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81]
Review Article
A review of complications of
odontogenic infections
Department of Oral and Maxillofacial Rishi Kumar Bali, Parveen Sharma, Shivani Gaba, Avneet Kaur,
Surgery, JN Kapoor DAV (C) Dental
College and Hospital, Yamunanagar, Priya Ghanghas
Haryana, India
ABSTRACT
DOI: How to cite this article: Bali RK, Sharma P, Gaba S, Kaur A,
10.4103/0975-5950.183867 Ghanghas P. A review of complications of odontogenic infections. Natl J
Maxillofac Surg 2015;6:136-43.
© 2015 National Journal of Maxillofacial Surgery | Published by Wolters Kluwer - Medknow | 136
[Downloaded free from http://www.njms.in on Wednesday, September 28, 2016, IP: 89.99.104.81]
Figure 1: Potential pathways of extension of deep fascial space infections of the head and neck
Edema and swelling of this space will cause superior Table 1: Risk factors for complications
and posterior displacement of the floor of the mouth Systemic factors
and tongue causing airway compromise Diabetes mellitus
• The parapharyngeal space has the shape of a cone Alcoholism
with its base facing the skull and communication HIV, measles, chronic malaria, tuberculosis
Hyper and hypo‑thyroidism
with the brain can result in a cerebral abscess.[10] Liver disease, renal failure, heart failure
Communication occurs via various foramina such Blood dyscrasias ,anaemia, sickle cell disease
as foramen ovale, foramen lacerum, and jugular Irradiation
Steroid therapy
foramen Cytotoxic drugs
• The pretracheal space lies anterior to the trachea, and Excessive antibiotics
it descends into the anterior mediastinum. Spread of Malnutrition
infection along this route is not common, accounting Allergic reactions
with a diagnosis of right temporal, infraorbital, buccal, Tracheostomy using local anesthesia has been considered
pterygomandibular space abscess. Despite surgical the gold standard of airway management in patients
and medical supportive care, the condition progressed with deep neck infections.[44,46] In a group of 36 patients
to sepsis leading to death.[4] Fardy et al. encountered with Ludwig’s angina, 16 underwent successful
one case of a 9‑year‑old patient developing toxic shock elective tracheostomy using local anesthesia; intubation
syndrome secondary to dentoalveolar abscesses. [33] attempts failed in 11 (55%) of the other 20 patients and
Despite the treatment, the patient died 2 days after resulted in acute airway loss that required emergency
admission to intensive care unit because of multisystem tracheostomy.[47]
organ failure.
The first successful fiberoptic nasotracheal intubation
It is of the utmost importance to diagnose sepsis as in a patient with Ludwig’s angina was reported in
early as possible.[34] The mainstays for the treatment of 1974. [23,48] Tissue edema and immobility, a distorted
severe sepsis includes the following principles: (1) Early airway, and copious secretions contribute to the difficulty
diagnosis, (2) treatment of the infection (antimicrobial of fiberoptic intubation. Ovassapian et al. reported the
therapy and surgical eradication of the inciting successful awake fiberoptic intubation of 25 of 26 with
infectious focus),[35] (3) resuscitation and hemodynamic severe neck space infection.[49] Success rate of 95% has
support (fluids and vasopressor therapy), (4) full organ been reported in literature with fiberoptic intubation.
support (renal replacement therapy and mechanical
ventilation), (5) modulation of the inflammatory Percutaneous transtracheal and percutaneous dilatational
response (recombinant human activated protein C), tracheotomy have limited application in surgical
(6) sedation and analgesia as needed, and (7) adequate management of airway.
nutrition. Studies [36,37] have shown that early and
adequate treatment with early, goal‑directed therapy
after the onset of a septic episode is associated with Descending Necrotizing Mediastinitis
increased favorable outcome.
It occurs as a complication of odontogenic or cervicofascial
Approximately 30–50% of patients presenting with a infections.[50‑53] Of the reported cases of DNM, 60–70%
clinical picture of severe sepsis have positive blood originate from OIs.[54] Diagnosis of DNM mandates that
cultures.[38] Failure to check blood cultures before the the relationship between mediastinitis and oropharyngeal
start of antimicrobial therapy will potentially influence infection is clearly established. According to Wheatley
the growth of blood‑borne bacteria and prevent a culture et al., most common primary oropharyngeal infection is
from becoming positive later.[39] odontogenic (25 of 43 cases) with mandibular second or
third molar abscess.[55] For the diagnosis of mediastinitis of
odontogenic origin, Estrera et al.[13] proposed the following
Respiratory Obstruction criteria: (1) Clinical manifestations of severe infection;
(2) characteristic radiographic findings in the neck
This is another most concerning complication of and chest of gas in the tissues, an air‑fluid level, loss
OIs. [16,40,41] Respiratory obstruction may be due to of normal cervical lordosis, and mediastinal widening;
swelling of floor of mouth, trismus, edema, and abscess and (3) establishment of a relationship between the dental
formation leading to narrowing and eventually to the infection and the development of mediastinitis.
loss of airway. Epiglottitis, peritonsillar abscess, and
retropharyngeal abscess may also lead to respiratory Review of the literature shows that although DNM
obstruction. In advanced cases, the patient can assume is quite rare, this variety of mediastinitis is a highly
various positions to relieve partial airway obstruction. lethal disease[7,56,57] with a mortality rate of 37–60% and
A retropharyngeal space abscess can cause the patient is frequently associated with pleural and pericardial
to assume the “sniffing position,” maneuver which effusion, compression of the local blood vessels, persistent
straightens the upper airway.[42] sepsis, and multiorgan failure.
Tracheal intubation in patients with deep neck infections A multidisciplinary approach is recommended for
is challenging. The distorted airway anatomy, tissue successful treatment of this life‑threatening infection.
immobility, and limited access to the mouth make
orotracheal intubation with rigid laryngoscopy
difficult.[41,43] Rupture of an abscess and aspiration of Other Thoracic Complications
pus have been reported during an attempted orotracheal
intubation [41] and blind nasal intubation. [44,45] Blind Early signs of thoracic involvement are difficult to
nasotracheal intubation should be avoided. interpret. According to Estrera et al.,[13] diffuse brawny
Lemierre’s Syndrome
Orbital Abscess
Lemierre’s syndrome is characterized by suppurative
thrombophlebitis of the IJV and is a metastatic Organisms from an odontogenic source may gain
infection. [33] In their literature search for Lemierre’s entrance to the orbit through local tissue planes, by
syndrome, primary site of infection was oropharynx hematogenous spread, or via involvement of the
in 59.5% of cases, followed by mastoiditis (15%) and paranasal sinuses. The orbital septum delineates these
7 cases with a primary OI (in the preantibiotic era, infections into pre‑ and post‑septal disease, which is
Lemierre’s syndrome carried a mortality rate of 83%). important because the latter has the potential to cause
The term postanginal sepsis is used interchangeably with severe complications.[62]
Lemierre’s syndrome, which was initially reported by
Courmont and Cade in 1901, but best described by Andre Orbital abscesses exhibit common signs and symptoms
Lemierre in 1936. Computed tomography of the neck such as chemosis, periorbital edema of the eyelid,
with contrast has been shown to be the best diagnostic reddening, hyperthermia, proptosis, extraocular muscle
modality because it allows visualization of the IJV and for dysfunction, and decreased visual acuity. Further,
the diagnosis of other complications such as pulmonary pursuit of diagnosis includes advanced imaging
emboli, abscesses, osteomyelitis, and arthritis.[58] techniques such as CT scans or MRI.[63]
Magnetic resonance imaging (MRI) and Doppler Early diagnosis and appropriate medical and surgical
ultrasonography can also be used for diagnosis. therapy are imperative for successful outcomes of this
A multidisciplinary approach is necessary to treat rarely occurring disease.
patients with Lemierre’s syndrome.
Retrograde spread of infection can lead to complications
such as CST, meningitis, cerebritis, brain abscess,
Cervical Necrotizing Fascitis or death. [64,65] At present, despite antimicrobial and
surgical management, a substantial amount of patients
It is characterized by an extensive, severe progressive with subperiosteal abscess still develop various visual
infection with dissection and necrosis of the soft tissues sequelae.[65] Haymaker[66] in 1945 by his study on 28 cases
along the cervical planes [45] and is associated with concluded that there was direct intracranial spread
mortality rate in between 20% and 40%. [59] Bacterial in 17 cases and by hematogenous route in 11 cases
enzymes and cell wall components play an essential role following dental extraction. His series included six cases
in local tissue destruction, dissemination of the infection, of intraorbital abscess.
and in systemic toxicity. Over time, the necrotic tissue
begins to separate with suppuration (approximately
on the 8th day). If the necrotizing process continues to Cavernous Sinus Thrombosis
spread, it involves the neighboring tissues and provokes
local or systemic complications. [29,60] The literature Septic CST is a rare condition.[67,68] Seven percent of all
shows that cervical necrotizing fasciitis complications cases of thrombosis of the cavernous sinus are of dental
origin. The cavernous sinuses and their connections are The management includes intravenous (IV) glucocorticoids
devoid of valves. Consequently, bidirectional spread in patients with evidence of mass effect from a brain
of infection, and thrombi can occur throughout this abscess. Odontogenic brain abscesses are best treated with
network. Organisms may reach the cavernous sinus a combination of IV ceftriaxone and IV metronidazole.
from the face by an anterograde route along ophthalmic
veins connected to angular veins, or by a retrograde route
along emissary veins connected to the pterygoid venous Osteomyelitis
plexus. Contrast enhanced CT scan may reveal the
primary source of infection, thickening of the superior Osteomyelitis may develop in the jaws after a chronic
ophthalmic vein, and irregular filling defects in the OI or for a variety of other reasons. [75,76] In a review
cavernous sinus. of 141 cases of jaw osteomyelitis in Nigeria, Adekeye,
and Cornah found OIs to be the cause of 38% of
Fewer than 40% of patients usually have full recovery, mandibular and 25% of maxillary involvement.[77] Pain
while the remainder of patients having neurological and tenderness, low‑grade fever, draining sinus tracts,
deficits such as extraocular muscle paresis, impaired suppuration, dental loss, and sequestrum (i.e., necrotic
visual acuity, hemiparesis, and focal seizures. Other bone fragment) formation are main clinical features. New
potential long‑term sequelae include hypopituitarism, bone and oral mucosa occasionally regenerate beneath
the syndrome of inappropriate secretion of antidiuretic the sequestra, probably because of activation of periosteal
hormone, and the vascular steal syndrome (i.e., retrograde osteoblasts by the infectious process.[77]
filling of the anterior circulation via the vertebral arteries).
Death generally occurs within 4–7 days if the diagnosis Wang et al. described the first case in which recurrent
is not made or when treatment is not instituted, usually vertebral osteomyelitis and psoas abscess developed
due to meningitis, brain abscess, or generalized sepsis. in a patient with a previously unrecognized atrial
septal defect and disease recurrence was ascribed to the
Management should be based on early diagnosis and presence of dental disease, which served as the source
prompt management with intravenous broad‑spectrum of infection.[78]
antibiotics and surgical intervention.[69]
On radiographs, osteomyelitis appears as
radiolucent (“moth‑eaten”) regions representing bony
Brain Abscess destruction and avascular necrosis, with evidence of
sequestrum formation and occasional pathologic fractures.
Dental cases of brain abscess have been published in Plain radiographs may not show the bony destruction
the literature.[70] Haymaker’s analysis of 28 fatalities in early stages of the disease. Bone scintigraphy allows
resulting from central nervous system infection included earlier detection. Frank osteomyelitis is characterized on
8 instances of brain abscess of odontogenic origin. Hollin CT by erosion involving the medullary and cortical bone.
and Gross reported a subdural empyema of odontogenic Proper surgical management and antimicrobial therapy
origin.[71,72] Direct spread tends to cause solitary abscesses, are must to avoid the complications.
whereas hematogenous spread usually results in
multiple abscesses. Anaerobic species are responsible
for the majority of cases of odontogenic (78%) brain Thrombocytopenia
abscess.[73]
In a case report by Kumar Verma and Rajan,[25] an adult
Clinically, there is usually a latent period of several male patient with OI, who developed life‑threatening
days or weeks before the appearance of symptoms of thrombocytopenia, is presented, developed due to
intracranial involvement. Initial complaints may be mild, increased platelet destruction, impairment of platelet
consisting mostly of headaches, malaise, and apathy. production, or adherence of platelets to damaged
Neurologic signs may appear later, depending on the endothelium. Consumptive coagulopathy such as
location of the lesion. In the case where there is suspicion DIC can also lead to a decrease in platelet count. The
of an intracranial space‑occupying mass, tests such as management of an OI complicated by thrombocytopenia
a brain scan and carotid arteriogram are necessary. presents a tricky situation to the surgeon.
The first radiologic signs of brain abscess can be seen
on CT examination 2–3 weeks after infection begins.
Encapsulation of the brain abscess occurs about 6 weeks Adult Respiratory Distress Syndrome
after infection, which is seen on contrast enhanced CT
as a radiopaque ring surrounding a central necrotic ARDS caused by sepsis secondary to the OI have been
region.[68,74] reported in literature. ARDS can be caused by many
conditions, among which the most common are sepsis OIs has decreased dramatically over the past 50 years.
and septic shock. However, they can still carry the potential for lethal
complications, especially in the immunocompromised
patient. However, attention to airway maintenance,
Assessment of Patients with Severe appropriate antibiotic therapy, and judicious surgical
Odontogenic Infection intervention enable the health care professions to
continue their remarkable progress in treating these
Assessment should focus on developing complications once‑dreaded infections. Recognition of the classic signs
such as airway compromise, the spaces involved, the of severe OIs by the general practitioner and expeditious
precise etiology of the infection, and identifying sepsis referral to a higher level of care benefits the patient and
symptoms. A sublingual space infection elevates the may be life‑saving.
tongue interfering with the articulation of sounds.
A retropharyngeal or lateral pharyngeal space abscess Financial support and sponsorship
can result in muffling of the voice. An impending airway Nil.
collapse should be suspected if the patient is sitting in
a sniffing position, drooling, and the use of accessory Conflicts of interest
muscles of respiration. There are no conflicts of interest.
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