Javad Yazdania, Ali Mortazavia, Mohammadali Ghavimia*

a Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Tabriz University of Medical Sciences, Tabriz, Iran

ARTICLE INFO ABSTRACTArticle Type:Case Report

*Corresponding author:Mohammadali GhavimiDepartment of Oral andMaxillofacial Surgery,Faculty of dentistry,Tabriz University of MedicalSciences, Tabriz, Iran

Tel: +98-411-3355965Fax: +98-411-3346977Email: m_ghavimi@yahoo.com

The infratemporal fossa is an anatomic space of great importance in the head.Abscesses of this space are rare but potentially life threatening. Regarding theproximity of some important anatomical features of the head, dealing withinfratemporal space infection needs great consideration both in examinationand surgical practice.In this case report, infratemporal space abscess formation following theremoval of zygomatic arch suspension wire in a healthy, male, young patientand its treatment protocol are presented.

Keywords: Infratemporal, Abscess, Maxillofacial infection

Introductionhe infratemporal fossa is an anatomicspace of great importance in the head [1-3]. Abscesses of this space are rare but

potentially life threatening. Regarding theproximity of some important anatomicalfeatures of the head, dealing with infratemporalspace infection needs great consideration bothin examination and surgical practice [4].Isolated infratemporal fossa abscess formationis a relatively rare condition. Infratemporalfossa abscess usually occur following themaxillofacial tuberculosis, maxillary sinusitis,maxillary fracture or pretonsiller infection; alsohas reported after maxillary third molarextraction and dental injection [5-7]. In this casereport, infratemporal space abscess formationfollowing the removal of zygomatic archsuspension wire in a healthy, male, youngpatient and its treatment protocol are presented.

Case ReportA 20-year-old ASA I male patient with the

chief complaint of severe swelling of bilateraltemporal and left suborbital regions wasadmitted to the Emergency Department of ImamReza Hospital. The patient’s clinical findings,included fever (38.5 °C in the axillary region),severe trismus (maximum jaw opening 5mm),lymphadenopathy in the sub-mandibular region,and headache (Fig.1).

The patient's history revealed a car accidenttwo months ago which had led to Le Fort IIfracture, and as a result, he had undergonemaxillary disimpaction and bilateral wiresuspension from zygomatic arches. Two daysfollowing the removal of suspension wiresswelling was observed. The patient had nohistory of systemic problems but smoking forthree years. Paraclinical evaluation revealed awhite blood cell count of 24,500 /mm3 whichreflected the severity of his situation. Thepatient was taken to the operating room andunder the endoscopic nasal intubation andgeneral anaesthesia; bilateral Gilles andintraoral incisions were carried out, and after

T

Journal of Craniomaxillofacial Research

Vol. 2, No. (1-2)

Bilateral infratemporal spaces abscess followingremoval of suspension wires: a case report

Received: 9 Mar 2015Revised: 20 Apr 2015Accepted: 1 May 2015

J Craniomax Res 2015;2(1-2):109-111

reaching the infratemporal space plenty of pusdrained. The drain was kept in place for fourdays for ongoing pus drainage. Empiricalintravenous antibiotic therapy was started withceftriaxone and metronidazole which weresubsequently changed to ampicillin andclindamycin after the results of microbialculture were available. Following the treatmentprocedure, the patient’s systemic situationimproved gradually and was discharged on thefifth post-operative day. The patient wasreviewed in the outpatient clinic 3, 10, 20 dayslater. Trismus lasted approximately for 3 weeks.Eventually, the patient’s recovery wassuccessful and there was no recurrence ofinfection.

DiscussionThe infratemporal fossa is an irregularly

shaped space below the greater wing of thesphenoid bone (containing the foramen ovale),lateral to the ramus of the mandible and the gapbetween the zygomatic arch and temporal bone.The lateral pterygoid plate forms the medialmargin while the maxilla forms the medialaspect of the space. The infratemporal fossacontains the temporalis muscle, medial andlateral pterygoid muscles, the pterygoid plexusof veins, the maxillary artery and its branches,and the chorda tympani. Infection of theinfratemporal and temporal fossae has beenattributed to several causes. Odontologicallyrelated infections have been most commonlyreported. Both maxillary and mandibular thirdmolar infections have been implicated. Othersources of infections described in thesemasticatory spaces include dental injections,maxillary sinus wall fracture and

haematogenous spread [8].Different manifestation might be observed

depending on the specific anatomical featureinvolved in the infection including pain, fever,trismus in acute infections and trismus withswelling in chronic infections and evenneurosensory deficit [9-11]. Trismus can be thediagnostic hallmark to distinguish infratemporalspace infection from other conditions with facialswelling. The precise information of imagingmodalities especially CT scan will allow fortimely and targeted diagnosis and treatment. CTscan is known as the only way to detectcharacteristic signs such as lucency and gasbubbles definitely [12]. The treatment shouldfocus on prevention of spreading infection withpossible life-threatening complications. As withany space occupying abscess, the routinetreatment required is drainage and medicalmanagement with appropriate antibiotics andhydration as required. As a result of potentialdelay in the diagnosis and definitive treatment,infection originating in the infratemporal fossacan spread upward to the base of skull ordownwards into the deep tissue spaces of theneck [11]. The treatment included incision anddrainage via intraoral and extraoral approaches[1]. In this case Gillies incision and intraoralapproach were used.

Suspension wires are being used in thetreatment of midface fractures. These wires mayextend from the zygomatic arch or frontal bonethrough the masticatory space into the oralcavity to attach to arch bars [13]. In thepresented case, bilateral infratemporal abscessoccurred following the removal of suspensionwires from zygomatic arches in a young,healthy patient. Reason might include pushingthe intraoral bacterial flora to the infratemporalspace while removing the wires. Based on ourliterature reviews only one case has beenreported about abscess formation at themasticatory space following removal ofsuspension wires [13].

ConclusionEven though it is a very rare condition,

infratemporal fossa abscess is a dangerousinfection which needs definite diagnosis,necessary surgical intervention and antibiotictherapy and patient monitoring.

References[1] Fonseca RJ, editor: Oral and maxillofacial

surgery, 1st ed. St. Louis: Saunders Elsevier,

Fig. 1.Severe bilateral temporal space swelling.

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Yazdania J, Mortazavi A, Ghavimi MA. Bilateralinfratemporal spaces abscess following removalof suspension wires: a case report. J Craniomax

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J Craniomax Res 2015;2(1-2):109-111