Cumhuriyet Dent J 2012;15(4):344-347 doi:10.7126/cdj.2012.1599 A rare complication following maxillary third molar extraction: infratemporal fossa abscess Sidika Sinem Soydan, DDS, PhD,a Burak Bayram, DDS, PhD,b Gorkem Muftuoglu, DDSc Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Baskent University, Ankara, Turkey. Received: 10 June 2012 Accepted: 07 July 2012 ABSTRACT Infratemporal fossa abscess formation is a very rare and life threatening condition and also its differential diagnosis is a very difficult process. Infratemporal fossa abscess following the non-infected, asymptomatic, erupted maxillary third molar extraction in a young and healthy patient is an unexpected and unusual complication. A 25 years old, male patient with a significant infratemporal fossa abscess and his treatment protocol was presented in this case report. Keywords: Infratemporal fossa abscess, infratemporal fossa infection, intraoral drainage, third molar extraction ---------------------------------------------------------------------------------------------------------------------------------------------------- INTRODUCTION In this case report, infratemporal fossa The masticator space lies down from the abscess formation following the infratemporal fossa to deep asymptomatic maxillary right third molar nasopharyngeal space. The infratemporal extraction in a healthy, male, young patient fossa is an irregularly shaped space below and its treatment protocol were presented. the greater wing of the sphenoid bone (containing the foramen ovale), lateral to CASE REPORT the ramus of the mandible and the gap A 25 years old, ASA I male patient between the zygomatic arch and temporal referred to the clinic with a significant pain bone.1 around his right temporal region. In Isolated infratemporal fossa abscess addition, he had high fever and his general formation is a relatively rare condition. situation was poor. Restricted mouth Infratemporal fossa abscess usually occurs opening was observed during the clinical following the maxillofacial tuberculosis, examination. maxillary sinusitis, maxillary fracture or Two weeks before he applied to our peritonsiller infection.2 The differential department, his erupted maxillary right diagnose of infratemporal fossa abscess is third molar was extracted in another clinic clinically complicated. The early diagnose without any complication. Two days of the infratemporal abscess formation is before he applied to our department, he important because it may cause intracranial started to receive an oral penicillin therapy. or neck spread of infection.3 Healing of oral mucosa was not sufficient ---------------------------------------------------- however there was not any infection or pus Sidika Sinem SOYDAN drainage at the extraction side clinically. Department of Oral and Maxillofacial Surgery Faculty of Dentistry He had a severe trismus and his maximal Baskent University interincisal distance was 9mm. Ankara, Turkey Radiographic evaluation was performed by Tel: +903122151336 Fax: +903122152962 digital panoramic radiography (Figure 1) e-mail: [email protected] and magnetic resonance imaging (MRI). Panoramic radiograph was normal however MRI revealed that there was an 344 Published online: 6 September 2012 Soydan et al. Figure 1. The extraction socket of the upper right third molar can be detected on the panoramic radiograph. A B Figure 2. A. The abscess formation behind the maxillary sinus can be detected by MRI on sagittal plane. B. The abscess formation behind the tuber of maxillary bone can be detected by MRI on coronal plane. abscess formation in the infratemporal antibiogram evaluation. Following the fossa (Figure 2A and 2B). puncture, the dissection was performed Intraoral puncture was made by 24 along the tuber of the maxilla and abscess gauge needle. was drained (Figure 3). The drain was The needle was directed superiorly, kept for 4 days for ongoing pus drainage. medially and posteriorly behind the tuber Combined intramuscular 1 gram of maxilla and moved in to the abscess ampicillin-sulbactam, 500 mili-gram oral formation. 4cc pus was aspirated and metronidazole were prescribed to the specimen was immediately forwarded for patient and patient used these antibiotics 345 Cumhuriyet Dent J 2012;15(4):344-347 doi:10.7126/cdj.2012.1599 infratemporal fossa part of the masticator space; this route is accepted as the most common pathway of infratemporal fossa infection.7 In the presented case, isolated infratemporal abscess occurred following the non-infected erupted maxillary third molar extraction in young, healthy patient. The possible reasons of the infection would be the unsterile tooth extraction procedure, needle track infection or infected hematoma. Infratemporal fossa abscess formation is generally occurs with external otitis, orbital cellulitis, panfacial cellulitis, maxillary sinus fractures, neighborhood Figure 3. The intraoral dissection and infections or mediastinitis. There are few drainage were performed along the tuber of infratemporal fossa abscess cases in the the maxilla. literature which were reported as an upper or lower third molar extraction complication.3,8,9 for one week period. Patient also used The primary challenge is diagnosis of muscle relaxants for two weeks. infratemporal fossa abscess because of its His mouth opening became 15 mm in localization. The clinical signs of seven days. infratemporal fossa abscess are restricted Trismus was keep going approximately mouth opening due to the influence of one month. Patient’s limited mouth medial pterygoid muscle and pain and; opening was improved by aggressive they are not different from any other physiotherapy with tongue bundles. The odontogenic infection findings. The pain is patients’ recovery was successful and there usually localized in front and upper side of was no recurrence of infection. the ear. Nasopharyngeal abscess, facial neuritis and temporal artheritis are the DISCUSSION possible differential diagnosis for The masticator space includes the infratemporal fossa abscess. MRI is the mandible, masseter, medial and lateral most prefarable technique for detection of pterygoid, and temporalis muscles. The the abscess formation in the infratemporal masticator space can be divided two fossa.10 separate spaces as superior infratemporal Exact diagnosis of infratemporal fossa fossa and medial deep nasopharyngeal abscess is essential because the treatments space.4 Some authors distinguish an of all differential diagnosis are variable. additional third space within the masticator The treatment of arthritis and neuritis is space, termed the submassateric space, performing only with the prescribing of located between the masseter muscle and steroids. The treatment of nasopharyngeal the ramus of the mandible.5 Most and infratemporal fossa abscess include frequently infected masticatory space is both drainage and antibiotics usage. If the submasseteric space.6 steroid prescribing to a patient who has Masticatory spaces infection usually infratemporal fossa abscesses, infection starts from the mandibular odontogenic will spread to the vital neighboring tissues. infections, may spread superiorly to the 346 Published online: 6 September 2012 Soydan et al. Intraoral drainage of the infratemporal diagnostic dilemma. Ear Nose Throat fossa abscess is a difficult procedure due to J 2009;88:23. the anatomic complexity and visualizing 3. Diacono M S, Wass A R. problems. Although early reports describe Infratemporal and temporal fossa an external approach to drainage the abscess complicating dental infratemporal fossa through a modified extraction. Accid Emerg Med Blair incision,11 the presented abscess was 1998;15:59-67. managed successfully by an intraoral 4. Chong V F H, Fan Y F. Pictorial approach without any recurrence, scar or review: radiology of the masticator patient hospitalization. space. Clin Radiol 1996;51:457-465. Due to previous antibiotic usage of the 5. Balatsouras D G, Kloutsos G M, patient, the result of the antibiogram test Protopapas D. Submassateric was unreliable. Infection had not been abscess. J Laryngol Otol taken under control despite of previously 2001;115:68-70. used amoxicillin. Intramuscular ampicillin- 6. Yonetsu K, Izumi M, Nakamura T. sulbactam was prescribed to the patient for Deep facial infections of odontogenic the improvement of the bio-availability of origin: CT assessment of pathways the antibiotic therapy and successful of space involvement. AJNR Am J treatment of IFA, which has the potential Neuroradiol 1998;19:123 -128. to spread to cranium or mediastinum. 7. Pepato A O, Yamaji M A K, Sverzut Ampicillin-sulbactam therapy was C E, Trivellato A E. Lower third preferred as it is effective on wide range of molarinfection with purulent penicillin resistant gram positive and discharge through the negative bacteria. Additionally, oral externalauditory meatus. Case report metronidazole was also given in order to and review of literature. Int J Oral control the possible existence of anaerobic Maxillofac Surg 2012; 41:380-383. bacteria and muscle relaxant was 8. Oliveira P J, Souza Maliska M C, prescribed to the patient for helping the Sawazaki R, Asprino L, Moraes M, improvement of limited mouth opening. Moreira R W. Temporal abscess after third molar extraction in the CONCLUSION mandible. J Oral Maxillofac Surg The clinicians should always be aware 2012;16:107-110. of the infratemporal fossa abscess 9. Mesgarzadeh A H. Post extraction formation as a differential diagnosis of infratemporal space infection: