Tongue cellulitis in a Young Man

Case 1:

THE CASE:

A 22-year-old man hashad a swollen tongue for the past2 days. The swelling is not associatedwith trauma, recent illness, or medicationuse. The patient denies dysphagia,drooling, and shortness ofbreath but does have some difficultyin speaking because of the swelling.To what do you attribute thepatient's condition?

• Ludwig angina

• Tongue cellulitis

• Angioedema

• Abscess

Case 1:

DISCUSSION:

On further questioning,the patient admitted that hehad had his tongue pierced 2 monthspreviously by an unlicensed vendor.He removed the barbell-shaped ornament2 days ago when he noted theswelling. The diagnosis was

tonguecellulitis.

Examination of the patient's oralcavity revealed moderate soft tissueswelling of the undersurface of thetongue with mild erythema but nofluctuance. Localized tenderness wasnoted in some lymph nodes; however,there was no airway obstruction.The patient was afebrile. A CTscan of the neck revealed no abscessor evidence of a deep space infection.Amoxicillin/ clavulanate potassiumwas prescribed, and the patient hadan uneventful recovery.The practice of body piercing ishundreds of years old. Although theearlobe is the site most commonlypierced in Western culture, other cultureshave preferred different sites,including the navel (the Pharaohs ofEgypt), the nipples (Roman centurions),and tongues (Mayans). Othersites include the face (eyebrows,nose, and lips) and the genital region(Prince Albert piercing). The tongueis the most common intraoral piercingsite. Body piercings are used assigns of loyalty; symbols of deviance,rebellion, or self-esteem; and for spiritual,sexual, and aesthetic purposes.Complications may include infection(hepatitis B, C, and D), cellulitisor abscesses, contact dermatitis, airwayobstruction, and chipped teeth.Although the most common skin infectionis attributable to

Staphylococcusaureus

, infections with

Pseudomonasaeruginosa

,

Mycobacterium

,

Clostridium tetani

, and group Aβ-hemolytic streptococci also havebeen reported.Treatment of these infectionsusually requires removal of the foreignbody, antibiotics--especially theβ-lactamase inhibitors (penicillins andcephalosporins)--and good hygiene.Antibiotic use is best guided by localantibiotic resistance patterns.

Ludwig angina

is an uncommonbut complicated infection, usuallyof dental origin. The infection may appeardeceptively benign; it usuallypresents as a bilateral, board-likeswelling involving the submental,submandibular, and sublingual space,often with massive swelling of thetongue and floor of the mouth (

Figure1

). Patients frequently reportdifficulty in swallowing, stiffness oftongue movements, trismus, fever,and chills.Asphyxiation, the most commoncause of death in these patients, mayoccur within a few hours; therefore,airway control is crucial. After theairway is cleared, high-dose antibiotic therapy is initiated. Penicillin isthe drug of choice; other options includeclindamycin andchloramphenicol. Surgical interventionmay be required if the infectiondoes not completely resolve withantibiotics.

Angioedema

represents vascularleakage beneath the dermis andsubcutis. Patients have localized, welldemarcated,non-pitting edema; theymay have symptoms ranging fromdysphonia or dysphagia to respiratorydistress, including complete airwayobstruction or death. These patientspresent with acute onset ofedema of the distensible tissue of theeyes, tongue, uvula, lips, or earlobes(

Figure 2

).Angioedema may be either acuteor chronic; it is thought to be IgEmediated,hereditary, drug-induced,or idiopathic. Recurrent angioedemais more likely to be hereditary. Drugsassociated with this disorder includeangiotensin-converting enzyme inhibitors,NSAIDs, aspirin, opiates,and radiocontrast agents. Treatmentincludes protection of the airway, administrationof corticosteroids andhistamine receptor blockers, andavoidance of exposure to the offendingagent, if one is identified.

Abscesses

may occur anywhereon or in the body. On the skin, thesewell-defined collections of pus areusually associated with erythema,localized swelling, and tenderness.Fever is usually absent unless systemicinfection is involved. Internalabscesses may be associated with avariety of nonspecific symptoms, includingfever, malaise, and fatigue.Treatment consists of incision anddrainage. Antibiotics are usually reservedfor patients who have a secondaryinfection or those who areimmunocompromised.

References:

FOR MORE INFORMATION:

• Dierks EJ, Meyerhoff WL, Schultz B, Finn R. Fulminantinfection of odontogenic origin. Laryngoscope.1987;97:271-274.
• Johnson, JT. Infectious Diseases and AntimicrobialTherapy of the Ears, Nose and Throat. Philadelphia:WB Saunders Co; 1997.
• Tweeten SS, Richman LS. Infectious complicationsof body piercing. Clin Infect Dis. 1998;26:735-740.