Facial swelling and odontogenic infection — branching viva

Opening

Examiner: A 6-year-old presents with three days of right-sided facial swelling, toothache and a fever of 38.6 degrees Celsius. The swelling is firm, warm and tender, there is a carious right lower molar tender to percussion, and he has no drooling, trismus or airway compromise. How do you approach this? [1]

Candidate: This is a spreading odontogenic cellulitis arising from the carious right lower molar. The periapical abscess has perforated the cortical bone and tracked into the buccal space, which is why the swelling is in the cheek — the buccinator attachment on the mandible determines the direction of spread. The key principle is source control: the offending tooth must be extracted or undergo endodontic treatment and any collection drained, because antibiotics alone cannot sterilise an established abscess. I would give analgesia — paracetamol 15 mg/kg every four to six hours — arrange urgent dental or oral-maxillofacial review for extraction or drainage, and add oral amoxicillin-clavulanate 45 mg/kg/day (amoxicillin component) in two divided doses because this is spreading cellulitis with systemic features. [1] [4]

Branch 1 — the antibiotic and disposition decision

Examiner: He is penicillin-allergic (non-anaphylactic). How does your antibiotic choice change, and do you admit him? [5]

Candidate: For a non-anaphylactic penicillin allergy I would use clindamycin 30 to 40 mg/kg/day orally in three to four divided doses, which covers oral streptococci and anaerobes, or metronidazole 30 mg/kg/day added to a cephalosporin. I would admit him if he is unable to tolerate oral intake, if he is young or systemically unwell, or if there is any doubt about follow-up — in which case I would give intravenous ampicillin-sulbactam (avoided in anaphylactic allergy) or clindamycin with metronidazole. As he is currently well and taking fluids, with a clear safety-net and reliable dental follow-up, he could be managed as an outpatient with early review at 48 to 72 hours. [5]

Examiner (probe): He returns at 48 hours with worsening swelling. What does that signal? [1]

Candidate: Failure to improve on antibiotics with source control — or worsening despite them — signals an undrained collection or deeper spread. I would reassess the source tooth, repeat the dental and clinical examination looking for a deeper space, and arrange contrast CT of the neck and face to define any collection and its fascial space. The corrective is repeat source control and drainage, not more antibiotics alone. [1] [3]

Branch 2 — Ludwig angina

Examiner: A different child: a 5-year-old with two days of jaw and neck swelling, now drooling, unable to open her mouth, with a muffled voice and a firm, woody, raised floor of mouth. What is this and what is your immediate priority? [2]

Candidate: This is Ludwig angina — a bilateral cellulitis of the submandibular, sublingual and submental spaces, usually from a mandibular molar. The signs are the bilateral submandibular swelling, the woody indurated and raised floor of mouth, the raised and displaced tongue, drooling, trismus and the muffled voice. My immediate priority is the airway. I would keep her sitting upright and leaning forward, not lay her flat, and not force an intraoral or oropharyngeal examination — because either can precipitate complete airway obstruction. I would summon senior anaesthetic help, ENT and oral-maxillofacial surgery immediately, because intubation will be difficult and a surgical airway must be ready as backup. [2] [3]

Branch 3 — resuscitation and definitive care

Examiner (probe): What is your resuscitation sequence once the teams arrive? [2]

Candidate: Obtain intravenous access, take blood cultures and inflammatory markers, and start broad-spectrum intravenous antibiotics covering oral aerobes and anaerobes — ampicillin-sulbactam 150 mg/kg/day (ampicillin component) in four divided doses, or clindamycin 30 to 40 mg/kg/day with metronidazole 30 mg/kg/day. Arrange contrast-enhanced CT of the neck and face only once the airway is secure and she is accompanied and monitored. She is then taken to theatre for surgical decompression of the involved spaces and extraction of the offending tooth — source control is the curative step. After theatre she is managed in high-dependency or intensive care because the airway can still deteriorate. [2] [5]

Examiner (probe): A colleague suggests corticosteroids. What is their role? [2]

Candidate: High-dose corticosteroids such as dexamethasone are used adjunctively in some centres to reduce oedema and improve trismus and airway patency, but the evidence is limited and their use is controversial. They are an adjunct, decided by the treating surgical and intensive-care team — never a substitute for airway control, antibiotics and surgical drainage. [2]

Close

Examiner: Summarise your safe approach to paediatric facial swelling of dental origin in one line. [1]

Candidate: Find the source tooth and extract or drain it, give antibiotics for spreading or systemic infection covering oral anaerobes, and escalate the child with drooling, trismus, a raised woody floor of mouth or a muffled voice as Ludwig angina — securing the airway with senior help before any imaging or instrumentation, because the airway is the threat. [1] [2] [3]