A 67-year-old patient was admitted to the ear, nose, and throat (ENT) emergency department of Al-Mouwasat University Hospital with a month-and-a-half complaint of swelling and pain in the right masticatory space, trismus, and right eye proptosis with purulence. He had a history of poorly controlled type 2 diabetes mellitus for 20 years, arterial hypertension, and coronary artery bypass graft surgery (CABG), all of which necessitated the use of glipizide, metformin, aspirin, carvedilol, atorvastatin, and ramipril medications.
The patient reported undergoing a dental procedure due to a right-sided mandibular tooth infection. Two days later, the right masticatory space began to swell. A local doctor prescribed intramuscular (IM) Ceftriaxone 1-gram injections twice a day for 20 days with no improvement. Later on, the swelling expanded to the right buccal, temporal, and circumorbital spaces, and then exophthalmos in the right eye began to develop.
The patient was referred to the emergency room of a hospital in Damascus. The oral and maxillofacial team requested a panoramic dental x-ray (Figure 1). The patient was given Ceftriaxone, Carbapenem, and Amikacin depending on the outcome of the bacterial culture and antibiotic sensitivity test, which revealed Enterobacter. The pus was obtained by needle aspiration of the buccal space. To drain the abscess, an oral cavity's right buccal and right temporal incisions were made, and a corrugated drain was inserted in both incisions. Despite treatment, the swelling got worse, and the right eye's visual acuity started to deteriorate. Before undergoing radiological evaluation and after hearing the doctors say that his situation was hopeless, the patient left the hospital on his own and ended up coming to our center. At the time of admission, the patient's overall health was poor, with arterial hypotension, fatigue, and fever.
During the ophthalmic exam, the right eye showed exophthalmos, a purulent discharge from the lateral canthus, a visual acuity of 0/10 with only light perception, normal directionality, an upper corneal density with lateral thinning and herniation of the iris, with the contents of the uvea protruding through a corneal ulcer, and upper eyelid ptosis (Figure 2).
The patient's head and neck were imaged using Magnetic resonance imaging (MRI) and Computed tomography scan (CT), which revealed the presence of abscess collections in the submasseteric space, ptyregomandibular space, deep temporal space, and infratemporal abscess spreading to the orbital cavity through the inferior orbital fissure. all of which were not addressed during the first procedure (figures 3).
Immediately following admission, the patient received Intravenous (IV) levofloxacin according to culture and sensitivity, and a second surgical procedure to manage the undrained abscesses was done by the ENT team.
The ophthalmology team opted to drain the orbital abscess and perform evisceration due to the patient's unresponsive endophthalmitis. In the evisceration cavity, an implant was placed. Two weeks following admission, a consistent decline in CRP was seen, the edema had significantly decreased, the purulent oozing ceased, the drains were taken out, and the patient was discharged.