Case Report

A.n atypical pathwayof 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 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 , 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 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 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 and surgical intervention after diagno- After 48 hr of parenteral 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 swelling, tooth remained sensitive to manipulation, there were , 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 . 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 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 (, pharyngomaxillary The patient had a quinsy 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- 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 , 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 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 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 .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 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 with the observation that tions. CT has been used extensively to identify and anaerobic bacteria outnumber aerobic species in the manage various maxillofacial pathoses. 11-15 The diag- oral19 cavity by 10 to one. nostic value of CT for head and neck infection include Greater resistance of bacteria to antibiotics, especially evaluating the degree of displacement of para- penicillin, has been another trend. Recent findings could pharyngeal soft tissues, differentiating between preclude penicillin as an automatic choice in head and cellulitis and abscess formation, and locating an ab- neck infections. Beta-lactamase-producing organisms scess anatomically25 An abscess on a CT scan can be can survive penicillin therapy and may even protect characterized by single or multiple loculations; low penicillin-susceptible organisms by enzymatic release density air and/or fluid at the center of the abscess; within the abscess. Brook2 found beta-lactamase activ- contrast enhancement of the abscess wall; and tissue ity in 46%of head and neck infections in children. Halula edema surrounding the wall and anatomic boundaries et al. 2° also described specific mechanismsfor the trans- that correspond to known fascial planes22 In this case, fer of clindamycin resistance in Bacteroides species. the atypical direct path of infection to the lateral pha- Penicillin and clindamycin have been shown to pro- ryngeal space could not have been detected with con- duce similarly good results in treating odontogenic ventional roentgenograms. Incorporating a CT allowed infections when the rate of penicillin resistance among prompt determination of abscess formation and delin- oral anaerobic bacteria is relatively low. Penicillin is eated the abscess location to facilitate drainage. felt by some authors to still be the antibiotic of choice Serious complications may develop from a lateral for maxillofacial infections of odontogenic origin. 1, 21 pharyngeal space infection. Contiguous spread to the Clindamycin is indicated in cases of penicillin allergy, retropharyngeal space is ominous, often seriously com- recent exposure to penicillin, failure of an infection to promising the airway and progressing to mediastinitis respond to penicillin therapy, or in cases where the due to its inferior communication with the posterior knownpathogen is Bacteroides21 fragilis. mediastinum. Along with septicemia, other complica- tions of deep neck space infection include jugular Dr. Loewenis a pediatric dental resident, Departmentof Pediatric thrombosis, hemorrhage of the great vessels, laryngeal Dentistry, Children’s Hospital of Wisconsin, Milwaukee; Dr. Conleyis assistant professor, departments of otolaryngology - edema, of the mandible, pneumonia, va- humancommunication and pediatrics, Medical College of Wis- gal involvement, meningitis, parotid abscess, and consin, Milwaukee;and Dr. Post is director, Departmentof Pedi- aspiration of purulent material following spontaneous atric Dentistry, Children’s Hospital of Wisconsin,Milwaukee. ruptureg,16 of the abscess, Management of a lateral pharyngeal space infection 1. DodsonTB, Perrott DH,Kaban LB: Pediatric maxillofacial of odontogenic origin must be prompt and accurate, infections: a retrospective study of 113 patients. J Oral with removal of the odontogenic infection nidus and Maxillofac Surg 47:327-30, 1989. 2. BrookI: Microbiologyof abscesses of the head and neck in parenteral antibiotic therapy. In cases of diffuse cellulitis children. AnnOtol Rhinol Laryngol 96:429-33, 1987. without localization, parenteral antibiotics alone often 3. Dzyak WR,Zide MF: Diagnosis and treatment of lateral are curative27 Surgical intervention is advised if no pharyngeal space infections. J Oral MaxillofacSurg 42:243- improvement is seen after 48-72 hr of parenteral anti- 9, 1984. biotic therapy. Exploration and drainage of the abscess 4. Broughton RA: Nonsurgical managementof deep neck in- fections in children. Pediatr Infect Dis 11:14-8, 1992. and removal of the offending tooth should then be 5. ChowAW, Roser SM, Brady FA: Orofacial odontogenic accomplished at the same time. In one recent study, infections. AnnIntern Med88:392-402, 1978. more than 50% of children with deep neck infections 6. Megran DW,Scheifele DW,Chow AW: Odontogenic infec- did not require surgical drainage. 4 The eight nonsurgi- tions. Pediatr Infect Dis 3:257-65,1984. cal patients in this study became afebrile in a mean of 7. Paonessa DF, Goldstein JC: Anatomyand physiology of head and neck infections (with emphasison the fascia of the 3.8 days (range 1-7 days) after instituting antibiotic face and neck). Otolaryngol Clin North Am9:561-80, 1976. therapy. The author’s recommended therapy paradigm 8. HoraJF: Deepneck infections. Arch Otolaryngo177:129-36, utilizes neck CT for differentiation of cellulitis from 1963. abscess and the presence or absence of respiratory dis- 9. Rabuzzi DD, Johnson JT: Diagnosis and Managementof tress to determine the need for early surgical incision Deep Neck Infections. American Academy of Otolaryngology, Washington, DC, 1978. and drainage. 10. BrandowEC Jr: Immediatetonsillectomy for peritonsillar The microbiology of deep space neck infections con- abscess. Trans AmerAcad Opthalmol Otolaryngol 77:412- tinues to evolve. In 1983, Streptococci (61%) and Staphy- 16, 1973.

222 AmericanAcademy of Pediatric Dentistry PediatricDentistry - 17:3, 1995 11. Murphy JB, Ilacqua J, Bianchi M: Diagnosis of acute maxil- 16. Beck AL: Deep neck infection. Ann Otol Rhinol Laryngol lofacial infections: the role of computerized tomography. 56:439, 722, 1947. Oral Surg Oral Med Oral Pathol 60:154-57, 1985. 17. Beck AL: The influence of the chemotherapeutic and antibi- 12. Holt GR, McManus K, Newman RK, Potter JL, Tinsley PP: otic drugs on the incidence and course of deep neck infec- Computed tomography in the diagnosis of deep neck infec- tion. Ann Otol Rhin & Laryngol 61:515-32, 1952. tions. Arch Otolaryngol 108:693-96, 1982. 18. Hunt DE, Meyer RA: Continued evolution of the microbiol- 13. Hall MB, Arteaga DM, Mancuso A: Use of computed ogy of oral infections. J Am Dent Assoc 107:52-54,1983. tomography in the localization of head-and-neck-space in- 19. Socransky SS, Manganiello SD: The oral microbiota of man fections. J Oral Maxillofac Surg 43:978-80,1985. from birth to senility. J Periodontol 42:485-96, 1971. 14. Schwimmer AM, Roth SE, Morrison SN: The use of comput- 20. Halula M, Macrina FL: Tn5030: a conjugative transposon erized tomography in the diagnosis and management of conferring clindamycin resistance in Bacteroides species. Rev temporal and abscesses. Oral Surg Oral Infect Dis 12(suppl. 2):S235-42,1990. Med Oral Pathol 66:17-20,1988. 21. Gilmore WC, Jacobus NV, Gorbach SL, Doku HC, Tally FP: 15. Endicott JN, Nelson RJ, Saraceno CA: Diagnosis and man- A prospective double-blind evaluation of penicillin versus agement decisions in infections of the deep fascial spaces of clindamycin in the treatment of odontogenic infections. J the head and neck utilizing computerized tomography. Oral Maxillofac Surg 46:1065-70, 1988. Laryngoscope 92:630-33, 1982.

M. MICHAEL. COHEN, SR., DMD, 19O5-1994 His legacy was pediatric stomatology Dr. M. Michael Cohen, Sr., an ant in Dentistry for Children to the U.S. Public Health internationally renowned clini- Service. He served as President of the Brookline Com- cian, researcher, and teacher in munity Council and presided over a wide range of pediatric stomatology, was born activities during the 1950s. He was a member of in Boston in 1905 and died in numerous organizations, including the International Cambridge, Mass., on October Association for Dental Research, Society for Research 17, 1994. He graduated from for Child Development, American Diabetic Associa- Tufts in 1928, practiced dentistry tion, New York Academy of Sciences, and the Royal in Boston and Brookline, and was Society of Health (UK). He was a Diplomate of the affiliated with Beth Israel Hospi- American Board of Pedodontics and held Fellowship M. Michael tal, Boston Floating Hospital, in the American Public Health Association and Amer- Cohen, Sr. New England Center Hospital, ican Association for the Advancement of Science. Children's Hospital Medical Center, Eunice Kennedy His first book, Pediatric Dentistry, went through Shriver Center, and Lakeville Hospital. two editions in 1957 and 1961. The first edition was Most of Dr. Cohen's academic career was at Tufts translated into Spanish. His second book, Minor University School of Dental Medicine. After his re- Tooth Movement in the Growing Child* appeared in tirement from Tufts in 1971, he joined the faculty of 1977 and was translated into Italian, Portuguese, Harvard School of Dental Medicine, where in 1978 and Japanese. the Michael Cohen, Sr. Teaching and Research Fund Dr. Cohen's academic legacy was pediatric was established to help support the departments of stomatology. He was the first dentist to look at the pediatric dentistry and oral medicine and oral pathol- mouth as a window of pediatric disease and lectured ogy. He was the 1982 recipient of the American Soci- widely on the subject. Early papers dealt with juve- ety of Dentistry for Children's Award of Excellence. nile , ectodermal dysplasia, the oral manifes- Dr. Cohen was the first dentist in the U.S. to hold tations of erythroblastic , dental development professorial rank in a pediatrics department in a medi- in pituitary dwarfism, dental age in the adreno- cal school (Tufts University) and the first in the U.S. genital syndrome, the dentition in congenital syphilis to be appointed stomatologist at a pediatric hospital and syndrome, and various aspects of trisomy (Boston Floating Hospital). Together with Dr. Manuel 21 syndrome. For years, he taught oral manifesta- Album, he was instrumental in establishing the Acad- tions of systemic disease to pediatrics house staff and emy of Dentistry for the Handicapped (now the Acad- dental students. emy of Dentistry for Persons with Disabilities). Dr. M. Michael Cohen, Sr. was truly a man for all He was also instrumental in establishing the Mas- seasons who reached out to help others. His academic sachusetts Cerebral Palsy Association and was its first legacy lives on in the endeavors of his students and the President. He was a member of the Massachusetts memories of the many people he influenced. He will Committee on Childhood and Youth and a Consult- be greatly missed by all those whose lives he touched.

Pediatric Dentistry - 17:3,1995 American Academy of Pediatric Dentistry 223