CC
A 62-year-old female presents to your clinic with ongoing pain and swelling of 4 weeks’ duration after incision and drainage of a multispacer submental–submandibular abscess.
HPI
One month before today’s visit, the patient was treated at the hospital for an acute submental–submandibular abscess. She underwent root canal treatment of tooth #19 and subsequently developed pain and swelling below her jaw 14 days after the procedure. She presented to the hospital with a leukocytosis of 18,000 cells/mm 3 and submental and submandibular edema and pain. Maxillofacial computed tomography (CT) with contrast showed multifocal low-attenuation collections with fat stranding in the ventral submental region and right submandibular space most consistent with an early abscess ( Fig. 26.1 ). Additionally, osseous dehiscence was noted on the lingual mandible adjacent to the root apices of tooth #19 ( Fig. 26.2 ). No osteolysis was noted anywhere other than the lingual cortex.
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Multifocal low-attenuation collections with fat stranding in the ventral submental region and right submandibular space as detailed earlier. Overall, this most likely represents right submandibular and submental phlegmon or early abscesses. There is osseous dehiscence medial to the root of the left mandibular molar (tooth #19) (best seen axial image 52, series 2). Findings raises suspicion for a spread of infection or abscess from left mandibular molar along the buccal mandibular gingiva. Otherwise, suggest correlation with caries of the mandibular incisors or right mandibular canine.
Initial axial CT scan ( Fig. 26.3 ) shows normal bone architecture of the mandible.
The patient was taken to the operating room (OR) for incision and drainage (I&D) of the submental and sublingual space abscess along with extraction of tooth #19. She had an uncomplicated hospital course and was discharged on postoperative day 4 on oral antibiotics (7-day course of amoxicillin-clavulanate 875/125) after removal of submental and submandibular drains. She presented to clinic 1 week after discharge from the hospital with ongoing pain from the anterior mandible–submental region with edema. An additional course of antibiotics was prescribed, and the patient followed up weekly with slow improvement. At the 1-month follow-up visit, she complained of persistent swelling and pain. A cone-beam CT (CBCT) scan was performed with significant mandibular osteolysis with mottled-appearing bone along the mandibular symphysis. Compared with the initial CT, there is noted increased density of the left mandibular body.
PMHX/medications/allergies/SH/FH
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Asthma–chronic obstructive pulmonary disease overlap syndrome
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Chronic cough
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Chronic kidney disease
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Hypertension
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Medications: albuterol inhaler, amlodipine
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Allergies: no known drug allergies
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Surgical history and family history are noncontributory.
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This patient denies any history of head and neck radiation or use of bisphosphonates. These are important factors to rule out to help differentiate between osteomyelitis and bisphosphonate-induced osteonecrosis and osteoradionecrosis. The patient is medicated for asthma, and her renal issues are stable and do not require dialysis or renal dosing adjustment. Other pertinent negatives include the absence of diabetes mellitus, no acquired viral or medication-induced immunocompromised state, nonsmoker, and no history of splenectomy.
Examination
Vital signs. Blood pressure is 126/84 mm Hg, heart rate is 74 bpm, respirations are 16 breaths per minute, and temperature is 37.4°C.
General. Well-appearing, well-nourished 62-year-old female who appears her stated age. Oriented ×3 in no acute distress.
Head and maxillofacial. Normocephalic, no notable facial asymmetry. Pupils equal, round, and reactive to light and accommodation. Extraocular movements are intact bilaterally, external ears are normal in appearance, external audial canal is clear, tympanic membrane is intact, septum is midline without deviation. Facial skin is free of lesions or masses. No trismus. Maximal interincisal movement is 40 mm. No sensory disturbances. Bilateral V3 sensation intact and normal.
Oral cavity. No lesions noted on the oral mucosa. Dentition is in good repair with restorations showing no signs of recurrent decay. No evidence of severe periodontal disease or dental mobility. Edentulous space #19 is well healed. Occlusion is stable and reproducible without signs of stepoffs. No mandibular exposed bone, mobility, or pathologic fracture. Floor of the mouth is soft and nonelevated.
Neck. Trachea midline, thyroid soft, and nonenlarged. Subtle submental edema is noted. This area is mildly tender to palpation. Surgical drain wounds from the submental and submandibular space are healed without any purulent exudate. There is mild lymphadenopathy present in the left submandibular nodes.
Imaging
The initial imaging study included a medical grade CT with contrast, which showed soft tissue rim-enhanced hypodense regions consistent with a submental and submandibular space abscess (see Fig. 26.1 ). Also evident on the scan is lingual cortical perforation adjacent to the roots of tooth #19 (see Fig. 26.2 ).
As the course of the process continued, mandibular osteolysis became apparent. These areas of osteolysis eventually were replaced with dense bone with increased cortical width.
At the 1-month follow-up visit, a CBCT scan was obtained that shows increased medullary spread of osteolysis and cortical mottling extending from the left body of the mandible to the symphysis ( eFig. 26.4 ).
eFig. 26.5 shows a panoramic view of the mottled-appearing left mandibular body and symphysis also taken on the 1-month follow-up visit.
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