Maria Wolniewicz, *Lidia Zawadzka-Głos
Idiopathic left-sided buccal abscess – a case report
Idiopatyczny ropień policzka lewego – opis przypadku
Department of Pediatric Otolaryngology, Medical University of Warsaw, Poland
Head of Department: Associate Professor Lidia Zawadzka-Głos, MD, PhD
Ropnie regionu głowy i szyi to istotny problem kliniczny. Znaczącą rolę w ich powstawaniu odgrywają zakażenia zębopochodne (przede wszystkim zmiany próchnicze czy stan po zabiegach stomatologicznych), odpowiadające za ok. 1/3 stanów zapalnych policzka. Właściwa diagnoza jest kluczowa dla ustalenia drogi postępowania terapeutycznego. Wśród dostępnych metod leczenia wyróżniamy antybiotykoterapię ogólnoustrojową samodzielnie lub w połączeniu z interwencją zabiegową, bądź też rzadziej interwencja zabiegowa jako jedyne działanie. Głównym celem leczenia jest ograniczenie infekcji oraz prewencja jej dalszego rozprzestrzeniania do głębiej położonych struktur (w tym istnieje ryzyko przekroczenia bariery krew-mózg). Dla zmian obejmujących przestrzenie powierzchowne zazwyczaj wystarczające jest badanie ultrasonograficzne odpowiedniej okolicy pozwalające na wstępną ocenę, a następnie monitorowanie procesu leczenia. Alternatywą wobec badania ultrasonograficznego jest badanie rezonansem magnetycznym, pozwalające na znacznie dokładniejszą, wielowymiarową analizę zajętego obszaru i łatwiejsze zróżnicowanie tkanek, jednak jest ono znacznie droższe i trudniej dostępne, a przez to też mniej dostępne w monitorowaniu efektów leczenia. Poniżej przedstawiamy przypadek nastolatki, u której rozwinął się idiopatyczny jednostronny ropień policzka lewego.
Abscesses of the head and neck region account for an important clinical problem. They are most frequently of dental origin (mainly due to carious changes or state after dental interventions), especially when located in the buccal region (about 1/3 cases). The correct diagnosis is the key to determine the proper treatment protocol: systemic antibiotics and/or surgical procedure (usually drainage) in order to prevent further progression of the inflammatory process (including transgression of the blood-brain barrier). Ultrasound is a sufficient first line diagnostic tool for the changes localized in the superficial spaces. Additionally, it is helpful in monitoring the effectiveness of the introduced treatment. Alternatively, MRI could be used, enabling more thorough 3D visualization of the affected areas and tissues differentiation, but due to its cost and availability its role is restricted, especially in monitoring (when examination needs to be repeated regularly). Below we would like to present a case report of our teenage patient, who developed idiopathic left-sided buccal abscess.
Abscesses of the head and neck region stand for one of the basic problems for general practitioners’ everyday practice (1). They can develop as single-space or multiple-space abscess (2). The most frequently involved are the submandibular, buccal, submental or canine spaces (2, 3). The crucial step is the right diagnosis enabling to assess the risk of purulent changes, which would further determine the proper treatment protocol: ambulatory treatment or the need of specialist surgical procedure (4, 5). Below we would like to present a case report of our teenage patient, who developed left-sided buccal abscess that required surgical intervention due to the emphasized local complaints and the evidence of an abscess in the ultrasound. Unfortunately, we could not identify one clear factor underlying for the observed inflammatory process.
Seventeen-year-old patient was admitted to our department during emergency service due to increasing swelling of the left cheek for the last few days with associated pain, without fever. She had no problems with breathing, had slightly deformed voice and suffered from problems with eating and drinking (mostly because of the pain discomfort). Physical examination on admission showed emphasized redness and edema of the left cheek, on palpation an inflammatory infiltration sized about 4 x 3 cm with fluid-filled area on pressing in its lower parts, localized superficially, was remarkable. Apart from that pronounced acnes on the face was noticeable. In laryngological examination of the mouth mucous was unremarkable, there were no carious lesions, no dental or gingival abnormalities. According to our patient she is regularly checked up by her dentist, has had no interventions recently. Her hair was dyed in various colors, she had a lot of earrings in her auricles, but denied self-piercing or other interventions in her cheek. She did not suffer from any chronic illnesses. She admitted to drinking alcohol occasionally on social meetings and smoking cigarettes, but denied drug in-take. One day before admission she was prescribed ambulatorily Amoxicillin/Clavulanic acid 1.0 g, one pill two times daily, but due to worsening of the complaints she referred to the emergency unit.
On ultrasound on admission (fig. 1, 2) an oval lesion sized 15 x 19 x 13 mm with hypoechoic, heterogenous, thick contents reflecting abscess characteristics within edematous soft tissues with marked vessels and enhanced blood-flow was described. The center of the lesion was localized superficially, about 5 mm beneath the skin surface. On laboratory tests WBC was normal, CRP was at the boundary of the norm (1.0 with the norm 0.0-1.0).
Fig. 1. Ultrasound on admission – oval lesion sized 15 x 19 x 13 mm with hypoechoic, heterogenous, thick contents, edema of the surrounding soft tissues – image reflecting an abscess
Fig. 2. Ultrasound on admission – edema within soft tissues, marked vessels with enhanced blood-flow surrounding the abscess
Continuation of the introduced ambulatorily Amoxicillin/Clavulanic acid in a does 1.2 g, 3 times daily, intravenously with additional Clindamycin 900 mg 3 times daily was planned. Moreover, our patient was qualified for the drainage of the abscess. The surgical intervention from the intraoral access was performed on the 2nd day of hospitalizations in general anesthesia as soon as we got SARS-CoV-2 results. A large amount of thick pus was drained from the lesion and sent for microbiological examination. During procedure ultrasound navigation was not used. The puncture of the lesion, followed by a drainage were performed after palpation and fixation of the cheek in the position, in which the lesion was best marked. The abscess’s cavity and the mouth were rinsed generously with Octenidine dihydrochloride (Octenisept), and then 0.9% natrium saline. Regular rinsing of the mouth with the solution of Octenidine dihydrochloride (Octenisept) and 0.9% natrium saline in a ratio 1:1 three times daily together with mechanical broadening of the abscess cavity were continued on the ward. Pus combined with blood was obtained till the 3rd day post-operatively during mechanical broadening when a serous content appeared and as a result it was decided to stop further interventions. With the course of treatment gradual relief of patient’s complaints and local improvement (diminished edema, inflammatory infiltration and blood flow resulting in reduced redness, no palpable fluid area) were observed. On the 7th day of antibiotic therapy we received microbiological results, which revealed growth of aerobic bacteria Citrobacter freundii and Enterococcus faecalis, with no resistance for standard antibiotics and at the same time prone to applied treatment (tab. 1).
Tab. 1. Microbiology results – antimicrobial resistance
|Antibiotics/identification||Citrobacter freundii ESBL-||Enterococcus faecalis|
|Ampicillin|| || ||S|| |
|Piperacillin/Tazobactam||S||≤ 4|| || |
|Cefotaxime||S||≤ 0.25|| || |
|Cefepime||S||≤ 0.12|| || |
|Amikacin||S||≤ 2|| || |
|Gentamycin||S||≤ 1|| || |
|Tobramycin||S||≤ 1|| || |
|Linezolid|| || ||S|| |
|Teicoplanin|| || ||S|| |
|Vancomycin|| || ||S|| |
|Trimethoprim/Sulfamethoxazole||S||≤ 20|| || |
|Streptomycin – high concentration|| || ||S|| |
|Gentamycin – high concentration|| || ||S|| |
S – susceptible to standard dose of an antibiotics
We performed control ultrasound (fig. 3, 4) in order to verify observed clinical improvement and to exclude persistence of any fluid/pus concentrations. It showed no evidence of an abscess. A lesion sized around 7 x 5 x 10 mm – the remainder of a drained abscess and a fistula of 15 mm length and 0.5-1.5 mm diameter – the effect of a performed procedure were described. After delivery of microbiology results due to good general condition of the patient she was discharged from the hospital with recommendation to continue Amoxicillin/Clavulanic acid 1.0 g, one pill two times daily for the next 7 days, followed by ultrasound examination and laryngological check-up, together with dental consultation.
Fig. 3. Ultrasound before discharge from the hospital – the remainder of a drained abscess, sized around 7 x 5 x 10 mm, with no evidence of pus/fluid
Fig. 4. Ultrasound before discharge from the hospital – the effect of a performed procedure, fistula of 15 mm length and 0.5-1.5 mm diameter, with no enhanced blood-flow or edema in surrounding tissues
The buccal space consists anatomically of a few layers, namely (from the outside) skin, the adipose tissue (called buccal fat pad), the buccopharyngeal fascia, the masseter muscle (infiltrated by the duct of the parotid gland), buccal glands (mucoserous) and finally, the inner layer of the mucous tissue of the oral cavity. Anteriorly, the cheek sticks to the mimic muscles of the face and their fascia, laterally borders with the parotid gland and its fascia, medially with the maxillary alveolar ridge and posteriorly with the zygomatic fascia. Fascial coverings separating the buccal space from the surrounding tissues are not complete, which promotes local spread of the inflammatory processes in this region (6).
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