Extrapleural empyema thoracis as a direct extension of Ludwig’s angina

A rare presentation of Ludwig's angina with facial nerve palsy, case report

INTRODUCTION AND IMPORTANCE OF CASE

Ludwig's angina is an inflammation of neck spaces making it immediately life-threatening. The infection spreads to adjacent planes destructing facial planes, aspirations of infective particles, or septic embolism to distant areas. Understanding the rare presentations will help early diagnosis and treatment.

PRESENTATION OF CASE

This is about a 40 years-old man who presented with painful anterior neck swelling of 7 days duration. A diagnosis of Ludwig's angina with unilateral facial nerve paralysis and treated with immediate incision and drainage.

CLINICAL DISCUSSION

Ludwig's may present clinical with a variety of complications. This complication may be related to ongoing sepsis or mass effects manifesting with airway compromise or nerve palsy.

CONCLUSION

Although facial nerve palsy associated with Ludwig's angina is rare, it improves with immediate surgical decompression.

Upper Respiratory Tract Infections in the Critically I11

A review of severe upper respiratory tract infections that present in the critically ill (supraglottitis [epi glottitis], deep neck infections, and sinusitis) is pre sented with attention to pathogenesis, pathophysiology, diagnosis, differential diagnosis, and treatment. Supra glottitis is increasingly diagnosed in adults and, as with children, early recognition is crucial to limit mortality. To aid in diagnosis and treatment, a management al gorithm is used. Deep cervical infections, usually exten sions of upper airway infections, can spread along fascial planes with fatal results. Knowledge of the interconnec tions between anatomical spaces is a prerequisite to diagnosis and treatment. Sinusitis will present in the critically ill as orbital or intracranial complications or as a nosocomial infection. Discussions of acute and chronic community-acquired sinusitis in general, noso comial sinusitis, and sphenoid sinusitis as a separate en tity highlight differences in clinical presentation and bacteriology that are important to diagnosis and treat ment.

Management of descending necrotizing mediastinitis

PURPOSE

One of the most dreaded and the most lethal form of mediastinitis is descending necrotizing mediastinitis (DNM).

PATIENTS AND METHODS

Between January 1990 and June 2001, 6 patients (mean age, 54.5 years; age range, 19 to 72 years) with DNM were treated in the Department of Thoracic Surgery of General Hospital of Attica "K.A.T." The primary etiology was odontogenic abscess in 3 patients and peritonsillar abscess in the other 3. Diagnosis was confirmed by computed tomography of the neck and chest. All patients underwent surgical drainage of the involved cervical region and mediastinum by monolateral cervicotomy and left thoracotomy.

RESULTS

The delay between the occurrence of thoracic symptoms and mediastinal drainage varied from 1 to 4 days. The thoracic approach and the side of the thoracotomy depended on the involved mediastinal compartments and side of pleural effusion. The duration of mediastinal drainage varied from 8 to 22 days (mean, 12.5 days). One patient died of multiorgan failure related to postoperative septic shock.

CONCLUSION

Delayed diagnosis and inadequate drainage are the main causes of the high mortality rate of DNM. Routine use of the computed tomography scan is highly recommended in patients with a deep cervical infection for early detection of mediastinitis at a time when the chest roentgenogram is still normal. If one realistically hopes to avoid the high mortality rate, aggressive surgical drainage and debridement of the neck and drainage of the mediastinum via a posterolateral thoracotomy by a multidisciplinary team of surgeons are required.

[Acute non-traumatic mediastinitis]

Acute mediastinitis is uncommon. When it occurs, it usually follows an esophageal perforation or thoracic surgery.

CASE REPORT

We report on a case of a ten-year-old girl with non traumatic mediastinitis secondary to a pleuro-pulmonary infection due to Klebsiella pneumoniae.

A case of extrapleural empyema

A 49-year-old man with diabetes mellitus and alcoholic liver cirrhosis presented with dyspnoea and fever. A chest computed tomography scan revealed three areas of loculated pleural effusion. Initially, the patient was thought to have an intrapleural empyema and was treated with intravenous antibiotics and closed drainage. However, as he did not improve, he was then treated with open drainage. During open drainage, the patient was diagnosed to have an extrapleural empyema and improved following open drainage treatment.

[Descending necrotizing mediastinitis. A case report]

Descending necrotizing mediastinitis which may occur as a complication of neglected oropharynx infection is an uncommon disease, although it is lethal in most cases. Trismus and dyspnea are usual with palpable crepitation located in the cervico-thoracic area. Early diagnosis can be confirmed with accuracy by CT scan. Treatment is based on early mediastinal drainage by cervical approach, intravenous antibiotics and reanimation. The reported case had a favorable outcome.

Descending cervical mediastinitis

Descending cervical mediastinitis is an uncommonly reported presentation of infection originating in the head or neck and descending into the mediastinum, which is fraught with impressive morbidity and mortality rates of 30% to 40% or more. We present the INOVA-Fairfax-Alexandria Hospital experience with descending cervical mediastinitis, January 1, 1986, to April 1, 1997; in addition we review the English-language medical and surgical literature with regard to this entity. Computed tomography and magnetic resonance imaging serve to aid both diagnosis and management. The application of broad-spectrum antibiotics should initially be empiric, with an eye to coverage of mixed aerobic and anaerobic infections. Definitive treatment mandates early and aggressive surgical intervention. All affected tissue planes, cervical and mediastinal, must be widely debrided, often leaving them open for frequent packing and irrigation. The treating physician must remain always alert to the further extension of infection, which, if it occurs, must be further debrided and drained. Tracheostomy serves a dual role of further opening cervical fascial planes and securing an often compromised airway.

Optimal treatment of descending necrotising mediastinitis

BACKGROUND

Descending necrotising mediastinitis is caused by downward spread of neck infection and has a high fatality rate of 31%. The seriousness of this infection is caused by the absence of barriers in the contiguous fascial planes of neck and mediastinum.

METHODS

The recent successful treatment of seven adult patients with descending necrotising mediastinitis emphasises the importance of optimal early drainage of both neck and mediastinum and prolonged antibiotic therapy. The case is also presented of a child with descending necrotising mediastinitis, demonstrating the rapidity with which the infection can develop and lead to death. Twenty four case reports and 12 series of adult patients with descending necrotising mediastinitis published since 1970 were reviewed with meta-analysis. In each case of confirmed descending necrotising mediastinitis the method of surgical drainage (cervical, mediastinal, or none) and the survival outcome (discharge home or death) were noted. The chi 2 test of statistical significance was used to detect a difference between cases treated with cervical drainage alone and cases where mediastinal drainage was added.

RESULTS

Cervical drainage alone was often insufficient to control the infection with a fatality rate of 47% compared with 19% when mediastinal drainage was added (p < 0.05).

CONCLUSIONS

Early combined drainage with neck and chest incisions, together with broad spectrum intravenous antibiotics, should be considered standard care for this disease.

Space-occupying and life-threatening infections of the head, neck, and thorax

Infections of the deep structures of the head and neck are polymicrobial, rapidly progressive, and frequently life-threatening. The bacteriology, clinical presentation, and the need for multidisciplinary management of these infections are stressed. In addition, this article discusses selected head and neck infections of immunocompromised hosts and postexposure prophylaxis for serious infections of the pharynx.

Descending necrotising mediastinitis

Descending necrotising mediastinitis is a rare but serious complication of oropharyngeal infections with high mortality. Diagnosis is frequently delayed, contributing to this high mortality, but awareness of such a complication and early diagnosis using computed tomographic scanning leads to prompt surgical drainage, proper antibiotic therapy, and survival.

Mediastinal and thoracic complications of necrotizing fasciitis of the head and neck

Mediastinal and thoracic extension of head and neck infections are rare but occur even in the modern antibiotic era. Early intervention is paramount to successful clinical outcome. 111Indium-labeled white blood cell (WBC) scan, a new imaging modality, appears to play a role in complementing computed tomographic (CT) findings, demonstrating early extension of disease, and following therapeutic efficacy. Together, the CT scan and WBC scan aid in directing early intervention and extent of surgery in this disease of high-potential mortality. We report 3 cases of deep head and neck infection complicated by mediastinal extension, including mediastinitis, pericardial effusion, and tamponade, empyema, and respiratory failure. Early surgical intervention included neck drainage, tracheostomy, thoracotomy, and pericardiotomy. While usually associated with greater than 50% mortality, all of the patients in this series survived. Based on our experience, we recommend prompt aggressive surgical debridement in treating mediastinal complications resulting from head and neck infections.

Descending necrotizing mediastinitis: transcervical drainage is not enough

One of the most lethal forms of mediastinitis is descending necrotizing mediastinitis, in which infection arising from the oropharynx spreads to the mediastinum. Two recently treated patients are reported, and the English-language literature on this disease is reviewed from 1960 to the present. Despite the development of computed tomographic scanning to aid in the early diagnosis of mediastinitis, the mortality for descending necrotizing mediastinitis has not changed over the past 30 years, in large part because of continued dependence on transcervical mediastinal drainage. Although transcervical drainage is usually effective in the treatment of acute mediastinitis due to a cervical esophageal perforation, this approach in the patient with descending necrotizing mediastinitis fails to provide adequate drainage and predisposes to sepsis and a poor outcome. In addition to cervical drainage, aggressive, early mediastinal exploration--debridement and drainage through a subxiphoid incision or thoracotomy--is advocated to salvage the patient with descending necrotizing mediastinitis.

Abscess of the mediastinum: a case report

In this report a rare case of mediastinal abscess secondary to purulent tonsilitis is reported. Generally this condition is consequent to systemic, cervical, thoracic, or abdominal infections.

Bilateral extrapleural effusions complicating bilateral pneumonia

In the case reported herein a patient developed bilateral pneumonia and septic shock and subsequently developed bilateral effusions. Chest roentgenograms, computed tomograms, and findings from analysis of the fluid within the chest were consistent with typical empyemas. When surgical decortication was attempted, the effusions were found to be anatomically extrapleural. Symptomatic improvement was noted following débridement.

Group A streptococcal pharyngitis and bacteremia associated with a Ludwig's angina-like syndrome

Ludwig's Angina (LA) is an infection of the submandibular and sublingual spaces usually initiated by abscesses of the inferior molars due to mixed oral flora. Pharyngitis due to group A beta-hemolytic streptococci (GABHS) rarely results in bacteremia. A patient presented with the classical findings of LA, and had no odontogenic focus but had GABHS pharyngitis and bacteremia. Attempts to isolate other microbiological organisms from the submandibular and sublingual spaces were unsuccessful. The patient required emergent tracheostomy and was treated with penicillin G for 4 wk with complete resolution of his clinical illness. The case demonstrates a previously unreported association between GABHS pharyngitis and the development of LA.

Subphrenic and mediastinal abscess formation: a complication of Ludwig's angina

A fatal case of cervical cellulitis is described in which mediastinal and subphrenic abscesses formed. Subphrenic abscess formation is a previously unrecorded complication of oro-pharyngeal infection. The anatomical pathways involved in the spread of infection from the neck to the abdomen and the difficulties in obtaining an airway in such a case are discussed.

[Mediastinitis caused by odontogenic anaerobic bacteria]

Anaerobic odontogenic mediastinitis appeared to be on the increase. The case described had a favourable outcome. The aetiology and pathology of this disease, the dreadful prognosis of which was a mortality rate of 50%, were discussed. The aggravating factors appeared to be general, these patients presenting a particular predisposition, due to steroids and malnutrition, and anatomical, as the cellulitis spread along cervical fascial planes. The treatment always required was mediastinal surgical drainage by a transcervical approach or by thoracotomy, the association of three antibiotics (a penicillin with an imidazole, an aminoglycoside or a macrolide) and a high energy and nitrogen intake.