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Mediastinal abscess and empyema complicating an odontogenic infratemporal fossa abscess
YBJOM-4983;
ARTICLE IN PRESS
No. of Pages 2
Available online at www.sciencedirect.com
ScienceDirect British Journal of Oral and Maxillofacial Surgery xxx (2016) xxx–xxx
Letter to the Editor
Mediastinal abscess and empyema complicating an odontogenic infra-temporal fossa abscess Sir, Odontogenic infection can spread through fascial planes into adjacent anatomical spaces. Spread to the mediastinum is rare but well-described and may be associated with thoracic empyema1,2 and mortality from mediastinal spread is thought to be around 30% to 40%.3 Our patient developed a mediastinal abscess and empyema from an odontogenic abscess of the infratemporal fossa. An otherwise healthy 28-year-old man presented to a district general hospital in the UK after four days of facial swelling, trismus, and toothache in the upper right quadrant, and one day of pleuritic chest pain that radiated to his back. His pulse was 112, oxygen saturation was 96% on air, his temperature was 37.6 ◦ C, and C-reactive protein was 393. He had trismus of 10 mm, right buccal swelling with purulent discharge from a sinus in the buccal mucosa, and multiple grossly carious teeth on the upper right. There was no swelling of his neck or beneath his tongue, cardiorespiratory examination was within normal limits, and we gave him antibiotics intravenously. A plain chest radiograph showed no abnormality and an electrocardiogram showed sinus tachycardia, but computed tomography (CT) of his thorax showed early bilateral consolidation in the lung with no pulmonary embolism. An echocardiogram was within normal limits, and so we diagnosed an infection of the lower respiratory tract and an abscess in the right buccal space with potential involvement of the deep masticator space. We extracted the carious teeth and explored the buccal space under a general anaesthetic. The cavity of the abscess extended into the infratemporal fossa, but there were no collections in the deep masticator space. Over three days his facial swelling improved but the chest pain continued and he developed type 1 respiratory failure. A repeat chest radiograph showed basal consolidation on the right side three days
Fig. 1. Computed tomogram of the chest showing pus in the mediastinum (arrows).
after operation, then a large right pleural effusion on day five, and an attempt at aspiration was not successful. CT of his neck and chest showed a large right empyema, consolidation of the right middle and lower lobes, and a mediastinal abscess (Fig. 1) with pus tracking down the carotid sheath (Fig. 2). Thick, purulent fluid was drained from his chest and we transferred him to the cardiothoracic unit. Repeat CT showed a reduction in the empyema, but a multiloculated mediastinal abscess persisted so we treated it with prolonged antibiotics. He was discharged on day 15 and made a good recovery. The specimens of pus did not grow any micro-organisms. Mediastinitis from odontogenic infection is common and may be accompanied by empyema, but we have not found any reports that describe it arising from an odontogenic abscess of the infratemporal fossa. The infratemporal fossa communicates with the parapharyngeal space, which provides a potential route into the mediastinum through the carotid sheath. Exploration of neck spaces may open fascial planes and encourage spread to the mediastinum. Although CT on admission had shown no collections in the neck or chest in our patient, the chest pain could have arisen from early mediastinal involvement, which had not yet formed pus that could
http://dx.doi.org/10.1016/j.bjoms.2016.08.013 0266-4356/© 2016 Published by Elsevier Ltd on behalf of The British Association of Oral and Maxillofacial Surgeons.
Please cite this article in press as: Cobb M, et al. Mediastinal abscess and empyema complicating an odontogenic infra-temporal fossa abscess. Br J Oral Maxillofac Surg (2016), http://dx.doi.org/10.1016/j.bjoms.2016.08.013
YBJOM-4983;
ARTICLE IN PRESS
No. of Pages 2
2
Letter to the Editor / British Journal of Oral and Maxillofacial Surgery xxx (2016) xxx–xxx
Ethics statement/confirmation of patient’s permission No ethical approval required. We obtained written consent from the patient to be included in this paper. References 1. Bounds GA. Subphrenic and mediastinal abscess formation: a complication of Ludwig’s angina. Br J Oral Maxillofac Surg 1985;23:313–21. 2. Dugan MJ, Lazow SK, Berger JR. Thoracic empyema resulting from direct extension of Ludwig’s angina: a case report. J Oral Maxillofac Surg 1998;56:968–71. 3. Pappa H, Jones DC. Mediastinitis from odontogenic infection. A case report. Br Dent J 2005;198:547–8.
Fig. 2. Computed tomogram of the neck showing pus tracking down the carotid sheath (arrow).
be detected radiologically. Clinicians should remain vigilant for the development of mediastinitis, even in patients with maxillary odontogenic infection and no involvement of the neck.
Mark Cobb Newcastle University Medical School, Framlington Place, Newcastle Upon Tyne, NE2 4HH Mhairi Little ∗ ST5, Oral and Maxillofacial Surgery, Royal Victoria Infirmary, Queen Victoria Road, Newcastle Upon Tyne, NE1 4LP Steve Liggins Locum Consultant, Oral and Maxillofacial Surgery, Broomfield Hospital, Essex, CM1 7ET ∗ Corresponding author. E-mail addresses: [email protected] (M. Cobb), [email protected] (M. Little), [email protected] (S. Liggins)
Conflict of interest We have no conflicts of interest.
Please cite this article in press as: Cobb M, et al. Mediastinal abscess and empyema complicating an odontogenic infra-temporal fossa abscess. Br J Oral Maxillofac Surg (2016), http://dx.doi.org/10.1016/j.bjoms.2016.08.013
ARTICLE IN PRESS
No. of Pages 2
Available online at www.sciencedirect.com
ScienceDirect British Journal of Oral and Maxillofacial Surgery xxx (2016) xxx–xxx
Letter to the Editor
Mediastinal abscess and empyema complicating an odontogenic infra-temporal fossa abscess Sir, Odontogenic infection can spread through fascial planes into adjacent anatomical spaces. Spread to the mediastinum is rare but well-described and may be associated with thoracic empyema1,2 and mortality from mediastinal spread is thought to be around 30% to 40%.3 Our patient developed a mediastinal abscess and empyema from an odontogenic abscess of the infratemporal fossa. An otherwise healthy 28-year-old man presented to a district general hospital in the UK after four days of facial swelling, trismus, and toothache in the upper right quadrant, and one day of pleuritic chest pain that radiated to his back. His pulse was 112, oxygen saturation was 96% on air, his temperature was 37.6 ◦ C, and C-reactive protein was 393. He had trismus of 10 mm, right buccal swelling with purulent discharge from a sinus in the buccal mucosa, and multiple grossly carious teeth on the upper right. There was no swelling of his neck or beneath his tongue, cardiorespiratory examination was within normal limits, and we gave him antibiotics intravenously. A plain chest radiograph showed no abnormality and an electrocardiogram showed sinus tachycardia, but computed tomography (CT) of his thorax showed early bilateral consolidation in the lung with no pulmonary embolism. An echocardiogram was within normal limits, and so we diagnosed an infection of the lower respiratory tract and an abscess in the right buccal space with potential involvement of the deep masticator space. We extracted the carious teeth and explored the buccal space under a general anaesthetic. The cavity of the abscess extended into the infratemporal fossa, but there were no collections in the deep masticator space. Over three days his facial swelling improved but the chest pain continued and he developed type 1 respiratory failure. A repeat chest radiograph showed basal consolidation on the right side three days
Fig. 1. Computed tomogram of the chest showing pus in the mediastinum (arrows).
after operation, then a large right pleural effusion on day five, and an attempt at aspiration was not successful. CT of his neck and chest showed a large right empyema, consolidation of the right middle and lower lobes, and a mediastinal abscess (Fig. 1) with pus tracking down the carotid sheath (Fig. 2). Thick, purulent fluid was drained from his chest and we transferred him to the cardiothoracic unit. Repeat CT showed a reduction in the empyema, but a multiloculated mediastinal abscess persisted so we treated it with prolonged antibiotics. He was discharged on day 15 and made a good recovery. The specimens of pus did not grow any micro-organisms. Mediastinitis from odontogenic infection is common and may be accompanied by empyema, but we have not found any reports that describe it arising from an odontogenic abscess of the infratemporal fossa. The infratemporal fossa communicates with the parapharyngeal space, which provides a potential route into the mediastinum through the carotid sheath. Exploration of neck spaces may open fascial planes and encourage spread to the mediastinum. Although CT on admission had shown no collections in the neck or chest in our patient, the chest pain could have arisen from early mediastinal involvement, which had not yet formed pus that could
http://dx.doi.org/10.1016/j.bjoms.2016.08.013 0266-4356/© 2016 Published by Elsevier Ltd on behalf of The British Association of Oral and Maxillofacial Surgeons.
Please cite this article in press as: Cobb M, et al. Mediastinal abscess and empyema complicating an odontogenic infra-temporal fossa abscess. Br J Oral Maxillofac Surg (2016), http://dx.doi.org/10.1016/j.bjoms.2016.08.013
YBJOM-4983;
ARTICLE IN PRESS
No. of Pages 2
2
Letter to the Editor / British Journal of Oral and Maxillofacial Surgery xxx (2016) xxx–xxx
Ethics statement/confirmation of patient’s permission No ethical approval required. We obtained written consent from the patient to be included in this paper. References 1. Bounds GA. Subphrenic and mediastinal abscess formation: a complication of Ludwig’s angina. Br J Oral Maxillofac Surg 1985;23:313–21. 2. Dugan MJ, Lazow SK, Berger JR. Thoracic empyema resulting from direct extension of Ludwig’s angina: a case report. J Oral Maxillofac Surg 1998;56:968–71. 3. Pappa H, Jones DC. Mediastinitis from odontogenic infection. A case report. Br Dent J 2005;198:547–8.
Fig. 2. Computed tomogram of the neck showing pus tracking down the carotid sheath (arrow).
be detected radiologically. Clinicians should remain vigilant for the development of mediastinitis, even in patients with maxillary odontogenic infection and no involvement of the neck.
Mark Cobb Newcastle University Medical School, Framlington Place, Newcastle Upon Tyne, NE2 4HH Mhairi Little ∗ ST5, Oral and Maxillofacial Surgery, Royal Victoria Infirmary, Queen Victoria Road, Newcastle Upon Tyne, NE1 4LP Steve Liggins Locum Consultant, Oral and Maxillofacial Surgery, Broomfield Hospital, Essex, CM1 7ET ∗ Corresponding author. E-mail addresses: [email protected] (M. Cobb), [email protected] (M. Little), [email protected] (S. Liggins)
Conflict of interest We have no conflicts of interest.
Please cite this article in press as: Cobb M, et al. Mediastinal abscess and empyema complicating an odontogenic infra-temporal fossa abscess. Br J Oral Maxillofac Surg (2016), http://dx.doi.org/10.1016/j.bjoms.2016.08.013