I'old 'em I had a toofake. 'Ree days ahgo. Wisdom toof."
Our new patient's bulk almost obscured the stretcher he lay on. His guards had brought him over from the prison, and he probably could have taken them both with one arm tied behind his back. But they'd had the foresight to handcuff him.
David, my resident, cautiously approached. Mr. Bryce had good reason to be upset; the left side of his face jutted out like a tennis ball. When he tried to speak, his tongue sounded stuck to the back of his throat.
David probed him gently.
"Ow! 'Oc, c'mon I need sumpn' for pain!" Mr. Bryce protested.
"Hold still just a second, sir," David soothed. "I need to get a sense of how far this extends." David carefully fingered the swollen cheek. When he completed the exam, he showed me the note Mr. Bryce's guards had brought.
"Started him on penicillin only yesterday. Left lower wisdom tooth infection, possibly early abscess. Nothing early about it anymore."
"Huge," I agreed. "How far over?"
"To the midline of the floor of the mouth."
Mr. Bryce was suffering, in part, because of the limits of a funny little bone called the hyoid. It's the small hard ridge you feel just above your Adam's apple. The hyoid's job is to hold muscle attachments from the tongue, trachea, and throat in place. And it does that job well. But there's one design flaw. The hyoid bone isn't wide enough to receive muscle attachments from the rear of the jaw, where the last two molar teeth sit. That's a problem. While the muscles on the floor of the mouth can act as a fire wall to keep infections from spreading back into the throat, there is only a weak physical barrier to infections if they crop up in the second molar or the third, the wisdom tooth. And bacterial infections are a constant threat at the warm, nutrient-filled border between gums and teeth. Once a pocket of pus breaks through the thin bone surrounding the tooth sockets, it can run amok into the throat and even down the chest.
To get some sense of how inflamed and infected his jaw muscles were, we asked Mr. Bryce to say "ah."
"Uhh" was the best he could manage. His throat was so narrowed by the swelling that David could barely fit two fingers between the top and bottom incisors.
I stepped up to Mr. Bryce and said, "Don't bite me, okay?"
His tongue, lifted from below by the infection, was starting to bulge out of his mouth. I needed to feel around the base of his molars for an abscess to lance. I got half a gloved finger in before he jumped.
My finger jerked back.
"Aw, doctor--'uhmfing for 'ain."
"It's coming. We're almost finished."
I retraced David's path along the swollen cheek. Sometimes tooth abscesses develop in clearly localized and accessible regions, making incision and drainage relatively easy tasks. But not Mr. Bryce's. The swelling, hard as a rock, stretched from the corner of his jaw to the upper part of his neck. No targets around there.
The throat swelling and the hardness in the floor of the mouth were signs of extensive infected tissue.
"Ludwig's?" David asked.
Ludwig's angina. More than 150 years ago, Wilhelm Frederick von Ludwig, a German physician, described an infection in the floor of the mouth and the neck that could move quickly, causing massive throat swelling and strangulation. In the old days, angina (from anchone, the Greek word for strangulation) connoted throat infection. In Europe it still does. Americans reserve it for heart pain, short for angina pectoris. In medical school, the term evoked visions of 19th-century Vienna and bearded Herren Professoren. It was an anachronism I never expected to encounter in the age of modern dentistry and penicillin. I was wrong: Poor access to dental care, a guaranteed spin-off of the balkanized American health system, has re-created 19th-century conditions in present-day Manhattan.
And Ludwig's angina still means big trouble. Untreated, it can kill patients within 24 hours.
After breaking through the thin bone of the wisdom tooth socket, Mr. Bryce's infection had surged in two directions. It had raced up his jaw and curved beneath the floor of his mouth, giving him the look of a mutant chipmunk. And it had moved back, pushing the tongue up against the palate, forward out of the mouth and, most dangerously, back into the throat.
As the infection moves backward, it shoves the tongue awfully close to the epiglottis. Shaped like a rose petal, this delicate structure projects above the windpipe, snapping shut when food or drink tumbles down our gullets. The tongue, if pushed back far enough, can sit on the epiglottis like an elephant, causing immediate suffocation. And in the most severe cases, the rear of the mouth swells so much that the windpipe itself is squeezed shut. In both instances, the only remedy is to cut a hole in the windpipe--a bloody and unpleasant procedure.
"What do you suggest?" I asked David.
"And Mordy," I added.
Mordy Hoschander is an oral surgeon, and he loves his work. We often call him in to work on patients who've fractured their jaws in brawls, and never in seven years have I seen him greet the emergency room staff with anything less than a smile.
"Looks like a Ludwig's," I told him over the phone. "We started him on Unasyn and clindamycin, and we're firing up the CAT scan." Those two potent antibiotics would clobber the bacteria and halt their spread to virgin territory.
"Sounds good," Mordy answered. "I'm on my way."
"You'll probably need surgery," I told Mr. Bryce. "We'll get a CAT scan right away to see if you have an abscess in there."
A CAT scan of a healthy mouth shows clean lines of the muscles and soft tissues lining the floor of the mouth. But Mr. Bryce's showed blotches at the site of his left wisdom tooth. No clear abscess caught my eye, but at least Mordy would have some idea what he was getting into. The surgery residents came to take Mr. Bryce up.
"The swelling's bigger than it was three hours ago," David told them. "This guy's sick."
Later that evening Mordy told me how things had gone.
"When we hit the operating room, the swelling had marched clear across his jaw. The tongue bulged out like a toad's. I was amazed the anesthesiologists could intubate him so quickly. Then we tried to get a look from the outside. We incised the softest spot in the cheek, probed down to the bone, then curled around the inside of the mandible. No pus."
At that point, Mordy said, he stitched a soft rubber drain into the wound and started probing the mouth. There was a suspicious bulging at the back, below and behind the tonsil. With Mr. Bryce's airway protected by the plastic endotracheal tube, Mordy could roam at will.
When he stuck in a needle, out came two teaspoons of pus. "Then we went after it with a blade," he added, "and massive amounts of pus came out. ŒPus!' I yelled at the residents. They turned green from the stink. Nastiest stuff you ever got in the same room with."
But Mr. Bryce still had a long way to go. The next day, his face and neck seemed to have swollen to twice the size that had so impressed us on his arrival. For the next 48 hours he could barely open his mouth. And he kept spiking fevers, even though his white blood cell count--a crude measure of infection--had started inching down. Worried, Mordy did another CAT scan to see if a new abscess had formed. Negative. He called the infectious disease consult for ideas on better antibiotic cocktails. But he agreed with our initial choice.
"Just wait," he said.
On the third morning, a smiling, hungry Mr. Bryce greeted his doctors.
"Boom," Mordy said. "Fever, white count, swelling--all came down."
"The cultures?" I asked.
"Oh, the usual brew: strep and anaerobic bacteria. We yanked the tube. An hour later he's having breakfast. Wanted pancakes! We held the line at clear liquids. The tongue is tough," Mordy marveled. "Great blood supply. Once you clean up the neighborhood, it's right back in business."
The case described in Vital Signs is based on a true story. Some details have been changed to protect the patient's privacy. ------------------------------------------------------------------------ Doctor on Call
Tony Dajer has been a contributor to Vital Signs since 1989. He grew up in Puerto Rico and attended college and medical school in the United States. Dajer and his wife, an attorney, have three children, and the family alternates between living in France and the United States. During the past five years, while the family home was in Paris, Dajer returned frequently for stints in the emergency room of New York University's Downtown Hospital. In August, the family returned to the New York area.