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Male With Throat Pain and Neck Swelling
IMAGES IN EMERGENCY MEDICINE Laura Andrews, MD; Sanjay Arora, MD 0196-0644/$-see front matter Copyright © 2015 by the American College of Emergency Physicians. http://dx.doi.org/10.1016/j.annemergmed.2014.11.010
Figure 1. Physical examination revealing tongue elevation, a firm and tender floor of mouth, and right-sided neck edema, ecchymosis, and crepitus.
Figure 2. CT of the neck demonstrating multiple abscesses and extensive air in the submandibular, tonsillar, parapharyngeal, and retropharyngeal spaces.
[Ann Emerg Med. 2015;65:e5-e6.] A 56-year-old man presented to the emergency department with a 3-day history of progressively worsening right-sided throat pain, neck swelling, and trismus. He reported fevers, chills, odynophagia, and dysphagia. On arrival, his blood pressure was 134/87 mm Hg, pulse rate 156 beats/min, temperature 101.5 F, and room oxygen saturation 93%. Physical examination revealed significant edema of the right side of the neck and discoloration of the overlying skin, with palpable crepitus (Figure 1). His tongue was elevated and the floor of his mouth was firm and ecchymotic. The patient reported no significant medical history, but his glucose level was 542 mg/dL, with evidence of diabetic ketoacidosis. Broad-spectrum antibiotics were administered and computed tomography (CT) of the neck was performed (Figure 2).
For the diagnosis and teaching points, see page e6. To view the entire collection of Images in Emergency Medicine, visit www.annemergmed.com. Volume 65, no. 4 : April 2015
Annals of Emergency Medicine e5
Andrews & Arora
Images in Emergency Medicine
IMAGES IN EMERGENCY MEDICINE (continued from p. e5)
DIAGNOSIS:
Necrotizing fasciitis in association with Ludwig’s angina. Ludwig’s angina is a soft-tissue infection of the floor of mouth, characterized by “woody” cellulitis of the submandibular space. Infection commonly spreads from an odontogenic source, causing elevation and posterior displacement of the tongue and possible airway compromise. Treatment involves intravenous antibiotics and early definitive airway management such as fiberoptic intubation or awake tracheostomy. With antibiotics and airway management, the mortality from Ludwig’s angina decreases from 50% to less than 4%.1,2 Necrotizing fasciitis, in contrast, causes rapidly progressive tissue necrosis, and treatment requires surgical debridement; despite aggressive treatment, mortality remains high, at 22% to 40%.3,4 Our patient was taken to the operating room urgently for awake tracheostomy and debridement. After multiple debridements followed by split-thickness skin graft, he was doing well at 4-month follow-up. Author affiliations: From the Department of Emergency Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, CA. REFERENCES 1. Shah RN, Cannon TY, Shores CG. Infections and disorders of the neck and upper airway. In: Tintinalli JE, Stapczynski J, Ma O, et al, eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 7th ed. New York, NY: McGraw-Hill; 2011; Available at: http:// accessmedicine.mhmedical.com.libproxy.usc.edu/content.aspx?bookid=348&Sectionid=40381727. Accessed November 26, 2014. 2. Weinberger PM, Terris DJ. Otolaryngology—head and neck surgery. In: Doherty GM, ed. Current Diagnosis and Treatment: Surgery. 13th ed. New York, NY: McGraw-Hill; 2010; Available on: http://accessmedicine.mhmedical.com.libproxy.usc.edu/content.aspx? bookid=343&Sectionid=39702802. Accessed November 26, 2014. 3. Mathieu D, Neviere R, Teillon C, et al. Cervical necrotizing fasciitis: clinical manifestations and management. Clin Infect Dis. 1995;21:51-56. 4. Subhashraj K, Jayakumar N, Ravindran C. Cervical necrotizing fasciitis: an unusual sequel of odontogenic infection. Med Oral Patol Oral Cir Bucal. 2008;13:E788-E791.
e6 Annals of Emergency Medicine
Volume 65, no. 4 : April 2015
Figure 1. Physical examination revealing tongue elevation, a firm and tender floor of mouth, and right-sided neck edema, ecchymosis, and crepitus.
Figure 2. CT of the neck demonstrating multiple abscesses and extensive air in the submandibular, tonsillar, parapharyngeal, and retropharyngeal spaces.
[Ann Emerg Med. 2015;65:e5-e6.] A 56-year-old man presented to the emergency department with a 3-day history of progressively worsening right-sided throat pain, neck swelling, and trismus. He reported fevers, chills, odynophagia, and dysphagia. On arrival, his blood pressure was 134/87 mm Hg, pulse rate 156 beats/min, temperature 101.5 F, and room oxygen saturation 93%. Physical examination revealed significant edema of the right side of the neck and discoloration of the overlying skin, with palpable crepitus (Figure 1). His tongue was elevated and the floor of his mouth was firm and ecchymotic. The patient reported no significant medical history, but his glucose level was 542 mg/dL, with evidence of diabetic ketoacidosis. Broad-spectrum antibiotics were administered and computed tomography (CT) of the neck was performed (Figure 2).
For the diagnosis and teaching points, see page e6. To view the entire collection of Images in Emergency Medicine, visit www.annemergmed.com. Volume 65, no. 4 : April 2015
Annals of Emergency Medicine e5
Andrews & Arora
Images in Emergency Medicine
IMAGES IN EMERGENCY MEDICINE (continued from p. e5)
DIAGNOSIS:
Necrotizing fasciitis in association with Ludwig’s angina. Ludwig’s angina is a soft-tissue infection of the floor of mouth, characterized by “woody” cellulitis of the submandibular space. Infection commonly spreads from an odontogenic source, causing elevation and posterior displacement of the tongue and possible airway compromise. Treatment involves intravenous antibiotics and early definitive airway management such as fiberoptic intubation or awake tracheostomy. With antibiotics and airway management, the mortality from Ludwig’s angina decreases from 50% to less than 4%.1,2 Necrotizing fasciitis, in contrast, causes rapidly progressive tissue necrosis, and treatment requires surgical debridement; despite aggressive treatment, mortality remains high, at 22% to 40%.3,4 Our patient was taken to the operating room urgently for awake tracheostomy and debridement. After multiple debridements followed by split-thickness skin graft, he was doing well at 4-month follow-up. Author affiliations: From the Department of Emergency Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, CA. REFERENCES 1. Shah RN, Cannon TY, Shores CG. Infections and disorders of the neck and upper airway. In: Tintinalli JE, Stapczynski J, Ma O, et al, eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 7th ed. New York, NY: McGraw-Hill; 2011; Available at: http:// accessmedicine.mhmedical.com.libproxy.usc.edu/content.aspx?bookid=348&Sectionid=40381727. Accessed November 26, 2014. 2. Weinberger PM, Terris DJ. Otolaryngology—head and neck surgery. In: Doherty GM, ed. Current Diagnosis and Treatment: Surgery. 13th ed. New York, NY: McGraw-Hill; 2010; Available on: http://accessmedicine.mhmedical.com.libproxy.usc.edu/content.aspx? bookid=343&Sectionid=39702802. Accessed November 26, 2014. 3. Mathieu D, Neviere R, Teillon C, et al. Cervical necrotizing fasciitis: clinical manifestations and management. Clin Infect Dis. 1995;21:51-56. 4. Subhashraj K, Jayakumar N, Ravindran C. Cervical necrotizing fasciitis: an unusual sequel of odontogenic infection. Med Oral Patol Oral Cir Bucal. 2008;13:E788-E791.
e6 Annals of Emergency Medicine
Volume 65, no. 4 : April 2015