Sir, we present a case from our emergency department when we were asked to see a 65-year-old lady who had presented with a 'facial swelling'. The information that was passed on via the triage nurse was that the dentist had sent the patient in from general practice and the 'dental abscess' was very large. The patient's GDP thought that she had a fascial space infection of dental origin but a five day history of a progressively worsening swelling was reported.

There was no airway compromise but extra-oral examination revealed a significant right facial swelling. This was diffuse and extended from the lower eyelid to the lower border of the mandible. It was extremely tender to touch; the patient had a marked trismus and was clearly distressed. The masseter was grossly inflamed and firm to touch. Upon intra-oral examination the gingivae and teeth were unremarkable however, on the right buccal mucosa there was ulceration and a pinpoint opening; upon palpation of this area it was extremely tender and was draining pus.

Investigations revealed that the patient was apyrexial, her white blood cell count was minimally raised (7.2 x 109/L), however, the C-Reactive protein was very high (136 mg/L). A panoramic radiograph revealed an edentulous posterior right hand segment, and there were no signs of active pathology in the adjacent teeth (Fig. 1). However, a small radio-opaque structure was evident. It was not entirely clear whether this was of relevance.

Fig. 1
figure 1

Radio-opague mass visible in URQ

Full size image

A provisional diagnosis was that of a facial soft tissue swelling possibly related to obstruction of Stensen's duct and in turn the right parotid gland. Which, we theorised, had caused buccal mucosal swelling that was then traumatised. A dental cause was highly unlikely. However, the size of the facial swelling was still considerable and merited further investigation.

The patient was treated with intravenous antibiotics and fluids and an urgent CT scan of the neck and face was arranged. This revealed an obstructing 6 x 3.3 x 2.5 mm calculus in Stensen's duct, significant right parotid gland swelling and right masseteric inflammation/phlegmon accumulation - additionally, the scan revealed multiple reactive lymph nodes in multiple planes of the neck. In short, the patient had a right parotid sialadenitits secondary to an obstructed Stensen's duct.

Upon review the following day, the patient reported that a small hard ball like stone had fallen out into the mouth - this seemed to confirm the diagnosis of a salivary stone. Salivary stones are calcified masses within the salivary glands and/or ducts,1 they account for over 50% of salivary gland disease,2 and the majority present in the submandibular glands, it has been reported that less than 10% of stones present in the parotid glands,3 so this is an unusual case. Parotid stones are an equal mixture of both organic and inorganic substances with minimal bacterial involvement.2 Pain is often secondary to salivary duct obstruction, bacterial ingress occurs with no protection from salivary fluid and the duct becomes a suitable environment for bacterial colonisation and proliferation,3 as in this case. One must rule out other non-dental causes of facial swelling such as dehydration or radiation induced sialadenitis, mumps and an acute presentation of Sjögren's syndrome. With the correct radiographic investigations and exclusion of the above a definitive diagnosis can be achieved.