1

Introduction

Ludwig’s angina is a rapidly spreading cellulitis of the floor of the mouth involving the submandibular, sublingual, and submental spaces that reaches these spaces through the posterior border of the mylohyoid muscle. It produces a hard induration of the floor of the mouth and the suprahyoid region bilaterally with elevation and posterior displacement of the tongue with airway compromise. Mortality exceeded 50%, but today, the use of antibiotics improved oral and dental hygene, and aggressive surgical intervention have significantly cut mortality (<10%) . Effective diagnosis and treatment are based on early recognition of the clinical process, airway under surveillance, use of intravenous antibiotics, and computed tomographic (CT) scan to determine the extent of infection and surgical drainage . In this report, we describe a case of Ludwig’s angina after a direct microlaryngoscopy, due to erosion on the internal face of the jaw caused by the laryngoscope.

2

Clinical report

On November 2006, a 57-year-old man had a consultation for dysphonia since 2 months ago with dyspnea of moderate efforts. The laryngoscopy showed an important Reinke’s edema of the left vocal fold without neoplastic lesions. Patient was asked to stop smoking (he smoked 80 cigarettes each day), and 2 months later, the patient was only smoking 5 cigarettes each day but had continued dysphonia and dyspnea. We explained the need of a microlaryngoscopy to treat the left vocal cord and to avoid the possibility of a malignant lesion. As personal history, the patient was allergic to penicillin and had psoriasis without treatment.

On December 2006, the patient underwent a direct microlaryngoscopy with a cordotomy of the left vocal cord, sucking a very organized edema. The patient was discharged 48 hours later.

Three days later, the patient came to the emergency department complaining about sore throat, dysphagia, odynophagia, and submentonian inflammation. Physical examination revealed saliva drooling with swelling of the floor of the mouth and both submandibular regions, with trismus. The right submandibular region was especially painful. On mouth examination, we found an erosion of the right internal face of the horizontal branch of the mandible, at the level of the third molar, which exposed periosteum and was produced by compression of the laryngoscope during the microlaryngoscopy due to the anatomical characteristics of the patient as follows: reduced cervical motion, obesity (>100 kg), short height (160 cm), and macroglossia. He was afebrile. There was no stridor or signs of upper airway obstruction. The initial white cell count was 15 400/mL, with 84% of which is neutrophils. Patient was admitted and treated with intravenous clindamycin (600 mg/8 h), gentamicin (80 mg/8 h), and methylprednisolone. After 3 days of treatment, the patient started complaining about pain on the left submandibular region, with edema of the floor of the mouth that looks like “double tongues.” White cell count was now 25 700/mL, with 90% of which is neutrophils. Urgent CT scan showed ( Fig. 1 ) an extended affectation of the mouth’s floor, with big and multiple heterogeneous hypodense lesions with ring enhancement by contrast, which affect both sublingual and submaxillary spaces, surrounding both submaxillary glands, reaching mandibular angles. Fat of the subcutaneous tissue and of the parapharyngeal spaces were infiltrated, with edema of the pharynx mucosa and multiple cervical lymphadenopathies.

Axial CT scan image showing hypodense lesions affecting both sublingual spaces, with an intense edema of the subcutaneous tissue and pharynx with reduction of the airway space.

Because of these findings, patient underwent placement of 2 drainages, intraoral and cervical. Intraoral drain produced abundant brown purulent secretion, and aspirated pus culture was obtained. Several incisions on the mouth’s floor were performed to help drainage.

Antibiotic intravenous treatment was changed for intravenous ciprofloxacin, (400 mg/12 h). Drainage tubes continue producing during 6 days, the symptoms of the patient improved, and submandibular inflammation disappear. Culture showed commensal flora of the oropharyngeal surface.

The patient underwent an orthopantomography and gammagraphy, to rule out dentarian or glandular origin, being both normal. Erosion of the horizontal branch of the mandible was covered by fibrin and was healing. Two weeks later, the patient performed a control CT scan that showed resolution of the lesions, but there is still an enlargement of the left submaxillary gland without presence of calculi.

Four weeks after the admission, the patient was discharged, asymptomatic; a CT scan was performed 2 weeks later with a normal result.