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Dental infections are common in children. Occam's razor, typically paraphrased, suggests that the simplest solution is most likely the right one. We report a case of an 11-year-old child who presented with right-sided facial swelling, fever, trismus, and a heavily broken-down right maxillary molar with a large apical radiolucency. After admitting the child, intravenous antibiotics and fluids were prescribed in preparation for the extraction of the UR6 and LR6 in theatre early the next morning. However, 9 hours later, before surgery, the patient unexpectedly and rapidly deteriorated neurologically. MRI and CT examination revealed a diagnosis of a subdural empyema. This emergency was managed with a multidisciplinary team, involving neurosurgeons, oral and maxillofacial surgeons, otolaryngologists, and radiologists. The case highlights the importance of not assuming that the simplest diagnosis is always the only, or most appropriate, one to make.
CPD/Clinical Relevance: Regarding patients with a facial swelling, high order thinking may be required in clinical diagnosis.
Article
Facial infections are common in children.1 The axiom ‘facial infection is odontogenic in origin until proven otherwise’ is often used in medicine.2 The symptoms of a dental abscess include pain in the affected tooth or region, redness and swelling in the face, a tender, discoloured or loose tooth, sensitivity to hot or cold, and halitosis. If the infection spreads systemically, fever and malaise may arise. In severe cases, patients can experience trismus, dysphagia or dyspnoea.3 Early diagnosis and treatment is therefore essential when managing such facial infections owing to the possibility of sepsis or spread to adjacent structures.4 Rare, but potentially fatal results of such spread are intracranial suppurative lesions, which can be difficult to diagnose, and can result in serious long-term morbidity if not managed promptly and appropriately.5 For this reason, a high index of suspicion is required if neurological deterioration occurs. Subdural empyema (SDE) accounts for over 20% of intracranial abscesses6 and occurs when pus collects between the outermost layer of meninges, the dura mater and the arachnoid mater. Signs and symptoms of SDE include fever, headache, confusion or drowsiness, nausea or vomiting, hemiparesis or hemiplegia, seizure, and a recent history of facial infection, surgery or trauma.6
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