Unilateral Facial Swelling and Jaw Deviation in Collegiate Wrestler

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HISTORY: 21 year-old Hispanic female collegiate wrestler presents with 5-day history of pain and swelling in her left anterior face and neck and rightward jaw deviation after being slammed to the mat during sparring drills. She reported pain at the time of the incident followed by difficulty in opening her mouth to eat. She denied fever or chills at the time. PHYSICAL EXAM: Non-toxic appearing, non-diaphoretic female in mild painful distress. Initial HEENT exam revealed rightward jaw deviation of approximately two teeth with significant edema and tenderness to palpation most notable over the left temporomandibular joint and within the muscle belly of the left sternocleidomastoid. Opening of mouth limited to approximately 2 cm due to pain. INITIAL DIFFERENTIAL DIAGNOSIS: 1. Mandibular fracture 2. Mandibular dislocation 3. Left facial contusion 4. Left sternocleidomastoid strain TEST AND RESULTS: Plain films of the mandible showed no obvious fracture or dislocation. The patient was then evaluated by Oral/Maxillofacial Surgery fellow. His impression was possible mandibular fracture and ordered methylprednisolone taper and follow-up in 3-4 days in his clinic. SECONDARY PRESENTATION: Prior to outpatient follow-up with OMS clinic, her pain worsened and she developed fever, nausea, and vomiting. She presented to the emergency room in sepsis with a fever, tachycardia, and leukocytosis of 19.2. SUBSEQUENT IMAGING AND MANAGEMENT: CT angiogram: Revealed 4x2 cm left parotid gland abscess, retropharyngeal fluid collection from C1-C5, and complete occlusion of the left internal jugular vein secondary to septic thrombophlebitis versus mass effect. She underwent urgent surgical drainage of left parotid gland abscess and remained in hospital for 4 days of IV antibiotics followed by 14-day course of trimethoprim/sulfamethoxazole. Post-op U/S ruled out septic thrombophlebitis in IJ. FINAL DIAGNOSIS: Parotid abscess with left internal jugular vein compression TREATMENT AND OUTCOMES 1. Oral trimethoprim/sulfamethoxazole for two weeks. 2. RTP was guided by ending of season and she was allowed to return to full activity in 4 weeks.