Volume 1, Issue 3 , Pages 185-187, September 2006
Masticator space abscess in a 21-month-old child
Article Outline
Summary
A 21-month-old male presented with fever, dehydration and severe trismus. A computerized tomogram of the head and neck was obtained that showed inflammatory stranding involving the right pterygoid, masseter and parotid spaces as well as fluid collection within the right pterygoid (masticator) space. Intraoral drainage was successful. S. Aureus was identified on culture from the drainage site. No apparent focus of infection was identified. Appropriate antibiotics were given and the patient recovered. It is postulated that an ascending infection from the oral cavity to the parotid gland with subsequent involvement of the right masticator space occurred.
Keywords: Trismus, Masticator space abscess, Child
1. Introduction
Trismus is not a common complaint in children and can be a challenge to correctly identify its etiology. Classically, trismus is seen with some temporomandibular joint disorders, post-radiation therapy for head and neck tumors, dentoalveolar abscesses involving the mandibular molars, traumatic injuries to the muscles of mastication after an inferior alveolar nerve block, and parotitis [1], [2], [3], [4], [6].
Children younger than 6 years of age do not often present with trismus. When they do, it is imperative that a meticulous medical history be obtained and a thorough physical examination completed. The airway is of primary concern and may be compromised depending upon the etiology of the trismus. A computerized tomogram (CT) of the head and neck should be obtained.
The purpose of this case report is to present a 21-month-old male with trismus as a presenting complaint. A diagnosis of right masticator space abscess was made without evidence of dental disease, traumatic injuries to the head and neck, parotid swelling or any other well-defined systemic disease.
2. Case report
A 21-month-old male was referred to the Pediatric Otorhinolaryngology service for evaluation of trismus. The patient had previously been healthy and had been having decreased oral intake, malaise and periodic fever up to 39
°C for 5–6 days prior to admission. The morning of admission, the mother noticed that the patient could not open his mouth. He had no airway compromise, respiratory symptoms or any other antecedent illnesses. No traumatic injuries were reported. Past medical history was unremarkable. Immunizations were current only up to 2 months of age. He had no known drug allergies and was not taking any medications.
On examination, the patient was febrile to 38.4°C, tachycardic (160beats/min), and had an oxygen saturation of 97% on room air. No stridor was noted. No respiratory compromise was present. He was arousable and uncooperative. An oral examination could not be done secondary to trismus; an interincisal distance was estimated to be 2mm. No extraoral fluctuance was noted. The neck was tender to palpation with bilateral shotty lymphadenopathy. No masses were palpated and the parotid gland was not enlarged. The remainder of the physical examination was unremarkable.
Laboratory examination showed an elevated WBC count of 16.8K/cu mm with 69% neutrophils and normal hematocrit and platelet count. Electrolytes were normal.
With marked trismus and concern for the presence of an abscess involving the muscles of mastication, a CT of the head and neck was obtained after securing the airway in the operating room with nasotracheal intubation. Results of the CT scan showed inflammatory stranding involving the right medial pterygoid, masseter and parotid spaces with a focal fluid collection within the right pterygoid space adjacent to the angle of the mandible which was concerning for an abscess (Fig. 1). The patient was returned to the operating room and after an adequate depth of anesthesia was obtained, a complete oral/pharyngeal examination was completed. No dental or gingival disease was present. No purulent material was observed at Stensen's duct and salivary flow was present. Fluctuance was palpable intraorally at the mandibular angle. An 18-gauge needle was inserted along the mandibular ramus. Frank pus was aspirated and sent for culture and susceptibility tests. The patient was started on clindamycin to cover for staphylococcal and streptococcal species as well as anaerobes. Culture of the purulent material showed the presence of S. Aureus and anaerobes, both susceptible to clindamycin. The patient was continued on clindamycin for one week after hospital discharge and did well.
Fig. 1.
Computerized tomogram showing inflammatory stranding in the right parotid space and fluid collection within the right masticator space.
3. Discussion
The masticator space has been defined as a separate fascial compartment containing the pterygoid, masseter and temporalis muscles and the mandible [2]. Lesions located in this space are usually situated in the ascending ramus or angle of the mandible. Trismus is extremely common with lesions within the masticator space [1], [2], [3], [4], [5]. Children with deep neck abscesses, defined as involving the retropharyngeal or parapharyngeal regions; anterior or posterior triangles; the submandibular or submental areas and the parotid gland [5], present differently than adults. Children younger than 4 years of age sometimes present with drooling, respiratory distress and stridor and less frequently with trismus [5]. Therefore, it may be presumed that deep neck abscesses may mimic signs and symptoms of respiratory illness. The hallmark of masticator space abscesses is trismus, tenderness over the affected area and sometimes swelling of the cheek [2], [3]. Parotid gland pathology can be confused with masticator space abscesses but trismus is not as severe [3]. Dental disease has been implicated with masticator space abscesses, especially with mandibular molars, presumably from posterior migration of microorganisms from these infected teeth [2], [3], [4].
There was no obvious source of infection for the patient in this report to explain the presence of S. Aureus in the cultured material from the right masticator space. S. Aureus is the most common organism responsible for parotid disease [7] and, according to Coticchia et al. [5], in children younger than one year of age with deep neck infections. Al-Belasy [4] reported that the parotid space can serve as a reservoir to the submassetic space. We could not clinically detect any abnormality of the right parotid gland. The CT scan showed inflammatory stranding within the parotid space without fluid collection. Recurrent parotitis has been reported to start in children less than three years of age [8]. Apparently an ascending infection from the oral cavity in conjunction with dehydration and reduced salivary flow predisposes the individual to parotid inflamation and painful swelling [8]. There is also an absence of pus at Stensen's duct even though patients are febrile [9] and the responsible organism is usually not staphylococcus [8].
It is speculated, in the absence of any identifiable source of infection, that the patient presented in this report experienced an ascending staphylococcal infection from the oral cavity secondary to dehydration which affected the right parotid gland. Bacterial migration to the right masticator space may have then occurred as reported by Al-Belasy [4]. Whether or not this case represents an initial episode of recurrent parotitis is unknown, but the absence of swelling of the right parotid gland along with isolation of S. Aureus suggests otherwise.
In summary, young children may present with fever, dehydration and severe trismus, which are suggestive of an infection involving the muscles of mastication. CT scans of the head and neck plus a detailed history and physical examination are important in identifying and adequately treating these infections.
References
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PII: S1871-4048(06)00047-5
doi:10.1016/j.pedex.2006.04.003
© 2006 Elsevier Ireland Ltd. All rights reserved.
Volume 1, Issue 3 , Pages 185-187, September 2006
