Case

A 45-year-old complains of a left posterior toothache for the past 2 weeks that they treated with salt water gargles. However, over the past 24 hours, they have developed fever and difficulty opening their mouth, talking and swallowing. On examination, the patient has a fever of 101°F, with a firm painful redness of the left neck just inferior to the mandible. They also have slight drooling from the left side lip and exhibits inspiratory stridor. They are sitting up, but anxious.  

Question 1/3 - What possibilities should be on your differential diagnosis?

Click on your selected option(s) below  (correct = 1, over-thinking = 2+)

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Correct!  Dental abscesses are relatively common occurrences and typically are self-limited or easily treated with oral antibiotics such as penicillin.  

Occasionally, an infection involving the molar teeth may extend into the submandibular space (submandibular cellulitis). The fever and erythema (redness) extending inferior to the mandible suggests that this has occurred in this patient. 

Incorrect. The parotid gland is located anterior to the ear, whereas in this patient the erythema (redness) is located inferior to the mandible suggesting the parotid is not involved.   

Incorrect. Tonsillitis usually results in inflammation of the tonsils visible through a throat examination, while this patient has a clear surface erythema inferior to the mandible.

Incorrect. The presence of tonsillolith stones may cause tickling sensations and is associated with hallitosis.

These can be painless or can cause some mild sore throat through to dysphagia depending on the severity, but are unlikely to be a primary source of infection. If that did occur it would be a tonsillitis with the associated symptoms and examination findings.

Incorrect. Tumors are usually painless and do not cause a fever, which is indicative of an infection.

Incorrect. While the patient does have a toothache, a simple cavity is not consistent with spreading erythema to regions inferior to the mandible. This suggests more than a simple cavity is occurring.