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    Mortality Associated With Odontogenic Infection!: Case Report

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    rizkyfm
    This case report describes a spreading maxillofacial infection from odontogenic origins that resulted in death. A young male presented with rapidly advancing neck swelling and was treated surgically and with antibiotics, but later died from massive hemorrhage into the chest cavity from an abscess that eroded the subclavian vein. The case highlights the importance of taking odontogenic infections seriously and providing prompt treatment.

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    Mortality Associated With Odontogenic Infection!: Case Report

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    rizkyfm
    41 views2 pages
    This case report describes a spreading maxillofacial infection from odontogenic origins that resulted in death. A young male presented with rapidly advancing neck swelling and was treated surgically and with antibiotics, but later died from massive hemorrhage into the chest cavity from an abscess that eroded the subclavian vein. The case highlights the importance of taking odontogenic infections seriously and providing prompt treatment.

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    This case report describes a spreading maxillofacial infection from odontogenic origins that resulted in death. A young male presented with rapidly advancing neck swelling and was treated surgically and with antibiotics, but later died from massive hemorrhage into the chest cavity from an abscess that eroded the subclavian vein. The case highlights the importance of taking odontogenic infections seriously and providing prompt treatment.

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    © All Rights Reserved
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    41 views2 pages

    Mortality Associated With Odontogenic Infection!: Case Report

    Uploaded by

    rizkyfm
    This case report describes a spreading maxillofacial infection from odontogenic origins that resulted in death. A young male presented with rapidly advancing neck swelling and was treated surgically and with antibiotics, but later died from massive hemorrhage into the chest cavity from an abscess that eroded the subclavian vein. The case highlights the importance of taking odontogenic infections seriously and providing prompt treatment.

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    PRACTICE

    case report

    Mortality associated with odontogenic


    infection!
    A. W. Green,1 E. A. Flower,2 and N. E. New,3

    Odontogenic causes are the most common source for spreading


    maxillo-facial infections.1 These infections can develop into life
    threatening events. However a fatal outcome is fortunately rare and
    is generally associated with an immunocompromised status.2,3 This
    case report highlights a spreading maxillo-facial infection, which
    resulted in massive haemorrhage from the subclavian vein into the
    pleural cavity and subsequent death of a young fit male patient.

    25-year-old male was referred with


    rapidly advancing bilateral neck
    swelling of 3 days duration. Examination
    revealed marked trismus (opening limited
    to approximately 1 cm), raised tongue
    and slight dysphagia but no respiratory
    problems.
    The patient admitted to being an irregular dental attender, with a history of intermittent dental pain over the previous
    4 months. A panoramic radiograph showed
    heavily carious teeth in both the right and
    left lower quadrants with associated periapical pathology (Fig. 1). There was no relevant previous medical history.
    The patient was taken to theatre, within
    3 hours of presentation, for removal of the
    carious teeth and extra-oral drainage.
    A fibre-optic awake intubation was performed and intra-venous antibiotics started
    at induction (500 mg amoxycillin and
    500 mg metronidazole both three times a
    day). Extra-oral incisions were performed
    and the carious teeth were extracted. No
    frank pus was located but extra-oral drains
    were placed. Over the next 2 days his condition significantly improved and he was discharged home.

    In brief
    Take odontogenic infections seriously
    Importance of regular dental
    check-ups
    Good oral hygiene and diet habits
    Rapid surgical and antibiotic
    treatment for spreading facial
    infections

    Two days later the patient reattended.


    He was pyrexial and had not been taking
    his antibiotics, as he found it difficult to
    swallow. Clinically pus was noted escaping from the extra-oral incision. Blood
    cultures were obtained and found to be
    positive for Streptococcus intermedius,
    which was sensitive to penicillin. Intravenous antibiotics were commenced,
    (benzyl penicillin 600 mg four times a
    day and metronidazole 500 mg three
    times a day). Over the next 4 days the

    extra-oral swelling and swallowing


    improved and the patient was discharged
    home, with oral antibiotics and a followup appointment arranged for 1 week
    later. No further contact was made by the
    patient. However, on the day of the
    patients scheduled follow-up appointment, he was unexpectedly brought to
    the A&E department by emergency
    ambulance, having suffered at home sudden haemorrhaging from the oral cavity
    and subsequent respiratory arrest. On
    admission the patients haemoglobin was
    5.8 x 109 g/dl. Initial examination
    revealed that the haemorrhage was arising
    deep within the aerodigestive tract and not
    from the mouth.
    Despite extensive resuscitation measures the patient suffered an electromechanical dissociation arrest and died
    2 hours later.
    At the post-mortem performed there,
    an abscess cavity was found at the root of
    the neck which communicated with the
    operation sites. It involved the subclavian vein and partially destroyed it. The
    subsequent haemorrhage tracked behind
    the pleura producing a mass and through
    the pleura into the pleural cavity producing a massive haemothorax measuring
    3,750 ml.
    The chest x-ray on admission showed a
    mass in the right side of the chest above the
    carina, which on post-mortem was shown
    to be blood trapped beneath the parietal

    1SHO Oral and Maxillo-facial Surgery, Queen


    Elizabeth Hospital, Kings Lynn, Norfolk; 2Consultant

    Oral and Maxillo-facial Surgery, Queen Elizabeth


    Hospital, Kings Lynn, Norfolk; 3Consultant
    Histopathologist, Queen Elizabeth Hospital, Kings
    Lynn, Norfolk
    *Correspondence to: A. W. Green, 6 King Street,
    Kings Lynn, Norfolk PE30 1ES
    REFEREED PAPER
    Received 21.08.00; Accepted 15.11.00
    British Dental Journal 2001; 190: 529530

    Fig. 1 Pre-operative
    orthopantomograph
    showing carious teeth
    and periapical pathology

    BRITISH DENTAL JOURNAL VOLUME 190 NO. 10 MAY 26 2001

    529

    PRACTICE

    case report
    readily through the soft tissues, because of
    its ability to produce hyaluronidase and
    streptokinase, which breaks down ground
    substance and fibrin. It has been postulated that mixed infections, involving
    Streptococcus intermedius and Fusobacterium, can produce rapidly spreading
    infections, because of a symbiotic reaction.6 However, Fusobacterium was not
    cultured in this case.

    Conclusion

    Fig.2 Chest x-ray showing


    mass in right side of chest
    above the carina

    pleura. The chest x-ray was taken prior to


    the final bleed (Fig. 2).

    Discussion.
    The post-mortem showed the lateral pharyngeal space to be the reservoir of
    infected material, which had tracked
    down around the carotid sheath to the
    root of the neck, where the subsequent
    haemorrhage occurred. Removal of the
    original odontogenic cause, supported by
    appropriate antibiotics, would normally
    result in resolution of the lateral pharyngeal space infection.4 In this particular
    case, however, infection continued,
    despite the apparent resolution of the
    neck swelling.
    Further clarification of the situation might
    have been obtained with additional imaging

    530

    of the neck. Plain film radiographs (lateral


    soft tissue C-spine and posterior anterior
    view of the same region) may have identified
    infection in the soft tissues.3 The ideal imaging modality would be magnetic resonance
    imaging or ultrasound, which clearly defines
    the spaces and also helps differentiate cellulitis from an abscess.5 Given the clinical picture at the time and the fact that the patients
    clinical condition was improving, both in the
    hospital and at home, there were no indications for further imaging.
    In deep neck infections from odontogenic origins the commonest causative
    organisms are generally Streptococci and
    oral anaerobes. In this case Streptococcus
    intermedius was isolated, which was sensitive to penicillin.
    Streptococcus intermedius spreads very

    This particular case highlights the importance of taking all odontogenic infections
    seriously and emphasises the need for
    early treatment and prompt referral when
    necessary.
    1

    3
    4
    5

    Zeitoun I M, Dhanarajani P J. Cervical cellulitis


    and mediastinitis caused by odontogenic
    infections: report of two cases and review of
    literature. J Oral Maxillofac Surg 1995; 53:
    203-208.
    Wong T. A nationwide survey of deaths from
    oral and maxillofacial infections: the Taiwanese
    experience. J Oral Maxillofac Surg 1999; 57:
    1297-1299.
    Peterson L J. Contemporary management of
    deep infections of the neck. J Oral Maxillofac
    Surg 1993; 51: 226-231.
    Krishnan V, Johnson J V, Helfrick J F.
    Management of maxillofacial infections. J Oral
    Maxillofac Surg 1993; 51: 868-873.
    Fielding A F, Reck S F, Barker W J. Use of
    magnetic resonance imaging for localization of
    a maxillofacial infection: Report of a case. J
    Oral Maxillofac Surg 1987; 45: 548.
    Peterson L P. Microbiology of head and neck
    infections. Oral Maxillofac Surg Clin N Am
    1991; 3: 247-257.

    BRITISH DENTAL JOURNAL VOLUME 190 NO. 10 MAY 26 2001

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