries bacteria widely through them. It involves the sub-
lingual and sub-mandibular spaces bilaterally (on both sides) almost
simultaneously; it readily spreads into the lateral pharyngeal and pterygoid spaces
and can extend into the mediastinum. The main features are rapidly spreading sub-
lingual and sub-maxillary cellulitis with painful, brawny swelling of the upper part
of the neck and the floor of the mouth on both sides. With involvement of the para–
pharyngeal space, the swelling tracks down the neck and œdema can quickly
spread to the glottis.
Swallowing and opening the mouth become difficult and the tongue may be pushed
up against the soft palate. The latter or œdema of the glottis causes worsening
respiratory obstruction. The patient soon becomes desperately ill, with fever,
respiratory distress, headache and malaise.
Management
The main requirements are:
• immediate admission to hospital
• procurement of a sample for culture and sensitivity testing
• aggressive antibiotic treatment
• securement of the airway by tracheostomy if necessary, and
• drainage of the swelling to reduce pressure.
