| Abstract|| |
Acute lingual swelling is a potentially life threatening clinical condition which is encountered very rarely, the differential diagnosis of which includes hemorrhage, infarction, abscess, tumor and edema. Herein we report a case of lingual abscess that presented with acute tongue swelling and respiratory distress after extraction of lower two incisor teeth.
Keywords: Airway obstruction, incisor tooth extraction, lingual abscess
|How to cite this article:|
Varghese L, Agarwal P, Rupa V. Unusual complication of dental extraction: Lingual abscess. Indian J Dent Res 2013;24:772-4
Acute lingual abscess is a rare, potentially life-threatening infection of the base or anterior part of the tongue, usually secondary to trauma or spread of infection from adjacent teeth and tonsils. Traumatic causes include accidental injury, injury by jagged teeth adjacent to the tongue, tongue-piercing, foreign bodies, fracture of the mandible and, rarely, following surgery to the tongue, teeth, or septum.  Cases of lingual abscess secondary to lingual tonsillar lesions and infected thyroglossal duct cysts have also been reported.  In some cases, the cause is not immediately apparent. 
|How to cite this URL:|
Varghese L, Agarwal P, Rupa V. Unusual complication of dental extraction: Lingual abscess. Indian J Dent Res [serial online] 2013 [cited 2020 Jun 3];24:772-4. Available from: http://www.ijdr.in/text.asp?2013/24/6/772/127633
Despite being subject to constant trauma and exposure to many potential pathogens, the tongue is relatively immune to infection. This could be due to constant mobility of the tongue, which helps saliva that bathes it to produce a continuous cleansing effect. The thick layer of keratinized mucosa of the tongue is not easily penetrated by microorganisms. The tongue muscle with its rich vascular supply and lymphatic drainage also prevents infection. The immunological properties of saliva provide a further barrier to invasion by microorganisms. Any breach in mucosa of the tongue either by drugs or trauma predisposes to tongue infections which can become severe. 
We report a patient with lingual abscess of the anterior part of tongue which developed following extraction of infected lower two incisor teeth. To the best of our knowledge this is the first reported case of this complication following extraction of incisor teeth.
| Case Report|| |
A 32-year-old man presented to the otolaryngology outpatient clinic with swelling of the tongue and inability to swallow of 5 days' duration following extraction of his lower two incisor teeth for toothache. He had been on IV antibiotics for few days at his hometown but further details were unavailable. As he did not improve, he elected to come to our centre for further care.
The patient had no associated fever or pain. However, he noted difficulty in breathing on lying supine a day prior to presentation. There was no history of trauma, bite wounds to the tongue or tongue piercing. He was not diabetic or immunodeficient. He admitted to having a tongue tie and mild misarticulation since childhood.
On physical examination, the patient was found to have mild stertor in the upright position. He was unable to close his mouth and there was drooling of saliva. A nontender, tense, fluctuant swelling involving the entire anterior two-thirds of the tongue and the floor of mouth, reaching up to the palate superiorly and occluding the view of the rest of oropharynx, was seen [Figure 1]. The overlying mucosa was mildly congested. A flexible laryngoscope could not be negotiated beyond the nasopharynx. The total white blood cell count was mildly elevated at 11 500 per cu.mm with 72% neutrophils. Contrast-enhanced CT scan of the tongue and neck showed a hypodense lesion with peripheral enhancement within the substance of the anterior 2/3 of tongue occluding the airway [Figure 2]. The differential diagnoses considered were lingual abscess, resolving lingual hematoma, lingual malignancy, and infected congenital lingual dermoid.
|Figure 1: Swelling involving anterior two-thirds of the tongue and the floor of mouth, reaching up to the palate superiorly|
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|Figure 2: CT scan showing a hypodense lesion with peripheral enhancement within the substance of the anterior 2/3 of tongue|
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It was decided to explore and drain the lesion. As oral, blind nasal, fiberoptic intubation was deemed difficult by anesthetists; an emergency tracheostomy was performed under local anesthesia. Initial wide bore needle aspiration revealed pus. This was followed by intraoral incision and drainage of the lingual abscess under general anesthesia taking into consideration the decision to divide the co existent tongue tie also. About 40 cc of pus was drained and sent for microbiological examination. A corrugated drain was stitched in and haemostasis achieved. Pus culture did not reveal any bacteria. Postoperatively, the patient was treated with broad spectrum antibiotics to which he responded remarkably well. The lingual drain was removed after 48 h and he was decannulated soon after. At discharge, the lingual swelling had reduced considerably [Figure 3], permitting him to eat normally.
|Figure 3: Postoperative picture showing reduction in swelling of tongue after drainage|
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| Discussion|| |
In the patient described, the rapid onset of tongue swelling following tooth extraction provided us clues to the etiology of the abscess. Soft tissue infections of odontogenic origin tend to spread along planes of least resistance from the supporting structures of the affected tooth to various potential spaces in the vicinity. Infections of the mandibular incisors and canines commonly erode anteriorly on the buccal aspect leading to vestibular abscesses rather than lingual abscesses, unlike the molars where the spread is in a lingual direction.  Reports of lingual abscess of odontogenic origin have usually been described with relation to infected molar teeth.  Hence, the posterior 1/3 of the tongue is usually involved. In this patient the infection had probably spread through the lingual aspect in the region of extracted incisors. The relative restricted mobility of the tongue because of the tongue tie also could have contributed to the progression of the infection.
The distinction between lingual abscess and lingual cellulitis often cannot be made clinically. This distinction is important because abscesses will not resolve without proper incision and drainage. On the other hand, incision into a cellulitic tongue is unnecessary and the condition may be managed efficiently by antibiotics alone. Therefore, imaging plays a role in determining the correct line of treatment. Imaging techniques such as ultrasonography, computed tomography (CT), and magnetic resonance imaging (MRI) have been used for evaluation of tongue swellings.  Ultrasound of the tongue in a case of lingual abscess shows a hypoechoic lesion surrounded by a hyper echoic ring.  However, sonography may not always be feasible since, when the tongue is swollen, the patient may experience discomfort or acute pain if it is pressed. Contrast-enhanced CT scanning shows a hypodense area with peripheral enhancement. This was well seen in our patient [Figure 2]. MRI scanning of the tongue, although expensive, is ideal to distinguish a lingual abscess from a malignancy. On MRI scanning of the tongue, a T1 hypo intense-T2 hyper intense lesion surrounded by a T1 hyper intense-T2 hypo intense rim that enhances diffusely after contrast injection suggests the diagnosis of abscess. 
In clinical practice, the organisms usually isolated from lingual abscess are Streptococcus and Staphylococcus species and anaerobes.  Often cultures grow multiple organisms. Cultures may be negative  in patients previously treated with antibiotics. This may be the cause of a sterile culture in our patient.
Early diagnosis and intervention is crucial and life saving for patients with lingual abscess. In patients who are not in respiratory distress, flexible nasopharyngolaryngoscopy helps in assessing the airway and ruling out other causes of airway obstruction. Management of lingual abscess is by drainage of the abscess either by incision and drainage or by aspiration with a wide bore needle after securing the airway. Some authors have found a particular advantage in aspiration rather than incision and drainage.  This mode of management may be sufficient for small or moderate-sized lingual abscesses. In the case of larger abscesses multiple, repeated aspirations may be required. Drainage has to be followed by appropriate antibiotics and management of underlying cause if any. As with other head and neck abscesses, timely drainage of the abscess with appropriate antibiotic therapy ensures rapid recovery.
| Conclusion|| |
Acute lingual abscess is a rare infection of the base or anterior part of the tongue, usually secondary to trauma or spread of infection from adjacent teeth and tonsils. Lingual abscess of odontogenic origin have usually been described with relation to infected molar teeth. This is the first reported case of this complication following extraction of incisor teeth. Prompt incision and drainage followed by antibiotic and analgesic coverage ensures complete recovery. Clinicians must be aware of this potentially life threatening complication.
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Department of Otorhinolaryngology, Christian Medical College, Vellore
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2], [Figure 3]