The lesion, along the patient's left jaw line, has not responded to antibiotic treatment. A colleague asks for your help.
A 20-year-old male is seen for an infection on the side of his jaw that has been unresponsive to multiple antibiotics; it has been present for 6 months. PMH, non-contributory: no pets, not sexually active, no known congenital lesions, no significant illnesses.
CBC = normal; comprehensive metabolic panel = normal; throat culture = normal flora; intermediate PPD skin test read as 0 mm of induration.
The sole finding is a soft, erythematous nodulocystic, 3 x 3 x 1-cm mass at the jaw line on the left side.
Answer: Periapical abscess.
A thoughtful history and thorough physical examination may also include a good dental assessment.
Most common cause of cutaneous sinus tracts involving face, neck; odontogenic sinus tracts are often misdiagnosed, mistreated; lesions often misinterpreted as chronic, treatment-resistant pyogenic nodules or granulomas. Early diagnosis may prevent unnecessary and ineffective treatment and reduce possibility of complications (ie, sepsis, osteomyelitis).
Refer patient with periapical abscess for dental evaluation. Typical course: tooth/teeth removed; antibiotics for deep facial infections, osteomyelitis. Microbiology: Gingival crevice:
Streptococcus sanguinis, Streptococcus mutans
Differential diagnosis for periapical abscess:
Squamous cell carcinoma; osteomyelitis; pyogenic granuloma; actinomycosis; deep mycosis; foreign body; congenital fistula.
A colleague asks you to see a 20-year-old who has been treated unsuccessfully with a series of antibiotics for a persistent lump along his jawline. Was something overlooked in exam?Follow the history and take a closer look in the slide show above.Â Resources Razavi SM, Kiani S, Khalesi S. Periapical lesions: a review of clinical, radiographic, and histopathologic features. Avicenna J Dental Res. 2015;7: e19435Brown RS, Jones R, Feimster T, Sam FE. Cutaneous sinus tracts (or emerging sinus tracts) of odontogenic origin: a report of 3 cases. Clin Cosmet Investig Dent. 2010;2:63-67. Print 2010.GimÃ©nez-GarcÃa R, Martinez-Vera F, Fuentes-Vera L. Cutaneous sinus tracts of odontogenic origin: two case reports. J Am Board Fam Med. 2015 Nov-Dec;28:838-840.