A rapidly enlarging neck swelling

A man in his mid 50s with type 2 diabetes and hypertension presented with four days of fever and worsening neck pain and swelling, initially left sided but subsequently spreading to the right. The pain and swelling had rapidly increased over the preceding 12 hours, forcing him to remove his dentures, and causing restricted mouth opening and progressive difficulty swallowing. His only remaining native tooth was his lower left first molar (LL7), all others having been extracted several years earlier owing to advanced decay.

Examination showed firm, tender bilateral submental and submandibular swelling with skin induration, mouth opening reduced to less than two finger breadths, and elevation and rightward displacement of the tongue by a prominent, fluctuant swelling of the left side of …