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Case 17 - Ludwig's Angina, Sialadinitis

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Let's have a look at this case. Coming down from

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above. As you can tell, I usually start from above.

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Look at the brain. Look at the orbits.

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Look at the parotid glands.

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Start with the nasopharynx,

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come downward.

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And we come into the oropharynx

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with the palatine tonsils.

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A little bit of asymmetry from right to left.

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That's not unusual, frankly.

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Parapharyngeal space looks pretty clean.

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But as we get down to the region

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of the submandibular gland,

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we notice that there is edema in the soft

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tissues of the right side of the face.

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Notice the edema in the subcutaneous

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fat versus the more clean,

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darker subcutaneous fat on the left side.

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And it looks like there's a halo of edema around

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the submandibular gland on the right side.

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Floor of the mouth,

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a little bit of edema and thickening, as well.

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And then as we come down into submandibular space,

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we see that the submandibular gland,

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again, remains somewhat irregular,

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a little bit lower density,

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and there's all this thickening of the

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tissues on the right side of the face.

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This is the platysma muscle and the subcutaneous fat.

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If we compare that to the normal platysma muscle,

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which is much thinner,

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and the clean subcutaneous fat on the left side.

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So this patient clearly has an inflammatory

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process going on.

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Look how large this right submandibular gland is.

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We don't even have the left submandibular gland

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anymore. We're below the left of submandibular gland,

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and we still have this inflammatory

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process going on all throughout,

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with submental lymph nodes and

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submandibular lymph nodes nearby.

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And you see this fluid collection,

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which is anterior to the strap muscles.

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So this is likely secondary to either a

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dental process, usually involving the molar teeth,

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or it could be from a primary submandibular

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process such as the passage of a recent stone

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which may lead to sialadenitis and secondary

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cellulitis and myositis, myositis

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of the platysma muscle.

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So the next thing to do is to clearly look at the

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teeth and for that we look on the bone windows often

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reconstructing in these sagittal plane to best get

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a look at the maxillary teeth as

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well as the mandibular teeth.

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And you can see that indeed we have this area

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of lucency around the root of the

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third molar on the right side.

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A little bit of erosion of the inner table of the

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mandible compared to the normal inner

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table of the mandible. And this indeed was the

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source of this inflammatory process in

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these submandibular and submental space. You know it's also

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the patient having even mastoiditis associated

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with this. So in this case, again,

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extension from a dental inflammatory process into

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the submandibular space and what some people would

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call Ludwig's angina. And this begs the question,

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is there any involvement of the jugular vein or

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the carotid artery? Here we have the nice,

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normal jugular vein on the left side to compare with

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the right jugular vein is, although narrowed here,

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is not thrombus.

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No clots within it and doesn't appear

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to show thrombophlebitis.

Report

Faculty

David M Yousem, MD, MBA

Professor of Radiology, Vice Chairman and Associate Dean

Johns Hopkins University

Tags

Neuroradiology

Head and Neck

Emergency

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