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Pathology · patient case with 3 questions

Spreading swelling of the upper face

Patient: 37-year-old man, emergency appointment.

Chief complaint: My face is swelling and it is getting worse quickly.

History: Two days of increasing swelling that began around an upper tooth. Now feels feverish and unwell.

Findings: Diffuse, firm, warm, erythematous swelling of the right upper face extending toward the medial canthus and lower eyelid. No fluctuance. Temperature 38.6°C. Grossly carious maxillary tooth with periapical tenderness.

Question 1

How is this soft tissue lesion best described?

  1. Cellulitis
  2. A localized fluctuant abscess
  3. A mucocele
  4. Angioedema
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Correct answer: A. Cellulitis

  • A. CORRECT. CELLULITIS is a diffuse, spreading, indurated infection of soft tissue with no defined pus collection. It is warm, erythematous, painful and firm rather than fluctuant, and it is the spreading quality that makes proximity to the eye dangerous.
  • B. An abscess is localized, fluctuant and well-circumscribed — the opposite of the diffuse induration described.
  • C. A mucocele is a benign salivary mucus-retention swelling, usually of the lower lip.
  • D. Angioedema is soft, non-tender, non-erythematous and not associated with fever or a carious tooth.

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Question 2

Spread to which structure is the greatest concern?

  1. Submental space
  2. Pterygomandibular space
  3. Cavernous sinus
  4. Retropharyngeal space
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Correct answer: C. Cavernous sinus

  • A. The submental space lies beneath the chin and drains mandibular anterior teeth.
  • B. The pterygomandibular space is entered from mandibular molars and is the target of an inferior alveolar nerve block.
  • C. CORRECT. The upper lip, nose and medial canthus form the DANGER TRIANGLE. Venous drainage here is VALVELESS, so infection can travel retrograde through the angular and ophthalmic veins to the CAVERNOUS SINUS, producing cavernous sinus thrombosis — ophthalmoplegia, proptosis, chemosis and a life-threatening intracranial infection.
  • D. The retropharyngeal space is involved in deep neck infections spreading posteriorly, not from the upper face.

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Question 3

What is the MOST appropriate immediate management?

  1. Perform incision and drainage in the dental chair
  2. Refer urgently to the emergency department for admission and intravenous antibiotics
  3. Prescribe a topical antibiotic and reassure the patient
  4. Prescribe an oral antibiotic and review in one week
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Correct answer: B. Refer urgently to the emergency department for admission and intravenous antibiotics

  • A. Incision and drainage is for a LOCALIZED fluctuant collection. There is no drainable pus here, and cutting into the danger triangle risks worsening spread.
  • B. CORRECT. Rapidly spreading facial cellulitis with fever and periorbital involvement threatens the orbit and the cavernous sinus. This needs hospital admission, intravenous antibiotics, and source control. Definitive extraction or drainage of the offending tooth follows once the patient is stabilized.
  • C. Topical antibiotics have no role in a deep spreading soft tissue infection.
  • D. An oral antibiotic with a one-week review dangerously under-treats a febrile, rapidly progressing infection near the orbit.

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