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Diagnosis of acute maxillofacial infections: The role of computerized tomography
Diagnosis of acute maxillofacial infections: The role of computerized tomography James B. Murphy, D.M.D., MS.,* Joseph Ilacqua, D.D.S.,** Michael Bianchi. D.D.S.,** Philadelphia, Pa. VETERANS ADMlNlSTRATlON
and
MEDICAL CENTER
Most acute maxillofacial infections are diagnosed by conventional dental and maxillofacial radiographic techniques. Computed tomography has greatly improved our ability to evaluate infections of the maxillofacial region that originate or extend into the contiguous soft tissues and paranasal sinuses. Four cases in which’computed tomography facilitated diagnosis and treatment of advanced infections of the maxillofacial region are presented. In one case an underlying neoplasm was identified. (ORAL SURG. ORAL MED. ORAL PATHOL. 60~154-157,
1985)
I
nfections of the maxillofacial region present distinct diagnostic problems for which radiographic techniques commonly employed for diagnosing pathologic conditions of the bony skeleton are of limited value. Infections of dental origin extending into the paranasal sinuses tend to be diagnosed via conventional sinus radiographs and on clinical grounds. The actual extent of the infectious process may be difficult to ascertain. The maxillary, ethmoidal, sphenoidal, and frontal sinuses are easily and more completely evaluated with computed tomography. The efficacy of treatment can be assessedby intra-and posttreatment CT scans. Patients with dental infections that extend into the parapharyngeal spacesare often difficult to evaluate clinically. Severe trismus, which frequently accompanies these infections, makes examination of the oral cavity and oral pharnyx difficult. Subjective findings, such as difficulty in swallowing and tachypnea, must be relied upon to assess the patient’s airway. Management of the airway in these infections is of primary concern. Computed tomography with soft-tissue-enhancement techniques is valuable in assessingthe displacement of parapharyngeal soft tissues and the secondary impairment of the airway that the soft-tissue displacement creates.’ Areas of localization of pus can be identified in this manner. Infections involving the major salivary glands can *Chief of Oral and Maxillofacial Surgery and Director General Practice Residency Program. **Senior Resident, Oral and Maxillofacial Surgery. 154
of the
be evaluated by conventional sialography. In some instances, however, the patient’s salivary ducts may be difficult to cannulate. In the absence of obvious salivary gland calculi, computed tomography may be helpful in distinguishing infiltrating neoplastic massesfrom salivary gland enlargement secondary to sialadenitis. Third-generation computerized tomographic scanning may eventually replace conventional tomography for the evaluation of maxillofacial pathosis. The improvement in spatial resolution, allowing very thin section scanning, and the use of contrast materials for soft-tissue enhancement have refined the use of CT scanning in the evaluation of infections of the maxillofacial region. Contrast materials containing 28% iodine are injected intravenously in a 50 ml bolus, followed by an intravenous drip of contrast material during scanning.* The soft-tissue enhancement that results is of great value in identifying areas of localization and extension of the infection. CASE 1
The patient was a 28-year-old man in whom an endodontic procedure on the maxillary right canine had been started previously. When he came to our clinic, the patient was complaining of severe right maxillary and periorbital pain. Examination revealed right intraorbital and medial orbital swelling with diplopia on extreme left lateral gaze. The patients’ oral temperature was 102.8” F. The patient was admitted to the oral surgery section and treatment with aqueous penicillin G, 2 million units every 4 hours, was started. Panoramic and conventional sinus radiographs revealed a right maxillary sinusitis. Because of the
Volume
Diagnosis of acute maxillofaciai
60
infections
155
Number ?
Fig. 1. CT scan reveals fluid level in posterior anterior ethmoid air cells (arrows).
and
Fig. 2. CT scan 10 days posttreatment reveals significant resolution. particularly of posterior air cells {arrow).
clinical evidence of periorbital extension of the infection, a computerized tomographic scan was ordered. The results revealed a right maxillary sinusitis with involvement of the right posterior and anterior ethmoid air cells (Fig. 1). The patient’s maxillary right first premolar and canine gave a nonvital response to pulp testing. The area was drained via an intraoral incision, and root canal therapy was completed. Antibiotic therapy was continued. A repeat CT scan 10 days later revealed significant resolution in both the ethmoid and maxillary sinuses (Fig. 2). CASE 2
The patient was a 32-year-old man in whom pain and swelling of the left mandibular angle had developed 4 days earlier. He was started on a regimen of erythromycin, 250 mg four times daily, at a local hospital emergency room. His presenting symptoms on arrival at our clinic were severe pain, trismus, and difficulty in swallowing. Clinical examination revealed a nonfluctuant swelling that obscured the left mandibular angle. Trismus limited the
Fig. 3. Extensive swelling (arrow).
airway
impingement
secondary
to
Fig 4. Area of necrosis within lateral ph:!ryngeal swelling (arrow).
patient’s interincisal opening to 1.0 cm. Oral examination was extremely difficult but revealed deviation of the soft palate and uvula to the right. A panoramic radiograph revealed a periapical lesion of the left mandibular second and third molars. Both teeth had deep carious lesions. The patient’s oral temperature was 102.2” F. Arterial blood gases were within normal limits. The white cell count was 14,700, with a shift to the left. Because of the potential airway impairment, and in an effort to better delineate the extent of the infection, a CT scan was ordered. This revealed a massive lateral pharyngeal swelling, which had partially occluded the airway superiorly (Fig. 3) but did not extend posteriorly or inferiorly to the level of the vocal cords. An area of localization could be seen within the mass (Fig. 4). Treatment with aqueous penicillin G. .i million units intravenously every 4 hours, was started. and a tracheostomy set was placed at the bedside. The patient was given warm saline rinses hourly. After the first. two doses of penicillin, his rectal temperature rose to 104.?.‘,F. Clinda-
156
Murphy,
Zlacqua, and Bianchi
Oral Surg. August.
1985
Fig. 5. Arrow points to well-circumscribed enlargement of the right submandibular gland.
Fig. 6. CT scan reveals massive peritonsillar swelling with central area of necrosis (arrows).
mycin, 600 mg every 6 hours, was added to the antibiotic regimen. The following morning the lateral pharyngeal swelling was draining spontaneously and the patient’s rectal temperature was 99.3” F. The trismus improved over the next 48 hours, and the patient was taken to the operating room for intraoral drainage with extraction of the lower left second and third molars.
revealed a rather cachectic looking man with difficulty in speaking and swallowing. His oral temperature on admission was 99.9”F. There was a massive fluctuant soft-tissue swelling of the right posterolateral pharyngeal wall. Palpation disclosed that the masswas filled with fluid and mildly tender. The patient was edentulous and had no trismus. He was admitted to the hospital and the fluctuant area was carefully aspirated. Yellow fluid, which was not grossly purluent, was aspirated. The immediate Gram stain revealed epithelial cells and white cells, but no bacteria were identified. A CT scan revealed a massive swelling of the oral pharynx, extending into the pharyngeal tissues (Fig. 6). A biopsy of the lesion revealed a squamous cell carcinoma of the oral pharynx. The patient was referred to the head and neck tumor board for definitive treatment.
CASE 3
A 58-year-old man came to our clinic with a firm, tender swelling of the right submandibular region. His temperature was 101.3” F. No drainage could be obtained from the right submandibular duct, and an occlusal radiograph failed to reveal any opaque calculi obstructing the duct. There was no clinical evidence to indicate that the swelling was of dental origin. Repeated attempts to cannulate the duct in the clinic were unsuccessful. The cannula could be passed only a few millimeters beyond the orifice. A CT scan revealed a well-circumscribed enlargement of the left submandibular gland. There was no evidence of extension beyond the capsule of the gland (Fig. 5). The patient was given aqueous penicillin G, 2 million units every 4 hours. His fever decreasedto 98.8” F, but the pain and swelling persisted. The patient was taken to the operating room where, following induction of general anesthesia, the right submandibular duct was dissected from the floor of the mouth and opened posteriorly. Copious amounts of pus immediately began to drain. A cannula was placed and contrast material was injected for an immediate sialogram. The sialogram was consistent with a diagnosis of sialadenitis. CASE 4
A 71-year-old man was referred to our clinic with a diagnosis of possible peritonsillar abscess. Examination
DISCUSSION
In Case 1 computed tomography not only was important in diagnosing the location and extent of the infection but also guided successful therapy. Brandt-Zawadski and colleague9 described two cases of extensive involvement of the paranasal sinuses secondary to odontogenic infection in which computed tomography was used in a similar manner. Involvement of the parapharyngeal spaces is one of the most dreaded complications of oral infections. Involvement of the lateral pharyngeal spacecan lead to acute upper airway obstruction and extension into the retropharyngeal space with possible mediastinal invasion. The advent of CT scanning has allow early diagnosis of extension of infection into these spaces. Diagnosis of impending acute upper airway obstruction facilitates decisive early airway management via
Volume Number
60 2
endotracheal intubation or tracheostomy.’ Surgical intervention can also be directed to areas of localization of ~us.~ The differentiation between inflammatory disease and neoplasia of the salivary glands may be somewhat difficult, as suggested by Bryan and coworkers.5 However, if there is strong clinical evidence to support an inflammatory enlargement, scanning may be helpful in confirming this, particularly if for any reason sialography cannot be performed. The differentiation of primary maxillofacial infections from infiltrating neoplasms with overlying necrosis is facilitated, especially if soft-tissueenhancement techniques are employed. CONCLUSION
Routine dentoalveolar infections can be evaluated on clinical grounds and with standard radiographic techniques. Extension of dental infections into contiguous structures (that is, soft tissues and paranasal sinuses) may complicate our assessmentof the extent of infection. The use of computed tomography has
Diagnosis of acute maxillofacial
infections
157
greatly enhanced our ability to evaluate and treat these often serious infections and, in some cases, to diagnose underlying pathologic conditions. REFERENCES I. Endicott JN, Nelson RJ, Saraceno CA: Diagnosis and management decisions in infections of the deep favzial spaces of the head and neck utilizing computerized tomqraphy. Laryn
goscope 92: 630-633. 19X2. 2. Rabinow K, Kell T. Gordon
PH: Sympostum on CT of the ear. nose. and throat. Radio1 Clin North :\n 22: 145-l 5Y, lYh4. MN, Menagi H. Federle MP. Rowe LD: 3. Brandt-Sawadski High resolution CT with image reformation in maxillofacisl pathology. AJR 138: 477-485, 1982. catheter 4. Cole DR. Bankoff M. Carter BL: Percutaneous drainage of deep neck infections guided by CT Radiology 152:
224. 1984. 5. Bryan RN, Miller tomography 19x2.
RH. Ferreyo RI, Sessions RB: Computed of the major salivary glands. AJR 139: 547-553.
Reprint requests to. Dr. James B. Murphy Department of Oral and Maxillofacial Surgerc Veterans Administration Medical Center University & Woodland Philadelphia. PA I Y104
and
MEDICAL CENTER
Most acute maxillofacial infections are diagnosed by conventional dental and maxillofacial radiographic techniques. Computed tomography has greatly improved our ability to evaluate infections of the maxillofacial region that originate or extend into the contiguous soft tissues and paranasal sinuses. Four cases in which’computed tomography facilitated diagnosis and treatment of advanced infections of the maxillofacial region are presented. In one case an underlying neoplasm was identified. (ORAL SURG. ORAL MED. ORAL PATHOL. 60~154-157,
1985)
I
nfections of the maxillofacial region present distinct diagnostic problems for which radiographic techniques commonly employed for diagnosing pathologic conditions of the bony skeleton are of limited value. Infections of dental origin extending into the paranasal sinuses tend to be diagnosed via conventional sinus radiographs and on clinical grounds. The actual extent of the infectious process may be difficult to ascertain. The maxillary, ethmoidal, sphenoidal, and frontal sinuses are easily and more completely evaluated with computed tomography. The efficacy of treatment can be assessedby intra-and posttreatment CT scans. Patients with dental infections that extend into the parapharyngeal spacesare often difficult to evaluate clinically. Severe trismus, which frequently accompanies these infections, makes examination of the oral cavity and oral pharnyx difficult. Subjective findings, such as difficulty in swallowing and tachypnea, must be relied upon to assess the patient’s airway. Management of the airway in these infections is of primary concern. Computed tomography with soft-tissue-enhancement techniques is valuable in assessingthe displacement of parapharyngeal soft tissues and the secondary impairment of the airway that the soft-tissue displacement creates.’ Areas of localization of pus can be identified in this manner. Infections involving the major salivary glands can *Chief of Oral and Maxillofacial Surgery and Director General Practice Residency Program. **Senior Resident, Oral and Maxillofacial Surgery. 154
of the
be evaluated by conventional sialography. In some instances, however, the patient’s salivary ducts may be difficult to cannulate. In the absence of obvious salivary gland calculi, computed tomography may be helpful in distinguishing infiltrating neoplastic massesfrom salivary gland enlargement secondary to sialadenitis. Third-generation computerized tomographic scanning may eventually replace conventional tomography for the evaluation of maxillofacial pathosis. The improvement in spatial resolution, allowing very thin section scanning, and the use of contrast materials for soft-tissue enhancement have refined the use of CT scanning in the evaluation of infections of the maxillofacial region. Contrast materials containing 28% iodine are injected intravenously in a 50 ml bolus, followed by an intravenous drip of contrast material during scanning.* The soft-tissue enhancement that results is of great value in identifying areas of localization and extension of the infection. CASE 1
The patient was a 28-year-old man in whom an endodontic procedure on the maxillary right canine had been started previously. When he came to our clinic, the patient was complaining of severe right maxillary and periorbital pain. Examination revealed right intraorbital and medial orbital swelling with diplopia on extreme left lateral gaze. The patients’ oral temperature was 102.8” F. The patient was admitted to the oral surgery section and treatment with aqueous penicillin G, 2 million units every 4 hours, was started. Panoramic and conventional sinus radiographs revealed a right maxillary sinusitis. Because of the
Volume
Diagnosis of acute maxillofaciai
60
infections
155
Number ?
Fig. 1. CT scan reveals fluid level in posterior anterior ethmoid air cells (arrows).
and
Fig. 2. CT scan 10 days posttreatment reveals significant resolution. particularly of posterior air cells {arrow).
clinical evidence of periorbital extension of the infection, a computerized tomographic scan was ordered. The results revealed a right maxillary sinusitis with involvement of the right posterior and anterior ethmoid air cells (Fig. 1). The patient’s maxillary right first premolar and canine gave a nonvital response to pulp testing. The area was drained via an intraoral incision, and root canal therapy was completed. Antibiotic therapy was continued. A repeat CT scan 10 days later revealed significant resolution in both the ethmoid and maxillary sinuses (Fig. 2). CASE 2
The patient was a 32-year-old man in whom pain and swelling of the left mandibular angle had developed 4 days earlier. He was started on a regimen of erythromycin, 250 mg four times daily, at a local hospital emergency room. His presenting symptoms on arrival at our clinic were severe pain, trismus, and difficulty in swallowing. Clinical examination revealed a nonfluctuant swelling that obscured the left mandibular angle. Trismus limited the
Fig. 3. Extensive swelling (arrow).
airway
impingement
secondary
to
Fig 4. Area of necrosis within lateral ph:!ryngeal swelling (arrow).
patient’s interincisal opening to 1.0 cm. Oral examination was extremely difficult but revealed deviation of the soft palate and uvula to the right. A panoramic radiograph revealed a periapical lesion of the left mandibular second and third molars. Both teeth had deep carious lesions. The patient’s oral temperature was 102.2” F. Arterial blood gases were within normal limits. The white cell count was 14,700, with a shift to the left. Because of the potential airway impairment, and in an effort to better delineate the extent of the infection, a CT scan was ordered. This revealed a massive lateral pharyngeal swelling, which had partially occluded the airway superiorly (Fig. 3) but did not extend posteriorly or inferiorly to the level of the vocal cords. An area of localization could be seen within the mass (Fig. 4). Treatment with aqueous penicillin G. .i million units intravenously every 4 hours, was started. and a tracheostomy set was placed at the bedside. The patient was given warm saline rinses hourly. After the first. two doses of penicillin, his rectal temperature rose to 104.?.‘,F. Clinda-
156
Murphy,
Zlacqua, and Bianchi
Oral Surg. August.
1985
Fig. 5. Arrow points to well-circumscribed enlargement of the right submandibular gland.
Fig. 6. CT scan reveals massive peritonsillar swelling with central area of necrosis (arrows).
mycin, 600 mg every 6 hours, was added to the antibiotic regimen. The following morning the lateral pharyngeal swelling was draining spontaneously and the patient’s rectal temperature was 99.3” F. The trismus improved over the next 48 hours, and the patient was taken to the operating room for intraoral drainage with extraction of the lower left second and third molars.
revealed a rather cachectic looking man with difficulty in speaking and swallowing. His oral temperature on admission was 99.9”F. There was a massive fluctuant soft-tissue swelling of the right posterolateral pharyngeal wall. Palpation disclosed that the masswas filled with fluid and mildly tender. The patient was edentulous and had no trismus. He was admitted to the hospital and the fluctuant area was carefully aspirated. Yellow fluid, which was not grossly purluent, was aspirated. The immediate Gram stain revealed epithelial cells and white cells, but no bacteria were identified. A CT scan revealed a massive swelling of the oral pharynx, extending into the pharyngeal tissues (Fig. 6). A biopsy of the lesion revealed a squamous cell carcinoma of the oral pharynx. The patient was referred to the head and neck tumor board for definitive treatment.
CASE 3
A 58-year-old man came to our clinic with a firm, tender swelling of the right submandibular region. His temperature was 101.3” F. No drainage could be obtained from the right submandibular duct, and an occlusal radiograph failed to reveal any opaque calculi obstructing the duct. There was no clinical evidence to indicate that the swelling was of dental origin. Repeated attempts to cannulate the duct in the clinic were unsuccessful. The cannula could be passed only a few millimeters beyond the orifice. A CT scan revealed a well-circumscribed enlargement of the left submandibular gland. There was no evidence of extension beyond the capsule of the gland (Fig. 5). The patient was given aqueous penicillin G, 2 million units every 4 hours. His fever decreasedto 98.8” F, but the pain and swelling persisted. The patient was taken to the operating room where, following induction of general anesthesia, the right submandibular duct was dissected from the floor of the mouth and opened posteriorly. Copious amounts of pus immediately began to drain. A cannula was placed and contrast material was injected for an immediate sialogram. The sialogram was consistent with a diagnosis of sialadenitis. CASE 4
A 71-year-old man was referred to our clinic with a diagnosis of possible peritonsillar abscess. Examination
DISCUSSION
In Case 1 computed tomography not only was important in diagnosing the location and extent of the infection but also guided successful therapy. Brandt-Zawadski and colleague9 described two cases of extensive involvement of the paranasal sinuses secondary to odontogenic infection in which computed tomography was used in a similar manner. Involvement of the parapharyngeal spaces is one of the most dreaded complications of oral infections. Involvement of the lateral pharyngeal spacecan lead to acute upper airway obstruction and extension into the retropharyngeal space with possible mediastinal invasion. The advent of CT scanning has allow early diagnosis of extension of infection into these spaces. Diagnosis of impending acute upper airway obstruction facilitates decisive early airway management via
Volume Number
60 2
endotracheal intubation or tracheostomy.’ Surgical intervention can also be directed to areas of localization of ~us.~ The differentiation between inflammatory disease and neoplasia of the salivary glands may be somewhat difficult, as suggested by Bryan and coworkers.5 However, if there is strong clinical evidence to support an inflammatory enlargement, scanning may be helpful in confirming this, particularly if for any reason sialography cannot be performed. The differentiation of primary maxillofacial infections from infiltrating neoplasms with overlying necrosis is facilitated, especially if soft-tissueenhancement techniques are employed. CONCLUSION
Routine dentoalveolar infections can be evaluated on clinical grounds and with standard radiographic techniques. Extension of dental infections into contiguous structures (that is, soft tissues and paranasal sinuses) may complicate our assessmentof the extent of infection. The use of computed tomography has
Diagnosis of acute maxillofacial
infections
157
greatly enhanced our ability to evaluate and treat these often serious infections and, in some cases, to diagnose underlying pathologic conditions. REFERENCES I. Endicott JN, Nelson RJ, Saraceno CA: Diagnosis and management decisions in infections of the deep favzial spaces of the head and neck utilizing computerized tomqraphy. Laryn
goscope 92: 630-633. 19X2. 2. Rabinow K, Kell T. Gordon
PH: Sympostum on CT of the ear. nose. and throat. Radio1 Clin North :\n 22: 145-l 5Y, lYh4. MN, Menagi H. Federle MP. Rowe LD: 3. Brandt-Sawadski High resolution CT with image reformation in maxillofacisl pathology. AJR 138: 477-485, 1982. catheter 4. Cole DR. Bankoff M. Carter BL: Percutaneous drainage of deep neck infections guided by CT Radiology 152:
224. 1984. 5. Bryan RN, Miller tomography 19x2.
RH. Ferreyo RI, Sessions RB: Computed of the major salivary glands. AJR 139: 547-553.
Reprint requests to. Dr. James B. Murphy Department of Oral and Maxillofacial Surgerc Veterans Administration Medical Center University & Woodland Philadelphia. PA I Y104