2 Infectious Diseases in Obstetrics and Gynecology (a) (b) Figure 1: Patient at presentation. (a) General view of the face. Note severe submental and upper neck swellings. (b) Trismus: this is the maximal mouth opening. beneﬁts of proceeding with emergent and immediate sur- gical intervention outweighed the risks. An emergent CT- scan showed ﬂuid collections in the left lateral pharyngeal space (Figure 2) extending to the level of the valleculae. Se- curing an airway via an awake ﬁberoptic nasal intubation was risky: a ﬁberoptic tube inserted into the pharynx might puncture an abscess and cause pus aspiration or swallowing. Therefore, an awake tracheostomy was performed using a 60- nonfenestrated Schiley endotracheal tube. At that time gen- eral anesthesia was administered and the patient was placed in slight left lateral decubitus position to decrease uterine aortocaval compression pressure. After usual sterile prepa- ration, lidocaine with epinephrine was inﬁltrated for local anesthesia. An incision was made at the submental and bilat- eral submandibular areas and blunt dissection to the lingual inferior border of the mandible was carried out. Through the submental incision, the blunt dissection continued through the mylohyoid muscle to the sublingual areas to access all ab- scesses. Tooth number 17 (lower left third molar) was then extracted since it was believed that this grossly carious and partially impacted tooth was the primary source for the in- fection. Upon removal, purulence was expressed through the extraction socket. Five additional grossly carious teeth were then extracted. Intraoral blunt dissection to gain access into the lateral pharyngeal space followed for drainage of another pus collection. Numerous Penrose drains and red rubber catheter drains were left in place to maintain drainage of pus and facilitate daily irrigation (Figure 3). Upon admission to the Surgical Intensive Care Unit, the Department of Ob/Gyn continued following up on the patient by frequent monitor- ing of the fetal heart rate. The patient was extubated after 6 days and remained in the hospital until discharge the follow- ing day. On discharge, the patient’s progress was monitored by the Departments of OMFS and Ob/Gyn. DISCUSSION The unique anatomy of the ﬂoor of the mouth plays an im- portant role in the development and extension of intraoral Figure 2: CT-scan demonstrating ﬂuid collections in the left lateral pharyngeal space (arrow). infections. The usual infectious course begins with a peri- apical dental abscess of the second or third mandibular mo- lar. The roots of these teeth extend inferior to the insertion of the mylohyoid muscle, so that if untreated, the infection may continue from primary spaces to penetrate the thin in- ner cortex of the mandible and will involve the posterior margin of the mylohyoid muscle to the submandibular space [2]. At this time, the infection may develop and progress at such an alarming rate that special precautions regarding air- way maintenance must be taken. Because the mandible, hy- oid bone, and superﬁcial layer of the deep cervical fascia limit tissue expansion associated with the developing edema, the ﬂoor of the mouth and the tongue base will become displaced superiorly and posteriorly, resulting in severe airway com- promise [2]. Further extension of the infection may spread into the mediastinum and the carotid sheath resulting in se- vere thoracal infection. Rupture of abscesses along the way may cause aspiration of pus into the lungs and/or even peri- carditis. Untreated, the mortality is close to 100 percent, both from the acute sepsis and from airway obstruction [1]. The patient with Ludwig’s angina will have severe and obvious extraoral swellings including bilateral submandibular, sub- mental, and sublingual spaces. Common presentation is ele- vation and displacement of the tongue, trismus, drooling of saliva, airway obstruction, dysphagea and/or dyspnea, and a hoarse (“hot potato”) voice. With extensive use of antibiotics, most facial infections improve before they have a chance to progress to Ludwig’s angina. The mortality rate from Lud- wig’s angina, when recognized, has decreased from 50 to 5 percent [1]. Therapy also includes early surgical removal of the source of infection (which is often grossly carious den- tition) via extraction, aggressive, and vigorous incision and drainage procedures with appropriate placement of drains, along with intense and prolonged antibiotic therapy and maintenance of a patient airway. While penicillin adminis- tered intravenously and in high doses is the empirical antibi- otic of choice, it is often recommended to use metronidazole as well. For patients who have had repeated episodes of dental infections, clindamycin is often the antibiotic of choice [1].