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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.

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