Man with a wound.

PATIENT PRESENTATION

A 75‐year‐old man with a history of diabetes presented to the emergency department (ED) with a large open submandibular wound. The patient reported a 3‐week history of right mandibular molar pain. He was evaluated by his dentist and was given a 10‐day course of antibiotics and was scheduled for a dental extraction upon completion. Three days after the initial evaluation, he developed submandibular swelling and pain and then drainage. At the time of dental follow‐up, he was immediately directed to the ED for further evaluation (Figure 1).

FIGURE 1

Submandibular abscess with orocutaneous fistula

In the ED, computed tomography imaging showed extensive gas throughout the right neck with a large oral cutaneous fistula consistent with Ludwig's angina with orocutaneous fistula formation (Figure 2).

FIGURE 2

Submandibular abscess with orocutaneous fistula with visualized musculature

DIAGNOSIS

Ludwig's angina with orocutaneous fistula

Ludwig's angina is a severe infection with ≈90% of cases arising from infection of the mandibular molars. This then can spread throughout the submandibular, sublingual, submental, and even mediastinal spaces. Some predisposing factors include dental caries, recent dental treatment, diabetes mellitus, and an immunocompromised state. The most frequently identified microorganisms are anaerobic, with streptococci being the most common among aerobic bacteria. The most feared initial complications include airway compromise and sepsis from extensive deep space infection, which can progress swiftly to death.  Surgical debridement and drainage along with effective antibiotics are the mainstays of treatment. Our patient was fortunate to develop a rare complication of Ludwig's, an orocutaneous fistula, which dramatically reduced the mortality of this disease process.