Submasseteric abscess Unlikely case of submasseteric abscess originating from a maxillary molar: The skipping lesion Abstract Objective Min Jim Lima & Alauddin Muhamad Husinb We report a case of submasseteric abscess originating from a maxillary tooth, complicated by underlying diabetes mellitus and a multidrug- a Oral Maxillofacial Surgery Department, Hospital Tanah Merah, Tanah Merah, Kelantan, Malaysia resistant organism. b Oral Maxillofacial Surgery Department, Hospital Sultanah Nur Zahirah, Kuala Terengganu, Terengganu, Malaysia Materials and methods Corresponding author: A 61-year-old male patient with uncontrolled diabetes mellitus presented with swelling on the left cheek of 2 weeks in duration with rapid Dr. Min Jim Lim Oral Maxillofacial Surgery Department progression to trismus, dysphagia and rupture of swelling with pus Hospital Tanah Merah discharge. Culture and sensitivity testing revealed the presence of 17500 Tanah Merah Klebsiella pneumoniae Kelantan multidrug- resistant . Based on the patient’s history Malaysia and clinical presentation, a diagnosis of submasseteric abscess originat- [email protected] ing from the maxillary molar was made. Antibiotic administration, con- trol of systemic disease and wound dressing were done as treatment. How to cite this article: Result Lim MJ, Muhamad Husin A. Unlikely case of submasseteric abscess originating from a maxillary The patient made a full recovery, with scarring on the ruptured region. molar: The skipping lesion. J Oral Science Rehabilitation. 2018 Dec;4(4):52–55. Conclusion Submasseteric abscess is a rare case of infection that can occur in the submasseteric space. As is commonly known, infection of the submas- seteric space originates from mandibular third molars; hence, maxillary molars seem to be an unlikely source of infection. Diagnosis of submas- seteric abscess 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; maxillary molar; skipping lesion. 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 diabe tes 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 mandible 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 pericoronitis of the third molar.3 intravenous crystalline penicillin 4 mega units The submasseteric space is a potential space Journal of Volume 4 | Issue 4/2018 53 Oral Science & Rehabilitation Submasseteric abscess 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 masseter muscle the submasseteric space, without having face involving the and its investing fascia. Submasseteric abscess infected the buccal space 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 find 1 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 becomes fluctuant and erythematous.5 K. 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, pterygomandibular space and the microbiology results, the abscess had rup- infratemporal space. 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.