Temporal space infections are rare and infrequently reported in the literature. Abscesses in this space have been reported secondary to maxillary sinusitis, maxillary sinus fracture, temporomandibular arthroscopy and drug injection.1-4More commonly, temporal space infections are associated with the extraction of infected and non-infected teeth.5-9 Those infections of odontogenic origin are far more frequently associated with maxillary molars.8,9
A 31-year-old female was referred to the Atlantic Center for Maxillofacial Surgery in Halifax, NS due to masticator space infection on October 30, 2008 (Fig. 1). The patient had undergone extraction of tooth 4-6 secondary to advanced caries 10 days prior by a general dentist (Fig. 2). The patient returned to the dentist two days later with increased pain and swelling. The dentist referred the patient to a local oral surgeon who started the patient on penicillin V 600 mg po q6h and flagyl 500 mg po q12h. The pain and swelling continued to increase over the following two days and the patient was admitted to the hospital and started on IV penicillin G 2 million units q4h and IV flagyl 500 mg q12h. A 6mg dose of decadron was also given. This therapy was continued in hospital for two days with no improvement and a CT was acquired reportedly showing no focal abscess. The oral surgeon consulted with an ENT surgeon who suggested switching the patient to clindamycin. By October 29, the swelling continued to get worse and the right temporal space became involved. A second CT was acquired this time showing abscesses medial and lateral to the mandibular ramus extending into the infratemporal fossa and temporal space. The patient was then transported to the Atlantic Center for Maxillofacial Surgery and admitted under a staff surgeon on October 30.
The patient's past medical history was significant for smoking 1/2 ppd for 10 years, and she was otherwise healthy. Past surgical history included extraction of wisdom teeth when she was 17 years old. On examination the patient was afebrile. Her heart rate was 63 and regular, respiratory rate was 16 and her blood pressure was 100/70 mmHg. The patient did not look well with a moderate to large buccal and temporal space swelling that was very painful to palpate. The painful areas were traced out using a tissue marker. Interincisal opening was 10mm. The patient had no shortness of breath or dysphagia. The chest was clear and heart sounds were normal. Laboratory values showed a slightly elevated white cell count.
The clindamycin was discontinued and penicillin G 3 million units IV q4h and Flagyl 500mg IV q12h was started. The patient was observed overnight and the following afternoon was reportedly feeling much better. The swelling and the painful area to palpate had both begun to decrease. Due to the rapid response the decision was made to monitor the patient and continue medical management. By November 3, the swelling had resolved even further and there were no areas painful to palpate. The patient looked well with an interincisal opening of 18mm. Antibiotics were switched to oral route (penicillin V 600 mg po q6h and flagyl 500 mg po q12h). The following day the patient was stable and discharged home on these medications for 14 days.
On November 12, the patient returned to the original local Oral Surgeon complaining of increased pain and swelling that began a few days prior. The patient was referred back to Halifax where she was admitted on November 13, and a new CT scan was obtained showing extension of the abscess into the temporal space (Fig. 3.) Once again the patient was afebrile and vital signs were stable. She was started back on IV penicillin and flagyl and taken to the OR that evening. Incision and drainage with culture swabs were completed from both an extraoral temporal approach and intraorally via an anterior ramus approach (Fig. 4.). This allowed access to superficial temporal, masseteric, pterygomandibular and infratemporal spaces. Good pus drainage was achieved from both incisions and penrose drains were placed and sutured using silk sutures. The penrose drains were removed on November 16, and the patient continued to show improvement. On November 17, the antibiotics were switched from IV to po. On November 18, culture and sensitivity returned showing light growth of respiratory flora and Eikenella. Susceptibility results were presumptive for Eikinella with susceptibility to Ampicillin, Ciprofloxacin, and Tetracycline, with resistance to Clindamycin. By November 19, the patient had no pain, her interincisal opening was 25mm, there was no drainage and the patient was discharged on Amoxicillin 500 mg PO q8h and Flagyl 500mg PO q12h for 14 days. The patient followed up with the local Oral Surgeon on December 18, 2008, was contacted by phone on January 5, 2009, and was reportedly doing well with no areas painful to palpate and opening three fingers wide.
On February 14, 2009, the patient was readmitted with pain in her right masseter, preauricular, and temporalis area with minor swelling. She had seen her family doctor two weeks previously with increased pain and was placed on a 14 day course of Levoquin 500 mg po once daily with no improvement in her symptoms. On admission all teeth tested vital and her interincisal opening was 33mm. A new CT scan showed no areas of abscess. She was afebrile and white cell count was normal. C-reactive protein and ESR were also normal. Infectious Diseases was consulted and recommended six weeks of Cefuroxime 500mg PO twice daily and Flagyl 500mg PO twice daily due to suspected bony involvement. The patient was seen most recently in late March with three days remaining in her antibiotic regimen and was doing well (Fig. 5).
The temporal space can be divided into superficial and deep temporal spaces. The superficial tempo ral space extends superiorly to the pericranium, lateral to the temporalis muscle and medial to the temporoparietal fascia (galea). Inferiorly this space is continuous with the masseteric space. The deep temporal space extends superiorly to the attachment of the temporalis muscle to the inferior temporal crest, lateral to the temporal bone and deep to the temporalis muscle. Inferiorly this space is continuous with the infratemporal space.10 The temporal space along with the infratemporal, masseteric and ptyerygomandibular spaces can be grouped together as the masticator space. The masticator space is defined by the superficial layer of the deep cervical fascia as it splits at the inferior border of the mandible. The lateral portion covers the masseter as it connects to the zygomatic arch and continues on to cover the temporalis muscle. The medial portion follows the medial pterygoid superiorly, then continues with the levator veli palatini fascia to the skull base.8 Spaces adjacent to the masticator space are the parotid space posteriorly, the parapharyngeal space medially, and the submandibular and sublingual spaces inferiorly.9 In a review of 45 deep fascial space infections of odontogenic origin by Yonetsu et al, 9 38 were extensions of mandibular infections and seven were extensions of maxillary infections. Only 10 of the 38 mandibular infections (26%) involved the temporal spaces while 100% of the maxillary infections involved the temporal spaces.
In a review by Rega et al8 of 30 patients with masticator space abscesses derived from odontogenic infection, five patients were found to have five space involvement. Of these five patients only one was associated with a lower molar. The extension of infection into the masticator space has been observed to frequently extend superiorly against gravity however the pathway is poorly understood.8,11 A submasseteric pathway aided by mastication forces has been proposed.8
The signs and symptoms of masseteric space infections are pain, fever, malaise, trismus, and swelling.7 Trigeminal neuralgia and paraesthesia affecting the maxillary and mandibular branches of the trigeminal nerve have been reported.6,7 When an infection involving this space is suspected, computed tomography remains the standard for diagnostic imaging of head and neck infections.12 When compared with magnetic resonance (MR) imaging, CT correctly diagnosed masticator space abscess in 30/30 patients however the extent of infection was underestimated in nine patients. Due to the availability, short imaging time, and good anatomical detail overall, CT is still the preferred method of imaging.12
Antibiotic therapy for infection of odontogenic origin is commonly chosen empirically. This is possible due to the well characterized composition of the microbial flora involved. 13 The bacteriology of such infections includes gram positive aerobic alpha-hemolytic streptococci, facultative anaerobes in the Streptococcus anginosus group, with strict anaerobic gram negative rods such as Prevotella, Porphyromonas and Fusobacterium species.13-15 Eikenella corrodens is an aerobic gram negative rod involved in a minority of infections with a known resistance to Clindamycin.13 Beta-lactamase production in odontogenic infections has been demonstrated in anaerobic gram negative bacteria ranging from 13.3% to 38.5%.13 Penicillin and metronidazole used in combination adequately cover the microbial flora of odontogenic abscess as metronidazole makes up for penicillin's limited activity against the ß-lactamase producing gram negative anaerobic bacteria.13,15
As with any space occupying abscess, the usual treatment required is drainage and medical management with appropriate antibiotics and hydration as required. Often, cases will respond quickly to antibiotic therapy alone and in these cases formal drainage may not be required. This was the presumptive initial belief in this case, however, she relapsed shortly after discharge from hospital with the only medical management being oral antibiotics. After her return for the second admission, the decision was quickly made that drainage would need to be established.
The general dental profession deals with abscessed teeth and regional infections all the time. Cases such as this remind us how aggressive these infections can become and demonstrate how much of a difference antibiotics make in outcome. There may be a time in the future where more resistant organisms create new challenges in odontogenic infection management
Archie Morrison, DDS, MS, FRCD(C) is Associate Professor Dalhousie University and Active Staff OMF Surgery QE II Health Sciences Centre Halifax, NS.
James Brady, BSc, DDS is Resident OMF Surgery Dalhousie University and QE II Health Sciences Centre Halifax, NS.
Oral Health Welcomes This Original Article.
1. Schmitz, John P (2007) "Shooters Abscess" of the neck presenting as a temporal space infection and misdiagnosed as an odontogenic infection. Texas Dental Journal 124, 1188-91.
2. Weiss BR. (1977) Infratemporal fossa abscess unusual complication of maxillary sinus fracture. Laryngoscope. Jul;87(7):1130-3.
3. Raghava N, Evans K, Basu S. (2004) Infratemporal fossa abscess: complication of maxillary sinusitis. J Laryngol Otol. May;118(5):377-8.
4. Chossegros C, Cheynet F, Conrath J. (1995) Infratemporal space infection after temporomandibular arthroscopy: an unusual complication. J Oral Maxillofac Surg. Aug;53(8):949-51.
5. Banerjee, S. C. (1966) Temporal osteitis and infratemporal space infection following dental extraction. Oral Surg Oral Med Oral Pathol. 1966 Jan;21(1):14-8.
6. Gallagher J, Marley J (2003) Infratemporal and submasseteric infection following extraction of a non-infected maxillary third molar. Br Dent J. 2003 Mar 22;194(6):307-9
7. Diacono MS, Wass AR. (1998) Infratemporal and temporal fossa abscess complicating dental extraction J Accid Emerg Med. Jan;15(1): 59-61.
8. Schuknecht B, Stergiou G, Graetz K. (2008) Masticator space abscess derived from odontogenic infection: imaging manifestation and pathways of extension depicted by CT and MR in 30 patients. Sep;18(9):1972-9. Epub 2008 Apr 17.
9. Yonetsu K, Izumi M, Nakamura T. (1998) Deep facial infections of odontogenic origin: CT assessment of pathways of space involvement. AJNR Am J Neuroradiol. 1998 Jan;19(1):123-8.
10. Peterson's Principles of Oral and Maxillofacial Surgery.
11. Jones KC, Silver J, Millar WS, Mandel L. (2003) Chronic submasseteric abscess: anatomic, radiologic, and pathologic features. AJNR Am J Neuroradiol. Jun-Jul;24(6):1159-63.
12. Bratton TA, Jackson DC, Nkungula-Howlett T, Williams CW, Bennett CR. (2002) Management of complex multi-space odontogenic infections. J Tenn Dent Assoc. Fall;82(3):39-47.
13. Stefanopoulos PK, Kolokotronis AE. (2004) The clinical significance of anaerobic bacteria in acute orofacial odontogenic infections. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. Oct;98(4):398-408.
14. Robertson D, Smith AJ. (2009) The microbiology of the acute dental abscess. J Med Microbiol. 2009 Feb;58(Pt 2):155-62.
15. Sands T, Pynn BR, Katsikeris N. (1995) Odontogenic infections: Part two. Microbiology, antibiotics and management. Oral Health. Jun;85(6):11-4, 17-21, 23 passim.
Temporal space infections are associated with the extraction of infected and non-infected teeth
Good pus drainagewas achieved from both incisions and penrose drains were placed and sutured using silk sutures