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Case Report

A.n atypical pathway f infection in an adolescentw th a deep neck space abscessRobynR. Loewen,DDSStephen F. Conley, MD, MSA. Charles Post, DDS

D eep neck space infections are a potential com-plication of odontogenic infection, but rarelyhave been reported in children. In a recentstudy, 113 pediatric patients were hospitalized withmaxillofacial infections with 32 from dental sources;however, the extension of these infections into deepneck spaces was not documented.In a similar study of67 children with abscess of the head and neck, only 15cases were determined to have submandibular, lateralpharyngeal, or retropharyngeal space involvement, andonly nine were attributed to dental infection. 2 Lateralpharyngeal space infections are more commonlyodontogenic n adults; in contrast, the likely predispos-ing factors in children are nasopharyngitis oradenoiditis. 3 Eight pediatric patients with lateral pha-ryngeal space infections were identified by Broughton,but no etiological determinations were given.Early diagnosis and treatment of lateral pharyngealinfections are essential because further progression ofinfection can be rapid. Severe trismus, limiting directexamination of the oropharyngeal region, often com-plicates clinical evaluation. In addition, the limited valueof conventional roentgenograms in locating the in-volved deep neck spaces makes definitive diagnosisdifficult. This case report describes a 14-year-old Afri-can-American emale whodeveloped a left peritonsillarand lateral pharyngeal abscess from an odontogenicsource. She was managedsuccessfully with appropri-ate antibiotics and surgical intervention after diagno-sis using computerized tomography (CT).Case report

A previously healthy 14-year-old African-Ameri-can female reported onset of dental pain in the leftmandibular quadrant in 1992. Two weeks later, thedental pain was accompanied by left cheek swelling,dysphagia, odynophagia, and decreased oral intake.Her pediatrician recommendeddental treatment forthe offending tooth, but the family refused because ofthe patients fear of needles. The patient received intra-muscular penicillin and an oral aminopenicillin. Two

days later she came to Childrens Hospital of Wiscon-sin emergency department with a progression of symp-toms and painful left neck swelling.Upon initial examination, the patient had a tem-perature of 38.7C (101.6F) without evidence of air-way distress. The oral cavity exam was limited by se-vere trismus, allowing only a 1-cm opening. Themandibular left permanent second molar had exten-sive decay with tenderness to percussion. No swellingor tenderness was present in either the floor of themouth or in the buccal vestibule. The left tonsil wasmedially displaced. Externally, a 3-cmodiameter areaof induration was present at the angle of the mandiblewith extension to the left jugulodigastric area. Thewhiteblood cell count was 18,200 with a leukocytosis. Alateral neck film indicated a good airway without

retropharyngeal soft tissue swelling.The patient was admitted to the otolaryngology ser-vice and intravenous clindamycin was initiated. A neckCT obtained I day after admission indicated soft tissueswelling of the left peritonsillar and lateral pharyngealspaces without evidence of abscess formation. A pan-oramic radiograph confirmed extensive decay of themandibular left permanent second molar withperiapical radiolucencies consistent with an acuteperiapical-alveolar abscess. The joint services deferredtooth extraction until the deep neck cellulitis andtrismus had resolved.After 48 hr of parenteral antibiotic therapy, the physi-cal findings remained unchanged and a low-grade fe-ver of 38.4C (101.1~F) persisted with nocturnal tem-perature spikes to 39.5 C (103.1 F). Induration becamemore ocalized at the left angle of the mandibleand thesubmandibular area. Persistent unchanged trismus pre-cluded a detailed oral exam. Although the involvedtooth remained sensitive to manipulation, there wereno associated gingival changes. A repeat neck CT scanwas obtained to assess lack of clinical response. A largeleft lateral pharyngeal and peritonsillar abscess wasidentified with a tract originating from the posteriorand inferior left mandibular border (Figs I & 2).

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Fig 1. CT demonstrating sinus tract (arrow)from posteroinferior mandibular margin tolateral pharyngeal space abscess.Fig 2. CT illustrating abscess (arrow) oflateral pharyngeal an d tonsillar spaceswith connection.

The patient had a quinsy tonsillectomy and extrac-tion of the mandibular lef t permanent second molarunder general anesthesia. No other treatment was per-formed. A bilobed abscess cavity involving theperitonsillar space with extension into the lateral pha-ryngeal space was confirmed intraoperatively. Culturesgrew Bacteroides melaninogenicus. Close inspection ofthe alveolar socket failed to ident i fy a sinus tract. Ex-amination of the remaining dentition revealed minorcaries on both maxillary second permanent molars andthe mandibular right second permanent molar. Thepatient had an uneventful recovery, was discharged onthe third postoperative day of a 10-day course of oralclindamycin, and had no postoperative sequelae. Shewas referred to her private dentist for restoration of theother carious teeth.Discussion

Odontogenic infections tend to spread to soft tis-sues via planes of least resistance to adjacent potentialspaces and must perforate bone before spreading tothedeeper fascial spaces. Themost common neck spacesinvolved in mandibular odontogenic infection includethe submandibular, masseteric, and sublingual.5 In theyoung child, the primary root apices are located super-ficially and anteriorly within the mandible and usuallydrain to the buccal aspect of the alveolus intraorally.The permanent first and second molar apices lie deeperand more posteriorly in the mandible and drainage ismore complex. Since the lingual bone of the posteriormandible is thinnest in relation to molar apices, infec-tions of the first and second permanent molars tend todrain lingually. The first molar has apices which arelocated superior to the mylohyoid muscle attachment,

and the re fore drain to thesublingual space. The sec-ond and third molar api-ces are below the mylo-hyoid attachment andtypically drain to the sub-mandibular space without sublingual involve-ment. Therefore, thespread of infection to deepneck spaces through thesubmandibular spacemust be anticipated in theteenager.6 A lateral pha-ryngeal space i n f e c t i o ncan occur by extension ofthe infection from the in-ternal compartment of themasseteric space or,rarely, from the subman-dibular space.7The lateral pharyngealspace (parapharyngealspace, pharyngomaxillary

space) is cone-shaped, with its base at the skull baseand its apex at the greater cornu of the hyoid. Thestyloid process and its muscles divide the lateral pha-ryngeal space into two compartments: 1) an anterior(prestyloid) space containing connective tissue,muscles, and lymph nodes, and 2) a posterior(retrostyloid) space containing the great vessels andnerves of the neck.7'9 An abscess of the anterior com-partment results in trismus from irritation of the inter-nal pterygoid muscle, medial deviation of the lateralpharyngeal wall, dysphagia, torticollis, swelling overthe parotid gland, and possible neck swelling with lossof the space behind the mandibular angle. An abscessof the posterior compartment has no trismus or tonsil-lar prolapse, but rather parotid swelling and medialdeviation of the posterior lateral pharyngeal wall.8Res-piratory distress can ensue with significant lateral pha-ryngeal wall swelling.

The peritonsillar space is a potential space definedmedially by the f ibrous capsule of the palatine tonsiland laterally by the superior constrictor muscle. Break-down of the tonsillar capsule during tonsillitis is theclassic source of infection of this space. Purulentmaterial in the midportion of the peritonsillar spaceappears to be prone to penetrate the superior constric-tor muscle and enter the lateral pharyngeal space.Trismus occurs from reflex irritation of the adjacentmuscles of mastication.10

Prompt and accurate diagnosis and treatment ofdeep neck space infections are crucial.Theclassic symp-toms of neck abscesses rarely are present today be-cause oral antibiotics can modify symptoms. Thus thedifferentiation of diffuse cellulitis from a distinct ab-scess cavity is complicated. In addition, the progres-

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sion of infection may be difficult to ascertain clinicallydue to significant local edema and trismus. The atypi-cal aspect of this case was the direct involvement of theanterior compartment of the lateral pharyngeal spacevia a sinus tract in the mandible rather than the moretypical intervening masseteric space infection.

The limitations of conventional roentgenograms canhinder prompt diagnosis of head and neck-space infec-tions. CT has been used extensively to identify andmanage various maxillofacial pathoses. 11-15 The diag-nostic value of CT for head and neck infection includeevaluating the degree of displacement of para-pharyngeal soft tissues, differentiating betweencellulitis and abscess formation, and locating an ab-scess anatomically25 An abscess on a CT scan can becharacterized by single or multiple loculations; lowdensity air and/or fluid at the center of the abscess;contrast enhancement of the abscess wall; and tissueedema surrounding the wall and anatomic boundariesthat correspond to known fascial planes22 In this case,the atypical direct path of infection to the lateral pha-ryngeal space could not have been detected with con-ventional roentgenograms. Incorporating a CT allowedprompt determination of abscess formation and delin-eated the abscess location to facilitate drainage.

Serious complications may develop from a lateralpharyngeal space infection. Contiguous spread to theretropharyngeal space is ominous, often seriously com-promising the airway and progressing to mediastinitisdue to its inferior communication with the posteriormediastinum. Along with septicemia, other complica-tions of deep neck space infection include jugularthrombosis, hemorrhage of the great vessels, laryngealedema, osteomyelitis of the mandible, pneumonia, va-gal nerve involvement, meningitis, parotid abscess, andaspiration of purulent material following spontaneousrupture of the abscess,,16

Management of a lateral pharyngeal space infectionof odontogenic origin must be prompt and accurate,with removal of the odontogenic infection nidus andparenteral antibiotic therapy. In cases of diffuse cellulitiswithout localization, parenteral antibiotics alone oftenare curative27 Surgical intervention is advised if noimprovement is seen after 48-72 hr of parenteral anti-biotic therapy. Exploration and drainage of the abscessand removal of the offending tooth should then beaccomplished at the same time. In one recent study,more than 50% of children with deep neck infectionsdid not require surgical drainage. 4 The eight nonsurgi-cal patients in this study became afebrile in a mean of3.8 days (range 1-7 days) after instituting antibiotictherapy. The authors recommended therapy paradigmutilizes neck CT for differentiation of cellulitis fromabscess and the presence or absence of respiratory dis-tress to determine the need for early surgical incisionand drainage.

The microbiology of deep space neck infections con-tinues to evolve. In 1983, Streptococci (61%) and Staphy-

lococcus species (32%) comprised the majority of purecultures in maxillofacial infections28 More recently,Brook2 found that the most common solates in pediat-ric head and neck infections are Staphylococcus aureus(aerobic) and Bacteroides species. In patients with den-tal infections as the predisposing factor, anaerobic iso-lates either as pure cultures or in a mixed flora pre-dominate. This is consistent with the observation thatanaerobic bacteria outnumber aerobic species in theoral cavity by 10 to one.9

Greater resistance of bacteria to antibiotics, especiallypenicillin, has been another trend. Recent findings couldpreclude penicillin as an automatic choice in head andneck infections. Beta-lactamase-producing organismscan survive penicillin therapy and may even protectpenicillin-susceptible organisms by enzymatic releasewithin the abscess. Brook2 found beta-lactamase activ-ity in 46%of head and neck infections in children. Halulaet al. 2 also described specific mechanisms or the trans-fer of clindamycin resistance in Bacteroides species.

Penicillin and clindamycin have been shown to pro-duce similarly good results in treating odontogenicinfections when the rate of penicillin resistance amongoral anaerobic bacteria is relatively low. Penicillin isfelt by some authors to still be the antibiotic of choicefor maxillofacial infections of odontogenic origin. 1, 21Clindamycin is indicated in cases of penicillin allergy,recent exposure to penicillin, failure of an infection torespond to penicillin therapy, or in cases where theknownpathogen is Bacteroides fragilis.1Dr. Loewens a pediatric dental resident, Departmentf PediatricDentistry, Childrens Hospital of Wisconsin, Milwaukee;Dr.Conley s assistant professor, departmentsof otolaryngology-humancommunication nd pediatrics, Medical College of Wis-consin, Milwaukee;nd Dr. Post is director, Department f Pedi-atric Dentistry, Childrens Hospital of Wisconsin,Milwaukee.

1. DodsonTB, Perrott DH,KabanLB: Pediatric maxillofacialinfections: a retrospective study of 113 patients. J OralMaxillofac Surg 47:327-30, 1989.2. Brook : Microbiology f abscesses of the head and neck inchildren. AnnOtol Rhinol Laryngol 96:429-33, 1987.3. Dzyak WR,Zide MF: Diagnosis and treatment of lateralpharyngealspace infections. J Oral MaxillofacSurg 42:243-9, 1984.4. Broughton RA: Nonsurgical management f deep neck in-fections in children. Pediatr Infect Dis 11:14-8, 1992.5. ChowAW,Roser SM, Brady FA: Orofacial odontogenicinfections. Ann ntern Med88:392-402, 1978.6. MegranDW,Scheifele DW,ChowAW:Odontogenic infec-tions. Pediatr Infect Dis 3:257-65,1984.7. Paonessa DF, Goldstein JC: Anatomyand physiology ofheadand neck infections (with emphasis n the fascia of theface and neck). Otolaryngol Clin North Am :561-80, 1976.8. HoraJF: Deepneck infections. Arch Otolaryngo177:129-36,1963.9. Rabuzzi DD, Johnson JT: Diagnosis and Management fDeep Neck Infections. American Academy ofOtolaryngology, Washington, DC, 1978.10. Brandow CJr: Immediate onsillectomy for peritonsillarabscess. Trans AmerAcad Opthalmol Otolaryngol 77:412-16, 1973.

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11. Murphy JB , I lacqua J, Bianchi M : Diagnosis of acute maxil-lofacial infect ions: the role of compute rized tomograp hy.Oral Surg Oral M ed Ora l Pathol 60:154-57, 1985.12. Hol t GR, McManus K, N e w m a n RK, Pot ter JL , Tinsley PP :Computed tomography in the diagnosis of deep neck infec-tions. Arch Otolaryngol 108:693-96, 1982.13. H a l l M B , A r t e a g a D M , Mancuso A: Use of computedtomography in the localization of head-and-neck-space in-fect ions. J Oral M a xi l lofa c Surg 43:978-80,1985.

14 . Schwimmer A M , Roth SE , M orrison SN: The use of comput -erized tomography in the diagnosis an d management oftemporal and infratemporal space abscesses.Oral SurgOralMed Oral Pathol 66:17-20,1988.15. Endicott J N , Nelson RJ , Saraceno CA: Diagnosis an d man-agement decisions in infect ions of the deep fascial spacesofthe head and neck ut il izing computerized tomography.Laryngoscope 92:630-33, 1982.

16. Beck A L : Deep neck infect ion. A nn Otol Rhinol Laryngol56:439, 722, 1947.17. Be ck AL : The influe nce of the chemotherapeut ic and antibi-otic drugs on the incidence an d course of deep neck infec-tion. A nn Otol Rhin & Laryngol 61:515-32, 1952.18. H u n t D E , M e y e r R A : Continued evolut ion of the microbiol-ogy of oral infect ions. J Am Dent Assoc 107:52-54,1983.19 . Socransky SS, M anganiel lo SD: The oral microbiota of manfrom birth to senility. J Periodontol 42:485-96, 1971.20. Ha lula M, Macr ina FL: Tn5030: a conjugative transposonconferring cl indam ycin resis tance in Bacteroides species.R e vInfect Dis 12(suppl. 2):S235-42,1990.21 . Gilmore W C, Jacobus NV, G orbach SL , Doku H C, Tally FP :A prospective double-bl ind evaluat ion of penicillin versusclindamycin in the t reatment of odontogenic infections. JOral Maxil lofac Surg 46:1065-70, 1988.

M. MICHAEL. COHEN, SR., DMD, 19O5-1994His legacy was pediatric stomatologyDr. M. Michael Cohen, Sr., aninternational ly renowned clini-cian, researcher, and teacher inpediatr ic stomatology, w as bornin Boston in 1905 an d died inCambridge, Mass., on October1 7 , 1994. H e g r a d u a t e d fromTufts in 1928, practiced dentistryin Boston and Brookline , and was

affiliated with Beth Israel Hospi-M . Mi c h a e l tal, Boston Floating Hospital,Cohen , Sr. New England Center Hospital,Children's Hospital M edical Center , Eunice Ke nnedyShriver Center , and Lakevi l le Hospital .

Most of Dr. Cohen's academic career was at TuftsUniversity School of Denta l Medicine . A fte r his re-tirem ent fro m Tuf ts in 1971, he joined the faculty ofHarvard School of Dental Medicine, where in 1978the M ichael Cohen, Sr. Teaching and R ese arch Fundw as es tabl i shed to h e l p s u p p o r t the depar tments ofpediatr ic dent i s t ry and ora l med icine and ora l p a thol -ogy. He w as the 1982 recipient of the American Soci-ety of Dent is t ry for Chi ldren ' s Award of Excel lence.D r. Cohen was the first dentist in the U.S. to holdprofessorial ran k in a pediatr ics department in a medi-ca l school (Tufts University) and the first in the U.S.to be appointed stomatologist at a pediatr ic hospita l(Boston Floating Hospital). Together with D r. M a n u e lAlbum, he was i n s t r u m e n t a l in es tabl i shing the Acad-emy of Dentistry for the H a n d i c a p p e d (now the Acad-emy of Dentistry for Persons with Disabil i t ies ) .H e w a s a ls o i n s t r u m e n t a l in es tabl i shing the Mas-sachuset ts C ere bral Palsy Association and was i ts firstPresident. He was a m e m b e r of the Massachuse t t sCommittee on Childhood and Y o u t h and a Consul t -

ant in Dent is t ry for Chi ldren to the U.S. Public HealthService. H e served as President of the B rookl ine Com-muni ty Council and presided over a wide range ofact ivi t ies dur ing the 1950s. He was a m e m b e r ofnumerous organiza t ions , including the In terna t iona lAssociation for Dental Research, Society for Researchfor Child Development , American Diabetic Associa-t ion, New York A cadem y of Sciences, and the Roy alSociety of Heal th (U K ). He w as a Diplom ate of theAmerican Board of Pedodontics and hel d Fel lowshipin th e American Public Health Association an d Amer-ican A ssociation for the A d v a n c e m e n t of Science.H is first book, Pediatric Dentistry, went throughtw o edit ions in 1957 and 1961. The first edit ion w ast ranslated into Spanish. H is second book, MinorToothMovement in the Growing Child* appeared in1977 and was t ranslated into I ta l ian, Portuguese,and Japanese .D r. C o h e n ' s a c a d e m i c l e g a c y w a s p e d i a t r i cstomatology. He was the first dentist to look at themout h as a window of pediatr ic disease and lecturedwidely on the subject. Early papers deal t with juve-nile diabetes , ectoderm al dysplasia, the oral manife s-ta t ions of erythroblastic anemia , denta l deve lopmentin p i t u i t a r y dwarf i sm, dental age in the adreno-geni tal syndrome, the de nti t ion in congenital syp hil isan d rubel la syndrome, an d various aspects of trisomy21 syndrome. For years, he taught oral manifesta-tions of systemic disease to pediatrics house staff an ddenta l s tudents .Dr. M . M ichael Cohen, Sr. was truly a man for al lseasons w ho reached out to help others. H is academiclegacy lives on in the e ndeav ors of his stude nts and thememories of the many people he inf luenced. H e willbe greatly missed by all those whose lives he touched.

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