| Abstract|| |
The objective of the article is to highlight and make people aware of a rare abscess which is often missed or misdiagnosed. As only a few cases have been reported, the authors feel that reporting such a case would help in proper management of the disease. We are presenting a 6.5-year-old male child with 3 weeks history of right facial swelling in the parotid region, with low-grade fever and trismus. Submasseteric abscess is a rare abscess which is often misdiagnosed as a parotid abscess or parotitis. Only a few cases have been reported. The cause is mostly dental in origin. Intravenous antibiotics often fail to alleviate the symptoms as this is a closed space and needs prompt drainage. Therefore, awareness of this complication of dental infections is vital for proper diagnosis and timely management.
Keywords: Head and neck abscess, parotid abscess, submasseteric abscess
|How to cite this article:|
Rai A, Rajput R, Khatua RK, Singh M. Submasseteric abscess: A rare head and neck abscess. Indian J Dent Res 2011;22:166-8
A submasseteric abscess is a rare complication encountered, most commonly, secondary to dental procedures of the third molar. The anatomic location of the submasseteric space renders diagnosis of this condition challenging. Awareness of this complication is the most important step in reaching the diagnosis. Due to its rarity, the incidence is not really known but we have come across only a few reported cases on literature search.  We report a very rare case of a 6.5-year-old child who presented with right submasseteric abscess.
|How to cite this URL:|
Rai A, Rajput R, Khatua RK, Singh M. Submasseteric abscess: A rare head and neck abscess. Indian J Dent Res [serial online] 2011 [cited 2014 Oct 25];22:166-8. Available from: http://www.ijdr.in/text.asp?2011/22/1/166/79990
| Case Report|| |
A 6.5-year-old male child with no previous medical illness presented to our department with 3 weeks history of right facial swelling. Initially, it was a small swelling which started in the area of the right angle of mandible. It was associated with mild pain and low-grade fever. The swelling gradually continued to grow in size and was painful. The patient had history of right lower toothache. There was no previous history of trauma to the face. There was no previous history of recurrent swelling in the parotid region.
On examination, there was a large diffuse swelling extending from the lower border of the right zygomatic arch down to the submandibular region [Figure 1]. It was firm and tender to touch and no fluctuation was elicited on palpation. Marked trismus was noted with mouth opening, about 1.25 cm of interincisor distance. Oral examination revealed caries in the right upper and lower second deciduous molars. A routine hemogram showed raised white cell count; urine examination and chest radiograph were found to be within normal limits.
Computed tomography (CT) scan showed the presence of a large (35 Χ 18 Χ 28 mm = 8.3 ml), irregular, hypodense, non-enhancing lesion deep to right masseter muscle, resulting in focal bulge on the overlying skin. Mild diffuse enlargement of right parotid and submandibular glands was seen showing homogenous mild enhancement. Right parotid gland was found compressed posteriorly [Figure 2]. Ultrasound of the swelling showed irregular hypoechoic lesion of volume 30-40 ml in the right masseter muscle area, pushing the right parotid gland posteriorly. Intravenous antibiotics (Cefotaxime 500 mg TDS, Metrogyl 250 mg TDS, Amikacin 250 mg BD) were given prior to surgery for 1 week.
An incision and drainage was performed under general anesthesia with the patient in supine position and head turned to the left. The abscess was drained via a horizontal incision 2 cm below the lower border of the right mandible [Figure 3]. Sub-platysmal skin flap was raised and the masseter muscle breached to expose the abscess. Pus was drained out and sent for culture and sensitivity [Figure 4]. The pus was sterile after 48 hours of incubation. A corrugated drain was inserted. Intravenous antibiotics as above were administered postoperatively for 1 week and continued with oral antibiotics(Amoxycillin-Clavulanic acid 375 mg TDS) for another 1 week. Upon review 2 weeks postoperatively, the swelling had totally resolved but the patient still had residual trismus. After 1 month postoperatively, the trismus resolved.
| Discussion|| |
The submasseteric space is one of three spaces that make up the main masseteric space, the other two being the inferior temporal and the pterygomaxillary space. In 1948, Bransby-Zachary demonstrated a true submasseteric space which is a bare area between the separate attachments of deep and middle portions of the masseter muscle, resulting in a potential space.  The insertion of a small, deep portion was limited to the lateral surface of the coronoid process and upper third of the ramus of the mandible. Insertion of the largest, superficial portion was restricted to the lower third of the ramus, especially posteriorly at the angle of the mandible. The middle portion was the smallest and inserted along a thin line curving posteriorly and superiorly over the middle third of the ramus [Figure 5]. Anteriorly, the submasseteric space is bounded by the inner surface of the masseteric fascia as it sweeps around the anterior aspect of the masseter muscle and ramus. In this area, it is in close relationship with the retromolar fossa. Posteriorly, the space is bounded by the fibrous parotidomasseteric sheet, and laterally bounded by the fibers of the masseter muscle. Medially, the periosteum of the lateral aspect of the ramus is found. Inferiorly, it is limited by the insertion of the masseter muscle along the inferior half of the ramus, and superiorly, it is in communication with the superficial temporal space.  As the submasseteric space has virtually no outlet, inadequately treated infections in this area rapidly progress to abscesses.
Although several routes of infection in this region are possible, Bransby-Zachary suggested that pericoronitis associated with third molar infection is probably the most frequent cause.  The infection usually follows extraction or dental procedures of the third molar. Infection from a posterior molar could track posteriorly and become sequestered there as an abscess. Other causes include infections secondary to misdirected injections to this area, i.e., inferior alveolar nerve block placed laterally to the ramus, extension of infections from surrounding spaces, osteomyelitis of the zygomatic or temporal bones and compound fractures involving the mandibular angle or ramus.
The differential diagnosis of swelling in this region includes parotid gland pathology, masseteric hypertrophy, temporo-mandibular joint disorders. ,
The severity of the infection depends on the virulence of the causative organisms, and presenting symptoms vary according to the severity and stage of disease. The common organisms associated with such abscesses may be either aerobic like α hemolytic streptococci, Staphylococcus, Streptococcus pneumoniae, Enterobacteriacae, Proteus, Klebsiella and Mycobacterium tuberculosis, or anaerobic like Bacteroides, Prevotella and Fusobacterium. Recognized symptoms include swelling and pain secondary to abscess collection in the confined space, trismus due to involvement of the masseter muscle, malaise and fever. 
The patient also had postoperative trismus due to residual spasm of the masseter muscle as a result of the inflammation.
| Conclusion|| |
In conclusion, submasseteric abscess is a rare abscess which is often misdiagnosed as a parotid abscess or parotitis. The cause is mostly dental in origin. Intravenous antibiotics often fail to alleviate the symptoms and needs prompt drainage.
| References|| |
|1.||Jones KC, Silver J, Millar WS, Mandel L. Chronic submasseteric abscess: Anatomic, radiologic and pathologic features. Am J Neuroradiol 2003;24:1159-63. |
|2.||Bransby-Zachary GM. The sub-masseteric space. Br Dent J 1948;84:10-3. |
|3.||Mandel L, Baurmash H. Submasseteric abscess. Oral Surg Oral Med Oral Pathol 1958;11:1210-9. |
|4.||Mandel L. Submasseteric abscess caused by a dentigerous cyst mimicking a parotitis: Report of two cases. J Oral Maxillofac Surg 1997;55:996-9. |
|5.||Menon K, Loke D, Rogers M. Submasseteric or parotid abscess?: The diagnostic dilemma. Otolaryngol Head Neck Surg 2005;9:25-7. |
|6.||Mandel L. Diagnosing protracted submasseteric abscess: The role of computed tomography. J Am Dent Assoc 1996;127:1646-50. |
Department of E.N.T. and Head & Neck Surgery, M.L.N. Medical College, Allahabad, Uttar Pradesh
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]