"Lumpy Jaw" in a 20-year-old Male Resists Treatment

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.

Lab tests/results:

CBC = normal; comprehensive metabolic panel = normal; throat culture = normal flora; intermediate PPD skin test read as 0 mm of induration.

Physical examination:

The sole finding is a soft, erythematous nodulocystic, 3 x 3 x 1-cm mass at the jaw line on the left side.

Nodulocystic mass

overlying the left mandible; measures 3 x 3 x 1 cm.

Is the physical examination complete? Are you satisfied with what you've found?

An oral examination

may prove useful in this case.

Finding:

A “gum boil” which suggests a periapical abscess that has drained.

What's your diagnosis?

Answer: Periapical abscess.

A thoughtful history and thorough physical examination may also include a good dental assessment.

Periapical abscess:

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).

Treatment:

Refer patient with periapical abscess for dental evaluation. Typical course: tooth/teeth removed; antibiotics for deep facial infections, osteomyelitis. Microbiology: Gingival crevice:

Bacteroides, Peptostreptococcus;

Tongue:

Streptococcus salivarius;

Tooth surface:

Streptococcus sanguinis, Streptococcus mutans

Differential diagnosis for periapical abscess:

Squamous cell carcinoma; osteomyelitis; pyogenic granuloma; actinomycosis; deep mycosis; foreign body; congenital fistula.

Characteristic sulfur-laden granule

seen from microscopic examination of drainage from patient with actinomycosis (sometimes asked on board exams).