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Neuroradiology Case of the Week

Case 94

Igor Mikityansky, MD and P-L Westesson MD, PhD, DDS

Clinical Presentation: A 58-year-old female with extensive history of steroid use, for her rheumatoid arthritis, presented with complaints of right mandibular pain associated with nausea and pain with swallowing. On examination she had erythema, warmth, swelling and tenderness to palpation over the right cheek and right side of her neck. She was intubated in ED for airway protection.

Radiological Findings: A contrast-enhanced CT demonstrates a well-defined cystic area with ring-enhancement measuring approximately 3.5 cm in maximal dimension just medial to the body and ramus of the right side of the mandible with the center around the submandibular gland. This tracks down in the submandibular, sublingual, parapharyngeal and pharyngeal spaces on the right side, anterior to carotid space. No definitive dental abnormality in the right side of the mandible is visualized. The right submandibular gland is swollen as is the right sternocleidomastoid muscle. Small lymph nodes are seen, but none is abnormal by CT size criteria. There is a swelling of the pharyngeal soft tissues eliminating free space around the endotracheal tube down to the larynx. The subglottic area and trachea are normal in caliber.

Diagnosis: Ludwig’s angina

Discussion: Ludwig’s angina is a cellulitis of the fascial spaces of the floor of the mouth and upper neck, initiated most frequently by dental infection, which has a fatal outcome in as many as 10% of cases because of compromise of the upper airway, spread to the anterior mediastinum, or both [1].
     More than 70% of Ludwig’s angina cases have dental etiology. The causative odontogenic infections classically located in the second and third lower molar teeth, since their apices are located just below mylohyoid ridges and are therefore in close anatomic proximity to the submandibular space [2].
     Less common primary infections include quinsy, sialadenitis, epiglottitis, and infection of thyroglossal cyst. In addition, Ludwig’s angina can follow infections after compound fractures of the mandible and penetrating injuries of the mouth, or even trauma from endotracheal intubation or bronchoscopy [2].
     Although majority of patients are otherwise healthy, conditions that predispose to severe periodontal infection, such as immunodeficiency, diabetes mellitus, neutropenia, aplastic anemia, glomerulonephritis, are suggested to put an individual at a higher risk of having Ludwig’s angina [2].
     Patients present with tooth pain, a history of recent dental extraction or poor dental hygiene, dysphagia, odynophagia, upper neck pain and swelling, and dysphonia and/or dysarthria. On physical examination there is usually an aggressive gangrenous cellulitis, fever, tachycardia, brawny induration, swelling and tenderness of submandibular space, and an elevated tongue [2].
     The majority of the patients have mixed polymicrobial infections. Recent papers reported the most commonly isolated organism was Streptococcus viridans in up to 39%, followed by anaerobes in about 35% [3].
     The complications of the Ludwig’s angina include airway compromise, mediastinitis, subphrenic abscess formation, pericardial and/or pleural effusion, empyema, osteomyelitis of the mandible, infection of the carotid sheath and possible rupture of the carotid artery, and suppurative thrombophlebitis of the internal jugular vein [2].
     Plain radiographs of the neck and chest may demonstrate the extent of soft tissue swelling, as well as reveal gas in the tissues, particularly in the setting of anaerobic infection. Plain chest radiography can also be used to look for intrathoracic extension of the infective process. Ultrasonography may highlight collections of puss, as well as reveal metastatic abscess formation. CT and MR may be used to confirm the presence of the airway edema and to identify and localize the fluid collection [2].
     Since supraglottic airways are usually edematous the airway maintenance becomes extremely important. Since endotracheal intubation is frequently difficult and edema may persist for along time, tracheotomy is frequently favored. Intravenous antibiotic therapy is a cornerstone. A combination of clindamycin, penicillin and metronidazole is commonly recommended until a specific pathogen is identified. Early surgical drainage is recommended in the setting of suppurative infection with dual goal: to evacuate the puss and to decompress closed fascial spaces in the neck. Infected teeth need to be extracted [2].

References:

1. Taveras and Ferrucci’s. Radiology on CD-ROM. LW&W; 2003:V3, Chapter 14.
2. Barakate MS, Jensen MJ, Hemli JM, Graham AR. Ludwig’s angina: report of a case and review of management issues. Ann Otol Rhinol Laryngol. 2001 May;110(5Pt1):453-6.
3. Parhiscar A, Har-El G. Deep neck abscess: a retrospective review of 210 cases. Ann Otol Rhinol Laryngol. 2001 May;110(11):1051-4.