|IMAGES IN RADIOLOGY
|Year : 2014 | Volume
| Issue : 2 | Page : 66-67
Masticator space abscess with bilateral retropharyngeal kissing carotid arteries
Binit Sureka, Arif Mirza, Rajesh Gothi, RK Mathur
Department of Radiodiagnosis, Saket City Hospital, New Delhi, India
|Date of Web Publication||21-May-2015|
Dr. Binit Sureka
Department of Radiodiagnosis and Imaging, Saket City Hospital, New Delhi - 110 017
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Sureka B, Mirza A, Gothi R, Mathur R K. Masticator space abscess with bilateral retropharyngeal kissing carotid arteries. J Laryngol Voice 2014;4:66-7
A 35-year-old female presented to the emergency room with rapid onset pain and swelling in the left side of face, painful trismus since 20 days and intermittent fever since 7 days following tooth extraction. On clinical examination, her pulse was 108 bpm, respiratory rate 38 cycles/min and blood pressure of 82/60 mmHg. The patient had cellulitis of the left side of the face. She is a known case of rheumatoid arthritis since last 10 years and was on long-term steroids.
The patient was referred immediately for a contrast-enhanced computed tomography (CECT) scan of the neck. CECT scan neck revealed masticator space abscess involving the left-sided muscles of mastication [Figure 1]. Incidental finding was made of dolichoectasia of bilateral cervical internal carotid arteries (ICAs) in the retropharyngeal space also known as "kissing carotids". Magnetic resonance image revealed atlanto-axial dislocation with basilar invagination causing cervico-medullary cord compression, likely as a consequence of long standing rheumatoid arthritis [Figure 2]. The patient was managed conservatively with intravenous antibiotics and discharged with advice to follow-up for neurosurgery opinion.
|Figure 1: (a) Contrast-enhanced computed tomography scan of neck shows bilateral retropharyngeal kissing carotids (arrowheads) and (b) abscess involving the left masticator muscles (arrows)|
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|Figure 2: (a) Axial T2-weighted magnetic resonance image (MRI) shows flow voids of bilateral internal carotid arteries (ICAs) in retropharyngeal space (arrowheads) and (b) sagittal T2-weighted MRI showing atlanto-axial dislocation and basilar invagination (arrow) causing cervico-medullary compression. Also flow-void of ICAs is appreciated anterior to spine (arrowhead)|
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Abscess formation in the masticator space is relatively rare, and it, usually, develops from odontogenic infections - pericoronitis, dental caries, periodontitis, or complications from dental procedures.  Pericoronitis or periodontitis can progress to alveolar ostitis or maxillare ostitis, which causes abscess formation in the masticator space.  The term kissing carotids refers to elongated and tortuous vessels that touch in the midline. They can be in the retropharyngeal space or intracranial-intrasphenoidal location (within the pituitary fossa, sphenoid sinuses, and sphenoid bones).  Radiologists should be aware of this anatomic variation as it may mimic intrasellar pathology and can lead to a catastrophic event if unreported before transsphenoidal or retropharyngeal surgery. Midline posterior interposition of both cervical ICAs is very rare with an incidence of 2.6% in patients with pharyngeal wall pulsations. This extreme deviation, in which both ICAs are located between the pharynx and the spine, has been rarely reported in the literature.  The superior laryngeal nerve that supplies the motor fibers of the cricothyroid muscle passes caudal and medial to the cervical portion of ICA. Thus, the nerve is at risk of stretching and damage in cases of extreme ICA displacement (similar to what occurs to the left recurrent laryngeal nerve when the left atrium enlarges). Clinically, these patients can present with long-standing hoarseness and finally upper respiratory failure as a consequence of posterior airway compression. 
| References|| |
Bratton TA, Jackson DC, Nkungula-Howlett T, Williams CW, Bennett CR. Management of complex multi-space odontogenic infections. J Tenn Dent Assoc 2002;82:39-47.
Spilka CJ. Pathways of dental infections. J Oral Surg 1966;24:111-24.
Pereira Filho Ade A, Gobbato PL, Pereira Filho Gde A, Silva SB, Kraemer JL. Intracranial intrasellar kissing carotid arteries: Case report. Arq Neuropsiquiatr 2007;65:355-7.
Curtin HD. The larynx. In: Som PM, Curtin HD, editors. Head and Neck Imaging. Mosby: Yearbook Inc.; 1996. p. 612-707.
Muñoz A, De Vergas J, Crespo J. Imaging and clinical findings in patients with aberrant course of the cervical internal carotid arteries. Open Neuroimag J 2010;4:174-81.
[Figure 1], [Figure 2]