The present study reports the case of a retired 59-year-old female, overweight (BMI 29.3 kg/m2), with decompensated type two diabetes mellitus (DM) and hypercholesterolaemia, under drug therapy (ezetimibe with simvastatin 1 tbt/day and metformin hydrochloride 1000 mg 1 tbt twice a day), no coronary artery disease or herpetic virus liver disease, previous appendectomy surgery under general anaesthesia, and common childhood rashes. The patient was treated during the COVID-19 period, and all indicated measures according to the scientific literature were taken to protect all medical workers and the patient. Seven days prior to emergency room (ER) admission, she reported swelling in the right mandibular region which showed progressive volumetric increase with spontaneous and on-palpation pain. She started a nonbetter-specified antibiotic therapy with no benefits at all so that a subsequent dysphonia and liquid and solid dysphagia developed. On ER physical examination, the patient presented a voluminous right half-face abscess, inability to speak correctly due to trismus, and oedema of the tongue and mouth floor (Figure 1). Optical fiber video exploration of the upper respiratory tract showed mucosal oedema and hyperaemia of both the hypopharynx and the larynx. Complete blood count and laboratory tests (the most relevant values are reported in Table 1), Sars-CoV2 swab (negative), orthopantomography (OPG) X-ray (Figure 2), computed tomographies (CT) of the head-neck (Figures 3 and 4), and chest (Figure 5) were performed. Skull CT underlined the presence of gas bubbles in both the cavernous sinuses, possible odontogenic focus on tooth 4.7, part of a prosthetic bridge (4.7-4.5); neck CT was positive for huge phlegmon and gas bubbles affecting the right half of the face and platysma, the right parotid gland posteriorly, extending up to the contralateral parotid capsule and sternocleidomastoid muscle medially and the thyroid space inferiorly; chest CT showed no pathological findings. Emergency surgical laterocervical abscess drainage appeared to be mandatory and was performed together with the homolateral submandibular gland sialoadenectomy. The patient also underwent a surgical tracheostomy, according to the previous optic fibre video evaluation, in order to secure the airways and ensure proper ventilation (Figure 6). Antibiotic therapy with Teicoplanin 400 mg and Levofloxacin 500 mg was prescribed (Targosid 400 (Teicoplanina) mg Endovein at 12 : 00 and 22 : 00 with Rocefin (Ceftriaxone) 2 g Endovein at 8 : 00 and 20 : 00, and Desometasone 8 MG at 8 : 00 and 22 : 00 + gastroprotectives.)
The day after the emergency surgery, neurosurgical signs (negative) and infectious disease (new antibiotic therapy: piperacillin/tazobactam 4.5 g and linezolid 600 mg) consultations were requested. Urgent head and neck-chest computed tomography (CT) scans were performed. Presence of bilateral gas bubbles in correspondence to the cavernous sinuses was revealed. At the level of the neck, a large phlegmonous collection was present with a considerable contextual air share located mainly in the right half of the face, the platysma, and the ipsilateral parotid gland capsule. Medially, it extended to the buccal floor to the left submandibular lodge and the sternocleidomastoid fascia. C-reactive protein value was reduced but still high. On the third day of hospitalization, the patient was admitted to the intensive care unit because septic shock had developed due to the patient requiring vasopressors to maintain a mean arterial pressure higher than 65 mmHg and presenting a serum lactate level greater than 2 mmol/L. SOFA score was 9, and fever was present (38.2 degrees C). Neck-chest CT showed increased phlegmonous collection, especially on the left side (extended to the left parotid gland), on the anterior region of the neck, and down to the superior mediastinal region in the retrosternal site. Head CT revealed almost complete reabsorption of the gaseous collections at the level of the cavernous sinuses on both sides; only a small gas bubble remained in the right cavernous sinus. Emphysema in the neck was also moderately reabsorbed. There were no signs of venous thrombosis of the cerebral vessels or neck. Thoracic surgery consultation revealed no need for emergency surgery and neck-thorax CT with contrast medium after 48 hours and revaluation. The patient proceeded to surgery (Figure 7). After local anaesthesia (mepivacaine 3%) without vasoconstrictor, tooth 1.7 was removed because of a periapical lesion with necrosis; afterwards, the prosthetic bridge 4.5-4.7 was sectioned with rotating instruments in order to save the 4.5. Tooth 4.7 was extracted together with the pontic 4.6. Since a radiopacity spot in area 4.8 was seen on the skull-CT, a surgical revision in this site was also carried out. Alveolar curettage was performed using Volkmann spoons, and two specimens of exudate, collected in the postextraction site (4.7) and in 4.8 area, were sent for histological and microbiological examination; after washing with physiological solution and rifamicine topic antibiotic, haemostis with oxidized regenerated cellulose gauzes (Tabotamp ) was performed.
The day after surgery, the patient was kept sedated and under controlled mechanical ventilation; SOFA score dropped from 9 to 8, and haemodynamic stability was achieved through vasopressors (noradrenaline). Fever was still present. In the following days, as the SOFA score dropped to 0 and discontinuation from amine support transpired, fever resolved, and the patient initiated successful weaning that resulted in disconnection from the ventilator on the 9th day of hospitalization. ENT (ear, nose, and throat) consultation revealed a thorough surgical treatment and suggested surgical wound dressing, washing with H2O2 and physiological solution through the drains. In addition, dentistry and thoracic surgery consultations were required. A new neck-thorax CT with contrast medium showed unchanged bilateral neck abscess and involvement of the anterior part of the neck down to the superior mediastinal region in the retrosternal site that did not require surgical treatment. After 10 days of hospitalization, chest X-ray did not show any variation compared to the previous evaluation, and the patient's condition was stable, being neurologically well oriented, hemodynamically stable, and with good gas exchange. On the 12th day, the patient was moved to the ENT ward. Patient discharge took place approximately 1 month after performing neck and chest CTs (Table 2 and Figure 8).
Check-up 3 months after discharge revealed no externally visible swelling (Figure 9) and a good intraoral tissues healing (Figure 10). Control OPG (Figure 11); CTs of head-neck and chest were requested and checked.
Neck-chest CT (13/02/2021): presence of bilateral gas bubbles in correspondence to the cavernous sinuses. At the level of the neck, a large phlegmonous collection with a considerable contextual air share located mainly in the right half face, the platysma, and the ipsilateral parotid gland capsule. Medially, it extended to the buccal floor to the left submandibular lodge and the sternocleidomastoid fascia.
Chest X-ray (bedridden) (14/02/2021): presence of tracheostomy tube with distal end in place; raised right hemidiaphragm with ipsilateral basal dysventilation; heart substantially within the limits.
CT neck-chest (15/02/2021): increase of the known phlegmon, especially on the left side (where it also extends to the left parotid gland) and also to the anterior region of the neck and down to the superior mediastinal region in the retrosternal site.
Cranial CT (15/02/2021): almost complete reabsorption of the gaseous collections at the level of the cavernous sinuses on both sides; currently, only a small gas box remains in the right cavernous sinus. Emphysema in the neck is also moderately reabsorbed; no signs of venous thrombosis of the cerebral vessels and neck.
Ct neck and thorax with contrast medium (17/02/2021): the known abscess collection in the neck bilaterally unchanged, especially on the left. It also extends to the anterior region of the neck and down to the superior mediastinal region in the retrosternal site; filiform the lumen of the pharynx and larynx. The pharyngolaryngeal spaces are obliterated. The remaining finds unchanged.
Chest X-ray bedridden (22/02/2021): no variation compared to the previous.
The written informed consent for the study and case publishing was obtained from the patient recruited.