HPI: The pain/edema was initially noted in the left lower lateral face and progressed to include anterior tongue. The patient was tolerating her secretions though it was painful for her to open her mouth. There was no history of oral trauma. No fevers, chills, headache, dizziness, vision changes, skin changes, and shortness of breath.

PMH: Rheumatoid arthritis on Methotexate, Adalimumab, and Leflunomide

PE:

-VS: T 37.1.C; BP: 156/98 mm Hg; HR: 115 beats/min; RR: 18 breaths/min, pulse ox: 96% on RA

-Gen: Well appearing

-HEENT/Neck: left submandibular edema with TTP. No overlying erythema. Tongue with mild distal edema, but no fluctuance; there was no tongue protrusion, trismus or drooling. Full ROM of the neck, with mild pain on neck rotation. No other oropharyngeal edema. Normal dentation without evidence of oral trauma

CT Max/Face W/Contrast (click on image to make bigger): 

Diagnosis????

Answer:

Tongue Abscess. Likley secondary to immunosuppression. Radiologist called to say he had never seen this before and according to the limited literature, it is rare. Less than 30 cases reported in the US.

Backround info: Spontaneous lingual (tongue) abscess is a rare life-threatening medical condition that may result in acute airway obstruction. The rich vascular supply, thick mucosa, and the anti-infectious characteristics of saliva make lingual abscess uncommon. Symptoms of a lingual abscess include tongue pain and swelling, odynophagia, dysphagia, difficulty speaking, changes in voice, tongue protrusion, and fever. 

The responsible organisms are usually normal flora from the oral cavity. The most common cause of a lingual abscess is direct trauma, whether this be from the teeth or a foreign body, and can also occur in association with dental infections. Immunocompromised state is considered a predisposing risk factor.

The differential diagnosis for lingual abscess includes aneurysm of the lingual artery, neoplasm, hemorrhage, infarction, cyst and angioedema. CT scan with IV contrast is generally recommended for improved characterization of the lesion, though it may be difficult to determine the etiology without surgical exploration and biopsy.

The treatment of a TA begins with airway assessment. Once airway stability is confirmed, further management includes broad-spectrum antibiotics to cover oral flora and consultation with either oral surgery or ENT to discuss drainage of the infection.