CASE
A 37-year-old man noted intermittent decreased sensation in his chin and lower lip with associated pain and swelling in his left lower jaw. He was planning to see his primary care physician (PCP) to have the symptoms evaluated when he fell off a ladder, injuring his neck and the side of his face. The patient went to the emergency department, where a series of cervical spine radiographs was performed and read as negative. The radiographs showed normal cervical curvature with preservation of the intervertebral disk spaces and no prevertebral soft-tissue swelling. Anti-inflammatory medications were prescribed, and the symptoms subsequently subsided.
About 2 weeks after the fall, the patient was shaving and noticed numbness in his left lip along with minor left facial pain and slight swelling. Uncertain whether or not the symptoms were related to his fall from the ladder, he went to see his PCP for further evaluation. After a thorough examination, the PCP was unable to find a definitive cause of the symptoms and observed that they were suggestive of a dental pathology.
The patient consulted his dentist, who found an impacted wisdom tooth. Once the tooth was removed, the facial pain diminished and the patient regained most of the sensation to his lip and face. Approximately 1 week after the tooth extraction, however, the patient again experienced diminished sensation in his face and pain in the left jaw. He also noticed more pronounced swelling in his left lower jaw. When neither his PCP nor his dentist was able to see him, the patient came to our urgent-care center.
Medical history revealed that 8 years earlier, the patient had had a sarcoma of the right knee. He underwent radical excision of the tumor followed by radiation therapy and has been disease-free ever since. The patient stated that he was allergic to codeine and was taking no medications. In addition, he denied using tobacco or alcohol and reported no history of radiation treatment to the head or neck region.
On examination, the patient was afebrile and vital signs were stable. There was no indication of respiratory distress. Mild facial swelling was apparent along the left lower angle of his jaw. During the oral examination, swelling was noted in the area where the wisdom tooth was removed, and the patient complained of pain when the area was palpated. No pus was expressed from the gums during palpation. There was no anterior or posterior adenopathy. The remainder of the physical examination was normal.
The patient was referred to an oral maxillofacial surgeon for same-day evaluation of the facial swelling. Panoramic radiography was performed (see Figure 1). What does this image show?