Fatal airway obstruction due to Ludwig's angina from severe odontogenic infection during antipsychotic medication: A case report and a literature review
Corresponding Author
Rutsuko Yamaguchi MD, MPH, PhD
Department of Forensic Medicine, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
Department of Legal Medicine, Graduate School of Medicine, Chiba University, Chiba City, Chiba, Japan
Correspondence
Rutsuko Yamaguchi MD, MPH, PhD, Department of Forensic Medicine, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan.
Email: [email protected]
Search for more papers by this authorKoichi Sakurada DDS, PhD
Department of Forensic Dentistry, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Bunkyo-ku, Tokyo, Japan
Search for more papers by this authorHisako Saitoh DDS, PhD
Department of Legal Medicine, Graduate School of Medicine, Chiba University, Chiba City, Chiba, Japan
Search for more papers by this authorMaiko Yoshida MD, PhD
Department of Legal Medicine, Graduate School of Medicine, Chiba University, Chiba City, Chiba, Japan
Search for more papers by this authorYohsuke Makino MD, PhD
Department of Forensic Medicine, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
Department of Legal Medicine, Graduate School of Medicine, Chiba University, Chiba City, Chiba, Japan
Search for more papers by this authorSuguru Torimitsu MD, PhD
Department of Forensic Medicine, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
Department of Legal Medicine, Graduate School of Medicine, Chiba University, Chiba City, Chiba, Japan
Search for more papers by this authorSatomi Mizuno DDS
Department of Forensic Medicine, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
Search for more papers by this authorHirotaro Iwase MD, PhD
Department of Forensic Medicine, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
Department of Legal Medicine, Graduate School of Medicine, Chiba University, Chiba City, Chiba, Japan
Search for more papers by this authorCorresponding Author
Rutsuko Yamaguchi MD, MPH, PhD
Department of Forensic Medicine, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
Department of Legal Medicine, Graduate School of Medicine, Chiba University, Chiba City, Chiba, Japan
Correspondence
Rutsuko Yamaguchi MD, MPH, PhD, Department of Forensic Medicine, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan.
Email: [email protected]
Search for more papers by this authorKoichi Sakurada DDS, PhD
Department of Forensic Dentistry, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Bunkyo-ku, Tokyo, Japan
Search for more papers by this authorHisako Saitoh DDS, PhD
Department of Legal Medicine, Graduate School of Medicine, Chiba University, Chiba City, Chiba, Japan
Search for more papers by this authorMaiko Yoshida MD, PhD
Department of Legal Medicine, Graduate School of Medicine, Chiba University, Chiba City, Chiba, Japan
Search for more papers by this authorYohsuke Makino MD, PhD
Department of Forensic Medicine, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
Department of Legal Medicine, Graduate School of Medicine, Chiba University, Chiba City, Chiba, Japan
Search for more papers by this authorSuguru Torimitsu MD, PhD
Department of Forensic Medicine, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
Department of Legal Medicine, Graduate School of Medicine, Chiba University, Chiba City, Chiba, Japan
Search for more papers by this authorSatomi Mizuno DDS
Department of Forensic Medicine, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
Search for more papers by this authorHirotaro Iwase MD, PhD
Department of Forensic Medicine, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
Department of Legal Medicine, Graduate School of Medicine, Chiba University, Chiba City, Chiba, Japan
Search for more papers by this authorThis work has been presented at the 104th Congress of the Japanese Society of Legal Medicine, September 24–25, 2020, in Kyoto, Japan.
Abstract
Ludwig's angina is characterized by inflammation of the sublingual and submandibular spaces and is mainly caused by odontogenic infection, which leads to cellulitis of the soft tissues of the floor of the mouth and the neck. This causes asphyxia due to elevation and posterior deviation of the tissues of the floor of the mouth. We report a fatal case of airway obstruction due to Ludwig's angina. A woman in her forties who had no physical complications, but had a mental illness, was undergoing outpatient dental treatment for caries in the first premolar of the left mandible. She was admitted to a psychiatric hospital because of insomnia caused by pain, where she developed cardiopulmonary arrest while sleeping and died 14 days after onset of the dental infection. Postmortem computed tomography (PMCT) prior to autopsy showed swelling of the soft tissues—from the floor of the mouth to the oropharyngeal cavity, the supraglottic larynx, and the prevertebral tissue. Autopsy revealed a markedly swollen face and neck, an elevated tongue, and a highly edematous epiglottis and laryngopharyngeal mucosa. There was also cellulitis and abscess of the facial, suprahyoid, and neck musculature, which suggested that the cause of death was asphyxiation due to airway obstruction. This was an alarming case, with mental illness leading to risk of severe odontogenic infection, and in which obesity and use of antipsychotic medication might have acted synergistically leading to airway obstruction. This is also a case of Ludwig's angina captured by PMCT, which has rarely been reported.
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