Pictorial case study - Submandibular swelling

A sore throat led to sudden problems with swallowing, explains Dr Jean Watkins.

Cellulitis of the neck
Cellulitis of the neck

This 55-year-old woman presented with a two-day history of fever and sore throat that had become worse, to the extent that she could no longer swallow her saliva. Her face was swollen and an inflamed, tender submandibular swelling had developed.

On examination she was sitting upright with her neck forwards and chin raised. Her breath was unpleasant, there was some trismus, the tongue was elevated by a brawny submandibular swelling, the tonsils were grossly enlarged and purulent, and her temperature was 38.5 degsC.

Her respiratory rate was slightly increased, but there was no respiratory distress. A diagnosis of severe tonsillitis with cellulitis of the neck was made and she was referred urgently for admission to hospital.

Management

The first priority is assessment of the airway. A streptococcal or staphylococcal infection is the most common cause and requires intensive treatment with a broad-spectrum IV antibiotic such as flucloxacillin, erythromycin or clindamycin. Swab cultures will indicate the infection and its sensitivities, suggesting alteration of medication if it fails to respond.

Discussion

Cellulitis of the neck is rare but potentially fatal, spreading along fascial planes and risking airway obstruction. Other complications are thrombosis of the jugular vein or carotid artery, emboli, aspiration pneumonia, cranial nerve involvement and septicaemia.

It is usually associated with orthodontic infection or a peritonsillar abscess. The former is more common in adults, the latter in children. Other possible causes are oral injury or infection of the salivary gland. The most vulnerable are diabetics, IV drug users and alcoholics.

Although the diagnosis can be suspected on clinical grounds, FBC, blood culture, swab culture from an abscess, X-ray and CT will help to evaluate the problem. It is treated as a medical emergency in hospital.

Differential diagnosis

  • Angioneurotic oedema
  • Carcinoma of the tongue
  • Sublingual haematoma associated with anticoagulation
  • Salivary gland abscess
  • Peritonsillar abscess
  • Dr Watkins is a retired GP in Hampshire

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