296
OSTEOMYELITIS OF THE ZYGOMATIC BONE
and provides intraoral implants that increase the stability and retentive properties of a mandibular prosthesis.
4. 5.
References
6. 1. Spiro RH, Gerold FP, Shah JP, et al: Mandibulotomy approach to oro-pharyngeal tumors. Am J Surg 150:466, 1985 2. McGregor IA, MacDonald DC? Mandibular osteotomy in the surgicai approach to the oral cavity. Head Neck Surg 5:457, 1983 3. Pinsolle J, Siberchicot F, Emparanza A, et al: Approach to the pterygomaxillary space and posterior part of the tongue by
J Oral Maxillofac 50:296-299.
7.
8.
lateral stair-step mandibulotomy. Arch Otolaryngol Head Neck Surg 115:313, 1989 Attia EL, Bentley KC, Head T, et al: A new approach to the pterygomaxillary fossa and parapharyngeal space. Head Neck Surg 6:884, 1984 Baker DC, Conley J: Treatment of massive deep lobe parotid tumors. Am J Surg 138:572, 1979 Spiro RI-l, Gerold FP, Strong EW: Mandibular “swing” approach for oral and oropharyngeal tumors. Head Neck Surg 3:37 1, 1981 Carraway JH, McGregor IA: Restoration of mandibular continuity after symphyseal osteotomy. Br J Plast Surg 34392, 1981 Small IA, Misiek D: A sixteen-year evaluation of the mandibular staple bone plate. J Oral Maxillofac Surg 44:60, 1986
Surg
1992
Osteomyelitis of the Zygomatic Bone: A Case Report R.M. BORLE, MDS,* AND S.R. BORLE, BDSt
Osteomyelitis is an inflammatory condition of bone involving the medullary cavity, the Haversian system, and the adjacent cortex. A review of the literature shows that the mandible is the most commonly involved facial bone. Because the maxillary bone has a better blood supply, the incidence of osteomyelitis is less.’ Adekeye et al observed that although fractures of maxilla are a common occurrence, they are seldomly involved by osteomyelitis.’ In the recent past, only one case of maxillary osteomyelitis secondary to trauma was reported.2 Zygomatic bone osteomyelitis also is an extremely rare occurrence. Adekeye et al published a review of 14 1 cases of osteomyelitis of the jaws and reported the incidence of malar bone osteomyelitis to be only 1.42%.’ Cutchavaree et al3 and Gupta et al4 in the past decade reported single cases of zygomatic bone osteomyelitis. In this article, another case of osteomyelitis of a fractured zygomatic bone resulting from improper immobilization is reported.
Received from the General Hospital, Wardha, India. * Oral and Maxillofacial Surgeon. t Dental Surgeon. Address correspondence and reprint requests to Dr R.M. Bode: Oral and Maxillofacial Surgery, Qr. No. 5, Guru Nanak Colony, M.G.I.M.S., Sevagram 442 102, Dist Wardha, MS., India. 0 1992 American Association of Oral and Maxillofacial Surgeons 0278-2391/92/5003-0017$3.00/O
Report of Case A 28-year-old man reported to the Department of Oral and Maxillofacial Surgery, General Hospital, Wardha (India) with a complaint of pus discharge from the cheek, infraorbital area, and lateral canthus region of the eye on the left side for 2 months. He had been in an automobile accident about j2% months earlier and had sustained a fractured, displaced zygomatic bone as well as lacerations in the temporal and infraorbital area on the left side. He had been treated elsewhere by a general surgeon, with the fracture being reduced and immobilized by direct fixation with intraosseous wires. The lacerations were closed primarily after debridement. Dehis cence developed, however, accompanied by the subsequent discharge of pus. The patient had been on antibiotic therapy since then. Examination at the time of hospitalization revealed a young, healthy, adult without any clinical evidence of systemic disease. There were pus-discharging sinuses near the lateral canthus of the eye, in the infraorbital area, and on the cheek on the left side. The skin around the sinuses was indurated and adherent to the bone (Fig I). A disfiguring scar was evident in the infraorbital and temporal areas. The left eye had a congested cornea and conjunctiva, and the lower eyelid showed ectropion. There was complete anesthesia in the area of distribution of the left infraorbital nerve. Facial nerve paresis was manifested by drooping of the left angle of the mouth. The intraoral examination was noncontributory. Radiographic examination revealed a nonunion of the fractured segment. The fracture had been previously immobilized by intraosseous wiring at the frontozygomatic and zygomaticomaxillary sutures, and at the anterolateral wall of the maxillary antrum. The twisted ends of the wires were seen lying freely in the tissues and the wire at the zygomaticomaxillary suture was noted to pass through the maxillary antrum (Fig 2). The sinus tracts on the face appeared to be in the area of the wire ends.
BORLE AND BORLE
FIGURE 3. Radiograph showing complete sequestration of the left zygomatic bone and the opaque maxillary sinus.
FIGURE 1. View of patient showing ectropion and multiple pusdischarging sinuses on the left side of the face.
FIGURE 2. Radiograph showing intraosseous wires with free ends lying in the soft tissue. One wire is seen passing through the maxillary sinus.
A sample of pus from the discharging sinus tract was submitted for culture and antibiotic sensitivity tests, which revealed growth of Staphylococci and Esheria cob. The patient was administered intramuscular ampicillin and gentamycin, and it was decided to remove the intraosseous wires. Under general anesthesia, the wires were exposed through separate incisions along the old scar and were removed. Osteolysis was seen around the wires. The unhealthy granulation tissue between the fracture lines and around the wires was curetted and ,Le ebumated ends of the fractured bone were freshened. The sinus tracts were also curetted. The wounds were loosely closed with sutures. They were irrigated daily with povidone iodine 5% (Betadine 5%) and hydrogen peroxide diluted in normal saline. Healing was slow, but steady. The discharge of pus was reduced significantly and the patient was discharged from the hospital on the 10th postoperative day to be followed up on an outpatient basis. During follow-up it was noted that the discharge of pus, although less, persisted. The sinus tract in the infraorbital area healed completely, but those in the buccal area and near
FIGURE 4.
Postoperative radiograph showing loss of the zygoma.
298
OSTEOMYELITIS OF THE ZYGOMATIC BONE
stopped. However, an ugly scar, the facial nerve paresis, and marked depression of the malar region remained (Fig 5). No further ophthalmic complications were noticed during a subsequent 4-month follow up. The patient was referred to the plastic surgeon for reconstruction and cosmetic rehabilitation.
Discussion A review of the literature shows that osteomyelitis of the zygomatic bone secondary to trauma is very rare. This can be attributed to the good vascularity of the bone. In the present case, the osteomyelitis apparently resulted from an improper immobilization technique. Direct fixation of the fractured segments can be done by intraosseous wiring at the frontozygomatic suture, which in most of the cases is enough to give adequate stabilization5 If there is need for further immobilization, it can be done by a figure-of-eight wiring at the inferior orbital border.5 If possible the wire should not pass through the maxillary antrum. In the present case, it is evident that the wire was passing through the maxillary antrum, and it is possible that there was a passage of the nasopharyngeal flora along it into the wound
FIGURE 5.
Postoperative photograph taken 4 months after surgery.
the lateral canthus of eye did not heal. The ectropion and the corneal congestion in the left eye were no longer present. Radiographic examination after 1 month showed complete sequestration of the zygomatic bone and adjoining part of the maxilla (Fig 3). The patient was hospitalized again and a sample of pus was submitted for culture and antibiotic sensitivity testing. Staphylococci and Proteus mirabilis were grown. As directed by the sensitivity test, the patient was given cephalexine and metronidazole orally. He was taken to the operating room where, under general anesthesia, a full-thickness flap was raised along the old scar and a sequestrectomy was performed (Fig 4). The eyeball was poorly supported laterally, as a major portion of orbital rim had sequestrated. After performing meticulous debridement, the wound was closed primarily with loose sutures, keeping a drain in place. The postoperative recovery was uneventful. The sinus tract healed completely within 15 days and the discharge of pus
causing contamination to such an extent that the healing was arrested and subsequently osteomyelitis developed. The pus-discharging sinuses on the face were found to be in relation to the twisted wire ends, which were lying freely in the adjacent soft tissue. It is also
possible that contamination occurred via the dehisced lacerations. The presence of staphylococci in the culture indicates contamination from the skin. Both of these factors ultimately contributed to the loss of zygomatic bone and an esthetic handicap for the patient. References 1. Adekeye EO, Comah J: Osteomyelitis of jaws. A review of 141 cases. Br J Oral Maxillofac Surg 23124, 1985 2. Comah J, O’Hare PM: Total maxillary necrosis following severe road accident. Br J Oral Surg 18:44, 198 1 3. Cutchavaree A: Osteomyelitis of zygomaticomaxillaxy complex. J Med Assoc Thailand 67:687, 1984 4. Gupta DS, Gupta MK, Oswal RH, et al: Osteomyelitis of facial bones. Report of two cases. Dent Dialogue 9:4 1, 1984 5. Rowe NL, Williams JL: Maxillofacial injuries. New York, NY, Churchill Livingstone, 1985, p 435
OSTEOMYELITIS OF THE ZYGOMATIC BONE
and provides intraoral implants that increase the stability and retentive properties of a mandibular prosthesis.
4. 5.
References
6. 1. Spiro RH, Gerold FP, Shah JP, et al: Mandibulotomy approach to oro-pharyngeal tumors. Am J Surg 150:466, 1985 2. McGregor IA, MacDonald DC? Mandibular osteotomy in the surgicai approach to the oral cavity. Head Neck Surg 5:457, 1983 3. Pinsolle J, Siberchicot F, Emparanza A, et al: Approach to the pterygomaxillary space and posterior part of the tongue by
J Oral Maxillofac 50:296-299.
7.
8.
lateral stair-step mandibulotomy. Arch Otolaryngol Head Neck Surg 115:313, 1989 Attia EL, Bentley KC, Head T, et al: A new approach to the pterygomaxillary fossa and parapharyngeal space. Head Neck Surg 6:884, 1984 Baker DC, Conley J: Treatment of massive deep lobe parotid tumors. Am J Surg 138:572, 1979 Spiro RI-l, Gerold FP, Strong EW: Mandibular “swing” approach for oral and oropharyngeal tumors. Head Neck Surg 3:37 1, 1981 Carraway JH, McGregor IA: Restoration of mandibular continuity after symphyseal osteotomy. Br J Plast Surg 34392, 1981 Small IA, Misiek D: A sixteen-year evaluation of the mandibular staple bone plate. J Oral Maxillofac Surg 44:60, 1986
Surg
1992
Osteomyelitis of the Zygomatic Bone: A Case Report R.M. BORLE, MDS,* AND S.R. BORLE, BDSt
Osteomyelitis is an inflammatory condition of bone involving the medullary cavity, the Haversian system, and the adjacent cortex. A review of the literature shows that the mandible is the most commonly involved facial bone. Because the maxillary bone has a better blood supply, the incidence of osteomyelitis is less.’ Adekeye et al observed that although fractures of maxilla are a common occurrence, they are seldomly involved by osteomyelitis.’ In the recent past, only one case of maxillary osteomyelitis secondary to trauma was reported.2 Zygomatic bone osteomyelitis also is an extremely rare occurrence. Adekeye et al published a review of 14 1 cases of osteomyelitis of the jaws and reported the incidence of malar bone osteomyelitis to be only 1.42%.’ Cutchavaree et al3 and Gupta et al4 in the past decade reported single cases of zygomatic bone osteomyelitis. In this article, another case of osteomyelitis of a fractured zygomatic bone resulting from improper immobilization is reported.
Received from the General Hospital, Wardha, India. * Oral and Maxillofacial Surgeon. t Dental Surgeon. Address correspondence and reprint requests to Dr R.M. Bode: Oral and Maxillofacial Surgery, Qr. No. 5, Guru Nanak Colony, M.G.I.M.S., Sevagram 442 102, Dist Wardha, MS., India. 0 1992 American Association of Oral and Maxillofacial Surgeons 0278-2391/92/5003-0017$3.00/O
Report of Case A 28-year-old man reported to the Department of Oral and Maxillofacial Surgery, General Hospital, Wardha (India) with a complaint of pus discharge from the cheek, infraorbital area, and lateral canthus region of the eye on the left side for 2 months. He had been in an automobile accident about j2% months earlier and had sustained a fractured, displaced zygomatic bone as well as lacerations in the temporal and infraorbital area on the left side. He had been treated elsewhere by a general surgeon, with the fracture being reduced and immobilized by direct fixation with intraosseous wires. The lacerations were closed primarily after debridement. Dehis cence developed, however, accompanied by the subsequent discharge of pus. The patient had been on antibiotic therapy since then. Examination at the time of hospitalization revealed a young, healthy, adult without any clinical evidence of systemic disease. There were pus-discharging sinuses near the lateral canthus of the eye, in the infraorbital area, and on the cheek on the left side. The skin around the sinuses was indurated and adherent to the bone (Fig I). A disfiguring scar was evident in the infraorbital and temporal areas. The left eye had a congested cornea and conjunctiva, and the lower eyelid showed ectropion. There was complete anesthesia in the area of distribution of the left infraorbital nerve. Facial nerve paresis was manifested by drooping of the left angle of the mouth. The intraoral examination was noncontributory. Radiographic examination revealed a nonunion of the fractured segment. The fracture had been previously immobilized by intraosseous wiring at the frontozygomatic and zygomaticomaxillary sutures, and at the anterolateral wall of the maxillary antrum. The twisted ends of the wires were seen lying freely in the tissues and the wire at the zygomaticomaxillary suture was noted to pass through the maxillary antrum (Fig 2). The sinus tracts on the face appeared to be in the area of the wire ends.
BORLE AND BORLE
FIGURE 3. Radiograph showing complete sequestration of the left zygomatic bone and the opaque maxillary sinus.
FIGURE 1. View of patient showing ectropion and multiple pusdischarging sinuses on the left side of the face.
FIGURE 2. Radiograph showing intraosseous wires with free ends lying in the soft tissue. One wire is seen passing through the maxillary sinus.
A sample of pus from the discharging sinus tract was submitted for culture and antibiotic sensitivity tests, which revealed growth of Staphylococci and Esheria cob. The patient was administered intramuscular ampicillin and gentamycin, and it was decided to remove the intraosseous wires. Under general anesthesia, the wires were exposed through separate incisions along the old scar and were removed. Osteolysis was seen around the wires. The unhealthy granulation tissue between the fracture lines and around the wires was curetted and ,Le ebumated ends of the fractured bone were freshened. The sinus tracts were also curetted. The wounds were loosely closed with sutures. They were irrigated daily with povidone iodine 5% (Betadine 5%) and hydrogen peroxide diluted in normal saline. Healing was slow, but steady. The discharge of pus was reduced significantly and the patient was discharged from the hospital on the 10th postoperative day to be followed up on an outpatient basis. During follow-up it was noted that the discharge of pus, although less, persisted. The sinus tract in the infraorbital area healed completely, but those in the buccal area and near
FIGURE 4.
Postoperative radiograph showing loss of the zygoma.
298
OSTEOMYELITIS OF THE ZYGOMATIC BONE
stopped. However, an ugly scar, the facial nerve paresis, and marked depression of the malar region remained (Fig 5). No further ophthalmic complications were noticed during a subsequent 4-month follow up. The patient was referred to the plastic surgeon for reconstruction and cosmetic rehabilitation.
Discussion A review of the literature shows that osteomyelitis of the zygomatic bone secondary to trauma is very rare. This can be attributed to the good vascularity of the bone. In the present case, the osteomyelitis apparently resulted from an improper immobilization technique. Direct fixation of the fractured segments can be done by intraosseous wiring at the frontozygomatic suture, which in most of the cases is enough to give adequate stabilization5 If there is need for further immobilization, it can be done by a figure-of-eight wiring at the inferior orbital border.5 If possible the wire should not pass through the maxillary antrum. In the present case, it is evident that the wire was passing through the maxillary antrum, and it is possible that there was a passage of the nasopharyngeal flora along it into the wound
FIGURE 5.
Postoperative photograph taken 4 months after surgery.
the lateral canthus of eye did not heal. The ectropion and the corneal congestion in the left eye were no longer present. Radiographic examination after 1 month showed complete sequestration of the zygomatic bone and adjoining part of the maxilla (Fig 3). The patient was hospitalized again and a sample of pus was submitted for culture and antibiotic sensitivity testing. Staphylococci and Proteus mirabilis were grown. As directed by the sensitivity test, the patient was given cephalexine and metronidazole orally. He was taken to the operating room where, under general anesthesia, a full-thickness flap was raised along the old scar and a sequestrectomy was performed (Fig 4). The eyeball was poorly supported laterally, as a major portion of orbital rim had sequestrated. After performing meticulous debridement, the wound was closed primarily with loose sutures, keeping a drain in place. The postoperative recovery was uneventful. The sinus tract healed completely within 15 days and the discharge of pus
causing contamination to such an extent that the healing was arrested and subsequently osteomyelitis developed. The pus-discharging sinuses on the face were found to be in relation to the twisted wire ends, which were lying freely in the adjacent soft tissue. It is also
possible that contamination occurred via the dehisced lacerations. The presence of staphylococci in the culture indicates contamination from the skin. Both of these factors ultimately contributed to the loss of zygomatic bone and an esthetic handicap for the patient. References 1. Adekeye EO, Comah J: Osteomyelitis of jaws. A review of 141 cases. Br J Oral Maxillofac Surg 23124, 1985 2. Comah J, O’Hare PM: Total maxillary necrosis following severe road accident. Br J Oral Surg 18:44, 198 1 3. Cutchavaree A: Osteomyelitis of zygomaticomaxillaxy complex. J Med Assoc Thailand 67:687, 1984 4. Gupta DS, Gupta MK, Oswal RH, et al: Osteomyelitis of facial bones. Report of two cases. Dent Dialogue 9:4 1, 1984 5. Rowe NL, Williams JL: Maxillofacial injuries. New York, NY, Churchill Livingstone, 1985, p 435
