Abstract
Diagnosis: Maxillary osteomyelitis Osteomyelitis of the maxilla is extremely rare because of its rich blood supply and thin cortical bone and because antibacterial therapy is usually effective.1-4 It has no age or sex predilection.5 Typically, osteomyelitis arises from periodontal trauma in premolar and molar regions, with slight variance depending on its chronicity but typically causing localized pain, swelling, and purulence.3-5 Osteomyelitis involves inflammation of bone, which commonly begins as an infection of the medullary spaces that extends to involve the periosteum of the affected area. The infection then becomes established in the cortical portion of the bone, leading to ischemia, necrosis, and sequestra.3-6 Unlike osteomyelitis in other regions of the body, which is predominantly due to Staphylococcus aureus, osteomyelitis of the maxilla is typically a polymicrobial infection that is caused by the many types of odontogenic microbial flora. Both gram-positive and gram-negative microorganisms, including S aureus,Staphylococcus epidermidis, streptococci, Bacteriodes, peptostreptococci, and other opportunistic pathogens, have been identified in maxillary osteomyelitis.3,4,6 Infection can be triggered by trauma, surgery, odontogenic infection, hematogenous spread, or vascular insufficiency, which can occur after radiation therapy. Factors that influence the immune system, including nutrition, diabetes, hypoxia, immune deficiency, state of vasculature, and tobacco and alcohol use, play important roles in the severity of osteomyelitis.4 Acute osteomyelitis of the jaws may manifest with fever, malaise, facial cellulitis, trismus, vascular congestion, and leukocytosis. Chronic osteomyelitis presents with swelling, localized pain, purulence, erythema over involved bone, intraoral or extraoral draining fistulae, and nonhealing bony and overlying soft tissue wounds.1,4,6 There are several complications that can result from chronic osteomyelitis. The neoplastic conversion of the inflammatory metaplasia to squamous cell carcinoma is quite rare and the incidence has been reported to range from 0.2% to 1.5%.4 However, more frequently, osteomyelitis of the maxilla is complicated by the creation of discontinuity defects that require reconstruction once the disease resolves or by the formation of a diffuse sclerosis of the medullary and cortical portions of the maxillofacial skeleton owing to the loss of tissue vascularization.4 Squamous cell carcinoma may mimic many of the signs and symptoms of osteomyelitis but can be differentiated based on biopsy results. The differential diagnosis should include malignant neoplasms of bone, such as osteosarcoma and Ewing sarcoma, as well as fibrous dysplasia, cherubism, hypertrophic osteroarthropathy, and healing fracture calluses. Chronic irritation as a result of poor-fitting dentures, fractures, and odontogenic infections should also be included in the differential diagnosis.7,8 Diagnosis is based on the presence of painful sequestra and suppurative areas of tooth-bearing bone that are unresponsive to debridement and conservative therapy.4 Computed tomography and magnetic resonance imaging are both used in the evaluative workup for maxillary osteomyelitis. Magnetic resonance imaging is the best modality for demonstrating invasion of the medullary cavity, and computed tomography is the optimal modality for imaging cortical invasion and calcified tissue.4,8 Positive radiologic findings include patchy areas of radiolucency and involucra enclosing sequestra, but these findings are usually delayed, except in cases of associated fractures.1,4 The lesion should be cultured to identify the specific pathogens so that the most effective antibiotic treatment can be initiated.4 Treatment of maxillary osteomyelitis includes incision and drainage, antibiotics, sequestrectomy, extraction of teeth, saucerization, decortication, and resection of the jaw.1,2,4,5 Penicillin, ampicillin, streptomycin, and clindamycin have been shown to be effective but have recently encountered bacterial resistance. Treatment against anaerobic bacteria can be enhanced by adding metronidazole to the regimen.1 Hyperbaric oxygen therapy can be administered concomitantly in unresponsive cases to enhance the local and regional immune response and to improve perfusion.2,4 As the infection resolves, hard and soft tissue reconstruction may be necessary to supplement the reparative process.4 If the abscess is not treated, it can lead to serious complications through the spread of infection.5 Article Residents and fellows in otolaryngology are invited to submit quiz cases for this section and to write letters to the ARCHIVES commenting on cases presented. Quiz cases should follow the patterns established. See Instructions for Authors. Material for CLINICAL PROBLEM SOLVING: RADIOLOGY should be submitted electronically via the online submission and review system at http://manuscripts.archoto.com. Reprints are not available from the authors. References 1. Adekeye EOCornah J Osteomyelitis of the jaws: a review of 141 cases. Br J Oral Maxillofac Surg 1985;2324- 35PubMedGoogle ScholarCrossref 2. Barry CPRyan CD Osteomyelitis of the maxilla secondary to osteopetrosis: report of a case. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2003;9512- 15PubMedGoogle ScholarCrossref 3. Hoen MMDowns RHLaBounty GLNespeca JA Osteomyelitis of the maxilla with associated vertical root fracture and Pseudomonas infection. Oral Surg Oral Med Oral Pathol 1988;66494- 498PubMedGoogle ScholarCrossref 4. Hudson JW Osteomyelitis of the jaws: a 50-year perspective. J Oral Maxillofac Surg 1993;511294- 1301PubMedGoogle ScholarCrossref 5. Houston GDBrown FH Differential diagnosis of the palatal mass. Compendium 1993;141222- 1232PubMedGoogle Scholar 6. Abitbol TESanti E Localized osteomyelitis following a restorative procedure. Gen Dent 1997;45390- 392PubMedGoogle Scholar 7. Belli EMatteini CAndreano T Sclerosing osteomyelitis of Garre periostitis ossificans. J Craniofac Surg 2002;13765- 768PubMedGoogle ScholarCrossref 8. Weber RSDuffey DC Lip and oral cavity. In: Townsend CM Jr, Beauchamp RD,Evers BM,Mattox KL, eds. Sabiston Textbook of Surgery.16th ed. Philadelphia, Pa: WB Saunders Co; 2001:536-539Google Scholar
Journal
Archives of Otolaryngology - Head & Neck Surgery
– American Medical Association
Published: Jun 1, 2006
Keywords: osteomyelitis,radiology specialty,maxilla
