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| CASE REPORT |
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| Year : 2015 | Volume
: 5
| Issue : 2 | Page : 113-116 |
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Uncommon complication of a common tooth extraction
SN Somashekhar, TP Vikram
Department of Surgery, J.J.M. Medical College, Davangere, Karnataka, India
| Date of Web Publication | 10-Mar-2016 |
Correspondence Address:
Dr. S N Somashekhar
#4347, 5th Main, S.S. Layout, B Block, Davangere - 570 004, Karnataka
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/2231-6027.178506
Cervicofacial infections of dental origin are the most difficult and complex issues in our day to day practice. Perceiving the severity of the condition at the earliest is of utmost importance since they are known to spread rapidly to the surrounding soft tissues and can even spread to vital structures such as paranasal sinuses, orbits, intracranial sites, and even to mediastinum. Orbital cellulitis is a postseptal cellulitis involving intraorbital muscles with diminishing visual acuity. Aggressive treatment more frequently with surgical intervention along with higher antibiotics in a well-equipped hospital is required since it is associated with rapid deterioration. A 40-year-old male who is a known diabetic and smoker underwent dental extraction and presented with fever, left facial swelling with the blurring of vision. Clinically he was in sepsis having crepitus over left facial swelling, edema of left eyelids with proptosis with facial nerve palsy. On investigating further, he was found to have left cervicofacial abscess associated with left orbital cellulitis due to odontogenic infection with very high blood sugar level. Cervicofacial abscess of odontogenic cause is a life-threatening complication. In this case report, we have highlighted the unusual findings of orbital cellulitis and facial nerve palsy associated with cervicofacial abscess since a handful of cases have been reported about the same in the literature. Early recognition with prompt surgical and antibiotic treatment is implemented for good prognosis and outcome. Keywords: Cervicofacial abscess, dental extraction, facial nerve palsy, odontogenic infection, orbital cellulitis
How to cite this article:
Somashekhar S N, Vikram T P. Uncommon complication of a common tooth extraction. Int J Oral Health Sci 2015;5:113-6 |
| Introduction | |  |
Tooth extractions are one of the most common procedures performed in dentistry.[1],[2] Though the outcome of these surgeries is dependent on accurate planning and surgical skills, it is also associated with the severity and nature of the disease itself and comorbidities of the patient like diabetes and immunosuppression. Numerous complications are observed after tooth extraction which is classified as minor (bleeding, swelling, trismus) which can be treated conservatively and major (hemorrhage, abscess formation, osteomyelitis, fistula) which requires hospital admission and more often surgical intervention.[2] Odontogenic infections have rapid spreading property due to local expansive tendency through the infiltration and destruction of cervical tissues following the anatomical cleavage plains connecting head and neck and also due to rich vascular and lymphatic network in this region connecting to distant sites such as orbit, paranasal sinuses, mediastinum, and intracranium.[3] Early recognition and treatment can lead to the favorable outcome.
| Case Report | | |
A 40-year-old male, a diabetic patient, was referred by a dentist for left facial swelling involving left upper and lower eyelids with high-grade fever. Dental extraction of left second and third mandibular molars was done 7 days back. He was having significant trismus (unable to open mouth more than 1 cm). Preoperative orthopantomogram showed periapical radiolucency in relation to left mandibular second and third molars [Figure 1]. | Figure 1: Postextraction photo of patient showing left hemifacial swelling, neck with left facial nerve palsy
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On examination, the patient was febrile, with pulse - 118 bpm, blood pressure - 100/88 mmHg. Swelling with crepitus were present on whole of the left cheek which was extending superiorly to the left eye and temporal region and also inferiorly on ipsilateral neck extending until first rib space. There was an incision with a corrugated drain in the left side of neck in an attempt to drain pus. Deviation of mouth toward right side associated with absence of nasolabial fold on the left was seen suggestive of left facial nerve paralysis [Figure 2]. | Figure 2: Orthopantomogram showing periapical lucency in relation to two, three left mandibular molars
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Intra-oral examination revealed the presence of unhealed extraction sockets with purulent discharge and buccal vestibular obliteration in the region of two, three mandibular molars. The overlying gingivae were erythematous and spongy. Trismus was also seen.
Ophthalmic examination: Left eye showed tender edematous eyelids with proptosis, lacrimal discharge, conjunctival chemosis, pupil mid-dilated and nonreactive to light, visual acuity was decreased with restriction of eyeball movements on all directions. Fundoscopy showed pallor on temporal aspect of optic disc with normal blood vessels but superficial and dot hemorrhages at the background. Intraocular pressure was raised. Findings were suggestive of left orbital cellulitis with compressive optic neuropathy. The right eye was normal.
Blood investigations showed increased total leukocyte count with increased blood sugar levels.
Magnetic resonance imaging (MRI) with contrast of head and neck showed multiple lesions with air pockets suggestive of abscess in left premaxillary, masticator space, left periorbital, parotid space, submandibular space, left alveolobuccal sulcus extending superiorly along the subcutaneous plane until temporal fascia and inferiorly up to left anterior chest wall up till sternal angle [Figure 3],[Figure 4],[Figure 5]. Orbital soft tissues enhancement including intraorbital muscles with proptosis and minimal subperiosteal collection suggestive of orbital cellulitis were noted [Figure 6]. | Figure 3: Magnetic resonance imaging with contrast (axial section) of head: Note the multiple lesions with air pockets suggestive of abscess in left premaxillary, masticator, periorbital, parotid, and submandibular spaces
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 | Figure 4: Magnetic resonance imaging with contrast of head (axial section) proptosis of the left eyeball with bulky edematous intraocular muscles and eyelids - orbital cellulitis
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 | Figure 5: Magnetic resonance imaging with contrast of head and neck (coronal section) extensive involvement of abscess occupying left hemifacial, neck, and chest wall
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 | Figure 6: Postoperative day 10 of drainage, showing resolution of edema of the left hemifacial region with facial nerve palsy
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The patient underwent prompt incision and drainage of the abscess with multiple incisions at nasolabial-fold, infraorbital region, and temporal region. Removal of sloughed out tissues on the left side of neck was done. Diabetes was controlled during the procedure with injection insulin. Pus culture sensitivity came positive for anaerobic infection. With the help of higher antibiotics and with daily aesthetic dressings, the abscess was controlled, edema reduced, and vision was started normalizing on the fourth postoperative day, but the chemosis with edema of the conjunctiva and facial nerve palsy persisted. Chemosis with edema of conjunctiva resolved in 15 days. The healing ulcer on neck is covered with split-thickness skin graft to avoid contracture. The residual facial nerve palsy persists even after 6 months of follow-up [Figure 6].
| Discussion | | |
Tooth extraction is a common procedure done in dental practice. After tooth extraction, in dental caries with periapical abscess good tooth socket irrigation should be given, curettage of all apical soft tissue done. Antibiotics should be used before and after extraction. Cervicofacial infections due to tooth extractions are the complex conditions wherein there will be rapid spread of infection to soft tissues and other vital structures of head and neck. It causes life threating complications like cavernous sinus thrombosis, respiratory failure due to mediastinitis, loss of vision due to orbital cellulitis and also septicemia.[2],[3],[4] The microbes can travel within the fasciomuscular planes, by the spread of inflammatory exudates and through lymphatic system causing loco-regional spread. Infection of maxillary teeth most commonly spread to the buccal space, whereas infection, originating in the mandibular teeth mostly spread to the submandibular, pterygomandibular, submasseteric, and buccal spaces.[5]
Spread to vital structures such as orbit occurs through the following ways. First, through the maxillary sinus into the inferior orbit through the inferior orbital fissure or defect in the orbital floor the most common route. Second, it can also spread through pterygopalatine regions. Third, ascending infection from the canine fossa to orbit and lastly through the retrograde spread through the ophthalmic vein.[6] In our case, maxillary sinus was spared.
Orbit has bony walls the intraorbital tissues as well as the globe are succumbed to the serious sequelae when an infection spreads. The prevalence of orbital cellulitis due to odontogenic cause is 2–5%.[7]
Imaging is essential in these conditions to rule out an intracranial spread such as parenchymal abscess, cavernous sinus thrombosis, and to rule out orbital abscess formation since it requires immediate surgical drainage to avoid blindness. In our case, we performed MRI with contrast of head and neck to rule out for the same.
Our case presented with ipsilateral facial nerve palsy. This complication can be explained on the basis of anatomical landmarks and compression, especially in association with local inflammation.[8] Unilateral palsy of facial nerve secondary to space infection has been rarely reported in literature. Ischemic neuropathy arising from the local toxic effects of a severe infection and the compression of the nerve due to an expanding abscess is another suggested mechanism.[9] However, the prevalence of facial nerve palsy secondary to odontogenic cervicofacial infection remains unrecorded in the literature.
Treatment involves aggressive surgical intervention. Early administration of high dose intravenous antibiotics covering Gram-positive, Gram-negative and anaerobes along with early drainage of the abscess to prevent extension of abscess and the complications associated with it. Prophylactic anticoagulants are recommended to prevent cavernous sinus thrombosis. Regular ophthalmic examinations are done to check for improvement of visual acuity and any deterioration through fundoscopic examination.
| Conclusion | | |
Tooth extraction is a common procedure in dentistry. Patients with co-morbid conditions like diabetes require good postoperative follow-up. With strict oral hygiene and repeated socket irrigation is essential to prevent cervicofacial infection. High index of suspicion should be made in these patients and appropriate investigations must be carried out on an emergency basis to know the severity of the disease and to decide upon the treatment modality. With timely intervention life-threatening complications can be prevented. Severe orbital cellulitis and facial nerve palsy are the uncommon complications noted with tooth extraction.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
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