Abstract
We describe a 58-year-old man with a unique complication of chronic mandibular osteomyelitis. He presented with a unilateral facial nerve palsy and a non-traumatic dislocation of the mandibular condyle into the middle cranial fossa combined with a temporal lobe abscess. An odontogenic infection had already been festering for 18 months. After stereotactic puncture, P. Aeruginosa was cultured out of the brain abscess and the patient was treated with a culture-based antibiotic therapy followed by condylectomy and myofascial temporalis flap. One year after the surgery, the patient had a partial ossification of the glenoid fossa, recovered mouth opening and sufficient function. This report shows that the rare complication of chronic mandibular osteomyelitis with concurrent brain abscess can be treated successfully using a combination of aggressive long-term culture-based antibiotic treatment and a multidisciplinary surgical approach.
Highlights
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non-traumatic dislocation of the mandibular condyle into the middle cranial fossa and a temporal lobe abscess.
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A very rare complication of chronic mandibular osteomyelitis.
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Successful treatment with antibiotic therapy followed by condylectomy and myofascial temporalis flap.
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The importance of early diagnosis and follow-up and the consequences if not done correctly.
1
Introduction
Intracranial displacement of the mandibular condyle into the middle cranial fossa is a rare phenomenon [ ]. Today, around 60 cases have been described in medical literature [ ]. It is usually caused by a traumatic incident where the condyle is ‘pushed’ through its bony roof into the middle cranial fossa [ ].
Adequate treatment can only be obtained using a multidisciplinary approach [ , ]. Patients have been treated with varying degrees of success with either closed reduction (most common in patients younger than 15 years), open reduction (most common in patients 16 years and older), condylectomy, condylotomy, temporomandibular joint (TMJ) implants or reconstructions whether or not involving craniotomy [ , ]. Open reduction of the condyle is advised especially in prolonged cases of TMJ dislocation [ , ].
In this report, a patient is presented with non-traumatic dislocation of the left condyle into the middle cranial fossa complicated with temporal lobe abscess and skull base osteomyelitis. Clinical presentation and therapeutic management are discussed and a review of the literature is provided.
1.1
Case presentation
A 58-year-old man with a history of COPD, liver cirrhosis and spleno-pancreatectomy, was referred to the emergency department (Glasgow Coma Scale 15/15). Clinical examination showed a mild left facial swelling with a facial nerve palsy (House-Brackmann (HB) score IV) and a reduced mouth opening (<25 mm) with chin deviation to the left side. There were no other neurological signs or symptoms present. Otomicroscopy showed a normal external ear canal and tympanic membrane, but a partial middle ear effusion. A matching mild conductive hearing loss could be diagnosed by pure tone air and bone conduction audiometry. Sensitivity of the face and neck was unaffected bilaterally. The oral cavity was fully edentulous with mandibular bone dehiscence on the left alveolar ridge. Blood test only revealed slightly elevated inflammatory values ( Table 1 ).
| Reference value | At presentation | 1 week after brain abscess drainage | Preoperative/3 months after initial presentation | 1 month postoperative | |
|---|---|---|---|---|---|
| WBC (10 3 / <SPAN role=presentation tabIndex=0 id=MathJax-Element-1-Frame class=MathJax style="POSITION: relative" data-mathml='μ’>𝜇μ μ L) a |
3.65–9.30 | 12.55 | 8.13 | 9.07 | 9.18 |
| CRP (mg/L) b | < 5.0 | 19.3 | 11.4 | 17.2 | 24.3 |
CT and MR imaging showed a left mandibular chronic ossifying osteomyelitis, an intracranial displacement of the left condyle and abcedation (24 × 12mm) of the lateral temporal lobe with signs of severe edema ( Figs. 1 and 2 ). The mandibular condyle was fully eroded and the glenoid fossa destructed with progression unto the mastoid, thus explaining the progressive middle ear and mastoid effusion. A bony erosion in the zygomatic arch was noticed because of articulation with the mandibular incisura. This phenomenon secured no further inward movement of the condyle. The bony lamella between mid-ear and the TMJ was still clearly visible. Enhancement of the facial (VII) and vestibulocochlear nerve (VIII) in the cisternal and intrameatal segment was also reported. A CT-scan of the thorax showed no signs of purulent collection.
The patient’s medical history excluded a traumatic incident but showed the existence of an odontogenic infection treated at a different hospital 18 months prior to first presentation. Despite surgical drainage and antibiotic treatment (amoxicillin/clavulanic acid and meropenem-vancomycin), the infection expanded to the neck and mediastinum. Cultures from repeated biopsy grew Streptococcus Anginosus and Pseudomonas Aeruginosa . The facial infection persisted, and chronic ossifying osteomyelitis of the left lower jaw was seen on CT and MR imaging 4 months after the initial odontogenic infection ( Fig. 3 ). Multiple debridements (curettage and saucerization of the mandibular cortex) were performed and different courses of antibiotic therapy were initiated without resolution (amoxicillin/clavulanic acid, meropenem-vancomycin, meropenem-fluconazole, co-trimoxazole, clindamycin, fluconazole). CT scan one year before presentation showed a chronic osteomyelitis of both the left mandible and a destruction of the glenoid fossa with intracranial condylar displacement towards the meninges of the left temporal lobe ( Fig. 4 ). Antibiotic treatment was continued (amoxicillin/clavulanic acid) but the patient withdrew from further treatment until two weeks prior to presentation. The patient had developed a left-sided facial nerve paresis for which he was referred to our center for further evaluation.
