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Acute facial cellulitis and trismus originating in the external auditory meatus
Acute facial cellulitis and trismus originating in the external auditory meatus D. W. Nitzan and A. Shteyer. Jerusalem, Israel DEPARTMENT OF ORAI. HEBREM’ UNIVERSITY
AND
MAXILLOFACIAL
SURGERY,
HADASSAH
FACULTY
OF DENTAL
MEDICI’bE
N
umerous fascial spaces in the head and neck have been described. Spread of infection in these areas depends on the anatomy of the spaces,which are partially separated from each other by muscles and/or by fascia.I-3Trismus is a common complication accompanying infection in this region becauseof the effect on the masticatory muscles or on the temporomandibular joint. Diagnosis and treatment of infections in the head and neck region are facilitated if one knows and understands the relationship between the different spaces and the possible location of the original infection. However, one should note that the same clinical appearance may originate from several foci in the head and neck.lm3 The purpose of this report is to describe an acute facial infection involved with trismus, originating in the external auditory meatus. Differential diagnosis and treatment are also discussed. CASEREPORT
A 43-year-old woman was referred to the Oral and Maxillofacial Surgery Clinic with severe pain in the right side of the face, accompanied by trismus. The patient reported that the symptoms had appeared suddenly early that morning. There was no history of any systemic disease or allergy to drugs. An extraoral examination revealed a red and very tender swelling in the right parotid area, extending toward the temporomandibular joint, tragus, and external auditory meatus (Fig 1). A discharge from the external auditory meatus was noticed. The clinical appearance was accompanied by marked lymphadenopathy, fever, malaise, and severe trismus. The differential diagnosis consisted of infection that might have spread from several sites: (1) infection of dental origin, (2) acute parotitis, (3) acute temporomandibular joint arthritis, and (4) otitis externa. The intraoral examination and radiographs ruled out the first possibility. Normal salivary secretion qualitatively as well as quantitatively eliminated the second possibility. The third possibility could not be disregarded, despite the normal appear262
Fig.
1. Enlarged external ear with periauricular
indura-
tion. ante of the TMJ radiographs, since the effect of the acute infection might not have yet been manifested in the bone or joint. Infection from the external ear rarely causes trismus, even though this possibility had to be considered. A bacterial culture was taken from the ear discharge and the patient was given antibiotics-amoxicillin 3 grams per day and cloxacillin sodium 3 grams per day. Twenty-four hours later there was no improvement. The bacteriologic culture revealed solitary growth of Pseudomonus aeruginosa sensitive to carbencillin, gentamicin, and the sulphonamides. Since Pseudomonasis a normal inhabitant of the external ear and under certain circumstances may cause the pathognomonic picture of malignant otitis externa,4 we ruled out the possibility of acute TMJ arthritis. The patient was referred to the ENT clinic for
Acute facial
Volume 62 Number 3
further evaluation. The diagnosis of malignant otitis externa (MOE) was confirmed, and the patient was treated with sulphonamides* (50 mg/kg per day) and local irrigations. Within 24 hours her condition had improved dramatically, and within 1 week she had fully recovered. DISCUSSION
Trismus associated with facial cellulitis usually indicates an infection of dental origin. However, it should be borne in mind that, although other uncommon infections may cause similar clinical appearance, a knowledge and understanding of the regional anatomy, the patient’s resistance, and the virulence of bacteria are essential for correct diagnosis and treatment of infections in this area.‘-) The final diagnosis in this case was malignant otitis externa, which was based on two major points: (1) the clinical appearance of swelling and rednessat the region of the external ear and the parotid salivary gland as well as the discharge from the external ear and (2) the isolation of Pseudomonas organisms from the discharge. Pseudomonas aeruginosa is a normal inhabitant of the external ear and, under certain conditions, may result in malignant otitis externa.4ssThis type of infection is rarely associated with trismus, but it might be associated with direct pressure or spread of infection toward the TMJ or the surrounding masticatory muscles via the parotid space and the pterygomandibular space. Usually treatment with the sulfonamides or carbenicillin and gentamicin yields satisfactory results.5~6When this infection occurs in patients with low resistance (elderly patients, diabetic patients), the diseasemay be fatal and must be treated with extreme caution. Treatment consists of high dosesof antibiotics (up to 24 to 30 grams daily of carbenicillin and 3 to 5 *Obtained from Taro under the commercial name sulfisoxazole. 500 mg tablets.
celhlitis
and trismus
263
mg/kg of gentamicin 3 times a day) and occasionally surgery.s-8 The case presented here indicates that malignant otitis externa may cause trismus by direct spread to the TMJ or masticatory muscles. In case of trismus, the first step of the differential diagnosis should concentrate on the more common causes, such as infections originating in the intraoral or perioral tissues. If these are ruled out, more distant areas must be considered as well. REFERENCES I. Laskin DM, Laskin JL: Odontogenic infections of the head and neck. fn Laskin DM: Oral and maxillofacial surgery. Vol. II. Oral surgery. St. Louis, 1985, The C.V. Mosby Company, pp. 219-253. 2. Moose SM, Marshall KS: Acute infections of the oral cavity. In Kruger GO: Textbook of oral and maxillofacial surgery, ed. 6, St. Louis, 1984, The C.V. Mosby Company, pp. 205-2 1.5. 3. Archer WH: Oral, face and neck infections. In Oral and maxillofaciai surgery ed. 5, Philadelphia, 1975, W.B. Saunders Company, Vol. 1, pp. 438-490. 4. Meltzer PE, Kelemen G: Pyocyaneous osteomyelitis of the temporal bone, mandible and zygoma. Laryngoscope 69: 1300-1316, 1959. 5. Caruso UC, Meyerhoff WL: Trauma and infections of the external ear. In Paparella MM, Shumrick PA: Otolaryngology, ed. 2, Philadelphia, 1980, W.B. Saunders Company, Vol. I I, pp. 1345 1349. 6. Feinmesser R, Wiesel YM, Argaman M, Gay I: Otitis externa-bacteriological survey. ORL J Oto-Rhino-Laryngol 44: 121-125, 1982. I. Chandler JR: Malignant external otitis. Laryngoscope 78: 1255, 1968. 8. Meyerhoff WL, Gates GA, Montabo PJ: Pseudomonas mastoiditis. Laryngoscope 87: 483, 1977. Reprint requests to: Dr. D.W. Nitzan Department of Oral and Maxillofacial Surgery Hebrew University-Hadassah Faculty of Dental Medicine P.O. Box I 172 Jerusalem 9 IO IO, Israel
AND
MAXILLOFACIAL
SURGERY,
HADASSAH
FACULTY
OF DENTAL
MEDICI’bE
N
umerous fascial spaces in the head and neck have been described. Spread of infection in these areas depends on the anatomy of the spaces,which are partially separated from each other by muscles and/or by fascia.I-3Trismus is a common complication accompanying infection in this region becauseof the effect on the masticatory muscles or on the temporomandibular joint. Diagnosis and treatment of infections in the head and neck region are facilitated if one knows and understands the relationship between the different spaces and the possible location of the original infection. However, one should note that the same clinical appearance may originate from several foci in the head and neck.lm3 The purpose of this report is to describe an acute facial infection involved with trismus, originating in the external auditory meatus. Differential diagnosis and treatment are also discussed. CASEREPORT
A 43-year-old woman was referred to the Oral and Maxillofacial Surgery Clinic with severe pain in the right side of the face, accompanied by trismus. The patient reported that the symptoms had appeared suddenly early that morning. There was no history of any systemic disease or allergy to drugs. An extraoral examination revealed a red and very tender swelling in the right parotid area, extending toward the temporomandibular joint, tragus, and external auditory meatus (Fig 1). A discharge from the external auditory meatus was noticed. The clinical appearance was accompanied by marked lymphadenopathy, fever, malaise, and severe trismus. The differential diagnosis consisted of infection that might have spread from several sites: (1) infection of dental origin, (2) acute parotitis, (3) acute temporomandibular joint arthritis, and (4) otitis externa. The intraoral examination and radiographs ruled out the first possibility. Normal salivary secretion qualitatively as well as quantitatively eliminated the second possibility. The third possibility could not be disregarded, despite the normal appear262
Fig.
1. Enlarged external ear with periauricular
indura-
tion. ante of the TMJ radiographs, since the effect of the acute infection might not have yet been manifested in the bone or joint. Infection from the external ear rarely causes trismus, even though this possibility had to be considered. A bacterial culture was taken from the ear discharge and the patient was given antibiotics-amoxicillin 3 grams per day and cloxacillin sodium 3 grams per day. Twenty-four hours later there was no improvement. The bacteriologic culture revealed solitary growth of Pseudomonus aeruginosa sensitive to carbencillin, gentamicin, and the sulphonamides. Since Pseudomonasis a normal inhabitant of the external ear and under certain circumstances may cause the pathognomonic picture of malignant otitis externa,4 we ruled out the possibility of acute TMJ arthritis. The patient was referred to the ENT clinic for
Acute facial
Volume 62 Number 3
further evaluation. The diagnosis of malignant otitis externa (MOE) was confirmed, and the patient was treated with sulphonamides* (50 mg/kg per day) and local irrigations. Within 24 hours her condition had improved dramatically, and within 1 week she had fully recovered. DISCUSSION
Trismus associated with facial cellulitis usually indicates an infection of dental origin. However, it should be borne in mind that, although other uncommon infections may cause similar clinical appearance, a knowledge and understanding of the regional anatomy, the patient’s resistance, and the virulence of bacteria are essential for correct diagnosis and treatment of infections in this area.‘-) The final diagnosis in this case was malignant otitis externa, which was based on two major points: (1) the clinical appearance of swelling and rednessat the region of the external ear and the parotid salivary gland as well as the discharge from the external ear and (2) the isolation of Pseudomonas organisms from the discharge. Pseudomonas aeruginosa is a normal inhabitant of the external ear and, under certain conditions, may result in malignant otitis externa.4ssThis type of infection is rarely associated with trismus, but it might be associated with direct pressure or spread of infection toward the TMJ or the surrounding masticatory muscles via the parotid space and the pterygomandibular space. Usually treatment with the sulfonamides or carbenicillin and gentamicin yields satisfactory results.5~6When this infection occurs in patients with low resistance (elderly patients, diabetic patients), the diseasemay be fatal and must be treated with extreme caution. Treatment consists of high dosesof antibiotics (up to 24 to 30 grams daily of carbenicillin and 3 to 5 *Obtained from Taro under the commercial name sulfisoxazole. 500 mg tablets.
celhlitis
and trismus
263
mg/kg of gentamicin 3 times a day) and occasionally surgery.s-8 The case presented here indicates that malignant otitis externa may cause trismus by direct spread to the TMJ or masticatory muscles. In case of trismus, the first step of the differential diagnosis should concentrate on the more common causes, such as infections originating in the intraoral or perioral tissues. If these are ruled out, more distant areas must be considered as well. REFERENCES I. Laskin DM, Laskin JL: Odontogenic infections of the head and neck. fn Laskin DM: Oral and maxillofacial surgery. Vol. II. Oral surgery. St. Louis, 1985, The C.V. Mosby Company, pp. 219-253. 2. Moose SM, Marshall KS: Acute infections of the oral cavity. In Kruger GO: Textbook of oral and maxillofacial surgery, ed. 6, St. Louis, 1984, The C.V. Mosby Company, pp. 205-2 1.5. 3. Archer WH: Oral, face and neck infections. In Oral and maxillofaciai surgery ed. 5, Philadelphia, 1975, W.B. Saunders Company, Vol. 1, pp. 438-490. 4. Meltzer PE, Kelemen G: Pyocyaneous osteomyelitis of the temporal bone, mandible and zygoma. Laryngoscope 69: 1300-1316, 1959. 5. Caruso UC, Meyerhoff WL: Trauma and infections of the external ear. In Paparella MM, Shumrick PA: Otolaryngology, ed. 2, Philadelphia, 1980, W.B. Saunders Company, Vol. I I, pp. 1345 1349. 6. Feinmesser R, Wiesel YM, Argaman M, Gay I: Otitis externa-bacteriological survey. ORL J Oto-Rhino-Laryngol 44: 121-125, 1982. I. Chandler JR: Malignant external otitis. Laryngoscope 78: 1255, 1968. 8. Meyerhoff WL, Gates GA, Montabo PJ: Pseudomonas mastoiditis. Laryngoscope 87: 483, 1977. Reprint requests to: Dr. D.W. Nitzan Department of Oral and Maxillofacial Surgery Hebrew University-Hadassah Faculty of Dental Medicine P.O. Box I 172 Jerusalem 9 IO IO, Israel