Ludwig's angina: case report and review

Ludwig's Angina an Emergency with Difficult Intubation: A Case Report

Deep neck space infections are really challenging to the otothinolaryngologist, intensivist and to the anesthetist for managing at a tertiary care center. Proper handling of such cases is needed in time to save the life of such patient. We reported a case 65 year female patient present with sudden onset of huge submental and submandibular swelling admitted in ICU with difficult intubation.

Rare Angina: A Case Report of Ludwig's Angina

Ludwig’s angina is the rapidly progressive cellulitis of the soft tissue of the neck and the floor of the mouth. Airway compromise is a frequent and potentially fatal sequela of Ludwig’s angina. Here we present a case of a 54-year-old African American male who presented with fever associated with painful swelling of the mouth and anterior neck. He was febrile and hypoxic on presentation. Imaging showed extensive involvement of the neck and mediastinum to the level of the clavicles. The diagnosis of Ludwig’s angina of periodontal origin was made, and intubation was performed for airway protection. Management was done by surgical debridement along with a course of broad-spectrum antibiotics. The patient’s condition improved, and he was discharged on oral antibiotics with a referral to a dentist. Our case demonstrates that early diagnosis, airway management, treatment with broad-spectrum antibiotics, and surgical intervention are vital for the successful management of severe cases of Ludwig’s angina.

Fatal airway obstruction due to Ludwig's angina from severe odontogenic infection during antipsychotic medication: A case report and a literature review

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.

Ludwig angina and sudden death

A 27-year-old man presented to hospital with neck swelling and difficulty breathing following a recent tooth extraction. He underwent uncomplicated surgical drainage of the submandibular region after which he became acutely short of breath and collapsed and was not able to be resuscitated. At autopsy the major findings were swelling of the neck due to diffuse cellulitis with edema and neutrophil infiltrates within connective tissue and marked submucosal edema of the epiglottis, glottic inlet and tonsils sufficient to cause airway obstruction. Cultures from the site of surgical intervention showed a mixed growth of Gram positive and negative bacilli and Gram positive cocci. Death was due to airway obstruction resulting from marked submucosal edema of the glottic inlet associated with submandibular cellulitis (Ludwig's angina) following extraction of a right lower first molar tooth. Lethal Lugwig angina, although rare in current forensic practice, may still present as a cause of acute upper airway occlusion and must be considered in the differential diagnosis of significant upper airway compromise.

Management of Ludwig’s angina. When is surgery necessary?

Deep neck space infections are of great risk for patients considering even death in certain cases. Collection of purulent secretions that can accumulate in a particular region of the neck is due to the anatomy of the deep neck fascia, muscles of the neck and compartments for blood vessels and organs in the neck region. Deep neck spaces communicate with each other and in some patients with morbidities like diabetes or other form of immuno-suppression extension can be great. Ludwig's angina is a form of abscess of the floor of the mouth with origin in teeth located on the mandible. Like any other abscess medical and surgical therapy are ways of treatment, but incision and drainage are mandatory. However, surgical management of such a complication might include other type of surgery as tracheostomy, blood vessels ligation, resection of necrotic tissue or even reconstruction.

Use of the TotalTrack VLM for emergent endotracheal intubation in predicted difficult airway with obstruction by expanding space-occupying lesions and reduced interincisor opening

Acute cervical pathology may lead to serious airway compromise resulting from anatomical distortion secondary to obstruction or deviation of the upper airway, scenarios where any airway device can be fallible. Passage of a fiberoptic bronchoscopy to expose the glottis may be very difficult and tracheostomy may be impractical or risky in advanced cases. We present the use of the TotalTrack VLM to secure the airway for emergent surgery in 2 uncooperative patients with difficult airway due to Ludwig's angina and neck hematoma, respectively, both accompanied by trismus.

Management and Novel Adjuncts of Necrotizing Soft Tissue Infections

Necrotizing soft tissue infections (NSTI) have been recognized for millennia and continue to impose considerable burden on both patient and society in terms of morbidity, death, and the allocation of resources. With improvements in the delivery of critical care, outcomes have improved, although disease-specific therapies are lacking. The basic principles of early diagnosis, of prompt and broad antimicrobial therapy, and of aggressive debridement have remained unchanged. Clearly novel and new therapeutics are needed to combat this persistently lethal disease. This review emphasizes the pillars of NSTI management and then summarizes the contemporary evidence supporting the incorporation of novel adjuncts to the pharmacologic and operative foundations of managing this disease.

Ludwig's Angina: Report of a Case and Review of Management Issues

Ludwig's angina, although uncommon, remains a potentially life-threatening condition because of the risk of impending airway obstruction. Effective treatment is based on early recognition of the clinical process, with the appropriate use of parenteral antibiotics, airway protection techniques, and formal surgical drainage of the infection. We present a case of Ludwig's angina together with a brief review of the relevant literature.

[Airway management in Ludwig's angina - a challenge: case report]

BACKGROUND

Ludwig's angina (LA) is an infection of the submandibular space, first described by Wilhelm Frederick von Ludwig in 1836. It represents an entity difficult to manage due to the rapid progression and difficulty in maintaining airway patency, a major challenge in medical practice, resulting in asphyxia and death in 8-10% of patients.

OBJECTIVE

Describe a case of a patient with Ludwig's angina undergoing surgery, with emphasis on airway management, in addition to reviewing the articles published in the literature on this topic.

CASE REPORT

Male patient, 21 years, drug addict, admitted by the emergency department and diagnosed with LA. Difficult airway was identified during the anesthetic examination. In additional tests, significant deviation from the tracheal axis was seen. Undergoing bilateral thoracoscopic pleural drainage, we opted for airway management through tracheal intubation using fiberoptic bronchoscopy, and balanced general anesthesia was proposed. There were no complications during the surgical-anesthetic act. After the procedure, the patient remained intubated and mechanically ventilated in the intensive care unit.

CONCLUSIONS

Airway management in patients with Ludwig's angina remains challenging. The choice of the safest technique should be based on clinical signs, technical conditions available, and the urgent need to preserve the patient's life.

A review of complications of odontogenic infections

Life-threatening infections of odontogenic or upper airway origin may extend to potential spaces formed by fascial planes of the lower head and upper cervical area. Complications include airway obstruction, mediastinitis, necrotizing fascitis, cavernous sinus thrombosis, sepsis, thoracic empyema, Lemierre's syndrome, cerebral abscess, orbital abscess, and osteomyelitis. The incidence of these "space infections" has been greatly reduced by modern antibiotic therapy. However, serious morbidity and even fatalities continue to occur. This study reviews complications of odontogenic infections. The search done was based on PubMed and Google Scholar, and an extensive published work search was undertaken. Advanced MEDLINE search was performed using the terms "odontogenic infections," "complications," and "risk factors."

Ludwig's Angina - An emergency: A case report with literature review

Ludwig's angina is a form of severe diffuse cellulitis that presents an acute onset and spreads rapidly, bilaterally affecting the submandibular, sublingual and submental spaces resulting in a state of emergency. Early diagnosis and immediate treatment planning could be a life-saving procedure. Here we report a case of wide spread odontogenic infection extending to the neck with elevation of the floor of the mouth obstructing the airway which resulted in breathlessness and stridor for which the patient was directed to maintain his airway by elective tracheostomy and subsequent drainage of the potentially involved spaces. Late stages of the disease should be addressed immediately and given special importance towards the maintenance of airway followed by surgical decompression under antibiotic coverage. The appropriate use of parenteral antibiotics, airway protection techniques, and formal surgical drainage of the infection remains the standard protocol of treatment in advanced cases of Ludwig's angina.

Ludwig's Angina-A Controversial Surgical Emergency: How We Do It

Objectives. To review the current protocols used for management of Ludwig's angina and to assess the efficacy of conservative measures in these cases. Methods. A retrospective review of patients who were admitted to our institution for management of Ludwig's angina between 2003 and 2010. Results. Two patients were identified. Both were managed successfully with conservative measures and close airway observation. None needed an emergency intubation or surgical tracheostomy. There were no mortalities, and both had a short hospital stay. Conclusion. Recently, management of Ludwig's angina has evolved from aggressive airway management into a more conservative one. This is based on close airway observation on a specialised airway unit and a serial clinical airway assessment. Improved imaging modalities, antibiotic therapy, surgical skills, and clinical experience are the key factors behind this change in practice.

Necrotizing soft tissue infections in the intensive care unit

Necrotizing soft tissue infection is a severe illness that is associated with significant morbidity and mortality. It is often caused by a wide spectrum of pathogens and is most frequently polymicrobial. Care for patients with necrotizing soft tissue infection requires a team approach with expertise from critical care, surgery, reconstructive surgery, and rehabilitation specialists. The early diagnosis of necrotizing soft tissue infection is challenging, but the keys to successful management of patients with necrotizing soft tissue infection are early recognition and complete surgical debridement. Early initiation of appropriate broad-spectrum antibiotic therapy must take into consideration the potential pathogens. Critical care management components such as the initial fluid resuscitation, end-organ support, pain management, nutrition support, and wound care are all important aspects of the care of patients with necrotizing soft tissue infection. Soft tissue reconstruction should take into account both functional and cosmetic outcome.

Ludwig's angina and airway considerations: a case report

INTRODUCTION

Patients with deep neck infections present challenging airways for an anesthesiologist. Patients with Ludwig's angina may die as a result of the inability to effectively manage the airway.

CASE PRESENTATION

Here we discuss the anesthetic management with fiberoptic intubation of a 45-year-old man with Ludwig's angina scheduled for emergency drainage.

CONCLUSION

Awake fiberoptic intubation under topical anesthesia may be the ideal method to secure the airway in advanced cases of Ludwig's angina. When fiberoptic bronchoscopy is not feasible, not available or has failed, an awake tracheostomy may be the preferred option.

Airway management in adult patients with deep neck infections: a case series and review of the literature

Patients with deep neck infections, especially those with Ludwig's angina, may die as a result of airway management mishaps. Skillful airway management is critical, but a safe method of airway control in these patients is yet to be established. We subjected patients with deep neck infections to fiberoptic tracheal intubation by using topical anesthesia to provide general anesthesia for surgical interventions. Patient characteristics and techniques for intubations were recorded on a special data-collection form. Of the 26 patients, 17 had Ludwig's angina, and 9 had other types of deep neck infections. Three patients were tracheally intubated while in the sitting position, 2 in Fowler's position, and 21 in the supine position with the head up 10 degrees-15 degrees. Tracheal intubations were successful in 25 patients: 19 nasally and 6 orally. After surgery, seven patients were kept tracheally intubated, and five patients had tracheostomies. Complications were limited to three cases of mild epistaxis and four oversedations with transient hypoxemia. Twelve patients remembered part of the procedure, and two considered it unpleasant. Tracheal intubation with a flexible bronchoscope by using topical anesthesia is highly successful in adult patients with deep neck infections. Tracheostomy using local anesthesia is recommended if fiberoptic intubation is not feasible, if the clinician is not skillful in the use of awake fiberoptic intubation, or if intubation attempts have failed.

Airway management in Ludwig's angina

A 37-year-old 91 kg man presented with features of Ludwig's angina. Anaesthesia for incision and drainage of his submandibular abscess was undertaken by two specialist anaesthetists with an otorhinolaryngological surgeon prepared for immediate tracheostomy. After preoxygenation, gas induction with sevoflurane in oxygen was followed by a gush of pus into the oral cavity and laryngospam causing acute upper airway obstruction. This resolved with 25 mg of suxamethonium and an endotracheal tube was passed into the trachea with difficulty. Options for management of the difficult airway in Ludwig's angina are discussed.