Case Report A.n atypical pathwayof infection in an adolescent w th a deep neck space abscess RobynR. Loewen,DDS Stephen F. Conley, MD, MS A. Charles Post, DDS eep neck space infections are a potential com- days later she came to Children’s Hospital of Wiscon- plication of odontogenic infection, but rarely sin emergency department with a progression of symp- D have been reported in children. In a recent toms and painful left neck swelling. study, 113 pediatric patients were hospitalized with Upon initial examination, the patient had a tem- maxillofacial infections with 32 from dental sources; perature of 38.7°C (101.6°F) without evidence of air- however, the extension of these infections into deep way distress. The oral cavity exam was limited by se- neck spaces was not documented.1 In a similar study of vere trismus, allowing only a 1-cm opening. The 67 children with abscess of the head and neck, only 15 mandibular left permanent second molar had exten- cases were determined to have submandibular, lateral sive decay with tenderness to percussion. No swelling pharyngeal, or retropharyngeal space involvement, and or tenderness was present in either the floor of the only nine were attributed to dental infection. 2 Lateral mouth or in the buccal vestibule. The left tonsil was pharyngeal space infections are more commonly medially displaced. Externally, a 3-cmodiameter area odontogenicin adults; in contrast, the likely predispos- of induration was present at the angle of the mandible ing factors in children are nasopharyngitis or with extension to the left jugulodigastric area. Thewhite adenoiditis. 3 Eight pediatric patients with lateral pha- blood cell count was 18,200 with a leukocytosis. A ryngeal4 space infections were identified by Broughton, lateral neck film indicated a good airway without but no etiological determinations were given. retropharyngeal soft tissue swelling. Early diagnosis and treatment of lateral pharyngeal The patient was admitted to the otolaryngology ser- infections are essential because further progression of vice and intravenous clindamycin was initiated. A neck infection can be rapid. Severe trismus, limiting direct CT obtained I day after admission indicated soft tissue examination of the oropharyngeal region, often com- swelling of the left peritonsillar and lateral pharyngeal plicates clinical evaluation. In addition, the limited value spaces without evidence of abscess formation. A pan- of conventional roentgenograms in locating the in- oramic radiograph confirmed extensive decay of the volved deep neck spaces makes definitive diagnosis mandibular left permanent second molar with difficult. This case report describes a 14-year-old Afri- periapical radiolucencies consistent with an acute can-Americanfemale whodeveloped a left peritonsillar periapical-alveolar abscess. The joint services deferred and lateral pharyngeal abscess from an odontogenic tooth extraction until the deep neck cellulitis and source. She was managedsuccessfully with appropri- trismus had resolved. ate antibiotics and surgical intervention after diagno- After 48 hr of parenteral antibiotic therapy, the physi- sis using computerized tomography (CT). cal findings remained unchanged and a low-grade fe- ver of 38.4°C (101.1~F) persisted with nocturnal tem- Case report perature spikes to 39.5 °C (103.1 °F). Induration became A previously healthy 14-year-old African-Ameri- morelocalized at the left angle of the mandibleand the can female reported onset of dental pain in the left submandibular area. Persistent unchanged trismus pre- mandibular quadrant in 1992. Two weeks later, the cluded a detailed oral exam. Although the involved dental pain was accompanied by left cheek swelling, tooth remained sensitive to manipulation, there were dysphagia, odynophagia, and decreased oral intake. no associated gingival changes. A repeat neck CT scan Her pediatrician recommendeddental treatment for was obtained to assess lack of clinical response. A large the offending tooth, but the family refused because of left lateral pharyngeal and peritonsillar abscess was the patient’s fear of needles. The patient received intra- identified with a tract originating from the posterior muscular penicillin and an oral aminopenicillin. Two and inferior left mandibular border (Figs I & 2). 220 AmericanAcademy of PediatricDentistry PediatricDentistry - 17:3,1995 and therefore drain to the sublingual space. The sec- ond and third molar api- ces are below the mylo- hyoid attachment and typically drain to the sub- mandibular space with out sublingual involve- ment. Therefore, the spread of infection to deep neck spaces through the submandibular space must be anticipated in the teenager.6 A lateral pha- ryngeal space infection can occur by extension of the infection from the in- ternal compartment of the masseteric space or, rarely, from the subman- Fig 1. CT demonstrating sinus tract (arrow) Fig 2. CT illustrating abscess (arrow) of dibular space.7 from posteroinferior mandibular margin to lateral pharyngeal and tonsillar spaces The lateral pharyngeal lateral pharyngeal space abscess. with connection. space (parapharyngeal space, pharyngomaxillary The patient had a quinsy tonsillectomy and extrac- space) is cone-shaped, with its base at the skull base tion of the mandibular left permanent second molar and its apex at the greater cornu of the hyoid. The under general anesthesia. No other treatment was per- styloid process and its muscles divide the lateral pha- formed. A bilobed abscess cavity involving the ryngeal space into two compartments: 1) an anterior peritonsillar space with extension into the lateral pha- (prestyloid) space containing connective tissue, ryngeal space was confirmed intraoperatively. Cultures muscles, and lymph nodes, and 2) a posterior grew Bacteroides melaninogenicus. Close inspection of (retrostyloid) space containing the great vessels and the alveolar socket failed to identify a sinus tract. Ex- nerves of the neck.7'9 An abscess of the anterior com- amination of the remaining dentition revealed minor partment results in trismus from irritation of the inter- caries on both maxillary second permanent molars and nal pterygoid muscle, medial deviation of the lateral the mandibular right second permanent molar. The pharyngeal wall, dysphagia, torticollis, swelling over patient had an uneventful recovery, was discharged on the parotid gland, and possible neck swelling with loss the third postoperative day of a 10-day course of oral of the space behind the mandibular angle. An abscess clindamycin, and had no postoperative sequelae. She of the posterior compartment has no trismus or tonsil- was referred to her private dentist for restoration of the lar prolapse, but rather parotid swelling and medial other carious teeth. deviation of the posterior lateral pharyngeal wall.8 Res- piratory distress can ensue with significant lateral pha- Discussion ryngeal wall swelling. Odontogenic infections tend to spread to soft tis- The peritonsillar space is a potential space defined sues via planes of least resistance to adjacent potential medially by the fibrous capsule of the palatine tonsil spaces and must perforate bone before spreading to and laterally by the superior constrictor muscle. Break- the deeper fascial spaces. The most common neck spaces down of the tonsillar capsule during tonsillitis is the involved in mandibular odontogenic infection include classic source of infection of this space. Purulent the submandibular, masseteric, and sublingual.5 In the material in the midportion of the peritonsillar space young child, the primary root apices are located super- appears to be prone to penetrate the superior constric- ficially and anteriorly within the mandible and usually tor muscle and enter the lateral pharyngeal space. drain to the buccal aspect of the alveolus intraorally. Trismus occurs from reflex irritation of the adjacent The permanent first and second molar apices lie deeper muscles of mastication.10 and more posteriorly in the mandible and drainage is Prompt and accurate diagnosis and treatment of more complex. Since the lingual bone of the posterior deep neck space infections are crucial. The classic symp- mandible is thinnest in relation to molar apices, infec- toms of neck abscesses rarely are present today be- tions of the first and second permanent molars tend to cause oral antibiotics can modify symptoms. Thus the drain lingually. The first molar has apices which are differentiation of diffuse cellulitis from a distinct ab- located superior to the mylohyoid muscle attachment, scess cavity is complicated. In addition, the progres- Pediatric Dentistry -17:3,1995 American Academy ofPediatric Dentistry 221 sion of infection may be difficult to ascertain clinically lococcus species (32%) comprised the majority of pure due to significant local edema and trismus. The atypi- cultures in maxillofacial infections28 More recently, cal aspect of this case was the direct involvement of the Brook2 found that the most commonisolates in pediat- anterior compartment of the lateral pharyngeal space ric head and neck infections are Staphylococcus aureus via a sinus tract in the mandible rather than the more (aerobic) and Bacteroides species. In patients with den- typical intervening masseteric space infection. tal infections as the predisposing factor, anaerobic iso- The limitations of conventional roentgenograms can lates either as pure cultures or in a mixed flora pre- hinder prompt diagnosis of head and neck-space infec- dominate. This is consistent