27 Facial swelling and dental abscess
Acute infections tend to present with facial cellulitis rather than a facial abscess with pus. Peter was febrile although he was not in any significant pain because the infection had perforated the cortical plate. The mainstay of treatment is removal of the cause – either pulpal extirpation or removal of the tooth.
Peter traumatized his upper right lateral incisor 3 weeks ago, sustaining a deep enamel dentine fracture. The dentine was dressed with calcium hydroxide and a compomer dressing was placed over the exposed dentine and enamel. He had a review appointment with his dentist the following week.
On Saturday morning his mother noticed that his cheek was becoming swollen and the tissues around his right eye ‘puffy and red’. He attended the accident and emergency department of the local hospital where he was prescribed amoxicillin 250 mg tablets to be taken three times daily for 5 days. Unfortunately, by Sunday evening Peter had become listless and his swelling had increased. He felt hot.
Extraorally there was facial asymmetry with a swelling of the right maxillary canine fossa. The overlying skin was red and hot. The right eye fissure was partially closed. Peter’s temperature was 39 °C. Maxillary canine fossa infections can spread via emissary veins, which have no valves, to the intracranial venous system causing either a cavernous sinus thrombosis or a brain abscess. The pathways of the IIIrd and VIth cranial nerves lie in the walls of the cavernous sinus. Thrombosis in the/>