Multidisciplinary Staged Management of a Complex Zygomatico-Buccal Abscess in a Diabetic High-Risk Gravida: A Case Report

Article information

J Wound Manag Res. 2026;22(2):106-112

Publication date (electronic) : 2026 June 30

doi : https://doi.org/10.22467/jwmr.2026.03545

Amira Azra Arisa Putri¹, Mufida Muzakkie^1,, Nuswil Bernolian², Yulianto Kusnadi³

¹Division of Plastic Reconstructive and Aesthetic Surgery, Department of Surgery, Dr. Mohammad Hoesin Central General Hospital, Faculty of Medicine Sriwijaya University, Palembang, Indonesia

²Division of Fetomaternal, Department of Obstetrics and Gynaecology, Dr. Mohammad Hoesin Central General Hospital, Faculty of Medicine Sriwijaya University, Palembang, Indonesia

³Division of Endocrine, Metabolic, and Diabetes, Department of Internal Medicine, Dr. Mohammad Hoesin Central General Hospital, Faculty of Medicine Sriwijaya University, Palembang, Indonesia

Corresponding author: Mufida Muzakkie, PhD, Division of Plastic Reconstructive and Aesthetic Surgery, Dr. Mohammad Hoesin Central General Hospital, Faculty of Medicine, Sriwijaya University, Jalan Jenderal Sudirman Kilometer 3.5, Palembang 30126, Indonesia, E-mail: mufida.muzakkie@gmail.com

Received 2026 January 23; Revised 2026 March 10; Accepted 2026 March 11.

Abstract

Introduction

Diabetes mellitus inherently impairs wound healing through microvascular dysfunction, defective angiogenesis, and immune dysregulation, leading to diminished tissue perfusion and heightened infection risk [1]. Altered growth factor expression disrupts re-epithelialization, making diabetic wounds prone to rapid progression [1]. While infections in the maxillofacial region generally spread easily along fascial planes and endanger vital structures [2], this process is significantly accelerated in diabetic patients, necessitating early surgical source control. Surgical management of maxillofacial infections during pregnancy carries the unique challenge of caring simultaneously for two patients, as pregnancy induces complex physiological changes that heighten maternal and fetal vulnerability [3]. Non-obstetric surgeries during pregnancy carry inherent risks, including the potential for preterm labor. Consequently, surgical decision-making must balance urgent source control against maternal-fetal hazards, favoring well-timed interventions and tissue preservation [4].

Herein, we report a case of a 35-year-old pregnant woman with diabetes mellitus who developed a complex maxillofacial infection, highlighting the diagnostic and management challenges in this high-risk clinical setting. The study was conducted in accordance with the Declaration of Helsinki and was approved by the Institutional Review Board of Mohammad Hosein Central General Hospital (IRB No. DP.04.03/D.XVIII.06.08/ETIK/024/2026). Written informed consent was secured from the patient, including permission to use and publish clinical images.

Case

A 35-year-old multigravida (G4P2A1) at 31 weeks’ gestation presented with a rapidly progressing right zygomatico-buccal abscess. Her medical history included poorly controlled type 2 diabetes mellitus and a high-risk obstetric background including two intrauterine fetal demises and one spontaneous abortion; notably, one prior loss was triggered by a similar infection. Clinical examination revealed a high-burden infection, clinically defined by a 35 cm² tense, fluctuant purulent collection with ill-defined borders and extensive induration, indicating surrounding cellulitis (Fig. 1). Advanced imaging was initially deferred to prioritize immediate metabolic stabilization. Initial vital signs demonstrated a blood pressure of 120/60 mmHg, heart rate of 110 beats/min, respiratory rate of 18 breaths/min, and temperature of 36.7 °C. Laboratory and arterial blood gas findings collectively confirmed systemic infection and severe metabolic derangement, characterized by marked hyperglycemia (blood sugar level 266 mg/dL, hemoglobin A1c 7.7%), leukocytosis (white blood cell count 24.92×10³/µL, 88% neutrophils), anemia (9 g/dL), and partially compensated metabolic acidosis (pH 7.253, bicarbonate 9.6 mmol/L, base deficit – 17.8 mmol/L). Ultrasonography showed cervical shortening, indicative of threatened preterm labor. The diagnosis comprised a complex right zygomatico-buccal soft tissue abscess in the context of uncontrolled diabetes mellitus, metabolic instability, and high-risk pregnancy. A history of prior adverse pregnancy outcomes established live birth as a shared primary objective.

Fig. 1

Clinical photograph of the preoperative right zygomatico-buccal abscess.

Management followed a prioritized clinical pathway, with the hospitalization course and interventions outlined in Table 1. During days 1–3, surgical intervention was strategically deferred to optimize the patient’s clinical status via intravenous insulin, tocolysis, and antenatal corticosteroids. To counteract the predictable steroid-induced hyperglycemia, rigorous intravenous insulin titration was maintained to keep blood glucose levels strictly within target ranges. Empirical intravenous ceftriaxone (1 g every 12 hours) and metronidazole were initiated on day 1 to mitigate the risk of deep-space extension. Following general stabilization, definitive surgical debridement was performed on day 4. The procedure consisted of incision, drainage, and meticulous excision of non-viable tissue until a healthy, bleeding wound bed was achieved, while ensuring the preservation of vital facial structures (Fig. 2). Surgery was performed under general anesthesia without neuromuscular blocking agents to minimize physiological stress, facilitate continuous intraoperative fetal monitoring, and ensure rapid maternal recovery. Transient intraoperative fetal heart rate decelerations were detected via cardiotocography and promptly resolved through maternal repositioning and fluid resuscitation.

Table 1

Timeline of key clinical status and multidisciplinary management during hospitalization

Fig. 2

Immediate postoperative clinical photography.

Histopathologic evaluation of intraoperative specimens confirmed pseudoepitheliomatous hyperplasia with suppurative granulomatous inflammation, verifying deep dermal involvement and excluding malignancy. Intraoperative cultures yielded Staphylococcus aureus (Gram-positive cocci 4+), guiding the transition from metronidazole to targeted oral clindamycin (300 mg every 8 hours) while continuing ceftriaxone. Postoperative wound care utilized a phase-based strategy (Table 2). During the inflammatory phase (postoperative day [POD] 1–7), alginate dressings were used to manage the high volumes of exudate. The apparent clinical worsening and increased edema observed on POD 3 were identified as the physiological peak of the inflammatory response—exacerbated by the patient’s diabetic state—rather than treatment failure. Therapy then transitioned to honey-based dressings (POD 8–11) to promote epithelialization until discharge on day 12 (Fig. 3).

Table 2

Phase-based postoperative wound care strategy and clinical rationale

Fig. 3

Short-term wound healing following right zygomatico-buccal abscess debridement. (A) Postoperative day 3; (B) postoperative day 7; (C) postoperative day 10; (D) postoperative day 12.

Wound closure was deliberately managed via secondary intention over the course of 9 weeks. Surgical closure techniques, such as local flaps or skin grafts, were deferred to minimize additional surgical stress during pregnancy and to avoid the high risk of graft failure in an infected diabetic wound bed. At discharge, the patient demonstrated stable glycemic control and reassuring fetal well-being. The patient subsequently delivered a healthy infant at 40 weeks’ gestation via elective cesarean section without neonatal complications (Fig. 4). Long-term follow-up at 18 months confirmed stable outcomes, complete wound closure, minimal keloid formation, and no functional impairment (Fig. 5).

Fig. 4

Mid-term wound healing following right zygomatico-buccal abscess debridement. (A) Four weeks postoperatively, with established granulation tissue and wound contraction. (B) Six weeks postoperatively, showing ongoing epithelialization. (C) Eight weeks postoperatively, demonstrating stable wound healing and maturation. (D) Pre-cesarean section at 9 weeks postoperatively, demonstrating incomplete epithelialization.

Fig. 5

Long-term follow-up at 18 months showing complete wound closure.

Discussion

Synthesizing the authors’ clinical experience with the findings of this case, it is evident that management of complex maxillofacial wounds in diabetic gravidas hinges on integrating five pillars: rigorous glycemic control, optimal surgical timing, thorough debridement, targeted antimicrobials, and phase-adapted wound care (Fig. 6).

Fig. 6

Multidisciplinary framework for complex maxillofacial infection management in pregnancy.

SSTIs account for 12.3% of global pregnancy-related infections, with diabetes increasing this vulnerability 3-fold and independently predicting larger abscesses. This patient’s 35 cm² abscess aligns with trends in which diabetic lesions significantly exceed non-diabetic averages [5]. Since impaired neutrophil function and vascular complications in diabetic gravidas necessitate aggressive management, targeting S. aureus, the predominant pathogen in such cases, is imperative [5,6].

Deferring surgery for metabolic stabilization was mandatory; the intraoperative mortality risk from uncorrected acidosis and electrolyte imbalance heavily outweighed the theoretical risk of infectious spread. According to Sudhakaran, elective surgery is contraindicated in patients presenting with acute metabolic abnormalities [7]. Furthermore, Sweitzer [8] has stated in a recent publication that an arterial pH <7.3 and HCO₃ <18 mEq/L represent critical physiological thresholds; proceeding with surgery under such uncorrected acidosis significantly increases the risk of 30-day mortality. Prioritizing preoperative optimization to achieve glycemic targets has been shown to reduce perioperative complications substantially.

The empiric initiation and subsequent adjustment of antibiotics were guided by safety profiles in the third trimester. Ceftriaxone demonstrates comparable benefits to standard cephalosporins in pregnancy, while clindamycin shows high target attainment in both maternal serum and umbilical cord blood (96%), ensuring adequate therapeutic levels without requiring dosage adjustments [9,10]. Furthermore, the literature confirms that metronidazole exposure is not associated with adverse delivery outcomes such as preterm birth or stillbirth [11].

The clinical course aligns with existing literature on diabetic wound biology, while emphasizing pregnancy-specific adaptations. Diabetes is known to cause profound immune dysregulation and alters key proteins necessary for tissue repair, promoting rapid progression and secondary infection [1]. Epidemiologically, severe head and neck infections in pregnancy carry critical risks; a systematic review of 69 case reports reported a 37.7% adverse outcome rate, necessitating emergency cesarean sections in 13% of cases to mitigate life-threatening hazards [12]. Aksoy et al. [2] identified diabetes as a key risk factor for extensive deep neck infections requiring early drainage; however, pregnancy necessitated timing adjustments for maternal stabilization and antenatal corticosteroids in our case.

Following infection control, phase-adapted wound management utilizing honey-based dressings offered substantial antimicrobial and pro-granulation benefits [1,13]. Fig. 7 outlines a proposed clinical pathway synthesized by the authors. This algorithm adapts severe soft tissue infection management guidelines [14,15] and evidence-based diabetic wound care [1,13] for the specific physiological demands of diabetic pregnancies. Specifically, the pathway emphasizes the early recognition of systemic toxicity and the absolute prioritization of prompt surgical source control (incision and drainage), which are fundamental in managing severe purulent infections [14]. Furthermore, adjuvant antimicrobial therapy is strictly indicated when the infection is complicated by a systemic inflammatory response or diabetes-induced immunodeficiency [15]. In such clinical scenarios, targeted oral clindamycin serves as a highly recommended treatment option once the isolate is confirmed to be susceptible [15].

Fig. 7

Management of severe soft tissue infection in pregnant diabetic patients. SSTI, severe soft tissue infection; ICU, intensive care unit; CTG, cardiotocography [1,13-15].

In conclusion, managing severe maxillofacial infections in pregnant diabetic patients requires a delicate balance between immediate surgical source control and maternal-fetal physiological limits. By prioritizing metabolic stabilization prior to surgical debridement, anticipating the glycemic impact of obstetric steroids, and employing safe, culture-guided antimicrobials, clinicians can effectively eradicate the infection. This collaborative approach ensures favorable wound healing without compromising the continuation of the pregnancy.

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