Presentation
Left facial and cervical soft tissue swelling, fever and trismus.
Patient Data
There is a left submandibular space, low-density collection with mild ring enhancement measuring 32.0 x 11.5mm in diameter (AP x width). There is a solitary, large, reactive, left-level Ib node. There are non-suspicious levels 1b, 2a and 2b, and right 5a lymph nodes bilaterally. There is left hemifacial soft tissue swelling, with an enlarged left masseter muscle, and regional inflammatory changes.
There is no parotid or submandibular (especially left) sialolithiasis.
Incidental nasopalatine foramen, right nasal and right ear piercing.
Incidental unilateral (unpaired) right anterior jugular vein.
Reconstruction and annotated images demonstrate the right anterior jugular vein, left submandibular abscess and the nasopalatine foramen.
3D images demonstrate an unpaired, right anterior jugular vein, receiving tributaries from several small right submandibular veins and joining the right internal jugular vein at a level just proximal to the right common carotid bifurcation and draining inferiorly into the right subclavian vein.
A repeat CT scan was performed for review, after 3 days of intravenous antibiotics and clinical improvement. The submandibular abscess is marginally smaller, however, there is significant improvement with respect to the regional soft tissue swelling and inflammatory changes.
Case Discussion
A case of a left submandibular space / submandibular gland abscess, proven to be odontogenic in origin and responding marginally to intravenous antibiotics. The initial differential diagnosis included an infected plunging ranula.
There is an incidental unpaired right anterior jugular vein, a normal variant, draining into the right subclavian vein. The anterior jugular vein is usually a paired external jugular venous tributary, however, in this instance, a left-sided anterior jugular vein is not identified. The asymmetry and unpaired nature of a large anterior vein lead to its appreciation and curiosity for a diagnosis.
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