Intraorbital abscess
A rare complication after maxillary molar extraction
STEFAN STÜBINGER, D.D.S.,
CHRISTOPH LEIGGENER, M.D., D.D.S.,
ROBERT SADER, M.D., D.D.S. and
CHRISTOPH KUNZ, M.D., D.D.S.
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ABSTRACT
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Background. The orbit is prone to being affected by an odontogenous infection, owing to its anatomical proximity to the maxillary sinus. A possible reason for an ophthalmic manifestation of a dental abscess is extraction of an acutely inflamed tooth.
Case Description. The authors describe the treatment of a man who had painful swelling and redness in the area of his right eye after having a maxillary molar extracted a few days previous. A general dentist referred the patient to the clinic after he began to experience a progressive deterioration of vision of his right eye. Emergency surgical intervention prevented impending loss of vision, and subsequent healing was uneventful.
Clinical Implications. To avoid serious complications, clinicians should not perform a tooth extraction when the patient is in the acute stage of a maxillary sinus infection. Appropriate diagnostic imaging and profound evaluation of the clinical state play major roles in managing the treatment of patients with inflammatory processes that involve the oral and paraoral regions.
Key Words: Intraorbital abscess; odontogenous infection; acute inflammation; tooth extraction
Odontogenous bone infections may develop from teeth damaged by caries, pulpal disease, acute periodontitis1 or, in rare cases, the empty alveolus after tooth extraction.2 Owing to their anatomical and topographic location at the roots, oral pathogens or inflammatory mediators can infiltrate quickly the adjacent sites (for example, the trigonum submandibulare or the maxillary sinus). This can result in tissue liquefaction and abscess formation, which can expand cranially as in the case of a maxillary sinus empyema. Obstruction of the upper airways, necrotic fasciitis,3 intraorbital abscess4 and intracranial abscess are familiar severe sequelae of ascending infections.5 Thanks to modern antibiotic therapy, such serious sequelae are rare. However, as these complications present special demands in managing illness, such diagnoses must be taken seriously, and the patient usually requires inpatient treatment. In particular, orbital abscesses and orbital phlegmonae demand expeditious treatment to control further bacteremia (for example, via the angular vein).
Clinicians should not perform a tooth extraction when the patient is in the acute stage of a maxillary sinus infection.
We present a case report on an orbital abscess that occurred after maxillary molar extraction and provide a comprehensive explanation of the pathogenesis and surgical procedure.
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CASE REPORT
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A 20-year-old man complained of massive swelling and redness in the area of his right eye. The swelling and redness had worsened over the previous two days and become critical in the past few hours (Figure 1
). The reason he came to the University Clinic for Reconstructive Surgery (Department of Cranio- and Maxillofacial Surgery, University Hospital, Basle, Switzerland) was that he was experiencing a progressive deterioration of vision in his right eye. Clinically, we observed a swollen, reddened and pressure-sensitive right cheek, as well as a severe, painful proptosis and chemosis of the right eye. The patient could not spontaneously open his right eye, and he had limited ocular movements. The eyeball was extremely sensitive to pressure, and we observed an ophthalmoplegia. We also saw a marked intraoral swelling of the superior vestibule that extended to the retromolar region.
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Figure 1. Frontal view of the patient with a right orbital abscess showing periorbital redness, swelling and proptosis.
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The patient reported that teeth nos. 1, 2 and 3 had been extracted two days previous because of throbbing pain and persistent cheek swelling on the right side. Immediately after surgery, the patient received antibiotic therapy (1 gram of amoxicillin/clavulanate acid by mouth three times a day). However, the patient’s condition did not improve after he received this therapy. He experienced severe proptosis and deterioration of vision, so his general dentist referred him to the clinic.
Radiologically, the panoramic radiographs taken before and after the teeth extractions showed complete shadowing of the right maxillary sinus, so that one could assume that an infection of the maxillary sinus already existed at the time of extraction. Therefore, we diagnosed the patient with a maxillary sinus empyema with involvement of the orbit. Because of the deterioration of the patient’s vision, we performed an emergency computerized tomography (CT) scan within 20 minutes. The CT scan revealed an abscess formation within the medial orbital region, as well as total obstruction of the right ethmoidal and maxillary sinuses leading to an anterocaudal displacement of the eyeball (Figure 2). Based on the patient’s history, we diagnosed him as having an odontogenous orbital abscess, which had disseminated via the maxillary sinus and the ethmoidal sinus cells. Because of the patient’s progressive loss of vision, we indicated that emergency care under local anesthesia was necessary to avoid further damage to the optic nerve.
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Figure 2. Axial computerized tomography scan shows a classic proptosis associated with an abscess of the orbit, as well as displacement of the medial orbital tissues and tenting of the posterior sclera.
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After the patient achieved anesthesia of the supra- and infraorbital nerve and infiltration anesthesia in the medial region of the right eyebrow and the right maxillary vestibule, one of the oral and maxillofacial surgeons (C.K.) made a medial blepharoplasty incision. He then exposed the supraorbital rim and the abscess cavity opened spontaneously, releasing a large amount of pus. To provide for further drainage, he also made an appropriate infraorbital incision and drained the abscess cavity. After rinsing the abscess cavity, he inserted a drainage tube for each incision. Subsequently, we created an iatrogenic oroantral fistula via the extraction alveolus at tooth no. 3 to release pus from the maxillary sinus (Figure 3). During surgery, the patient reported a marked improvement of symptoms after the release of pressure from the intraorbital abscess. We also inserted a drainage tube intraorally and fixed it with sutures (Figure 4).
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Figure 3. Creation of an oroantral fistula via the extraction alveolus at tooth no. 3 to release pus from the maxillary sinus.
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Figure 4. Intraoperative sites with fixed and sutured drainage tubes both intraorally and supra- and infraorbitally.
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In addition to surgery, we started the patient on antibiotic and steroid therapy to prevent further spread of the inflammatory infection into the orbital soft tissues and to prevent continued damage to the optic nerve as a result of the edema. The patient received 2.2 g of amoxicillin/clavulanate acid intravenously three times a day and 0.5 g of metronidazole intravenously three times a day. The patient also received 8 milligrams of dexamethasone intravenously three times a day to prevent swelling. The patient continued the intravenous therapy until his discharge from the clinic. We rinsed the patient’s abscess cavity and maxillary sinus daily, and, as a result, his local symptoms (especially his impaired vision) improved noticeably. We discharged him after one week of inpatient treatment. On radiographs, we observed a complete repneumatization of the maxillary sinus at this time. At an outpatient visit two weeks after surgery, we noted that the patient’s disorder had healed without complication and that his vision had returned to normal.
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DISCUSSION
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The cause and diagnosis of serious odontogenic infections and their tendency to spread has been described extensively in the literature.6–8 The anatomical proximity of the root apexes to the surrounding soft tissues favors pathogen transmission into the periodontal ligament,9 since pathogens will take the path of least resistance.10 Dental infections that spread beyond the tooth socket can initiate an infection in adjacent muscles and in connective tissue structures. According to this theory, a primary odontogenic infection of the maxilla can be transferred to the orbit via various pathways. The most commonly described route is via the maxillary sinus11,12; in the case we present, an empyema initially formed in the maxillary sinus leading into the orbit via the inferior orbital fissure and ascended into the ethmoidal sinus cells. A rare route is via the pterygopalatine or infratemporal fossa13; access to the orbit is gained by the ophthalmic vein via the pterygoid vein plexus. The pathogens also can reach the orbit via the facial vein and the angular vein. These veins communicate in the region of the medial canthus via its venous anastomosis with the supratrochlear veins and the supraorbital veins. Finally, odontogenous infections can reach the orbit via the canine fossa and the lower eyelid.14,15
Our patient’s case began with an acute infection of the maxillary sinus that was present at the time of the molar extraction. We retrospectively confirmed the patient’s typical symptoms when taking his history: sensitivity to pressure and percussion in the region of the maxillary teeth; swelling and pain on pressure in the cheek region; and worsening of symptoms when the patient bent over, coughed or lifted heavy objects. Typical, generalized symptoms of sinusitis are a general feeling of illness accompanied by fatigue and fever, secretion of purulent fluid, leukocytosis and a raised blood sedimentation rate. As a result of our patient’s molar extraction, the alveolar bone, which had been harmed by both the apical infection and the sinusitis, was infected locally.
In our patient’s case, the typical periodontal pathogens were Peptostreptococcus, Prevotella, Porphyromonas, Fusobacterium and Streptococcus viridans.16,17 Murakami and colleagues18 proved that Porphyromonas endodontalis led to abscess formation in the maxillofacial region. With the help of monoclonal antibodies against a lipolysaccharide of this black-pigmented anaerobe, they demonstrated a significant increase of this pathogen in odontogenic abscesses. P. endodontalis usually occurs in periapical lesions, radicular cysts and periodontal abscesses,19 and it influences the inflammatory effect of cytokines. It also is involved decisively in the spread of dental inflammatory foci in the orbit. Therefore, when dealing with an orbital abscess, clinicians should select additional supportive antibiotic therapy that affects such typical periodontal pathogens as oral anaerobes and S. viridans.
To avoid such a dramatic course as that in the odontogenic infection we described in our case report, clinicians should not perform a tooth extraction when the patient is in the acute stage of a maxillary sinus infection. In some cases, however, if adequate drainage can be guaranteed at an early stage (for example, through a broad alveolar socket in combination with the selection of the correct antibiotic), an immediate extraction of carious teeth can be considered. Therefore, it is mandatory not to use the same anesthetic injection needle for more than one injection to avoid spreading infection. The sequelae may include not only spreading the infection to specific anatomical areas, but also transmitting pathogens to the bone, resulting in trauma to the alveolar walls. Acute osteomyelitis, which is not necessarily limited to the jawbone, can only be treated under inpatient conditions.20,21
In the case of an empyema of the maxillary sinus, clinicians should rinse the maxillary sinus and perform an apicostomy on the causative tooth before extracting it. Clinicians also should evaluate if pain relief can be achieved by creating a window to the nose in the lower nasal passage, and they should prescribe a supportive antibiotic therapy, as well as a decongestant.22 After repeated rinsing and wound cleaning, clinicians can perform endodontic therapy or tooth extraction.23
After the acute infection has been treated, only a minimal risk of spreading the odontogenic infection remains; therefore, complications subsequent to tooth extraction such as those mentioned previously should be uncommon. The clinicians’ evaluation of the maxillary odontogenic foci should include precise assessment of the maxillary sinus as a possible origin for the severe infection sequelae. In this regard, appropriate diagnostic imaging and profound evaluation of the clinical state play a major role in managing the treatment of patients with inflammatory processes that involve the oral and paraoral region. By outlining the exact anatomical extent of the inflammatory process and eliminating the risk of spreading infection, clinicians can avoid having the patients experience further complications, because improper initial treatment can be ruled out. If these basic requirements cannot be fulfilled, clinicians should refer patients with a serious odontogenic infection to a specialist. It is important that general dentists have a competent knowledge of the identification, management, prevention and sequelae of oral and maxillofacial infections, as they often are the first health care professionals to be called in such emergency cases.
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CONCLUSIONS
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A severe and sometimes life-threatening infection with abscess formation in surrounding tissue structures can occur if a tooth extraction is performed when the patient is in the acute stage of a maxillary sinus infection. Therefore, it is essential that general dentists be aware of the possible ways odontogenous infections can spread and that they know how to manage such complications in the case of emergency.
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FOOTNOTES
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Dr. Stübinger is a dentist, University Clinic for Reconstructive Surgery, Department of Cranio- and Maxillofacial Surgery, University Hospital, Spitalstr. 21, CH-4031 Basle, Switzerland, e-mail "sstuebinger{at}uhbs.ch". Address reprint requests to Dr. Stübinger.
Dr. Leiggener is an oral and maxillofacial surgeon, University Clinic for Reconstructive Surgery, Department of Cranio- and Maxillofacial Surgery, University Hospital, Basle, Switzerland.
Dr. Sader is an oral and maxillofacial surgeon, University Clinic for Reconstructive Surgery, Department of Cranio- and Maxillofacial Surgery, University Hospital, Basle, Switzerland.
Dr. Kunz is an oral and maxillofacial surgeon, University Clinic for Reconstructive Surgery, Department of Cranio- and Maxillofacial Surgery, University Hospital, Basle, Switzerland.
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CASE REPORT
