Submasseteric abscess

Submasseteric abscess Unlikely case of submasseteric Unlikelyabscess originating case of submasseteric from a maxillary molar:abscess The originating skipping from lesion a maxillary molar: The skipping lesion

Abstract

ObjectiveAbstract

Min Jim Lima & Alauddin Muhamad Husinb We report a case of submassetericObjective abscess originating from a maxillary tooth, complicated by underlying diabetes mellitus and a multidrug- a Min OralKementerian Jim Maxillofacial Lima & Kesihatan Alauddin Surgery MuhamadMalaysia, Department, Oral Husin Maxillofacial Hospitalb Tanah Surgery We report a case of submasseteric abscess originating from a maxillary Merah,Department, Tanah Hospital Merah, Kelantan, Tanah Merah, Malaysia Tanah Merah, Kelantan, resistant organism. b tooth, complicated by underlying diabetes mellitus and a multidrug- a OralMalaysia Maxillofacial Surgery Department, Hospital TanahSultanah b Nur Zahirah, Kuala Terengganu, Terengganu, Malaysia Merah,Kementerian Tanah KesihatanMerah, Kelantan, Malaysia, Malaysia Oral Maxillofacial Surgery resistant organism. Materials and methods b OralDepartment, Maxillofacial Hospital Surgery Sultanah Department, Nur Zahirah, Hospital Kuala Sultanah Terengganu, NurTerengganu, Zahirah, KualaMalaysia Terengganu, Terengganu, Malaysia Corresponding author: A 61-year-old male patientMaterials with uncontrolled and methods diabetes mellitus presented with swelling on the left of 2 weeks in duration with rapid CorrespondingDr. Min Jim Lim author: A 61-year-old male patient with uncontrolled diabetes mellitus presented Oral Maxillofacial Surgery Department progression to , dysphagia and rupture of swelling with pus Hospital Tanah Merah discharge.with swelling Culture on the and left sensitivity cheek of testing 2 weeks revealed in duration the presence with rapid of 17500Dr. Min Tanah Jim LimMerah Oral Maxillofacial Surgery Department progression to trismus, dysphagia and rupture of swelling with pus Kelantan multidrug- resistant Klebsiella pneumoniae. Based on the patient’s history Hospital Tanah Merah Malaysia discharge. Culture and sensitivity testing revealed the presence of 17500 Tanah Merah and clinical presentation, a diagnosis of submasseteric abscess originat- Kelantan multidrug- resistant Klebsiella pneumoniae. Based on the patient’s history [email protected] ing from the maxillary molar was made. Antibiotic administration, con- Malaysia andtrol clinicalof systemic presentation, disease and a diagnosis wound dressing of submasseteric were done abscess as treatment. originat- [email protected] ing from the maxillary molar was made. Antibiotic administration, con- How to cite this article: trol of systemic disease and woundResult dressing were done as treatment. HowLim MJ, to Muhamad cite this Husin article:A. Unlikely case of submasseteric abscess originating from a maxillary The patient made a full recovery,Result with scarring on the ruptured region. Limmolar: MJ, The Muhamad skipping Husin lesion. A. Unlikely case of J Oral Science Rehabilitation. 2018 Dec;4(4):52–55. submasseteric abscess originating from a maxillary The patient made a full recovery, with scarring on the ruptured region. molar: The skipping lesion. Conclusion J Oral Science Rehabilitation. 2018 Dec;4(4):52–55. Submasseteric abscess is a rareConclusion case of infection that can occur in the submasseteric space. As is commonly known, infection of the submas- setericSubmasseteric space originates abscess fromis a rare mandibular case of infection third molars; that hence,can occur maxillary in the molarssubmasseteric seem to space. be an unlikely As is commonly source of known, infection. infection Diagnosis of the of submas- seteric spaceabscess originates that originates from mandibular from maxillary third molars; molars hence, can be maxillary difficult owingmolars to seem its rarity to be anand unlikely thus the source unlikeliness of infection. of being Diagnosis the first of submasdiagnosis- thatseteric comes abscess to mind. that originates from maxillary molars can be difficult owing to its rarity and thus the unlikeliness of being the first diagnosis that comes to mind. Keywords

Submasseteric abscess; maxillaryKeywords molar; skipping lesion.

Submasseteric abscess; maxillary molar; skipping lesion. 52 Volume 4 | Issue 4/2018 Journal of Oral Science & Rehabilitation 52 Volume 4 | Issue 4/2018 Journal of Oral Science & Rehabilitation Submasseteric abscess

Introduction statim, followed by 2 mega units every 6 h. The patient was also referred to the medical depart- Submasseteric abscess is a rare complication ment for management of underlying diabetes that commonly has dental origins, particularly mellitus. The patient was prescribed a 500 mg the mandibular third molars.1 However, the metformin oral tablet once daily. Aspiration was development of a submasseteric abscess from done with a size 16 syringe needle, but yielded maxillary molars is scarcer. We could find only no product. It was regrettable that a CT scan 1 case report in our literature search.2 Owing to was not available at that time. the rarity and late symptomatic manifestation On day 5 after admission, there was a break- of such cases, diagnosis may not be easy for the down of the overlying skin with pus discharge general practitioner. Management of submas- at the left posterior submandibular region, seteric abscess can be further complicated in extending to the submasseteric region. The patients with impaired immune systems or margin of the wound was friable and necrotic. infected with multidrug-resistant organisms. In However, the patient claimed that the pain had this article, we would like to highlight the case subsided with the absence of dysphagia. Wound of a patient who presented with a rare submas- debridement was done, and it was irrigated with seteric abscess from an unlikely origin, compli- chlorhexidine and normal saline. A rubber tube cated by uncontrolled diabetes and a multi- was placed to allow further drainage (Fig. 2). drug-resistant organism. Topical metronidazole was placed on the wound and covered with gauze. A swab was taken and sent for culture and sensitivity testing. The result Case report was penicillin-resistant Klebsiella pneumoniae with sensitivity to cefuroxime. Hence, cefuroxime A 61-year-old male patient with underlying was chosen as a replacement for penicillin. Daily diabe­tes mellitus presented to the Dental wound dressing was done, together with the Department with the chief complaint of swell- placement of topical metronidazole. ing on the left cheek with a duration of 2 weeks. On day 13, the swelling over the left subman- The patient claimed that the swelling had begun dibular and submasseteric region had subsided. at the left angle of the jaw and had been increas- The patient did not have any dysphagia or tris- ing in size. The swelling was accompanied by mus. There was no more pus discharge from the severe throbbing pain and difficulty in swallow- wound or from the rubber drain, and only a raw ing. Upon further probing, the patient said that wound was exposed (Fig. 3). After the rubber he had undergone a difficult and unsuccessful drain had been removed, a wound dressing was extraction of the maxillary left second molar done and the wound was left to heal by second- 2 weeks prior. ary intention. A full-mouth scaling and removal Upon physical examination, there was a of the retained root of the maxillary left second large, diffuse swelling on the left face involving molar were done. The patient was then dis- the left masseter region and extending to the charged with a weekly appointment for review left submandibular region with the loss of pal- and wound dressing. pable mandibular angle (Fig. 1). The swelling The patient was followed over a 2-month was firm, tender, warm and erythematous. The period. At the last follow-up, the patient patient was also experiencing trismus, with ­presented with scarring of the area posterior to mouth opening of 20 mm interincisally. Intraoral the left angle of the that was slightly examination revealed poor oral hygiene and a darker than the surrounding skin, but with retained root of the maxillary left second molar, ­minimal contracture (Fig. 4). which was tender to percussion. The gingiva surrounding the retained root of the maxillary left second molar was assessed to be suffi- Discussion ciently healed, without any signs of infection. The teeth and the gingiva on the opposing arch In 1948, Bransby-Zachary described a potential were healthy. An immediate diagnosis of sub- space that constitutes a masticator space known masseteric cellulitis with possible involvement as the submasseteric space.3 He mentioned that of the lateral pharyngeal space was made. The the common cause of submasseteric space patient was immediately warded and given infection was of the third molar.3 intravenous crystalline penicillin 4 mega units The submasseteric space is a potential space

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Fig. 1 Fig. 2

Fig. 1 formed between the lateral wall of the mandible hematoma was presumed to have extended into Swelling of the left of the and the medial aspect of the the submasseteric space, without having face involving the and its investing fascia. Submasseteric abscess infected the or the infratemporal left masseter region. is often not the foremost diagnosis when a space tissue. This gave an impression of the Fig. 2 patient complains of swelling of the jaw owing infection skipping through the aforementioned 1 A rubber drain was placed to its rarity. A study has shown that the most space to the submasseteric space. for pus drainage. commonly involved orofacial space is the sub- We were only able to find1 other similar mandibular space, followed by the buccal space case, which was reported by Gallagher and and lastly the submasseteric space.4 It is often Marley, for which they hypothesized that an thought to be trismus, as its first sign is spasm infected hematoma was formed at the infratem- of the masseteric muscle, resulting from the poral region before extending into the submas- irritation of the muscle fiber by the infection. seteric space.2 Extraoral examination cannot determine its K. pneumoniae is frequently isolated as a severity, as the swelling is often firm and mild major infective organism in diabetic patients. in the early stages, owing to its being confined Empirical antibiotic therapy of amoxicillin with by the masseteric muscle. The swelling is iso- clavulanic acid together with metronidazole, lated, involving the angle of the mandible, and coupled with surgical drainage, should provide tender and diffuse in nature. Once the infection a satisfactory outcome.4 However, in this patient, penetrates the muscle fibers, the swelling owing to the presence of penicillin-­resistant K. becomes fluctuant and erythematous.5 pneumoniae, the patient’s condition did not The submasseteric space is connected to respond to the administration of penicillin­ and other spaces, including the buccal space, sub- rapidly deteriorated. By the time we had obtained mandibular space, and the microbiology results, the abscess had rup- . However, the submasse- tured through the overlying skin. After changes teric space is by no means directly connected to were made in the antibiotic administration, there any maxillary teeth. It would seem rather impos- was a significant improvement of the wound. We sible for the maxillary molar to be the origin of noticed a significant reduction in pus discharge the submasseteric abscess. We postulated that, from the wound and an increase in healthy gran- according to the patient’s history, an infected ulation tissue formation. It is regrettable that, hematoma may have formed in the buccal space owing to the rapid progression of the infection, or infratemporal space, owing to the traumatic we could not prevent the ­breaking down of and unsuccessful extraction. However, the heal- superficial tissue, leading to permanent scarring. ing of the gingiva at the extraction site pro- The control of the patient’s diabetic condi- ceeded normally, without any signs of infection. tion was a major concern in our management. This meant that there was a formation of an ­Diabetes has been considered a factor reducing isolated and infected hematoma. The infected host response, as it may lead to hyperglycemia,

54 Volume 4 | Issue 4/2018 Journal of Oral Science & Rehabilitation Submasseteric abscess

Fig. 3 SubmassetericFig. 4 abscess

Fig. 3 Fig. 4

disrupt cellular immunity and complement We would likeCompeting to thank the interests Director General of Fig. 3 activation. Complication of deep neck infection Health Malaysia for his permission to publish Healing of the perforated is also frequently reported in patients with Thethis authorsarticle. declare that they have no compet- wound. diabetes.4 ing interests. Fig. 4 disruptThe management cellular immunity of this patientand complement would have Competing interests Fig. 3 Scarring at the area posterior activation.been greatly Complication improved if of a deep CT scan neck had infection been toHealing the left of anglethe perforated of the isavailable. also frequently The diagnosis reported of in submasseteric patients with The authors declare that they have no compet- mandible.wound. diabetes.abscess would4 have been made much earlier. ing interests. WithThe CT management imaging as a of guide, this patient a proper would incision have Fig. 4 Scarring at the area posterior beenand drainage greatly wouldimproved have if beena CT donescan tohad provide been to the left angle of the available.an outlet for The the diagnosis abscess, preventing of submasseteric a break- mandible. abscessdown of thewould overlying have been tissue. made much earlier. With CT imaging as a guide, a proper incision References and drainage would have been done to provide an outlet for the Conclusionabscess, preventing a break- 1. down of the overlying tissue. Jones KC, Silver J, Millar WS, Mandel L. Chronic submasseteric abscess: This case highlights what seems to be an impos- anatomic, radiologic,References and pathologic features. sible diagnosis. While the submasseteric space → AJNR Am J Neuroradiol. 2003 Jun–Jul;24(6):1159–63. is not a neighboringConclusion space of maxillary teeth, the 1. Jones KC, Silver J, Millar WS, Mandel L. possibility of the spread of infection exists. At 2. Chronic submasseteric abscess: Gallagher J, Marley J. Infratemporal and anatomic, radiologic, and pathologic Thispresent, case no highlights paper addresses what seems the risk to be level an ofimpos such- submasseteric infection following features. extraction of a non-infected maxillary siblea complication diagnosis. Whileof the the extraction submasseteric of maxillary space → AJNR Am J Neuroradiol. third molar. 2003 Jun–Jul;24(6):1159–63. isteeth. not a Severeneighboring systemic space diseaseof maxillary or a teeth, multi the- → Br Dent J. 2003 Mar;194(6):307–9. possibilitydrug-resistant of the organism spread couldof infection be the exists.culprit Atof 2. Gallagher J, Marley J. Infratemporal and 3. present,such a seemingly no paper addresses impossible the diagnosis. risk level of It such is submasseteric infection following Bransby-Zachary GM. The submasseteric extraction of a non-infected maxillary ahoped complication that, from of this the paper,extraction practitioners of maxillary will space. third molar. → Br Dent J. teeth.be made Severe aware systemic of such disease complications or a multi and- → Br Dent J. 1948;84:10–3. drug-resistantprompted to investigate organism further could be to managethe culprit such of 2003 Mar;194(6):307–9. 4. 3. sucha case a in seemingly a timely manner. impossible diagnosis. It is Rao DD, Desai A, Kulkarni RD, Bransby-Zachary GM. The submasseteric Gopalkrishnan K, Rao CB. Comparison of hoped that, from this paper, practitioners will space. maxillofacial space infection in diabetic → Br Dent J. be made aware of such complications and and nondiabetic patients. 1948;84:10–3. → Oral Surg Oral Med Oral Pathol Oral prompted to investigateAcknowledgment further to manage such Radiol Endod. 4. 2010 Oct;110(4):e7–12. a case in a timely manner. Rao DD, Desai A, Kulkarni RD, Gopalkrishnan K, Rao CB. Comparison of This case report was supported by the Oral 5. maxillofacial space infection in diabetic Hupp JR, Ellis E, Tucker MR. Contempo- Maxillo facial Surgery Department (Unit Bedah and nondiabetic patients. rary oral and maxillofacial surgery. 5th ed. → Oral Surg Oral Med Oral Pathol Oral → St. Louis, MO: Mosby; 2008. 728 p. Mulut), HospitalAcknowledgment Tanah Merah, Malaysia. Radiol Endod. 2010 Oct;110(4):e7–12.

This case report was supported by the Oral 5. Journal of Volume 4 | Issue 4/2018 55 Maxillo facial Surgery Department (Unit Bedah Hupp JR, Ellis E, Tucker MR. Contempo- Oral Science & Rehabilitationrary oral and maxillofacial surgery. 5th ed. Mulut), Hospital Tanah Merah, Malaysia. → St. Louis, MO: Mosby; 2008. 728 p.

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