A 50 yo M presents to the ED w/ dental pain and facial swelling, worsening over the last 2 weeks. He denies fever, voice changes or dysphagia. On exam his temp is 99.1, HR 122 and spo2 98%. He is nontoxic appearing, has no trismus or drooling, but there is noted erythema and swelling of the L cheek down to the level of the clavicle. A CT is obtained and shown below. What's the diagnosis? (scroll down for answer) 

Answer: Gas producing facial cellulitis and abscess of the L masticator space (with concern for early Ludwig's angina)

• Facial space infections
• Almost always of dental origin
• Most common deep space infection= PTA
• Diagnosis you must consider in any patient w/ rapidly progressive facial/neck cellulitis-- Ludwig's Angina
• Definition
• Rapidly progressing bilateral cellulitis involving both submylohyoid and sublingual spaces, without lymphatic involvement, and generally without abscess formation
• Presentation
• Fever, chills, malaise, dental/mouth pain
• +/- stiff neck, drooling, dysphagia, voice changes
• Trismus usually absent unless infection has also spread to parapharyngeal space
• On exam:
• typically mouth held open due to lingual swelling
• palpable crepitus in submandibular space
• Diagnosis
• CT of face/neck with contrast  
• Management
• Airway managment is #1 concern!
• consider glidescope, fiberoptic nasal intubation
• Antibiotics 
• Unasyn 3g IV q 6h OR Ceftriaxone 2g IV q 12h + Flagyl 500mg IV q 8h
• PCN allergy: Clindamycin 600mg IV q 8 hr + Levaquin 750mg IV q 24h  
• Add vancomycin for anyone w/ MRSA risk
• Early surgical consult
• Complications
• Mediastinitis
• Cavernous sinus thrombosis

References:

• Chow, AW et al. Submandibular space infections (Ludwig’s angina). In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA.

• Tintinalli, JE. Tintinalli's Emergency Medicine: A Comprehensive Study Guide. 8th ed. New York, NY: McGraw-Hill Education LLC, 2016