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患者女性,46岁。因左下后牙肿痛1月伴同侧面部肿胀3周入院。发病以来,曾在外院应用抗菌素静点及左龈颊沟切开引流等治疗无效。查体:一般状况良好,全身检查无明显阳性体征。专科检查:左嚼肌区中度肿胀,肤温肤色正常,触之中等硬,压痛++。456区齿槽明显肿胀,龈组织充血水肿,456松动Ⅲ°并浮动,无龋洞,无分泌物,开口度约1.5cm。左颌下触及一约2cm×2.2cm巴结,偏硬,压痛+。WBC:9.6×10~9/L,N:70％,L:28％,E:2％。曲面断层片示56齿槽骨破坏吸收至根尖并形成根尖肉芽肿。初步论断:左嚼肌间隙感染(牙源性)。
Patient female, 46 years old. Due to lower left posterior teeth swelling pain accompanied by swelling of the lateral side of the hospital for 3 weeks. Since the onset, the use of antibiotics in the outer hospital static point and left gingival cheek groove incision and drainage and other treatment is invalid. Physical examination: the general condition is good, no obvious positive signs of systemic examination. Specialist examination: moderate swelling of the left chewing muscle, skin temperature and skin color normal, touching the medium hard, tenderness ++. 456 area crooked obvious swelling, gingival congestion and edema, 456 loose Ⅲ ° and floating, no cavities, no secretions, the opening of about 1.5cm. Left mandibular touch and about 2cm × 2.2cm knot, partial hard, tenderness +. WBC: 9.6 × 10 ~ 9 / L, N: 70%, L: 28%, E: 2%. Curved tomography showed 56 alveolar bone destruction absorbed into the apical and the formation of apical granuloma. Preliminary conclusion: left cheek muscle interstitial infection (odontogenic).