A rare case of submandibular abscess complicated by stroke
A 33-year-old male presented to our institution with a left submandibular abscess secondary\nto dental infection. He had a three-day history of left jaw pain, lethargy, fever and\ndecreased PO intake. He had no significant medical history. Examination findings included\nmoderate to severe trismus and marked left submandibular swelling, and his 38th tooth was\ntender on palpation. His initial WCC was 18.7 with a neutrophilia and CRP was 153. Contrast\nCT demonstrated localized abscess in the left submandibular space.\nUltrasound reported a small hypoechoic mass on the medial aspect of the left submandibular\ngland. He was admitted and commenced on IV ceftriaxone, metronidazole and dexamethasone. His\nsymptoms and biochemical markers improved over the following three days and he was\ndischarged home on oral cephalexin and metronidazole. Drainage was initially considered\nunnecessary due to the small size of the collection and excellent clinical response.\nForty-eight hours after discharge, the patient re-presented to the same institution with\nright-sided weakness, confusion and sudden expressive aphasia. On examination, he was\nafebrile, had a BP of 159/92 and PR of 70. His GCS was 11, and he had a right upper motor\nneuron seventh nerve palsy and had decreased power in his right arm with hemi-sensory loss.\nHis WCC was 14, CRP 45 and ESR 61. A non-contrast head CT scan was normal.\nA CT angiogram of the head and neck was performed which demonstrated a tight stenosis\n(greater than 90%) involving the mid-left internal carotid artery over a distance of\napproximately 2 to 3 mm ().\nA 1 cm-segment of thrombus was noted in the superior branch of the left MCA at the level of\nthe anterior end of the Sylvian fissure and an abscess was seen involving the floor of mouth\nand submandibular space ().\nMRI showed acute left inferior frontal cortical infarct in the distribution of the left MCA\n(). It also showed further\nenlargement of the left submandibular space fluid collection, consistent with abscess\nformation with a focus of gas.\nThe patient was taken to theatre for a left transcervical incision and drainage of abscess\nand removal of the left submandibular gland. The findings at operation included a large left\nsubmandibular gland, adherent to the surrounding fascia. There was a large quantity of\nnecrotic tissue surrounding the gland with fistula extending to the gingival mucosa adjacent\nto the 38th tooth. The tooth was removed.\nSubsequent MRA of the neck performed one week postoperation demonstrated a stable stenosis\nof the distal left ICA at the level of C1 and, to a lesser extent, the right ICA. There was\nresolution of the left-sided submandibular fluid collection and the associated inflammatory\nchange. ECHO/Holter monitor screen, thrombophilia screen and cholesterol studies were\nunremarkable.\nTwo months later, the patient was admitted for an elective left carotid endarterectomy via\na combined transcervical and mandibular osteotomy approach. The findings at operation were a\nsmall internal carotid artery with an obvious stenosis, with intimal hyperplasia, 1 cm away\nfrom the base of the skull. His postoperative progress was complicated by a 10th, 11th and\n12th cranial nerve paresis secondary to postoperative oedema. This improved throughout his\npostoperative stay with some mild deficit remaining at discharge.