Masticator Space Research Articles

Unilateral isolated fracture of the pterygoid plate: a case report

Pterygoid plate fractures are often associated with Le Fort fractures and accompanied by other facial fractures such as frontal sinus and naso-orbital-ethmoid fractures; isolated pterygoid plate fractures are extremely rare.
 Le Fort fractures must be surgically treated with fixation of unstable fracture segments to re-establish bone form and function, and the pterygoid process must be surgically stabilized; however, surgical treatment is unnecessary in isolated pterygoid plate fractures.
 Here, we report a rare case of isolated unilateral fracture of the pterygoid process in a 71-year-old female patient who had a syncopal episode with secondary head injury and a hematoma at the base of the right orbit.
 A computed tomography scan showed unilateral right pterygoid plate fracture with signs of emphysema in the ipsilateral masticatory space. The patient also had a fracture of the medial wall of the right maxillary sinus with hemosine, but no fractures of the skull base or theca. She was treated conservatively.

Intraoral Impalement Injury with Electric Toothbrush Head to the Infratemporal Fossa: A Case Report

Study Design Case Report. Objective To discuss the case of a 55-year-old man who complained of swelling and pain in the left cheek. Methods Computed tomographic images showed a shadow of retained electric toothbrush head in the left infratemporal fossa, heterotopic free air, and abscess formation in the masticatory space. Foreign body removal and surgical drainage were performed under general anesthesia. Result The patient was discharged 6 days postoperatively. Conclusion Computed tomography should invariably be performed on patients with intraoral impalement injury.

Huge parapharyngeal space tumor: Case report and short literature review

Abstract The parapharyngeal space (PPS) has a special anatomical and clinical importance from the point of view of its content, communication and vicinity with major and vital structures. Tumors of the parapharyngeal space are uncommon, the most incriminated being the salivary gland tumors, neurogenic tumors, especially Schwannomas and paragangliomas, and lymphoreticular lesions. The correct diagnosis of the PPS tumors must include the radiologic evaluation represented by the computed tomography (CT) and the magnetic resonance imaging (MRI). The therapeutic plan depends on the imagistically identified aspect. We report a case of a 40-year-old male, who initially noted a massive tumor of the left side of the neck within 15 years. The cervical CT scan revealed, in the upper third of the left side of the neck, in the projection of the parotid and masticatory space and the submandibular region, under the lower jaw, medially at the level of cervical vertebrae C1 – C4, to the front of the sternocleidomastoid muscle, a volumetric formation irregular in shape, with clear and uneven contours, dimensions 40x65x85 mm, uniform density +30H. Transverse cervical approach was chosen for the surgical investigation.

The diagnostic dilemma of Masticator space tumor

The masticator space is an anatomical and functional entity centered on the mandibular ramus, which divides it into medial and lateral compartments. The masticator spaces considered paired supra-hyoid cervical spaces on each side of the face that extend from the angle of the mandible to the parietal bone. The masticator space contains the mastication muscles, posterior mandible, and mandibular nerve. They are separated from the nasopharynx by the parapharyngeal spaces bilaterally. Primary malignancy of the masticator space is very uncommon.Here we report a diagnostic dilemma of primary masticator space malignancy mistaken by nasopharyngeal carcinoma as the patient 40-year old gentleman presented with left lateral rectus palsy and left nasopharynx fullness.

Extragingival peripheral ameloblastoma arising in the infratemporal fossa: A case report with an assessment of proliferative activity

AbstractBackgroundPeripheral ameloblastoma is an extraosseous variant of ameloblastoma. We report a rare case arising in an extragingival location.Case PresentationThe patient was a 79‐year‐old man with a firm nodule in the right‐side buccal mucosa. Imaging examinations showed a well‐demarcated mass in the right masticator space (infratemporal fossa). The diagnosis of ameloblastoma was made from the biopsy specimen. After conservative tumor excision, the patient had no recurrence during the follow‐up period of eight and a half years. The Ki‐67 labeling index indicated the nonaggressive nature of the tumor.ConclusionConservative surgery is applicable to extragingival peripheral ameloblastomas.

In Reply to the Letter to the Editor Regarding “Multicompartmental Epidermoid Cyst Causing Chronic Parotid Gland and Masticator Space Muscle Atrophy”

In Reply to the Letter to the Editor Regarding “Multicompartmental Epidermoid Cyst Causing Chronic Parotid Gland and Masticator Space Muscle Atrophy”

Letter to the Editor Regarding “Multicompartmental Epidermoid Cyst Causing Chronic Parotid Gland and Masticator Space Muscle Atrophy”

Letter to the Editor Regarding “Multicompartmental Epidermoid Cyst Causing Chronic Parotid Gland and Masticator Space Muscle Atrophy”

Surgical Neck Emphysema Post Elective Tonsillectomy: Case Report and Literature Review.

Neck emphysema after tonsillectomy surgery is very rare. We present a case documenting the conservative management of a post-tonsillectomy neck swelling, accompanied by crepitus. Computed tomography revealed a large air density at the region of the right masticator space and the masseter muscle, proximal to other deep neck spaces and muscles. Further investigations of her associated symptoms resulted in an additional diagnosis of systemic lupus erythematosus. We have also explored the signs and symptoms associated with such cases, along with a discussion of the literature published on surgical emphysema post-tonsillectomy.

Proposed sub-compartmentalization of high infratemporal fossa involvement in gingivobuccal cancers and its impact on clinical outcome and staging: A narrative review

According to the American Joint Committee on Cancer (AJCC) eighth edition, involvement of the masticator space and infratemporal fossa (ITF) by oral cancer signifies advanced disease (T4b), which is most often deemed unresectable. The extent of ITF involvement impacts the management and outcomes. The extent of T4b disease needs to be subclassified for optimal management. T4b disease with infra-notch extension is associated with a favorable prognosis compared to supra-notch disease. Certain cases with supra-notch involvement may potentially be converted to resectable disease following neoadjuvant chemotherapy. We performed a comprehensive search of abstracts of ITF subdivisions and their impact on staging as per the AJCC eighth edition. We included studies reporting data on ITF subdivisions and their impact on clinical outcomes. The key words for Medical Subject Headings were “cross-sectional imaging,” “oral carcinoma,” “AJCC 8th edition,” “infratemporal fossa,” “masticator space,” “survival,” and “neoadjuvant chemotherapy.” We selected 30 studies that had been published in English. We propose that the T4b category needs to be classified into compartments that have predictive and prognostic implications, including Compartment 1 comprising the low ITF (medial pterygoid and masseter), Compartment 2 comprising the anterior high ITF (retroantral fat), Compartment 3 comprising the posterior high ITF, Compartment 3a comprising the paramandibular compartment (temporalis), Compartment 3b comprising the lateral pterygoid, and Compartment 3c comprising the perineural compartment (pterygopalatine fossa and pterygomaxillary fissure). Our proposed subclassification of T4b will impact the patients' management and outcomes.

Percutaneous Sclerotherapy of a Large Trans-Spatial Oropharyngeal Venous Malformation Using Multimodality Guidance

A 37-year-old woman with a large, infiltrative face and neck venous malformation (VM) was treated with percutaneous sclerotherapy using combined ultrasound, fluoroscopy, and computed tomography (CT) guidance. No institutional review board approval was required for this case report. Symptoms included pain, swelling, difficulty in swallowing, and facial pressure. On magnetic resonance imaging, the VM involved the right masticator, parotid, and parapharyngeal spaces, causing laryngeal narrowing (Fig 1).

Fascial space infection patients reporting to department of oral and maxillofacial surgery at Dasmesh Institute of Research and Dental Sciences, Faridkot

This aim of this study is being conducted to assess the incidence of fascial space infection and its management in patients presenting to department of Oral and Maxillofacial Surgery at Dasmesh Institute of Research and Dental Sciences, Faridkot. This retrospective study was done the in the Department of Oral and Maxillofacial Surgery Dasmesh Institute of Research and Dental Sciences, Faridkot, India, from January 2015 to December 2020. Total 84 fascial space infection record of previous five year patients (reporting to Department of Oral and Maxillofacial Surgery was evaluated. Patients reported with fascial space infection with age group from 16-70 yrs and ASA I & I were included in this study. The age group most commonly involved was in the third and fourth decades of life. The mean age group was 33.55. Males (55.95%) were more commonly involved than females (44.05%). The most commonly involved space was Right submandibular space infection (17.86%) followed by left submandibular space infection 15.48, R buccal space infection (9.52%), Left buccal space infection (7.14%), Right infraorbital space infection (7.14%), Left pterygomandibular space infection (7.14%),Space infection wrt left submandibular space, submental space, left sublingual space(5.95%), Masticatory space infection with impending submandibular + submental cellulitis (5.95%).

Sclerosing rhabdomyosarcoma of the gingiva mimicking malignant peripheral nerve sheath tumor: a case report

Background: Spindle cell/Sclerosing rhabdomyosarcoma is the rarest variant of rhabdomyosarcoma, accounting for 5-10% of all rhabdomyosarcoma cases. Pathologically, these tumors can provide a variety of features and can resemble other tumors, thus often difficult to diagnose. We report a case of sclerosing rhabdomyosarcoma of the gingiva with histomorphology mimicking a malignant peripheral nerve sheath tumor. Case Presentation: The patient was a 39-years old Balinese male who noticed a lump on the left gum since 9 months ago. Head CT scan revealed a solid mass with soft tissue density at the left lower gingiva that extend superiorly and laterally, involving the left parapharyngeal and masticator spaces, infiltrated into the left mylohyoid muscle and left medial and lateral pterygoid muscles, and caused destruction of the left mandibular ramus and alveolar process of the left maxilla. The initial biopsy showed the proliferation of atypical spindle cells with a pattern resembling peripheral nerve sheath tumor and concluded as a low-grade malignant peripheral nerve sheath tumor. Wide excision specimen consists of proliferation of low-grade atypical spindle cells arranged in a fascicular pattern with foci of strap cells embedded in glassy eosinophilic sclerosis matrix. Some parts of the tumor showed palisading nuclei. The tumor cells were diffusely positive for desmin and negative for S100. This case was finally diagnosed as sclerosing rhabdomyosarcoma.Conclusion: Sclerosing rhabdomyosarcoma should be considered when atypical spindle lesions occur between the hyalinized stromal matrix of the head and neck in adults. Because of wide differential diagnosis, an adequate sampling, careful microscopic examination, and immunohistochemistry staining can avoid misdiagnosis.

Achieving negative resection margins in oral cavity cancer with masticator space involvement-Is it feasible? International collaborative study.

Masticator space involvement in oral cavity squamous cell carcinoma (OCSCC) is considered an unresectable disease. Nevertheless, achieving negative resection margins is feasible in limited masticatory space involvement. A multi-institutional study on OCSCC patients with masticator space invasion who underwent surgical resection. Margin status was assessed according to anatomic tumor involvement of the inframandibular and supra-mandibular notch. One-hundred and thirty-two patients met the inclusion criteria. Then, 67 patients (50.8%) were diagnosed with a supra-notch tumor and 65 (49.2%) with an infra-notch disease. Negative margins were more common in the infra-notch group (43.3 vs. 23.1%, p= 0.014), and positive margins were more common in the supra-notch group (41.5 vs. 23.9%, p= 0.041). Multivariable analysis demonstrated that supra-notch tumors had an increased likelihood for involved resection margins (odds ratio=2.46, p= 0.036). OCSCC patients with masticator space involvement are prone for positive surgical margins in tumors extending above the supra-mandibular notch.

Mucormicosis rinocerebral e infeccin por SARS-CoV-2. Revisión de caso clínico e imagenológico en un paciente con diabetes mellitus mal controlada

The clinical case of a 52-year-old man is presented, with a pathological history of type 2 diabetes mellitus and systemic arterial hypertension, the two with 3 years of evolution and metabolically decompensated for 8 months of evolution. He started with symptoms suggestive of SARS-CoV-2, which evolved in 2 weeks with increased dyspnea, fever, and left eye edema, for which he received in-hospital management. Control studies were performed, including computed tomography of the chest and skull, the first CO-RADS 5 report (very high suspicion of SARS-CoV-2 infection) with a severity scale due to severe extension; the second reported pneumocephalus in the left temporal fossa, left ocular infectious process, which conditioned proptosis, left intraorbital emphysema with involvement of the optic nerve and erosion of adjacent bone structures, as well as emphysema to the left masticatory space. During his stay, he presented an acute infectious process in the maxillary region, left eye and palate, for which mucormycosis pathology was suspected, and treatment with intravenous amphotericin was started. He required intensive therapy management and surgical intervention derived from the extension of the infection, which affected the brain tissue and generated complications and the death of the patient. Mucormycosis is a low prevalence and rapidly progressive disease caused by fungi of the Mucoraceae family of the Mucorales order. It is the fastest evolving fatal fungal disease in humans. For this reason, timely detection and treatment is of utmost importance for the survival of those affected by this agent. Keywords: Rhinocerebral mucormycosis; SARS-CoV-2 infection; COVID-19.

Clinical T4b Squamous Cell Carcinoma Resection With Hemimandibulectomy and Temporomandibular Joint Reconstruction With Bridging Plate and Modified Dautrey Procedure

Clinical T4b oral squamous cell carcinoma is traditionally considered nonoperable. We present a case of right mandibular squamous cell carcinoma (PT4bN0M0, stage IVB). The tumor had extended to the right mandibular condylar head and masticatory space. The patient received right modified radical neck dissection and radical operation with hemimandibulectomy to remove the right mandibular condyle. Then, we reconstructed the resected portion with an anterior lateral thigh free flap and bridging plate, which was bent to form an artificial condyle and fixed using the modified Dautrey procedure. The patient had stable postoperative occlusion and normal hinge movement of the temporomandibular joint. After postoperative concurrent chemotherapy and radiotherapy, the patient is under regular out patient department follow-up with satisfactory jaw function and oral intake.

Imaging findings in invasive rhino-orbito-cerebral mucormycosis in post–COVID-19 patients

Rhino-orbito-cerebral mucormycosis (ROCM) is a life-threatening addition to the COVID-19 disease spectrum and is caused by an angioinvasive saprophytic opportunistic fungus. Early diagnosis is important to avoid disease spread and mortality. Contrast-enhanced magnetic resonance imaging plays a major role in detection of intraorbital and intracranial extension. We present imaging findings of 15 patients with post-COVID-19 rhino-orbito-cerebral mucormycosis who were diagnosed with invasive sinus mucormycosis at our institution and are currently undergoing treatment. All patients were diabetics, and 80% had a history of steroid intake during the course of COVID-19 treatment. There was a male preponderance (73.3%). The maxillary sinus was most commonly involved (86.7%). Orbital and intracranial invasion was seen in 73.3% and 60% of patients, respectively. The presence of retroantral, facial, infratemporal, and orbital fat stranding was an early sign of extrasinus spread. Other common sites of extrasinus involvement were the orbit and face, followed by the orbital apex, masticator space, pterygopalatine fossa, bone, skull base, cavernous sinus, brain, and internal carotid artery. In conclusion, early detection of extrasinus spread of mucormycosis by imaging is important so that aggressive treatment can be given and mortality can be reduced.

English

Deep neck spaces are regions of loose connective tissue present between three layers of deep cervical fascia, namely, superficial, middle, and deep layers. The investing layer is the superficial layer, the pre-tracheal layer is the intermediate layer, and the prevertebral layer is the deep layer. Deep neck space infection (DNI) is defined as an infection in the potential spaces and actual fascial planes of the neck. Spread of infection occurs along communicating fascial boundaries. These deep neck spaces may be further classified into 3 anatomic groups, relative to the hyoid bone: Those located above the level of the hyoid, those that involve the entire length of the neck, those located below the level of hyoid. The patterns of infection may include abscess formation, cellulitis, and necrotizing fasciitis. Antibiotics and surgical drainage form the mainstay of treatment. There are some spaces in the neck present between these layers of deep cervical fascia. These deep neck spaces are filled with loose connective tissue. Deep neck space infection involves the spaces and fascial planes of the neck. Spread of infection occurs along communicating fascial boundaries after overcoming the natural resistance of the fascial planes. With relation to the hyoid bone, these deep neck spaces are further classified as follows: 1. Spaces above the level of the hyoid bone (peritonsillar, submandibular, parapharyngeal, masticator, buccal, and parotid spaces). 2. Spaces that involve the entire length of the neck (retropharyngeal, prevertebral, and carotid spaces). 3. Spaces located below the level of hyoid bone (anterior visceral or pre - tracheal space). Infection may present either as abscess, cellulitis, or necrotizing fasciitis. The mainstay of the management are antibiotics and surgical drainage.

Analysis of misses in imaging of head and neck pathology by attending neuroradiologists at a single tertiary academic medical centre

To analyse errors in head and neck (H&N) pathology made by attending neuroradiologists at a single tertiary-care centre. A neuroradiology quality assurance (QA) database of radiological errors was searched for attending physician errors in H&N pathology from 2014-2020. Data were limited to computed tomography (CT) and magnetic resonance imaging (MRI) reports. Data were collected on missed pathologies and study types. Misses were grouped into three categories: central neck (thyroid gland, aerodigestive tract), lateral neck (salivary glands, lymph nodes, soft tissues), and face/orbits (orbits, sinuses, masticator space). During the study period, a total of 283,248 CT and MRI neuroradiology examinations were interpreted (all indications). Seventy-four H&N misses were identified comprising 85.1% perceptual and 14.9% interpretive errors. The distribution of errors was face/orbits (37.8%), central neck (36.5%), and lateral neck (25.7%). Clinically significant errors were found most commonly in the aerodigestive tract (21%), orbits (17.7%), masticator space, and parotid glands (14.5% each). The majority (67.6%) of the misses were detected on examinations that were not performed for a primary H&N indication; MRI brain was the most common examination (27%). Clearly malignant or potentially malignant masses accounted for 48.6% of all misses. The majority of H&N misses were perceptual and were detected on examinations not performed for a H&N indication. Clearly malignant or potentially malignant masses represented half of all misses.

Deep Neck Infections: Demographic and Clinical Factors Associated with Poor Outcomes

Introduction: Deep neck infections (DNIs) are abscesses located in the profound spaces of the neck and constitute one of the most common otolaryngological life-threatening emergencies. The aim of this study is to review the clinical and demographic data of patients with DNI and identify factors associated with prolonged hospitalization, reoperation, and mortality. Methods: Retrospective review and analysis of 75 patients with DNI admitted from January 2015 to December 2019 in a tertiary referral hospital. Results: Of 75 patients, 50 (66.6%) were males and 25 (33.3%) females. Age ranged from 18 to 91 years with a mean of 41.79 (±15.48). DNIs were odontogenic in 49 patients (65.3%). History of diabetes mellitus (DM) was positive in 26 patients (34.6%). The submandibular space was involved in 57 patients (76%). Streptococcus spp. were isolated in 35 patients (46%). Intubation for airway preservation was needed in 21 patients (28%) and tracheostomy in 6 (8%). Mediastinitis presented in 8 patients (10.67%), with a mortality rate of 62.5% (n = 5). Mean hospital stay was 9.13 days (±7.2). DM (p = 0.016), age (p = 0.001), BMI classification 3, 4, and 6 (p = 0.041), and intensive care unit (ICU) admission (p = 0.009) were associated with a longer stay. Surgical drainage was performed after 1.71 days (±1.65). Surgical reintervention was needed in 6 cases (8%) and was associated with temporal (p = 0.001) and masticator (p = 0.002) space involvement and DM (p = 0.009). Overall mortality was 8% and decreased to 1.5% when mediastinitis was excluded. Mediastinitis (p = 0.001), ICU admission (p < 0.0001), Streptococcus spp. (p = 0.019), and low hemoglobin levels (p = 0.004) were associated with mortality. Discussion/Conclusion: DNIs are entities associated with high morbimortality. Mediastinitis and airway obstruction are life-threatening possible complications and should be promptly evaluated. Low HB could be used as a predicting factor for mortality.

AN UNUSUAL CASE OF STEROID-RESISTANT IGG4-RD AFFECTING THE MAXILLARY ALVEOLAR PROCESS

<h3>Introduction</h3> Immunoglobulin G4-related disease (IgG4-RD) is an autoimmune fibroinflammatory condition that is becoming increasingly recognized in the head and neck. I present a rare case of IgG4-RD originating in the alveolar process of the maxilla with orbital and maxillary sinus involvement that was unresponsive to traditional management. <h3>Case Presentation</h3> A 37-year-old Somalian woman presented with a 4-month history of progressive swelling of her right cheek and trismus. She had paresthesia and neuropathic pain affecting the V2 and V3 regions of the right trigeminal nerve. Testing of cranial nerve V revealed that she had decreased light-touch sensation over the site of swelling. Her hearing was reduced on the right side based on a whisper test. <h3>Investigations</h3> Ultrasound, magnetic resonance imaging, and computed tomography confirmed a mass centered on the right maxillary alveolus extending into the right buccal and masticator space, maxillary sinus, and orbit with involvement of the right infraorbital and greater palatine nerves. Histopathologic analysis revealed a storiform pattern of stromal fibrosis with a lymphoplasmacytic infiltrate and obliterative vasculitis. There was an increased number of IgG4⁺ plasma cells on immunostaining. <h3>Treatment</h3> She was started on corticosteroid but showed no response. Treatment with cyclophosphamide and rituximab provided improvement clinically and symptomatically. <h3>Discussion</h3> Clinically, IgG4-RD presents as a tumefactive, tissue-destructive lesion and often mimics malignant tumors, which can complicate diagnosis. IgG4-RD can be managed medically, and it is important to differentiate this disease from other pathologies in order to avoid invasive surgical management.