Year : 2021 Month : May Volume : 10 Issue : 22 Page : 1741-1745

A Non-Sinus Forming Mandibular Actinomycotic Osteomyelitis with a Submandibular Gland Swelling - A Case Mimicking a Periapical Infection

Suma Gundareddy Nagendra Reddy1, Ravina2, Dayashankara Rao Jingade Krishnojirao3 Debdip Mandal4

1, 2, 4 Department of Oral Medicine & Radiology, SGT University, Gurugram, Haryana, India. 3Department of Maxillofacial Surgery & Diagnostic Sciences. College of Dentistry, Qassim University. Saudi Arabia.

CORRESPONDING AUTHOR

Dr. Suma Gundareddy Nagendra Reddy, E 101, RV 2, Plot 16, Sector 23, Dwarka - 110077, Delhi, India.
Email : sumagndaya@gmail.com

INTRODUCTION

Involvement of the submandibular gland in actinomycotic osteomyelitis in the absence of sinus is rare. Cervicofacial form is characterized by contiguous spread, suppurative osteomyelitic & granulomatous inflammation of the mandible and formation of multiple abscesses and hallmark discharging sinuses draining sero- sanguinous fluid containing sulphur granules.

As the imaging finding of this entity is rarely described, in this case report, a rare case of mandibular actinomycotic osteomyelitis, with a submandibular swelling, but without draining sinus is reported. The imaging findings of cone beam computed tomography (CBCT) & ultrasonography (US) of the case are discussed with a review.

In subacute stage, mandibular actinomycosis may show no hallmark sinuses. Sclerotic margins around the lesion may be found on radiograph. Imaging is useful in ruling out clinical diagnostic challenge when it includes involvement of mandible & submandibular region.

Cervicofacial actinomycosis commonly occurs as perimandibular infection, rarely as osteomyelitis of the mandible.1 It may present as two distinct morphological patterns; first, "lumpy jaw," and second, simulating an acute pyogenic infection affecting the submandibular area, discharging sinus being a hallmark finding.1 Other variant reported include chronic osteitis, osteolytic lesion, hard nodule on the tongue, lockjaw, periapical, or paradental abscess. Diagnosis of cases presenting in multiple areas in the absence of multiple discharging sinuses is a challenge.2 Usefulness the imaging findings are rarely enumerated.

This report is of a twin presentation of a non - sinus forming actinomycotic mandibular osteomyelitis and a submandibular swelling, along with a review of various diagnostic imaging features.

PRESENTATION OF CASE

In the third decade, a male patient presented with six - month - old painful swelling below the angle of the lower jaw. History revealed, fracture of the right mandible in an accident a year back, treated with inter-maxillary fixation. A few months later, the patient returned with a painful right mandibular tooth mimicking a periapical infection. The attempted endodontic treatment failed to relieve the symptoms. The tooth was extracted due to a persistent infection, in spite of endodontic treatment. Three months later, a soft and painless swelling appeared in the right submandibular region, which gradually enlarged to become firm and painful. There was no history of draining sinus, fever, cough, weight loss. Medical, family, and psychosocial history was unremarkable. Despite the repeated medication of antibiotics and analgesics, partial remissions and exacerbations of the swelling continued.

Extraoral examination revealed a diffuse mild swelling over the right angle of the mandible, and an oval, 2.5 cm x 3.5 cm, swelling in the ipsilateral submandibular region 1 cm anterior to the sternocleidomastoid muscle, 1 cm below the lower border of the mandible, with well - defined borders, smooth surface, & bluish - purple coloured overlying skin. (Figure1). Swelling in the submandibular gland region was firm, tender, non – fluctuant. The skin over the swelling was indurated, but no sinus/pus discharge was present. Right submandibular tender lymphadenopathy was present.

On intraoral examination, there was no source of dental sepsis in the molar region. On palpation, the vestibule showed mild obliteration of the vestibule and tenderness. The panoramic image revealed ill-defined radiolucency, 3.05 x 1.68 cm in size, in the mandible extending from the second molar till the anterior ramus, resorbing the external oblique ridge. The lesion showed a moth-eaten appearance, with irregular

sclerotic borders. (Fig. 2). CBCT showed an osteolytic lesion,

 

mild expansion of the buccolingual cortical plate predominantly in tooth no. 48 region, effacement, and disruption of the lingual cortex, with irregular areas of dense trabecular pattern (Fig. 3). Radiographic impression was chronic osteomyelitis of the mandible.

 

 

 

An ultrasound examination suggested an inflammatory lesion in the submandibular gland. It showed a roughly circular hypoechogenic area in the right submandibular region measuring 2.1 x 1.4 cm, with multiple echogenic foci, the largest measuring 2.5 mm, oedematous changes in the overlying skin, subcutaneous tissue. (Fig. 3) Fine needle aspiration cytology (FNAC) from the submandibular swelling confirmed the final diagnosis as actinomycosis. (Fig. 3)