A 17-month-old African American girl, with no significant past medical history, is brought to the Pediatric Emergency Department (PED) with acute onset of swelling in the floor of her mouth. The mother is a reliable historian who denies any recent illness, fever, travel, change in food/new food intake, drugs, or significant injury/trauma.
The girl was in her usual state of health when the mother dropped her at the daycare in the morning. However, after returning home from daycare in the evening, the mother noticed her daughter to be more irritable, drooling, and refusing to eat. The mother also noted a bright red-colored swelling underneath the child’s tongue (Figure 1), which prompted this PED visit. The mother denies any visible rashes, new skin lesions, bleeding, bloody stools, diarrhea, or dark-colored urine.
Exam and testing
On oral exam, bright erythematous, nontender, firm masses were seen underneath the patient’s tongue on both sides of the frenulum area (Figure 1). Mild bleeding was noted from the swelling. Each swelling was 2- to 3-cm in size and located underneath the tongue, appearing firm, noncompressible, and symmetrical in size on either side of the frenulum. Some blood-stained saliva was noted over the swelling. Elevation and bright red-colored swelling under the oral mucosa were consistent with the hematoma noted.
Sublingual caruncles looked swollen and elevated. There was no evidence of any wheezing, stridor, or difficulty with respiration. On examination of the neck, clinicians noted a small swelling in the midline that was soft, fluctuant, and tender to touch, located just behind the chin (Figure 2).
Blood workup showed: white blood cell (WBC) count, 12.5; hemoglobin, 12.4 g; aspartate transaminase (AST)/alanine transaminase (ALT), 33/15; erythrocyte sedimentation rate (ESR), 19 mm/h; uric acid, 1.5 mg/dL; lactate dehydrogenase (LDH), 304 IU/L; C-reactive protein (CRP), 1.04 mg/dL; prothrombin time (PT), 12.8 sec; activated partial thromboplastin (aPTT), 34 sec; international normalized ratio (INR), 1; fibrinogen, 407 mg/dL.
Based on the above results, the possible differential diagnoses of oral cavity swellings in the floor of the mouth are numerous (Table):
Ludwig angina is a bilateral infection of the submandibular space including sublingual and submylohyoid (submaxillary) space. It is characterized by brawny induration of the floor of the mouth with an elevation of the tongue, potentially obstructing the airway. Ludwig angina is up to 90% odontogenic in origin. Other causes are peritonsillar/parapharyngeal abscess, oral lacerations, and mandibular fractures. Fever, neck swelling, bilateral submandibular swelling, and elevation of the tongue are the common mode of presentation. The most common etiologies are aerobes, anaerobes, alpha-hemolytic streptococci, Staphylococcus aureus, and Bacteroides. High-dose intravenous (IV) penicillin, clindamycin, and metronidazole are the best agents for infection. Complications are sepsis, pneumonia, asphyxia, and respiratory obstruction.1
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