A 42-year-old male who came to the emergency department complaining of swelling and bilateral submandibular pain of two days duration and did not remit with analgesic and oral antibiotic treatment during the 48-72 hours prior.
As medical history of interest highlights only the fact of being a smoker of 2 packs/day and severe alcoholism.
The patient complained of pain in the fourth quadrant molars of 10-15 days of evolution.
Physical examination revealed a severe trismus together with dyspnea and odynophagia as signs of severity, a septic mouth and submandibular swelling with more evident inflammatory features on the right side and ipsilateral laterocervical crepitation.
The intraoral examination draws attention a septic mouth with pain on pieces 47 and 48 to percussion.
In the general laboratory, the only data that draws attention is a leukocytosis of 15,000x109/l with slight deviation to the left.
Arterial oxygen saturation was 98%, chest plaque without pathological signs and axillary temperature of 37.5° C. In orthopantomography a 48 mesialized and impacted tooth decay piece 47 was observed.
A CT scan of the neck showed a large dissection of the cervical planes from the submandibular region to the last cervical sections, showing a large amount of gas density at the laterocervical and retroesophageal levels, as well as deviation of the airway to the left material.
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We extended the axial sections to the mediastinal space where an image compatible with purulent collection and gas at the posterior mediastinum level was observed.
Empirical intravenous antibiotic therapy was initiated with amoxicillin-clavulanate 2 g-125 mg every 8 hours and gentamicin 80 mg every 8 hours.
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Together with the Surgery Department, the patient undergoes an emergency surgical procedure, performing a wide cervical incision following the anterior edge of both the thoracic mucopurenoid and plentiful cervical ostomy.
We leave rigid drainages with intermittent aspiration at the laterocervical, retroesophageal and mediastinal level, all of them placed from the cervical incision.
Intensive care unit admission was not performed.
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During the following four days, purulent material was removed through the cervical drains and on the fifth day, after performing broncho-fibroscopy prior to extubation, there was evidence of tracheal granuloma of unknown origin which led to the decision of extubation.
After the results of the culture of the purulent material, where different families of Streptococo (anginosus and intermedius) grow, Senmona aeruginosa and Prevotella ruminicula enter each patient with antibiotic treatment based on
During the following days the patient has a correct clinical evolution, so after 22 days of hospital discharge is given prior extraction of the 47 and 48 sites in outpatient clinics of our drainage catheter removal site and regional approach, through external drainage approach.
