A 38-year-old man comes to the emergency department for evaluation of jaw swelling and pain. Two weeks ago, the patient cracked a molar in his right lower jaw after biting on an unpopped popcorn kernel and underwent tooth extraction. Yesterday, he developed a fever and the right side of his jaw began to swell. The pain has been worsening in that area, and the patient is having trouble swallowing. Temperature is 38.2 C (100.8 F), blood pressure is 130/82 mm Hg, pulse is 112/min, and respirations are 22/min. Oxygen saturation is 99% on room air. On examination, the patient appears ill and is drooling. His tongue appears elevated and is displaced posteriorly. The floor of the patient's mouth feels firm. His neck is erythematous, warm, and feels woody. This patient is at greatest risk for which of the following immediate complications?

Question

A 38-year-old man comes to the emergency department for evaluation of jaw swelling and pain.  Two weeks ago, the patient cracked a molar in his right lower jaw after biting on an unpopped popcorn kernel and underwent tooth extraction.  Yesterday, he developed a fever and the right side of his jaw began to swell.  The pain has been worsening in that area, and the patient is having trouble swallowing.  Temperature is 38.2 C (100.8 F), blood pressure is 130/82 mm Hg, pulse is 112/min, and respirations are 22/min.  Oxygen saturation is 99% on room air.  On examination, the patient appears ill and is drooling.  His tongue appears elevated and is displaced posteriorly.  The floor of the patient's mouth feels firm.  His neck is erythematous, warm, and feels woody.  This patient is at greatest risk for which of the following immediate complications?

Quizplus · Accepted Answer

Ludwig angina is a rapidly progressive cellulitis of the submandibular and sublingual spaces. Most cases arise from contiguous (rather than lymphatic) spread of polymicrobial dental infections in the mandibular molars. This contiguous spread results in bilateral edema of the submandibular and sublingual spaces. As the submandibular area becomes tender and indurated, the floor of the mouth becomes elevated and displaces the tongue posteriorly, which may lead to acute airway obstruction. Additional clinical features of Ludwig angina include a neck that is often described as "woody" or "brawny" but has no associated lymphadenopathy. As with other lesions that threaten the airway, patients with examination findings concerning for impending airway obstruction (eg, drooling, inability to lay flat, tripod positioning) should have their airway secured, regardless of current oxygen saturation. This is because oxygen saturation is often maintained until very rapid decompensation (within minutes). Therefore, these patients require continued assessment and, if needed, intervention to secure the airway (eg, nasotracheal intubation, awake tracheostomy). tripod positioning (Choice A) Infection within the retropharyngeal space can present with dysphagia, hoarseness, and shortness of breath; however, this is due to edema in the posterior pharyngeal wall rather than displacement of the tongue. It is most likely to extend through the alar fascia into the "danger space", which can then progress into the posterior mediastinum and result in acute necrotizing mediastinitis. "danger space" (Choice C) Carotid artery rupture occurs when the vasa vasorum supplying the carotid is injured; it is most often a complication of head and neck cancer (eg, tumor invasion, tissue removal) and is not typically associated with deep neck space infection. (Choice D) Infections originating in the maxillary space, not the mandibular space (as seen in this patient), can spread to the infratemporal space and orbit and progress to cavernous sinus thrombosis. (Choice E) Acute otitis media can spread throughout the temporal bone and cause facial nerve palsy due to inflammation of the nerve as it travels through the tympanic and mastoid portions of the temporal bone. Submandibular space infections do not typically cause facial nerve palsy. (Choice F) Deep neck space infections are prevented from spread into the epidural space by the vertebral column, posterior longitudinal ligament, and dura. Educational objective: Ludwig angina is a rapidly progressive cellulitis of the submandibular and sublingual spaces. Airway obstruction can occur due to displacement of the tongue posteriorly. References: Infections of the neck. (http://www.ncbi.nlm.nih.gov/pubmed/30454783)

A 38-Year-Old Man Comes to the Emergency Department for Evaluation