Infratemporal Fossa Abscess Complication of Dental Injection

CLINICAL NOTE Infratemporal Fossa Abscess Complication of Dental Injection Douglas Leventhal, MD; David N. Schwartz, MD, DMD he infratemporal fossa (ITF) is a rare anatomic site for abscess formation. Infections in this space have been found following maxillary sinusitis, maxillary sinus fracture, temporomandibular arthroscopy, dental infection, and tooth extraction.1-5 The ITF is bounded superiorly by the sphenoid bone, medially by the lateral pterygoid plate, anteriorly by Tthe maxilla, posteriorly by the deep parotid region, and laterally by the mandibular ramus. The ITF contains important neurovascular structures and communicates with the orbit and middle cra- nial fossa. Therefore, infection may spread to these areas leading to rapid clinical deterioration. Prompt diagnosis and initiation of treat- lofacial surgeon, where she was diag- ment is of the utmost importance in man- nosed with a buccal space infection and was aging this condition. This case of an ITF admitted to the hospital. The patient was abscess may have resulted from multiple afebrile, and her complete white blood cell needle sticks necessary to achieve anes- count was 6500/µL (to convert to ϫ109/L, thesia prior to a dental procedure. This is multiply by 0.001). A computed tomo- a potentially unusual cause of infection, graphic scan of the head and sinus was per- but the presenting symptoms and subse- formed and showed no evidence of ab- quent imaging study led to the diagnosis. scess formation (Figure 1). The following Incision and drainage was performed lead- morning, the patient underwent extrac- ing to clinical improvement. tion of the right second maxillary molar and incision and drainage of the buccal space REPORT OF A CASE infection, which revealed no fluid collec- tion. The patient was discharged the fol- A 39-year-old, otherwise healthy woman lowing day and continued taking clinda- with a history of a dental filling placed in mycin and levofloxacin. the second maxillary molar 2 weeks prior The patient’s symptoms worsened over was admitted to the hospital for a right buc- the ensuing 6 days, prompting a visit to cal space infection. The patient stated that the emergency department. On examina- she required multiple needle sticks as well tion, she was afebrile and showed no signs as maxillary nerve block anesthesia to of respiratory distress. She had diffuse achieve adequate anesthesia for the filling right-sided facial swelling over the tem- placement. The patient noted no dental poral, maxillary, and submaxillary re- complaints prior to the filling placement, gions. She had right masseter muscle but after the procedure she began experi- spasm with moderate submaxillary indu- encing severe pain in the right side of her ration. There was no proptosis, extraocu- mouth. She returned to the dentist and re- lar movements were intact, and gross vi- ceived clindamycin. The patient’s dental sual acuity appeared normal. There was pain became increasingly more severe and marked trismus with an interincisal op- she began to develop right-sided facial ening of about 5 mm, making intraoral ex- swelling and trismus. At this point, she amination difficult. The right Stenson duct sought treatment from an oral and maxil- appeared inflamed but without purulent discharge. The prior dental extraction Author Affiliations: Department of Otolaryngology–Head & Neck Surgery, socket appeared to be healing well; how- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania. ever, there was fullness in the surround- (REPRINTED) ARCH OTOLARYNGOL HEAD NECK SURG/ VOL 134 (NO. 5), MAY 2008 WWW.ARCHOTO.COM 551 Downloaded from www.archoto.com at Scott Memorial Library @ Thomas Jefferson Univ., on March 16, 2009 ©2008 American Medical Association. All rights reserved. an uncommon complication of dental infections and tooth extrac- tions. Although rare, it is important to recognize the possibility of this clinical entity following any dental procedure. This case exemplifies the diffi- culty in clinical diagnosis of an ITF abscess. Given the patient’s history, the exact etiology of the abscess formation is unclear. Most cases of ITF abscesses occur following spread from an odontogenic infection or dental extraction. The possibility of a dental infection prior to Figure 1. Initial computed tomographic scan, Figure 3. Repeated computed tomographic scan which was viewed as having no evidence of (coronal view) showing infratemporal fossa placement of the dental filling may abscess. abscess (arrow). be considered in this case; how- ever, our patient had no clinical signs of infection at presentation and had cavity was widely opened, and ap- no medical conditions predispos- proximately 15 mL of pus was lib- ing her to severe infections. Further- erated and examined for cultures. more, her symptoms seemed to ap- The cavity was copiously irrigated pear directly following the dental with isotonic sodium chloride so- filling procedure. Schwimmer et al4 lution, and a 0.5-inch Penrose described 3 patients with ITF ab- drain was then placed through the scesses following dental extrac- open intraoral wound into the ab- tions. In each case, the patients’ scess cavity. symptoms began shortly after re- Over the next few days, the pa- moval of the tooth. Gallagher and tient clinically improved, and she was Marley5 also described a case of ITF able to tolerate a soft dysphagia diet. infection that followed extraction of The drain was left in place and she a clinically noninfected tooth. In this continued to have minimal intra- case, the patient’s pain and facial oral purulent drainage. She re- swelling manifested prior to tooth Figure 2. Repeated computed tomographic scan mained afebrile, and her complete (axial view) showing infratemporal fossa extraction. In retrospect, the initial white blood cell count, which peaked abscess (arrow). computed tomographic scan at 16 100/µL, had subsequently de- (Figure 1) taken shortly after our pa- clined to 5800/µL. The culture grew ing buccal space. She exhibited hyp- tient’s dental filling procedure, rare Staphylococcus aureus, rare esthesia in the right V dermatome. which was viewed as normal, 3 Staphylococcus species (coagulase Nasopharyngeal laryngoscopy re- showed asymmetry between the in- negative), rare Streptococcus viri- vealed mild right pharyngeal full- fratemporal areas and a possible dans, and rare Candida albicans. The ness with a widely patent airway. phlegmon. This suggests that the in- patient was discharged on postop- The patient’s complete white blood fectious process in the ITF had be- erative day 4 with the drain in place cell count on admission was 11 300/ gun prior to the dental extraction. and was prescribed a 10-day course µL. A repeated computed tomo- One hypothesis as to the etiol- of doxycycline. graphic scan revealed a 3.8-cm right ogy of the abscess is from the mul- At 1-week follow-up, she con- ITF abscess, possibly extending tiple needle sticks and maxillary tinued to show improvement and down the right pterygoid muscle nerve block anesthesia that the pa- the drain was removed. She still (Figure 2 and Figure 3). tient received prior to her dental had considerable trismus, but her The following day the patient filling placement. In a maxillary interincisal opening had improved was taken to the operating room nerve block, the needle enters the to 1.5 cm. The patient was in- for incision and drainage of the pterygopalatine fossa, which is di- structed on range-of-motion exer- right ITF abscess. The risks, ben- rectly connected to the ITF. The cises and was referred for physio- efits, and alternatives were ex- pterygoid plexus of veins is in close therapy. Close follow-up was also plained to the patient, and in- proximity to the area approached recommended. formed consent was obtained for with this technique and, if entered, the procedure. Using a Keen ap- may lead to hematoma formation. proach, we bluntly dissected along COMMENT Therefore, the patient may have the posterior buttress of the maxil- developed a hematoma within the lary sinus. We cautiously dissected Infratemporal fossa abscess is a rare ITF that subsequently became in- superolaterally and then posteri- condition that is scantly described fected. In addition, the insertion of orly to enter the abscess space. The in the literature. It has been cited as the needle may have seeded organ- (REPRINTED) ARCH OTOLARYNGOL HEAD NECK SURG/ VOL 134 (NO. 5), MAY 2008 WWW.ARCHOTO.COM 552 Downloaded from www.archoto.com at Scott Memorial Library @ Thomas Jefferson Univ., on March 16, 2009 ©2008 American Medical Association. All rights reserved. isms into the pterygopalatine fossa Submitted for Publication: Febru- ing; February 14-18, 2007; Marco and ultimately into the ITF. ary 8, 2007; accepted March 15, 2007. Island, Florida. Correspondence: David N. Schwartz, MD, DMD, Associates in Ear, Nose, CONCLUSIONS Throat & Facial Plastic Surgery, 103 REFERENCES Old Marlton Pike, Medford, NJ 08055 This case of an ITF abscess high- ([email protected]). 1. Raghava N, Evans K, Basu S. Infratemporal fossa lights the importance of prompt Author Contributions: Drs Leven- abscess: complication of maxillary sinusitis. J Laryn- diagnosis because of the potential thal and Schwartz had full access to gol Otol. 2004;118(5):377-378. for spread into the orbit and skull all the data in the study and take re- 2. Weiss BR. Infratemporal fossa abscess unusual com- base. Given the numerous avenues sponsibility for the integrity of the plication of maxillary sinus fracture. Laryngoscope. for the infection to disseminate, a data and the accuracy of the data 1977;87(7):1130-1133. 3. Chossegros C, Cheynet F, Conrath J. Infratempo- patient’s condition can rapidly analysis. Study concept and design: ral space infection after temporomandibular ar- deteriorate, leading to grave con- Leventhal and Schwartz. Critical re- throscopy: an unusual complication. J Oral Max- sequences. The presenting signs vision of the manuscript for important illofac Surg.

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