M2 ANATOMY

A 38-year-old gentleman presents to the Emergency Department with unrelenting pain involving the lower right mandible and right posterior mandibular teeth.  He was well until a week previously when he first experienced a low grade pain in this area which initially subsided upon taking ibuprofen.  Over the ensuing week, the pain gradually intensified and the patient now describes it as a 9 on a scale of 1-10. Pain is intensified with drinking both cold and hot liquids. The patient also admits to intermittent fever and chills.  His past medical history includes a fracture of the right proximal humerus and right upper ribs with a traumatic pneumothorax secondary to a fall from a motorcycle five years previously.  The patient takes no regular medications, has no allergies, and is employed as an automobile mechanic.  He does not have a formal relationship with a dentist and no continuity of care in oral health.  

Physical examination notes a 38-year-old gentleman in moderate distress cradling the right side of his jaw and lower face with his right hand.  His vitals are HR 90, RR 14, BP 142/82, oxygenation levels of 95%, and Temp of 100.5 F.  Intraoral examination notes mild erythema and edema surrounding tooth #30 with mild draining of purulent material at the buccal margin of the tooth.  There is exquisite pain noted to mild percussion of tooth #30 with the handle of a dental mirror.  There is no compromise of the airway and the head and neck exam is otherwise normal.  The patient’s heart rate and rhythm are regular and his lungs are clear.  The exam is otherwise noncontributory. 

You contact the general dentist on call for emergencies, and she advises you that she will come in to evaluate the patient and take the patient to the dental suite for focused radiographs and a full dental examination.  She requests that you give the patient 300 mg Clindamycin PO and asks you to perform a nerve block with lidocaine for pain control.

Unfortunately, the emergency dentist is caught in a traffic jam on the expressway and it has been two hours since your telephone conversation. At this point, your patient begins experiencing exquisite pain with attempts to open the mouth. A reexamination of the head and neck reveals the beginning of swelling involving the lower jaw and neck which you did not notice earlier.  

Your patient is now beginning to experience increasing shortness of breath and he has an increased rate of respiration.  His temperature is now 101.8°F with a HR of 110 beats per minute, blood pressure of 160/90 mmHg, a respiratory rate of 25 breaths per minute and oxygenation levels of 90%. At this point, IV access is established and a plan for intravenous antibiotics is put in place. With the continued input of the dentist, you consult otolaryngology and the patient is scheduled for urgent surgical decompression under general anesthesia.