An Adopted 43-Year-Old With Bad Breath, Dyspnea, Dysphagia

Alexander B. Norinsky, DO; Andrew Caravello, DO; James Espinosa, MD


July 14, 2022


The patient's airway was compromised secondary to parapharyngeal abscess and cellulitis due to Haemophilus influenzae infection.

Lemierre syndrome is a rare clinical entity wherein bacterial infection (specifically Fusobacterium necrophorum) spreads from the peritonsillar spaces to involve the internal jugular vein, causing a purulent thrombophlebitis with potential for embolization. A contrast-enhanced CT scan of the neck exhibits distended jugular veins, with wall enhancement and intraluminal filling defects. Ultrasonography may be considered as well, with diagnosis confirmed by exhibiting the bacteria on blood cultures. Management includes antibiotics, abscess drainage, and internal jugular vein ligation or excision.

Ludwig angina is a gangrenous cellulitis of the soft tissues of the mouth's floor and neck, classically characterized following a dental procedure. Specifically, infection extends directly from the second or third molar via the submandibular, sublingual, submaxillary, and retropharyngeal spaces. It is very aggressive, and management principles are similar to retropharyngeal abscesses: airway stabilization and early empiric antibiotic coverage. Implicated bacteria, as in retropharyngeal infections, are polymicrobial (eg, Staphylococcus , Streptococcus , Bacteroides ). Although often seen in the healthy population, the immunocompromised demographic (eg, those with diabetes, alcoholism, or autoimmune conditions) is particularly susceptible. Historically, mortality was found to be as high as 50%; that statistic has decreased to less than 10%.

Epiglottitis is rapidly progressive inflammation of the supraglottic structures (epiglottis, arytenoids, and aryepiglottic folds). As with retropharyngeal infections, H influenzae used to be the most commonly cited bacteria; however, the H influenzae type b (Hib) vaccine has significantly limited the incidence and severity of epiglottitis nowadays. As opposed to retropharyngeal space infections, direct visualization via nasopharyngoscopy of the inflamed epiglottis and periepiglottic structures remains the preferred modality for diagnosis and trending progress/management. The classic finding on lateral neck radiographs is the "thumb sign" (swollen epiglottis) as well as thickened aryepiglottic folds and loss of the vallecular space. One study found excellent sensitivity and specificity parameters when using 7 mm thickness of the epiglottis and 4.5 mm of the aryepiglottic folds as cutoffs.[1]

Bacterial tracheitis is also a relatively infrequent clinical entity, with the most commonly encountered clinical vignette involving a pediatric patient with classic croup-like symptoms that do not respond to croup interventions. The length of the oropharynx may be affected; the cricoid cartilage is the most critically important site because it is the narrowest point of the pediatric trachea. The most commonly cited pathogens include Staphylococcus aureus, Streptococcus species, Klebsiella , Peptostreptococcus, Bacteroides, and anaerobes; the leading cause is Moraxella catarrhalis .

To diagnose parapharyngeal abscess with cellulitis, the practitioner must maintain a high index of suspicion. Physical examination findings are notoriously unreliable; one series found as few as 37% of case reports reviewed noting visible swelling of the posterior pharynx.[2] Negative examination findings with high suspicion mandate further investigation. This case is similar; the most important and concerning physical examination finding in this patient was preference for erect positioning despite discomfort. Other less specific but relevant findings included the erythematous posterior pharynx, poor dentition, foul-smelling odor, and hoarse voice.


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