Treatment of Pterygoid Muscle Abscess
Pterygoid muscle abscess requires immediate surgical drainage combined with broad-spectrum intravenous antibiotics covering Gram-positive, Gram-negative, and anaerobic organisms. 1
Primary Treatment Approach
Surgical Drainage (Mandatory First-Line Treatment)
Incision and drainage is the cornerstone of treatment and must be performed for all pterygoid muscle abscesses. 1 The surgical approach can be tailored based on anatomic accessibility:
- Endoscopic transseptal approach through the maxillary sinus is a feasible minimally invasive technique for accessing infratemporal fossa abscesses involving the pterygoid muscles 2
- Intraoral drainage (both bedside and operative) has been successfully employed for lateral pterygoid abscesses 3
- Thorough evacuation of pus with probing of the cavity to break up loculations is essential during drainage 1
Critical Pitfall to Avoid
Never attempt needle aspiration alone, as it has a low success rate of 25% overall and <10% with MRSA infections, often leading to recurrence and inadequate source control. 1, 4
Antibiotic Therapy (Concurrent with Surgery)
Empiric broad-spectrum intravenous antibiotics must be initiated immediately covering the polymicrobial flora typical of deep neck space infections 1:
Recommended regimens include:
Duration: 4-7 days based on clinical response and resolution of inflammation 1
Extended therapy (up to 7 days) may be required for immunocompromised or critically ill patients 1
Special Consideration for MRSA Coverage
Given the prevalence of community-acquired MRSA in soft tissue infections, vancomycin should be added to the empiric regimen if MRSA is suspected or the patient has risk factors 5
Anatomic and Etiologic Considerations
Pterygoid muscle abscesses most commonly arise from:
- Odontogenic spread following dental extraction, particularly in poorly controlled diabetic patients 2, 3
- Parapharyngeal space lymphadenitis with secondary extension 6
- Lemierre syndrome with thrombophlebitis and septic emboli, where Streptococcus constellatus, Fusobacterium species, or Slackia exigua may be causative organisms 7, 8
Monitoring and Follow-Up
Patients with ongoing signs of infection beyond 7 days warrant diagnostic re-evaluation with repeat imaging to assess for inadequate source control or complications 1
Persistent fever, bacteremia, or failure to improve indicates inadequate drainage requiring potential reoperation. 1
Key Clinical Pearls
- Pterygoid muscle abscesses present with trismus, facial pain, and fever and can mimic peritonsillar abscess clinically 6, 3
- Contrast-enhanced CT imaging is essential for diagnosis and surgical planning, revealing abscess location and associated complications such as internal jugular vein thrombophlebitis 7, 8
- Bilateral pterygoid abscesses are exceptionally rare but have been reported in Lemierre syndrome with odontogenic origin 8
- Poor oral hygiene and diabetes are significant risk factors for infratemporal fossa infections 2, 8