A 46-year-old man presented with a 3-day history of a toothache, sore throat, decreased appetite, fevers, chills, and halitosis. His symptoms failed to improve with antibiotic therapy, and he was noted to have altered mental status and difficulty with breathing. His medical history was significant for poorly controlled diabetes mellitus, hypertension, seizures, pancreatitis, and tobacco and alcohol abuse.
On physical examination, subcutaneous crepitus was palpable in the anterior aspect of the neck. Examination of the oral cavity revealed multiple carious teeth. Transnasal fiberoptic laryngoscopy demonstrated necrotic tissue in the nasopharynx, extending into the posterior pharynx to the level of the soft palate, with a normal-appearing larynx. The patient acutely developed airway obstruction and required intubation for airway protection. A lateral x-ray film of the neck, obtained on arrival to the emergency room, showed soft tissue emphysema involving the paratracheal and prevertebral soft tissues, extending from the nasopharynx to the thoracic inlet (Figure 1). A computed tomographic scan showed air and inflammatory changes tracking in the prevertebral soft tissues and subcutaneous tissues of the neck, extending rostrally to the pterygomaxillary fissure and caudally into the superior mediastinum Figure 2, Figure 3, and Figure 4), as well as a fluid collection around the left mandible (Figure 2, arrow), consistent with an abscess. Laboratory tests revealed a white blood cell count of 23 000/µL (52% segmented neutrophils and 16% band cells). The results of a lumbar puncture and a rapid streptoccus test were negative.