0:00

This was a 36 year old who presented with fever.

0:05

So here was the lesion again.

0:09

And in this case, once again,

0:12

we wanna do our localization.

0:15

And what we see is that it's, again,

0:18

close to the sublingual glandular tissue.

0:22

It's more medial to that, so still in the floor of the mouth. But,

0:27

um, it looks almost embedded in the, uh, tongue.

0:31

And it has a rim of enhancement with a lower density center.

0:36

We do have some lymph nodes that are present that are, um,

0:41

not particularly enlarged.

0:44

And when you have a 36 year old with a fever,

0:48

we're going to shift from a neoplastic etiology to more of a,

0:53

um, inflammatory infectious etiology. So, um,

1:00

the other thing to remark upon is the impact it has on the, uh,

1:05

ve. The VE is the airspace in front of the epiglottis,

1:08

and we see that the left side is impinged upon. Um,

1:14

we see that there is some, uh,

1:17

edema here at the base of the tongue in the, um,

1:23

prepo area, and, um,

1:26

a little bit of effacement at the level of the palatine tonsils.

1:31

So, um, this, uh,

1:36

lesion should be in the inflammatory category.

1:40

Given that it has a little bit of a rim of enhancement,

1:43

we're more likely to suggest that it represents an abscess.

1:47

And at that point we want to think about what are the

1:51

potential complications of an infection in this location.

1:56

So there's two basic

2:01

L words that you have to know with regard to,

2:06

um, infections in this location.

2:10

One of them is, l is lemire syndrome,

2:15

which is a complication of pharyngitis,

2:20

and it's also known as post anginal sepsis,

2:24

which could be from a pharyngitis or tonsillitis that

2:29

progresses to sepsis,

2:30

and it may lead to thrombo phlebitis of the jugular

2:35

vein. So when you have infections in this location,

2:39

you do want to consider the carotid chief structures to

2:44

see whether there's thrombo or arteritis that may occur with

2:49

pharyngitis and tonsillitis. So here's an example of one that's in the tonsil,

2:54

and here you can see the patient's had septic emboli into the lung,

2:58

which is one of the complications. Here's the jugular vein,

3:02

normal jugular vein, jugular vein with some thrombus.

3:05

And here's another example, carotid artery,

3:07

jugular vein with thrombus with thrombo phlebitis and septic emboli.

3:11

So that's Lemire syndrome. The other is

3:17

Ludwig Angelo.

3:19

So Ludwig angina usually is from a odontogenic infection that

3:24

affects the oral cavity or the oropharynx.

3:27

It's a inflammation of the sublingual and submandibular spaces.

3:32

So we're close there and it leads to cellulitis

3:37

soft tissues of the floor, of the mouth and neck. What the problem is,

3:40

is that it can lead to obstruction of the airway,

3:44

which is why I pointed out at the level of the molecular that you have some

3:49

narrowing there. Let's look at these images. Here's the dental infection,

3:54

here's the surgical change.

3:57

Here's our CT sagal reconstruction showing at the level

4:02

of the oropharynx, no airway. Here's the trachea. And, um,

4:06

the airway being narrowed.

4:09

So important point on the inflammatory cases is look at the

4:13

caral sheath, look for thrombo fabi, look at the lungs,

4:16

see whether their septic emboli look at the impact on the, um,

4:21

on the airway. So

4:25

we go back to our

4:29

images here and we scroll.

4:32

Certainly the SGL larynx looks fine.

4:36

We have some degree of narrowing of the airway, but,

4:42

and I would probably describe it in the cross-sectional,

4:45

what this diameter is.

4:48

So for the airway, do we need to measure the diameter?

4:52

So, you know, one person's minimal is another person's moderate,

4:57

is another person's severe. So I'm a measurer. So yeah,

5:01

so I would give the measurement. It's the same thing with, uh, for example,

5:05

when you have a big goiter that's narrowing the trachea. Um,

5:10

while there are certain parameters that the clinicians look for that are

5:15

measured, um, I like providing that.

5:18

So that way if I say five millimeters is moderate,

5:22

but the e n d guy says five millimeters, that's good.

5:25

That's only mild narrowing. Um, it's subjective.

5:29

Whereas if we give objective information, I think it's helpful. So yes,

5:33

in this case I would measure the width of that transverse,

5:38

uh,

5:38

width of that airway at the level of the palatine tonsils and give it to them.

5:42

Okay. And they'll do, they'll,

5:44

they'll look clinically or they'll see whether if the patient's gasping for

5:47

breath, breath and short of breath and coughing, you know, then it,

5:51

it's a difference between, um, someone who's not, uh, you know,

5:56

pulling to breathe. Yeah.