Open Access
Issue
J Oral Med Oral Surg
Volume 24, Number 3, October 2018
Page(s) 122 - 124
Section Cas clinique / Short case report
DOI https://doi.org/10.1051/mbcb/2018012
Published online 10 October 2018

© The authors, 2018

Licence Creative Commons
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Clinical observation

The patient was a 24-year-old active male smoker (5 pack-years) with no relevant medical history. He was referred by an oral surgeon for emergency management for persistent submandibular cellulitis that had been resistant to previous medical treatment. The patient gave a history of experiencing a left submandibular pain over a 1-week period and complained of trismus for 2 days.

One week before the referral, he consulted a practitioner and was prescribed amoxicillin for 7 days at a dose of 2 g/day in combination with nonsteroidal anti-inflammatory agents (250 mg doses of niflumic acid) administered systematically three times/day. Treatment was substituted 1 week later with a combination of amoxicillin/clavulanic acid 3 g/day with a steroidal anti-inflammatory agent (betamethasone 4 mg/day).

Approximately 8 days after the initial visit, the patient consulted a second practitioner, who prescribed prednisolone of 60 mg/day the day before he was referred to our department. The patient then consulted a third practitioner, who urgently referred him to our service.

At presentation, the patient showed signs of systemic infection. The clinical examination at arrival revealed a painful left submandibular swelling, severe trismus with a narrow 8-mm residual mouth opening, and presence of odynophagia without any dyspnea or dysphonia. An orthopantomogram revealed that tooth no. 38 was noncarious and impacted (Fig. 1). A provisional diagnosis of suppurative pericoronitis of the left third mandibular molar complicated by parapharyngeal cellulitis and trismus was made.

Emergency contrast computed tomography (CT) was performed to confirm and refine the diagnosis. It revealed an abscess measuring 26 mm × 44.5 mm × 50 mm in a posterolingual position on the left mandible and a satellite edema of the oropharynx, resulting in a mass effect at the supraglottic junction (Fig. 2).

The initial clinical examination suggested an inflammatory reaction. In the emergency department, the patient underwent abscess drainage and avulsion of the causal tooth under general anesthesia, after which a Delbert-type drainage flap was put in place. All the anti-inflammatory agents were discontinued and only the amoxicillin/clavulanic acid combination was maintained at a dosage of 3 g/day, together with level-I and level-II analgesics.

The postoperative period was marked by a significant, soft, left hemifacial swelling that was not present before the operation (Figs. 3 and 4).

A fresh CT scan was performed due to the lack of postoperative improvement, along with the presence of large swelling below the zygomatic arch and the persistent signs of inflammation.

An infected hematoma, left zygomatic abscess, with peripheral enhancement, measuring 44 mm × 48 mm × 66 mm was observed, indicating a poorly localized abscess with widespread infiltration of satellite muscles (Fig. 5).

After observing the zygomatic swelling, anticoagulation via a preventative dose of low-molecular-weight heparin was prescribed, considering the risk of thrombophlebitis of the facial vein.

The initial mandibular posterolingual abscess had completely regressed. A second surgery under general anesthesia was performed to drain the abscess, resulting in the drainage of blood stained pus. Further evaluation revealed that this abscess had not become continuous with the original abscess. Moreover, original abscess site had already begun healing. The source of the second abscess fluid collection was situated in the distal vestibular root of the maxillary premolars, within the soft tissue of the cheek. After drainage, a Delbert-type drainage flap was put in place (Fig. 4).

There were no postoperative complications after the second surgery, but the trismus slowly decreased. The mouth opening improved to 15 mm by day 5 after the second operation but it did not resolve completely.

Clinical follow-up on day 9 after the second surgical intervention revealed an improvement in mouth opening to 20 mm, and physical therapy with self-rehabilitation was prescribed. Physical examination during rehabilitation revealed a tender muscular cord involving the medial pterygoid muscle.

In conclusion, the patient was hospitalized for a total of 11 days for pericoronitis of 38 with an abscess that was initially ameliorated by anti-inflammatory agents; however, thereafter, the case was complicated by a superinfection of the postoperative hematoma within the mandibular elevators (Fig. 5).

thumbnail Fig. 1

Axial CT scan with contrast administration taken on the day of admission.

thumbnail Fig. 2

Clinical aspect at D1 of first procedure.

thumbnail Fig. 3

Clinical findings on postoperative day 3 after the first procedure.

thumbnail Fig. 4

Coronal CT scan with contrast administration on postoperative day 4 after the first procedure.

thumbnail Fig. 5

Initial orthopantomogram.

Discussion

Odontogenic facial cellulitis is a bacterial infection of the facial tissues that can pose a significant risk to the patient [1]. Such cases are frequently encountered in odontology and oral surgery departments. Several common and rare causes exist for this condition. In the present case, an unusual complication was observed in the postoperative phase [2,3].

The origin of the left perimaxillary hematoma that appeared in early postoperative care should be specified. No sites other than 38 were explored during the first operation. The only plausible assumption is that of torn muscular insertions of the affected mandibular elevators, causing widespread bloody infiltration of the muscles, which was secondarily infected to form the septic hematoma [4]. Indeed, the tight trismus did not decrease after the induction of anesthesia, but the mouth opening was insufficient for the alveolectomy. Hence, the mouth had to be forced open for the extraction of the impacted tooth 38. The appearance of perimaxillary edema on postoperative day 1 indicates the infection of the affected soft tissue, especially in light of the obvious reduction in perimandibular and submandibular edema on the left side.

Our experience with this case forces the reevaluation of treatment in cases where cellulitis complicated by trismus.

Indeed, the avulsion of a third impacted mandibular molar often requires a sufficient vestibular and distal alveolectomy with coronal and/or inter-radicular separation, which only involves a certain degree of buccal opening for a certain period of time. This discussion brings to the fore the appeal of avulsing the affected tooth at a separate time from when the emergency surgery is performed.

With regard to the case presented here, the patient underwent two intubations while being awake under very difficult conditions as evidenced by the induction durations: durations between the start of anesthesia and intubation being 46 min and 52 min for the first and second surgeries, respectively. Such maneuvers are associated with significant morbidity/mortality. The current knowledge allows us to predict to a certain degree, the aesthetic/functional sequelae and the possibility of a subsequent adjuvant surgical procedure with the type of strap muscle release.

Conflicts of interests

The authors declare that they have no conflicts of interest in relation to this article.

References

  1. Obaitan I, Dwyer R, Lipworth AD, Kupper TS, Camargo CA, Hooper DC, et al. Failure of antibiotics in cellulitis trials: a systematic review and meta-analysis. Am J Emerg Med. août 2016;34:1645–1652. [CrossRef] [Google Scholar]
  2. Calon B, Schellenberger C, Gros C-I, Bornert F, Ludes PO, Féki A. Tuméfactions cervico-faciales per et post-opératoires immédiates en chirurgie bucco-dentaire. Méd Buccale Chir Buccale. 2013;19:251–257. [CrossRef] [Google Scholar]
  3. Peron J-M, Mangez J-F. Cellulites et fistules d'origine dentaire. EMC (Elsevier Masson SAS, Paris), Stomatologie/Odontologie, 22-033-A-10, 2002, Médecine buccale, 28-370-C-10, 2008. [Google Scholar]
  4. Couly G. Anatomie topographique maxillo-faciale. EMC (Elsevier Masson SAS, Paris), Stomatologie, 22-001-C-10, 1978, Médecine buccale, 28-050-U-10, 2008. [Google Scholar]

All Figures

thumbnail Fig. 1

Axial CT scan with contrast administration taken on the day of admission.

In the text
thumbnail Fig. 2

Clinical aspect at D1 of first procedure.

In the text
thumbnail Fig. 3

Clinical findings on postoperative day 3 after the first procedure.

In the text
thumbnail Fig. 4

Coronal CT scan with contrast administration on postoperative day 4 after the first procedure.

In the text
thumbnail Fig. 5

Initial orthopantomogram.

In the text

Current usage metrics show cumulative count of Article Views (full-text article views including HTML views, PDF and ePub downloads, according to the available data) and Abstracts Views on Vision4Press platform.

Data correspond to usage on the plateform after 2015. The current usage metrics is available 48-96 hours after online publication and is updated daily on week days.

Initial download of the metrics may take a while.