0:00

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

0:03

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

0:06

Look at the brain. Look at the orbits.

0:09

Look at the parotid glands.

0:11

Start with the nasopharynx,

0:12

come downward.

0:14

And we come into the oropharynx

0:18

with the palatine tonsils.

0:20

A little bit of asymmetry from right to left.

0:22

That's not unusual, frankly.

0:25

Parapharyngeal space looks pretty clean.

0:28

But as we get down to the region

0:30

of the submandibular gland,

0:32

we notice that there is edema in the soft

0:34

tissues of the right side of the face.

0:37

Notice the edema in the subcutaneous

0:39

fat versus the more clean,

0:41

darker subcutaneous fat on the left side.

0:46

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

0:49

the submandibular gland on the right side.

0:53

Floor of the mouth,

0:54

a little bit of edema and thickening, as well.

0:57

And then as we come down into submandibular space,

1:01

we see that the submandibular gland,

1:03

again, remains somewhat irregular,

1:06

a little bit lower density,

1:07

and there's all this thickening of the

1:09

tissues on the right side of the face.

1:12

This is the platysma muscle and the subcutaneous fat.

1:16

If we compare that to the normal platysma muscle,

1:19

which is much thinner,

1:20

and the clean subcutaneous fat on the left side.

1:25

So this patient clearly has an inflammatory

1:28

process going on.

1:29

Look how large this right submandibular gland is.

1:32

We don't even have the left submandibular gland

1:35

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

1:37

and we still have this inflammatory

1:39

process going on all throughout,

1:42

with submental lymph nodes and

1:45

submandibular lymph nodes nearby.

1:47

And you see this fluid collection,

1:49

which is anterior to the strap muscles.

1:52

So this is likely secondary to either a

1:56

dental process, usually involving the molar teeth,

2:00

or it could be from a primary submandibular

2:03

process such as the passage of a recent stone

2:07

which may lead to sialadenitis and secondary

2:10

cellulitis and myositis, myositis

2:13

of the platysma muscle.

2:15

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

2:18

teeth and for that we look on the bone windows often

2:23

reconstructing in these sagittal plane to best get

2:26

a look at the maxillary teeth as

2:29

well as the mandibular teeth.

2:32

And you can see that indeed we have this area

2:34

of lucency around the root of the

2:38

third molar on the right side.

2:41

A little bit of erosion of the inner table of the

2:44

mandible compared to the normal inner

2:46

table of the mandible. And this indeed was the

2:49

source of this inflammatory process in

2:53

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

2:56

the patient having even mastoiditis associated

3:00

with this. So in this case, again,

3:04

extension from a dental inflammatory process into

3:08

the submandibular space and what some people would

3:11

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

3:16

is there any involvement of the jugular vein or

3:20

the carotid artery? Here we have the nice,

3:23

normal jugular vein on the left side to compare with

3:26

the right jugular vein is, although narrowed here,

3:30

is not thrombus.

3:32

No clots within it and doesn't appear

3:33

to show thrombophlebitis.

Case 17 - Ludwig's Angina, Sialadinitis

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