Facial Swelling
UnFiNiShEd CaSe CoMe BaCk LaTeR
History of Present Illness:
A man in his 50s presents to urgent care for 2 days of right facial swelling and pain. He denies any fever but does state he has a bad taste in his mouth.
Vital Signs & Physical Exam:
Vital signs are normal except for mild tachycardia. Exam is notable for severe facial swelling on the right. Dentition looks good
Initial Diagnostic Testing:
- Labs: WBC = 14, BMP normal, CRP = 20
- Imaging: a CT scan is done
What is the most likely diagnosis?
- A) Dental carries & Ludwig’s angina
- B) Salivary stone & Sialoadenitis
- C) Tonsillar stone & Tonsillitis
- D) Enlarged lymph node
SCROLL DOWN FOR ANSWERS & 1-MINUTE CONSULT
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ANSWER
- A) Dental carries & Ludwig’s angina: not seen, but a good thought. Sialoadenitis can lead to Ludwig’s
- B) Salivary stone & Sialoadenitis: CORRECT; there is a salivary stone in Stensen’s duct (see arrow on image below), and a swollen parotid gland.
- C) Tonsillar stone & Tonsillitis: CT initially read out as a tonsillar stone but after the EM doc called him he had an ENT radiologist look at it and changed his reading
- D) Salivary abscess: not seen but infection suspected in this case due to pus pouring out of Stensen’s duct
- E) Enlarged lymph node: not seen, but clinicians often think an enlarged parotid gland is a swollen node.
1-Minute EM Consult on the topic for this case from the Emergency Medicine 1-minute Consult Pocketbook
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CASE CONCLUSION: Amylase was elevated. There was pus coming from Stensen’s duct. The patient was sent to the ED for emergent ENT consultation and possible admission for IV ABX and stone removal.