A 54-year-old man comes to the emergency department after 2 days of fever, chills, dysphagia, and drooling. The patient has been unable to eat or drink due to pain in his mouth and neck. He has a history of heavy alcohol use but does not use recreational drugs. Temperature is 38.8 C (101.8 F), blood pressure is 110/70 mm Hg, pulse is 108/min, and respirations are 22/min. The patient appears toxic with drooling and a muffled voice. The tongue is displaced posteriorly and superiorly due to a swollen area on the floor of the mouth. The bilateral submandibular area is tender, indurated, and nonfluctuant with palpable crepitus. Which of the following is the most likely source of infection in this patient?

Question

A 54-year-old man comes to the emergency department after 2 days of fever, chills, dysphagia, and drooling.  The patient has been unable to eat or drink due to pain in his mouth and neck.  He has a history of heavy alcohol use but does not use recreational drugs.  Temperature is 38.8 C (101.8 F), blood pressure is 110/70 mm Hg, pulse is 108/min, and respirations are 22/min.  The patient appears toxic with drooling and a muffled voice.  The tongue is displaced posteriorly and superiorly due to a swollen area on the floor of the mouth.  The bilateral submandibular area is tender, indurated, and nonfluctuant with palpable crepitus.  Which of the following is the most likely source of infection in this patient?

Quizplus · Accepted Answer

Ludwig angina is a rapidly progressive cellulitis of the submandibular space. Most cases arise from dental infections in the mandibular molars that spread contiguously down the root into the submylohyoid (and then sublingual) space. The infection is usually polymicrobial with a mixture of oral aerobic (eg, viridans streptococci) and anaerobic bacteria. Patients develop symptoms rapidly with systemic (fever, chills, malaise) and local compressive (eg, mouth pain, drooling, dysphagia, muffled voice, airway compromise) manifestations. Physical examination findings are often striking due to mass effect from edema. The submandibular area is usually tender and indurated, and the floor of the mouth is often elevated, displacing the tongue. Anaerobic, gas-producing bacteria may cause crepitus. CT scan of the neck confirms the diagnosis and rules out an abscess. Most patients are treated with intravenous antibiotics (eg, ampicillin-sulbactam, clindamycin) and removal of the inciting tooth. Drainage and surgery are rarely required as the process is cellulitic and typically nonsuppurative, but they may be required if there is no improvement with antibiotics. Impaired respiratory status requires prompt attention and early intervention with a mechanical airway. (Choice A) Hematogenous spread is a common cause of endocarditis, osteomyelitis, and septic joints. (Choice B) Epiglottitis can cause life-threatening airway obstruction with sore throat, fever, muffled voice, and drooling. However, this patient has swelling on the floor of the mouth and in the submandibular area (not in the supraglottic structures or laryngeal tracheal area), making Ludwig angina more likely. (Choice C) Lymphadenopathy is typically absent in Ludwig angina. Lymph nodes can rarely cause airway obstruction in tuberculosis lymphadenitis (scrofula). (Choice D) Tonsillitis may rarely cause airway obstruction with hoarseness and stridor. However, the palatine tonsils would not result in inflammation beneath the tongue and in the submandibular area. (Choice E) The parotid gland is located on the lateral face superficial to the masseter muscle. It is not affected in Ludwig angina. Parotid gland edema may be seen with mumps or secondary bacterial infection after parotid duct obstruction. Educational objective: Ludwig angina is a rapidly progressive cellulitis of the submandibular and sublingual spaces. The source of infection is most commonly an infected mandibular molar. Early intervention with intravenous antibiotics prevents airway compromise in most cases.

A 54-Year-Old Man Comes to the Emergency Department After 2