This was an interesting presentation from a Peds shift.

15 y/o AAM with no significant medical history who presents with facial swelling. Patient noticed significant swelling to the left side of his face upon awakening in the morning. The swelling involved his entire left cheek, inferior lid of his left eye, upper lip and part of his right cheek. The patient denies any pain, tongue swelling, voice change, difficulty breathing or swallowing, fevers, recent ill symptoms (cough, congestion, vomiting, diarrhea), dysuria, hematuria, rectal bleeding, sore throat, ear complaints. He denies any new exposures including new medications, new soaps, detergents, animal exposures, environmental exposures, recent travel, insect bites.

PMH:none. PShx: had 4 wisdom teeth removal 1 month prior (finished antibiotics), no other recent surgeries or dental work. No EtOH, drugs. No current medications. No known allergies.

Vitals: 97.8, 90, 110/70, 18, 99 % on RA

Exam: HEENT- moderate swelling of the left buccal area, inferior lid of the left eye, upper lip. Mild swelling to the right buccal area. No erythema or palpable areas of fluctuance. No swelling surrounding the right eye. No conjunctival injection. No erythema within the ears, TMs normal. No mastoid tenderness. No lingual swelling, no erythema within the mouth or palpable areas of fluctuance. No signs of infection from previously removed wisdom teeth. No posterior oropharyngeal swelling or uvular deviation. No lymphadenopathy.

Heart- normal. Lungs- clear, no wheezing or stridor. Abdomen- normal. No CVA tenderness.

Treatment started with Benadryl for possible allergic reaction. Basic labs obtained and urine for possible nephrotic syndrome. WBC-17, otherwise normal. Urine with 200 protein, no RBC or WBC- nephrology consulted and recommended repeat POC labs as outpatient and follow-up in clinic, but no intervention at this time. Patient had mild improvement with Benadryl. Discharged home with Benadryl and steroids.

Patient re-presents 6 hours later (just came back for my shift the next day)

Facial swelling has worsened. Now involves bilateral buccal areas, bilateral lower eyelids and upper lip. No fevers, no difficulty breathing, no dysphagia. Patient had taken 1 repeat dose of Benadryl at home and had not started steroids yet. No other changes in HPI except patient mentions some bleeding from the inside of his upper lip. Upon exam, patient has some bleeding and purulent drainage from the gumline of his left central incisor. No palpable fluctuance, but able to express drainage with pressure to upper lip.

Labs obtained: WBC 17, CRP 1.6, ESR 41. UA- minimal protein. All other labs unremarkable. CT face with contrast obtained showing left central incisor periapical abscess with cortical erosion as well as extensive cellulitis of the midface. Also some concern for phlegmon within the paranasal sinus. ENT, OMFS, and finally pediatric dentistry consulted. Patient admitted for IV clindamycin, Unasyn for cellulitis and dentistry consult for possible root canal versus tooth extraction.

Bottom line: Odontogenic infections can cause orofacial infections and rarely but more importantly peripharyngeal space infections as well as jaw osteomyelitis. If concerned about deep facial infection, CT face is warranted. Treatment includes draining of pus from abscesses (either through I&D or needle aspiration) and culture as well as antibiotic therapy. Common regimens include a penicillin plus metronidazole, clindamycin, augmentin, or unasyn depending on disposition. Dentistry should be involved whether through consult or outpatient follow-up for root canal versus tooth extraction.