Man with jaw pain after complicated wisdom tooth extraction.

PATIENT PRESENTATION

A 57‐year‐old male with history of hypertension and hyperlipidemia presented to the emergency department (ED) complaining of left jaw pain and swelling. The patient was referred to the ED by an oral surgeon at an outside facility because of concerns about worsening periodontal infection after a second failed extraction of tooth #17 the day before. The patient had an incomplete extraction 46 days before complicated by postoperative wound infection treated with amoxicillin, later complicated by Clostridium difficile infection treated with oral vancomycin. On physical examination, the patient was afebrile with normal vital signs. The patient had mild trismus, left jaw swelling, and tenderness along the buccal gum line along the left jaw adjacent to teeth #15–17. A bedside ultrasound was performed along the left jawline (Figure 1). Oral surgery was consulted with concern about mandibular osteomyelitis due to cortical disruption visualized on the ultrasound. A subsequent maxillofacial computed tomography scan confirmed the disruption (Figure 2).

FIGURE 1

(A) Normal right mandible and masseter. (B) Left masseter edema. Irregularity along the cortical surface of the mandible (red arrow). No evidence of abscess

FIGURE 2

Computed tomography scan of partially extracted left mandibular third molar with cortical erosion of the surrounding lateral mandibular bone (red arrow). Asymmetrical swelling of left masseter muscle and superficial soft tissue stranding. No soft tissue fluid collection

DIAGNOSIS

Mandibular osteomyelitis

Bedside ultrasound is a useful tool for evaluating unilateral face or neck swelling in the ED, as it can help distinguish between an abscess, lymphadenopathy, sialolithiasis, sialadenitis or other pathologies. In this case, bedside ultrasound led to the diagnosis of osteomyelitis when cortical disruption of the mandible was visualized. Cortical disruption visualized on ultrasound is a very specific finding, with one study done by Ezzat et al estimating 100% specificity in children. Emergency physicians should consider sonographic visualization of underlying bones to assess for underlying osteomyelitis when evaluating localized swelling. ,