A 44-year-old male patient complaining of dyspnea, severe pain, and progressive swelling in his jaw and neck for the last 14 days came to our emergency unit. Due to the rapidly extending swelling, he was hospitalized for 5 days in a private hospital, where a chest X-ray, neck, and soft tissue X-ray (Figure 1) and blood examinations were performed. The patient also received intravenous antibiotics (ceftriaxone, metronidazole, levofloxacin, omeprazole, and ketorolac; dosage unknown), yet, as there was no improvement to the size of the swelling, the patient was referred to our hospital.
Physical examination revealed that swelling on the right submandibular region extended to the sublingual region, submental region, and the left submandibular region (with a size of 10 x 6 x 2 cm), reddish, febrile, fluctuated, and tender. The patient was febrile (38.8 C), had trismus, 102 beats per minute (bpm) pulse rate, respiratory rate is 26 breaths/minute, SpO2 was 98.2%, and 100/60 mm Hg blood pressure. No history of asthma or allergy was reported. The HIV and tuberculosis results came back negative, and the patient had no history of a dental visit. Therefore, past medical history was considered as non-contributory. Intraoral findings revealed a gangrene pulp of the #47 tooth and pericoronitis around the #48 impacted tooth. No other cavities were detected, regardless of the poor oral hygiene. Supporting clinical and laboratory examination included sequential organ failure assessment (SOFA), complete blood count, blood gas analysis, chest AP Lateral X-ray, and neck and soft tissue X-ray. The Erythrocyte Sedimentation Rate (ESR) test was not performed. Once the laboratory results were obtained (Table 1), a diagnosis of Ludwig's angina and septic shock was confirmed. In regard to the septic shock management, the patient received an infusion of norepinephrine.
The patient was taken to the operating room immediately. A tracheostomy, emergency drainage, and tooth extraction (47, 48) were performed. Culture and sensitivity tests of blood and pus were performed but yielded a negative outcome. To allow further drainage, a Penrose drain was placed at the submandibular area, submental area, and (posterior) sublingual area (Figure 2). The patient was admitted for 10 days and received intravenous meropenem (1 g, three times per day), cefotaxime (1 g, three times per day), and metronidazole (500 mg, three times per day) as his antibiotics regimen. Another blood test was performed on the 5th and 10th day after the surgery, while another thorax X-ray was performed on the 10th day. The tracheostomy tube was removed on the eighth day. The patient was discharged on the 10th day following clinical improvement (significant reduction of the swellings in all regions: submandibular, sublingual, and submental), pus production was less than 5 cc/day, mouth opening was more than 3 cm, the patient no longer experienced swallowing difficulty, and vital signs were normal. The blood test results (except for the white blood count that was slightly higher than normal value: 14.930/mm3) and thorax photo results were in favor of this decision.