Recurrent Right Facial Swelling with Dental Symptoms: Odontogenic Sinusitis Requiring Source Control
This patient requires urgent dental evaluation and definitive treatment of the underlying odontogenic source—repeated courses of azithromycin without addressing the dental pathology promotes antibiotic resistance and delays curative treatment. 1
Clinical Diagnosis
This presentation is highly consistent with recurrent odontogenic maxillary sinusitis:
- Pressure in upper teeth preceding facial swelling is pathognomonic for odontogenic sinusitis, indicating dental root involvement with secondary sinus infection 1
- Absence of nasal symptoms does not exclude sinusitis—atypical presentations are common with odontogenic sources 1
- Temporary improvement with azithromycin followed by recurrence over 3-4 years indicates the infection source has never been eradicated 2
Immediate Management Priority
Stop prescribing repeated antibiotic courses and obtain urgent dental consultation with the following workup:
- Dental examination with periapical radiographs to identify abscess, periapical pathology, or periodontal disease in the right maxillary teeth 1
- CT scan of sinuses if dental source is not immediately apparent, to evaluate for chronic rhinosinusitis or other pathology 1
- Consider panoramic radiograph to assess for impacted teeth, cysts, or other bony pathology
Definitive Treatment
The American Dental Association mandates that definitive treatment must be performed promptly once dental pathology is confirmed 1:
- Extraction of non-salvageable tooth
- Root canal therapy for salvageable tooth with periapical infection
- Incision and drainage if abscess is present
- Perioperative antibiotics may be indicated depending on extent of infection, but only as adjunct to definitive treatment 1
Why Azithromycin Alone is Inadequate
Azithromycin produces temporary improvement but not "focused cure" when the etiologic source remains 2:
- Azithromycin achieves excellent tissue levels for 7 days after a 3-day course and has good activity against oral pathogens 2
- However, recurrence of dental infections occurs when antibiotics temporarily improve symptoms without eradicating the source 2
- Repeated courses without source control promote antibiotic resistance and are explicitly discouraged by the American College of Physicians 1
If Antibiotics Are Needed Perioperatively
Should antibiotics be required around the time of definitive dental treatment:
- Azithromycin 500 mg daily for 3 days is appropriate for odontogenic infections when combined with source control 2
- Alternative: Amoxicillin-clavulanate is first-line for odontogenic infections in most guidelines
- Do not use azithromycin as monotherapy without addressing the dental source 1
Common Pitfall to Avoid
The critical error here is treating recurrent infections with repeated antibiotic courses without ever investigating or treating the underlying dental pathology. This 18-year-old has suffered for 3-4 years because the source was never addressed—the pattern of tooth pressure preceding swelling makes the diagnosis obvious in retrospect 1. Every recurrence represents a missed opportunity for definitive cure.