Presentation
Neck swelling and pus discharge from mouth for one week, associated with hoarseness of voice and dysphagia.
Patient Data
Multi-loculated rim enhancing collections at the floor of mouth, which involves bilateral sublingual and submandibular spaces. Extension of these collections to subcutaneous region. Multiple air pockets noted within these collections.
Intramuscular abscesses noted within bilateral mylohoid muscles, left anterior belly of digastric muscles, bilateral platysma muscles and left hyoglossus muscle. Mild swelling of the right masseter and right sternocleidomastoid muscles raises suspicion of infiltration. Left masticator space is normal.
Increased fat streakiness within the right parapharyngeal space and bilateral buccal regions. Left parapharyngeal space is normal. Mild effacement and medial displacement of right pharyngeal mucosal space due to extension of the abscess/inflammation of the right palatine tonsil. Due to swelling and abscesses at the floor of mouth. there is mild superior and posterior elevation of the tongue.
Partial stenosis of the airway at the oral cavity and oropharynx.
Empty tooth socket noted at the left lower third molar tooth in keeping with recent tooth extraction and can represent odontogenic infection source.
Both submandibular salivary glands are swollen. Bilateral subcentimeter cervical lymph nodes in all levels.
Carotid arteries and both jugular veins in bilateral carotid spaces are well opacified, without CT evidence of thrombosis.
No retropharyngeal or visualized mediastinal collection.
Case Discussion
CT features are in keeping with Ludwig angina (cellulitis floor of mouth) complicated with multiple sites of abscesses. This infection has resulted in elevation and posterior displacement of the tongue resulting in partial stenosis of airway at oral cavity and oropharynx.
The etiology is most likely from odontogenic source (left lower third molar tooth region- recent extraction). Patient has background history of diabetes mellitus on insulin treatment, which was poorly controlled.
Patient went on to have incision and drainage for abscesses as well as vigorous intravenous antibiotics.
Pus culture isolated Klebsiella pneumoniae.
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