Abstract
This manuscript reports an uncommon case of inferior third molar facial abscess with purulent secretion drainage through the left external acoustic meatus. The patient’s left external acoustic meatus was filled with a purulent secretion observed on a CT scan. He underwent surgery to drain the facial abscess. Despite facial abscesses being routine occurrences, the literature does not contain many case reports of odontogenic facial abscesses with drainage via the external acoustic meatus. These situations occur in two possible ways: multiple fissures in the anterior wall of the cartilaginous portion of the external acoustic meatus; and congenital defects that are occasionally present in the anterior-superior aspect of the external acoustic meatus, known as the foramen of Huschke, which allow communication between the external acoustic meatus and mandibular fossa. These defects may also predispose the patient to the spread of the infection or tumour from the external auditory canal to the infratemporal fossa and vice versa. No otological sequelae were observed in this case. The authors conclude that the hypothesis of bone malformation cannot be excluded, and affirm that any facial abscess requires appropriate and immediate treatment for adequate resolution, by removing the causal factor and providing systemic support.
Odontogenic infections involving primary and secondary facial spaces are common. Knowledge of the anatomy of the facial spaces involved during an infection is of great importance. Complications, such as airway compromise, mediastinitis, cavernous sinus thrombosis, brain abscesses and necrotizing fasciitis, may occur if the proposed surgical treatment and chosen antibiotic therapy are not correct, possibly provoking life-threatening morbidity and the death of the patient .
This manuscript reports an uncommon case of inferior third molar facial abscess with purulent secretion drainage through the left external acoustic meatus.
Case report
A 30-year-old man was referred to the Accident and Emergency Department of the authors’ hospital on 2 November 2008. He complained of pain on the left side of the face and during swallowing, and presented with drainage of a purulent secretion through the left external acoustic meatus ( Fig. 1 ), a limited mouth aperture and altered dental occlusion. There was no relevant medical or social history.
The patient related that, approximately 20 days before this consultation, he had felt discomfort in the left preauricular region on being examined by a physician, who did not find any evidence of an alteration of the left ear. The patient was given a muscle relaxant and referred to his dental practitioner with a hypothetical diagnosis of temporomandibular dysfunction. The patient sought a new evaluation with another dental practitioner because the clinical symptoms had not resolved. Pericoronaritis was suggested as a diagnostic hypothesis. On 2 November 2008, the tooth (left inferior third molar) was extracted by that dental practitioner.
The examination revealed a moderate swelling in the left preauricular region, redness in the left mastoidean region, altered dental occlusion, redness and swelling in the left palatal region and occluded sutures on the surgical wound of the extracted left inferior third molar, without purulent secretion drainage. During palpation and compression of the oedematous region, a pus discharge could be noticed simultaneously from the intraoral surgical wound and left external acoustic meatus. Subsequent to aspiration of the external acoustic meatus, the presence of a communication path was noted whilst examining with an otoscope. The purulent secretion sample collected was sent for bacteriological culture analysis and an antibiogram, but no bacterial growth was observed.
Radiographs of the anteroposterior view of the mandible and, left lateral oblique view of the mandible and computed tomography (CT) scans (axial and coronal incidences) were taken. No bone alterations were noticed, but an image suggesting gaseous content in the lingual region was seen next to the left inferior third molar alveolus ( Fig. 2 ), and the left external acoustic meatus was filled with a purulent secretion easily observed on the CT scan ( Fig. 3 ).
The patient was admitted on the same day and was given intravenous amoxicillin and clavulanic acid (1 g every 6 h), ketoprofen (100 mg every 8 h), ranitidine (50 mg every 8 h), bromopride (10 mg every 8 h in case of vomiting or nausea) and sodium dipyrone (1 g every 6 h in case of pain).
The patient underwent surgery on the day after admission under general anaesthesia to drain the facial abscess. After the collection of a new sample of the purulent secretion for another bacteriological culture analysis and antibiogram, a 1 cm submandibular incision was made for dissection, with a large, curved haemostat, reaching the preauricular region and the lingual aspect of the left inferior third molar region. Inspection of the alveolus and subperiosteal inspection of the previous surgical wound were undertaken. Profuse irrigation with 0.9% saline solution was performed; a no. 12 irrigation drain and a Penrose no. 1 drain were lodged and sutured in the skin with Nylon 5-0 sutures. The surgical alveolus wound was sutured with Vicryl 4-0 sutures.
Over 3 days, the patient was followed postoperatively whilst still hospitalized. 0.9% saline solution irrigation was managed via irrigation drains, the facial gauze dressings were changed and, in some instances, aspiration of the remaining secretion via the left external acoustic meatus was performed prior to Otosynalar ® application. The irrigation drains and Penrose drain were removed 48 and 60 h postoperatively, respectively. No bacterial growth was observed in the bacteriological culture.
After discharge, the patient was referred for evaluation by an otorhinolaryngologist. The absence of injuries to the internal ear structures was verified, and there was no evidence of any hearing loss during the audiometric examination. Follow-up reviews were instituted until the closure of the fistula localized in the left external acoustic meatus. Oral amoxicillin and clavulanic acid (1 g 6/6 h) were maintained for an additional 7 days and the patient was asked to return for postoperative review.
After 7 postoperative days, the patient presented with significant improvement in the range of mandibular mobility, with no purulent secretion drainage through the left external acoustic meatus, uneventful repair of the intraoral surgical wound and no complaint of pain. The patient is still under periodic follow-up reviews, and no alterations have been observed.
15 months after surgery, a cone beam CT scan was taken for evaluation. Communication between the external acoustic meatus and the glenoid fossa was observed ( Fig. 4 ).
