What's the Diagnosis? By Dr. Abby Renko

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





  • 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