Figure 2.

Case vignette #2. (A) on admission; (B) after initial surgery: tracheostomy, incision and drainage; (C) on discharge. A 21-year-old male with an empty past medical history presented with a large bilateral submandibular swelling (A). He had toothache for 1 week and visited a traditional healer who had prescribed a topical herbal medication. On admission, the patient was alert, circulatory stable, and afebrile but had difficulty breathing; there was an inspiratory stridor, and the maximum mouth opening was 30 mm (inter-incisal distance); with pus draining into the oral cavity. The Hb level was 15.3 g/dL. The diagnosis of peri-mandibular cellulitis with airway compression was made, and intravenous antibiotics were administered (ceftriaxone 2 g OD, metronidazole 500 mg TID, and gentamycin 320 mg OD). Single-dose dexamethasone 10-mg IV was administered considering the stridor, continued with 4-mg IV QID. Also, the patient was nebulized with adrenaline in normal saline solution. The right-sided submandibular abscess was incised and drained. One day after admission, the patient deteriorated, with saturation dropping to 69% and prolonged apnea periods. During an emergency cricothyroidotomy, the previous incision on the right was extended to enhance drainage of pus (B). Three days later, there were crepitations and swelling in the left supraclavicular region, and an incision and drainage as well as a debridement were performed. On D6, the patient was considered stable enough for removal of the tracheostoma. He recovered uneventfully, with the prominent complaint of excess of saliva in the mouth cavity and trismus, both improving over the next 3–4 weeks. Three weeks after admission the mouth opening was sufficient for removal of the infected and decayed molar. Six weeks after admission the patient was discharged, with a mouth opening of 40 mm (C). At that time he received paracetamol for gum pain; his wounds were not fully granulated yet. Six weeks after discharge the patient was consulted by phone, and no complications were reported. This figure appears in color at www.ajtmh.org.