29 year old male referred by ED for sore throat and jaw trismus with a provisional diagnosis of quinsy (para-tonsillar abscess). On the phone, ED doc said, he also has a large right sided neck swelling and the tonsils “don’t look too asymmetrical”.
Could this be quinsy? NO!
On review of the patient, he did have trismus and a large right neck swelling. Also, the patient added, “I have always had rotten teeth and I think this is a bad tooth infection”. The patient is right.
On examination: jaw trismus, large right neck swelling involving the jugulodigastric region (anterior triangle, inferior to angle of mandible) and extending over the submandibular region. Swelling feels hot and tense. Patient is drooling, Tongue is elevated (not swollen). Right inferior molars are rotten. Tonsils look normal and symmetrical. More importantly, the floor of his mouth feels swollen, tense and tight.
Ludwig’s angina secondary to odontogenic infection. This could become an airway emergency.
Paratonsillar abscess (quinsy) is an abscess formation behind the tonsil in the paratonsillar space (between tonsil and superior constrictors). Key findings: inflamed asymmetrical tonsils, uvula deviated to opposite side, bulging of abscess seen superiorly over upper pole of tonsil and soft palate, jaw trismus. Neck swelling is not likely. Neck lumps due to lymphadenopathy is possible.
Ludwig’s angina is cellulitis in the submandibular space. Think of it as compartment syndrome of the floor of mouth. It is often due to teeth infection. It can rapidly lead to an airway compromise as the tight space result in swelling posteriorly and inferiorly. Key findings: rotten teeth! trismus, tongue elevation (not swelling) due to tense swelling on floor of mouth, deep neck space infection and inflammation.
Imagine intubating a patient with trismus, tongue elevation and tight floor of mouth. Hence not a small number of these patients get emergent awake fibreoptic intubation or tracheostomy (up to 20% according to some reports).
Tips for docs: The patient tells you that he has rotten teeth. Believe him. Examine the floor of mouth and teeth when you think that a patient has any intra-oral infections. The clues are hidden there in the history and examination.