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Degouy G, Nicot R, Poissy J, Mathieu D, Parmentier-Decrucq E. Risk factors for difficult ventilatory weaning in intensive care patients with cervical cellulitis. JOURNAL OF STOMATOLOGY, ORAL AND MAXILLOFACIAL SURGERY 2022; 123:e396-e401. [PMID: 35227951 DOI: 10.1016/j.jormas.2022.02.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 02/11/2022] [Accepted: 02/23/2022] [Indexed: 06/14/2023]
Abstract
PURPOSE Cervical cellulitis is an infrequent but serious infection. The management of the upper airways is difficult, at the actual time of intubation but also regarding the necessity of maintaining mechanical ventilation. The objective of this study is to identify risk factors on admission to the intensive care unit for difficult ventilatory weaning in patients with cervical cellulitis. METHODS Between January 2013 and December 2018, this retrospective observational study was performed in an intensive care unit with 10 beds in a university hospital recognized as a reference center for the management of cellulitis. All intensive care patients receiving mechanical ventilation after surgery for cervical cellulitis were eligible. Difficult ventilatory weaning was defined as mechanical ventilation lasting more than 7 days or failure of extubation as established by the WIND 2017 study. RESULTS We included 120 patients with severe cervical cellulitis. The median age was 43 years. Eighteen patients (16%) presented mediastinal extension. The risk factor for difficult ventilatory weaning (n = 49) in multivariate analysis was a high level of procalcitonin on admission (OR at 1.14[1.005-1.29]; p<0.042) and the protective factor was surgery in an expert center (OR at 0.11[0.026-0.47]; p<0.003). Eight patients required a tracheotomy in our study: 3 patients during surgery and at a later time for the other 5 of our 8 patients. CONCLUSION No intensive care studies have investigated ventilatory weaning risk factors in patients with cervical cellulitis. Yet simple criteria seem to predict this risk. It is now necessary to confirm them by a multicenter prospective study.
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Affiliation(s)
- Guillaume Degouy
- Intensive Care Unit and Hyperbaric Center, Lille University Hospital.
| | - Romain Nicot
- Service de Chirurgie Maxillo-Faciale et Stomatologie, Lille University Hospital.
| | - Julien Poissy
- Intensive Care Unit and Hyperbaric Center, Lille University Hospital.
| | - Daniel Mathieu
- Intensive Care Unit and Hyperbaric Center, Lille University Hospital.
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Umeshappa H, Shetty A, Kavatagi K, Vivek GK, Vaibhav N, Mohammed I. Microbiological profile of aerobic and anaerobic bacteria and its clinical significance in antibiotic sensitivity of odontogenic space infection: A prospective study of 5 years. Natl J Maxillofac Surg 2021; 12:372-379. [PMID: 35153434 PMCID: PMC8820308 DOI: 10.4103/njms.njms_1_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 06/21/2020] [Accepted: 01/01/2021] [Indexed: 11/10/2022] Open
Abstract
Introduction: Odontogenic infections are mixed aerobic-anaerobic microbial flora. Infections caused by anaerobic bacteria are serious and life-threatening. The microbial specificity in odontogenic infections is technique sensitive depending on the sampling and culturing of specimens. Materials and Methods: A prospective study was carried out on 100 consecutive cases of odontogenic infections treated at our institute over a period of 5 years by surgical intervention and intravenous antibiotics. This study evaluates the pathogenic potential and virulence factors of aerobes and anaerobes as well as its synergistic interrelations with other infectious flora, by culturing of specimens and testing antibiotic sensitivity in standard microbiological methodology in correlation with patient demographic factors. Results: Of the 100 patients of odontogenic space infection, males were more affected, between third and fourth decades. Caries is the most common etiology with involvement of mandibular molars. Submandibular and buccal space is commonly involved. The most common microorganisms isolated being Staphylococcus aureus and Streptococcus viridans are facultative anaerobes which belong to aerobes and Peptostreptococcus predominated among obligate anaerobes. The empirical antibiotic regimen followed is amoxicillin plus clavulanic acid with Metronidazole, followed by surgical treatment. Clindamycin was preferred as the second line of choice in patients resistance to penicillin drugs with comparable efficacy in it. Conclusion: Our study expanded the knowledge base of the microbial flora associated with odontogenic infections, with special reference to anaerobes. Successful management of odontogenic space infection lies in decompression, removal of etiological factors, and also in selecting appropriate antimicrobial therapy depending on microbial flora isolated, for recovery of patients and preventing complications associated with fascial space infection.
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Affiliation(s)
- Hemavathi Umeshappa
- Department of Oral and Maxillofacial Surgery, Sri Rajiv Gandhi Dental College and Hospital, Bengaluru, Karnataka, India
| | - Akshay Shetty
- Department of Oral and Maxillofacial Surgery, Sri Rajiv Gandhi Dental College and Hospital, Bengaluru, Karnataka, India
| | - Kiran Kavatagi
- Department of Microbiology, Subbaiah Institute of Medical Sciences, Shivamogga, Karnataka, India
| | - G K Vivek
- Department of Oral and Maxillofacial Surgery, Sri Rajiv Gandhi Dental College and Hospital, Bengaluru, Karnataka, India
| | - N Vaibhav
- Department of Oral and Maxillofacial Surgery, Sri Rajiv Gandhi Dental College and Hospital, Bengaluru, Karnataka, India
| | - Imran Mohammed
- Department of Oral and Maxillofacial Surgery, Sri Rajiv Gandhi Dental College and Hospital, Bengaluru, Karnataka, India
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DELANTONİ A, SARAFOPOULOS A, TSİROPOULOS G, DENİZ A, ORHAN K. Ludwig’s Angina: Case series with description of the ultrasonographic features of the emergency conditions. JOURNAL OF EMERGENCY MEDICINE CASE REPORTS 2020. [DOI: 10.33706/jemcr.800027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Bowe CM, Elliott JA, Schnittger T, Kearns GJ. Decision-making in awake fibre optic intubation for patients with severe dentofacial infection: which patients will require fibre optic intubation? Ir J Med Sci 2019; 189:1039-1045. [PMID: 31811621 DOI: 10.1007/s11845-019-02145-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Accepted: 11/15/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Risk factors for advanced airway intervention among patients with dentofacial infection (DFI) are poorly understood. The appropriate delivery of clinical care to this patient group raises challenging anaesthetic service provision issues. The purpose of this study was to identify factors which may predict a requirement for an awake fibre optic intubation (AFOI) technique for airway management in this patient population. METHODS A retrospective analysis of data for consecutive patients admitted with DFI were analysed at the Oral & Maxillofacial department at St James's Hospital, Dublin from July 2014-July 2015 was carried out. Receiver operating characteristic analysis determined optimal cut-off values predictive of AFOI, and multivariate logistic regression determined independent risk factors for AFOI. RESULTS One hundred and twenty-five patients (64 male, 61 female) were admitted with DFI. The mean age was 35.9 years (range 16-91). AFOI was carried out in 58 (67.4%) patients who required GA. Increasing age was associated with an increase likelihood of AFOI (P = 0.047 95% CI 1.07(1.00-1.14). Reduced mouth opening was significantly associated with requirement for AFOI (28.8 ± 8.6 vs. 14.8 ± 8.6 mm, P < 0.0001). On receiver operating characteristic (ROC) analysis, mouth opening predicted requirement for AFOI with 87% accuracy (AUC 0.87 [95% CI 0.80-0.95], P < 0.0001). Using a cut-off value of 16.5 mm predicted subsequent AFOI with 96.7% (95% CI 78.1-100.0%) specificity and 65.6% (95% CI 51.4-77.8%) sensitivity. Initial C-reactive protein (CRP) was significantly associated with requirement for AFOI (60.1 ± 40.0 vs. 121.3 ± 89.8, P = 0.002). A CRP value of over 110 mg/L predicted subsequent AFOI with 95.8% (95% CI 78.9-100.0%) specificity. CONCLUSION Increasing age, reduced mouth opening < 16.5 mm, and an increased serum admission CRP > 100 mg/L on admission significantly increase the requirement for AFOI on multivariate and univariate regression analysis. The availability of anaesthetists experienced in AFOI is essential for safe management of these patients.
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Affiliation(s)
- Conor M Bowe
- Oral & Maxillofacial Surgery Department, Dublin 8, Ireland.
| | | | - Tom Schnittger
- Department of Anaesthesia, St. James' Hospital, Dublin, Ireland
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Wilson C, Simonds E, Iwanaga J, Oskouian RJ, Tubbs RS. Pseudoaneurysm of Posterior Ascending Branch of Vertebral Artery: Previously Unreported Case. World Neurosurg 2018; 112:158-160. [PMID: 29391298 DOI: 10.1016/j.wneu.2018.01.135] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Revised: 01/16/2018] [Accepted: 01/17/2018] [Indexed: 10/18/2022]
Abstract
BACKGROUND Pseudoaneurysms are less common than true aneurysms. Herein, we present a rare case of a mass of the right posterior ascending artery. CASE DESCRIPTION This was identified during routine dissection of an adult female cadaver. Histology demonstrated that the mass was a pseudoaneurysm. The mass was located posterior to the right alar ligament superior to the right portion of the transverse ligament and measured 7.37 mm and 2.97 mm. CONCLUSIONS To our knowledge, such a case has not previously been reported. Epidural masses anterior to the cervical dura mater at the craniocervical junction should consider such a pathology in the differential diagnosis.
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Affiliation(s)
| | - Emily Simonds
- Seattle Science Foundation, Seattle, Washington, USA
| | - Joe Iwanaga
- Seattle Science Foundation, Seattle, Washington, USA; Division of Gross and Clinical Anatomy, Department of Anatomy, Kurume University School of Medicine, Kurume, Fukuoka, Japan.
| | | | - R Shane Tubbs
- Seattle Science Foundation, Seattle, Washington, USA; Department of Anatomical Sciences, St. George's University, Grenada, West Indies
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6
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Jacobs TE, Irwin RS, Raptopoulos V. Upper Respiratory Tract Infections in the Critically I11. J Intensive Care Med 2016. [DOI: 10.1177/088506669000500401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
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.
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Affiliation(s)
- Teresa E. Jacobs
- Department of Medicine, University of Massachusetts Medical School
| | - Richard S. Irwin
- Department of Medicine, University of Massachusetts Medical School
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7
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Singh M, Kambalimath DH, Gupta KC. Management of odontogenic space infection with microbiology study. J Maxillofac Oral Surg 2014; 13:133-9. [PMID: 24822004 DOI: 10.1007/s12663-012-0463-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2012] [Accepted: 12/20/2012] [Indexed: 10/25/2022] Open
Abstract
INTRODUCTION Dental infection has plagued humankind for as long as our civilization has been a fight against microorganisms by man dates back to ancient civilization. The discoveries of antibiotics are encouraging trends towards conquest of the microbial infection. MATERIALS AND METHODS This study emphasizes the detection of pathogenic microorganisms by microbiological examination and culture of specimens representative of the infection, importance of early and correct diagnosis of infections, prompt treatment and supportive care. RESULTS The age group most commonly involved was in the third and fourth decades of life. Extraction followed by incision and drainage was done. The most commonly involved space was submandibular followed by buccal space. Thirty isolates were obtained. 43 % of the strains were strict anaerobes and 39 % were aerobes, with mixed growth was seen in 18.52 %. Amongst aerobes alpha hemolytic Streptococcus aureus and Peptostreptococcus as anaerobes were the most predominant followed by Bacteroides and Prevotella. Mixed aerobic and anaerobic isolates were obtained from 18.52 % of total cases. Overall resistance to Penicillin was 22 %, amongst aerobes. CONCLUSION Amoxicillin and Clavulanic acid combination performed better, as 100 % strains were sensitive to it. The results of this study saw a changing trend in terms of predominance of anaerobic bacteria over aerobic ones.
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Affiliation(s)
- Mamta Singh
- Department of Oral and Maxillofacial Surgery, Modern Dental College and Research Centre, Residence No. 2, Collector Bungalow Residency Area, Indore, 452001 MP India
| | - Deepashri H Kambalimath
- Department of Oral and Maxillofacial Surgery, Modern Dental College and Research Centre, Residence No. 2, Collector Bungalow Residency Area, Indore, 452001 MP India
| | - K C Gupta
- Department of Oral and Maxillofacial Surgery, Modern Dental College and Research Centre, Residence No. 2, Collector Bungalow Residency Area, Indore, 452001 MP India
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Mohan A, Rajendra Prasad B, Sharma SM, Pai D, Karikal A. The role of systemic condition in the management of maxillofacial infections. J Maxillofac Oral Surg 2012; 10:250-2. [PMID: 22942596 DOI: 10.1007/s12663-010-0116-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2010] [Accepted: 10/14/2010] [Indexed: 10/18/2022] Open
Abstract
Ludwig's Angina is a rare type of facial infection which formerly invariably was fatal but now with adequate surgical and antibiotic treatment has a much reduced mortality. In spite of the recent advances in therapy, rare and potentially life threatening complications may still arise from time to time and as a result account for significant morbidity and mortality. A case of Ludwig's angina reported at A.B Shetty Memorial Institute of Dental Sciences, Mangalore, India resulting in fatality, in spite of surgical and antibiotic treatment, due to underlying systemic condition and involvement of multiple resistant organisms. The condition was worsened by subsequent esophageal rupture and death occurred due to multiple organ failure.
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Affiliation(s)
- Amit Mohan
- Department of Oral and Maxillofacial Surgery, A.B Shetty Memorial Institute of Dental Sciences, Deralakatte, Mangalore, Karnataka 575018 India
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9
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Is surgical airway necessary for airway management in deep neck infections and Ludwig angina? J Crit Care 2011; 26:11-4. [DOI: 10.1016/j.jcrc.2010.02.016] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2009] [Revised: 02/23/2010] [Accepted: 02/27/2010] [Indexed: 11/20/2022]
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10
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Abstract
A retrospective study was performed on fourteen cases of deep cervical space infections in the neck admitted for diagnosis and treatment to the ENT Department, during a period of seven years from 1989-1997. Of the fourteen, four patients had Ludwig's angina and of the fourteen, one had a very serious complication resulting in death. Early diagnosis and adequate treatment were of paramount importance. The role of tracheostomy and management of airway in deep cervical space infections of the neck is discussed to gether with bacteriology, antibiotic treatment and surgical management.
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Affiliation(s)
- S. Kaluskar
- ENT Department, Tyrone County Hospital, Omagh, UK
| | - P. Bajaj
- ENT Department, Tyrone County Hospital, Omagh, UK
| | - P. Bane
- ENT Department, Tyrone County Hospital, Omagh, UK
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12
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Gaspari RJ. Bedside ultrasound of the soft tissue of the face: A case of early Ludwig’s angina. J Emerg Med 2006; 31:287-91. [PMID: 16982363 DOI: 10.1016/j.jemermed.2005.11.044] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2005] [Revised: 07/11/2005] [Accepted: 11/02/2005] [Indexed: 10/24/2022]
Abstract
A case is reported of a 38-year-old man presenting with early Ludwig's angina. It is difficult to differentiate superficial from deep infections of the face and neck by physical examination alone. The diagnosis of this condition with bedside soft tissue ultrasound of the face is described. Ludwig's angina is an uncommon infection of the deep tissues of the face and neck that usually evolves from more superficial infections such as dental abscesses.
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Affiliation(s)
- Romolo J Gaspari
- Division of Emergency Ultrasound, Department of Emergency Medicine, University of Massachusetts School of Medicine, Worcester, Massachusetts, USA
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13
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Chaudhary N, Agrawal S, Rai AK. Descending Necrotizing Mediastinitis: Trends in a Developing Country. EAR, NOSE & THROAT JOURNAL 2005. [DOI: 10.1177/014556130508400418] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Descending necrotizing mediastinitis is believed to be a rare and serious complication of odontogenic and oropharyngeal infections. It is associated with a high (up to 40%) mortality rate, which can be attributed to delays in diagnosis and inadequate surgical drainage. Between May 1999 and September 2002, we treated 7 cases at our institution in New Delhi, indicating that such fulminating infections are not so rare in developing countries. In our 7 cases, a high index of suspicion and early computed tomography helped us make a rapid diagnosis and initiate prompt treatment, which resulted in a favorable outcome in 6 cases (mortality rate: 14.3%).
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Affiliation(s)
- Neena Chaudhary
- Department of Otolaryngology, Safdarjung Hospital, New Delhi
| | - Sanjay Agrawal
- Department of Otolaryngology, Safdarjung Hospital, New Delhi
| | - Anil K. Rai
- Department of Otolaryngology, Safdarjung Hospital, New Delhi
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14
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Biasotto M, Pellis T, Cadenaro M, Bevilacqua L, Berlot G, Di Lenarda R. Odontogenic infections and descending necrotising mediastinitis: case report and review of the literature. Int Dent J 2004; 54:97-102. [PMID: 15119800 DOI: 10.1111/j.1875-595x.2004.tb00262.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Descending necrotising mediastinitis is a rare complication secondary to oral surgery or odontogenic infections which ultimately spreads to the mediastinum through the anatomical cervical spaces. Delay in diagnosis, despite broad-spectrum antimicrobical therapy and extensive surgical intervention, results in an unacceptably high mortality rate (almost to 40%). A case study is presented as a rationale for a review of the current literature and to analyse the evolution in therapies, both medical and surgical from Pearse in 1938 to today.
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15
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Potter JK, Herford AS, Ellis E. Tracheotomy versus endotracheal intubation for airway management in deep neck space infections. J Oral Maxillofac Surg 2002; 60:349-54; discussion 354-5. [PMID: 11928085 DOI: 10.1053/joms.2002.31218] [Citation(s) in RCA: 75] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE The aim of the present study was to compare costs and outcomes for patients with deep neck infections who were treated with either tracheotomy or endotracheal intubation. MATERIALS AND METHODS The charts of 85 patients with deep neck space infections were retrospectively studied. Requirements for inclusion in the study were incision and drainage in the operating room, involvement of more than 1 deep anatomic space, impending airway compromise, and maintenance of a postoperative artificial airway. The 85 patients were divided into 2 groups based on the type of airway used for treatment. Group 1 (n = 34) included patients who received a tracheotomy, and group 2 (n = 51) included patients whose airways were maintained with endotracheal intubation until the swelling had resolved sufficiently for extubation. RESULTS Patients in group 1 had a shorter overall hospital stay (4.8 vs 5.9 days, NS) and spent less time in the intensive care unit (1.1 vs 3.1 days, P <.05). The overall incidence of complications was 6% for group 1 and 10% for group 2. The rate of complications secondary to loss of airway was 3% for group 1 and 6% for group 2. Average costs associated with intensive care resources were 5 times greater and overall hospital stay costs were 60% greater for group 2. CONCLUSIONS Although both methods of airway control are useful and have a unique set of complications, the use of tracheotomy allowed earlier movement to a noncritical care unit and was associated with fewer intensive care costs and less overall cost of hospitalization. Tracheotomy may therefore provide better utilization of critical care resources in this group of patients.
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Affiliation(s)
- Jason K Potter
- Oral and Maxillofacial Surgery, University of Texas Southwestern Medical Center, Dallas, TX 75390-9109, USA
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Sakamoto H, Aoki T, Kise Y, Watanabe D, Sasaki J. Descending necrotizing mediastinitis due to odontogenic infections. ORAL SURGERY, ORAL MEDICINE, ORAL PATHOLOGY, ORAL RADIOLOGY, AND ENDODONTICS 2000; 89:412-9. [PMID: 10760723 DOI: 10.1016/s1079-2104(00)70121-1] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Acute purulent mediastinitis caused by oropharyngeal infection is termed descending necrotizing mediastinitis. Such infections usually have a fulminate course, leading to sepsis and frequently to death. The purpose of this study is to show the importance of early diagnosis, aggressive surgical intervention, and optimal antibiotics chemotherapy in controlling this fatal infectious disease. STUDY DESIGN Two patients with descending necrotizing mediastinitis due to odontogenic infection who were treated at our institution are described. RESULTS Both patients survived. CONCLUSIONS From the patients, 23 different aerobic and anaerobic bacteria were isolated. All of the isolates were susceptible to carbapenem. Early evaluation by means of cervicothoracic computed tomography scanning was extremely useful for diagnosis and surgical planning. Knowledge of anatomic pathways from the mouth to the mediastinum is essential. We believe that tracheostomy is not always necessary. In both of the cases presented, mediastinal drainage was completed through use of a transcervical approach. However, a more aggressive drainage including tracheostomy might be necessary when the infection extends below the carina.
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Affiliation(s)
- H Sakamoto
- Tokai University, Department of Oral Surgery, School of Medicine, Kanagawa, Japan
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Britt JC, Josephson GD, Gross CW. Ludwig's angina in the pediatric population: report of a case and review of the literature. Int J Pediatr Otorhinolaryngol 2000; 52:79-87. [PMID: 10699244 DOI: 10.1016/s0165-5876(99)00295-5] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Ludwig's angina is a rapidly progressing cellulitis involving the submandibular neck space. It is characterized by brawny induration of the submental region and floor of mouth, bearing the potential for rapid airway obstruction. Airway management, antibiotics, and judicious surgical intervention are the mainstays of successful therapy. We present a case of Ludwig's angina in a 5-year-old child and offer a meta-analysis of pediatric cases of Ludwig's angina described in the literature over the past 30 years. The presentation, etiology, management, and potential complications of this disorder in the pediatric population are discussed.
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Affiliation(s)
- J C Britt
- Department of Otolaryngology-Head and Neck Surgery, University of Virginia Health Sciences Center, P.O. Box 10008, Charlottesville, VA 22906-0008, USA
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Abstract
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.
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Affiliation(s)
- S P Neff
- Department of Anaesthesia, Green Lane Hospital, Auckland, New Zealand
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19
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Hernández-Cosido L, Jiménez M, Varela G. [Tracheotomy complicates disease in patients with mediastinitis of oropharyngeal origin]. Arch Bronconeumol 1997; 33:315-6. [PMID: 9289331 DOI: 10.1016/s0300-2896(15)30605-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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20
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González Aragoneses F, Moreno Mata N, Orusco Palomino E, Vázquez Pelillo J, Peña González E, Folque Gómez E. Mediastinitis descendente necrosante de origen orofaríngeo. Arch Bronconeumol 1996. [DOI: 10.1016/s0300-2896(15)30722-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
Modern dental care and use of antibiotics for oral infections have made Ludwig's angina rare. To avoid acute airway obstruction, emergency physicians must be able to rapidly recognize and treat this condition. A typical case of Ludwig's angina is presented, followed by a review of clinical findings and therapeutic modalities. Emphasis is made on airway management, antibiotics, and surgical drainage.
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Affiliation(s)
- S J Spitalnic
- Department of Emergency Medicine, Brown University, Rhode Island Hospital, Providence 02903, USA
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Abstract
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.
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Affiliation(s)
- H Alsoub
- Hamad Medical Corporation, Doha, Qatar
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Iwu CO. Ludwig's angina: report of seven cases and review of current concepts in management. Br J Oral Maxillofac Surg 1990; 28:189-93. [PMID: 2135660 DOI: 10.1016/0266-4356(90)90087-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Ludwig's angina is a rare type of facial infection, which formerly invariably was fatal, but now, with adequate surgical and antibiotic treatment, has a much reduced mortality. Seven cases, two of which were fatal, were managed at the University of Benin Dental Hospital, Nigeria between 1981 and 1986. In five cases large doses of antibiotics, incision and drainage and extraction of involved teeth, proved to be effective therapy without the need for tracheostomy. In the two fatal cases, death was associated with inadequate antibiotic therapy.
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Affiliation(s)
- C O Iwu
- School of Dentistry, University of Benin, Nigeria
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Wheatley MJ, Stirling MC, Kirsh MM, Gago O, Orringer MB. Descending necrotizing mediastinitis: transcervical drainage is not enough. Ann Thorac Surg 1990; 49:780-4. [PMID: 2288561 DOI: 10.1016/0003-4975(90)90022-x] [Citation(s) in RCA: 143] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
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.
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Affiliation(s)
- M J Wheatley
- Department of Surgery, University of Michigan Medical Center, Ann Arbor 48109
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Abstract
Antibiotics can be used as an adjunct to endodontic treatment in a number of ways--locally, systemically and prophylactically. The local or intra-canal use of antibiotics in the form of medicaments is common. However, the commercially available agents for this purpose may not be the ideal mixtures. Systemic antibiotics should be restricted to patients who have local signs of infection, malaise and elevated body temperature. Prophylactic use of antibiotics has been recommended for patients 'at risk' of infective endocarditis, in some pre-surgical situations and following avulsion and replantation of teeth. The tendency towards indiscriminate antibiotic use should be discouraged. The use of broad spectrum drugs should be restricted so that these medications remain effective in serious situations.
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Affiliation(s)
- P V Abbott
- University of Western Australia, Perth Dental Hospital
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Rubin MM, Cozzi GM. Fatal necrotizing mediastinitis as a complication of an odontogenic infection. J Oral Maxillofac Surg 1987; 45:529-33. [PMID: 3473201 DOI: 10.1016/s0278-2391(87)80015-0] [Citation(s) in RCA: 35] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
A lethal thoracic infection originating in the oropharynx is described. Despite massive antibiotic therapy, tracheostomy and two attempts at cervicomediastinal drainage, the patient expired.
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