The anatomy of the fasciae of the face and neck with particular reference to the spread and treatment of intraoral infections (Ludwig's) that have progressed into adjacent fascial spaces

Fascial structure of the anterior mediastinum: the surgical figure of the sternopericardial ligament and the role of affixing the thymus to the pericardium

Background

The fascial anatomy of the anterior mediastinum has not been thoroughly investigated. Only the sternopericardial ligament (SPL) has been defined and is often described as two independent tendons. However, these descriptions differ from our observations of thoracic surgery. Here, we aimed to precisely investigate the fascial anatomy, particularly the SPL, of the anterior mediastinum.

Methods

We surgically and radiologically observed and analyzed the fascial anatomy of the anterior mediastinum in patients who underwent surgery for anterior mediastinal disease at our institution between July 2009 and August 2018.

Results

A total of 55 thoracoscopic surgeries were performed. We observed a sagittal layer of fibrous tissue bridging the pericardium and sternum, in addition to the well-known fascial layers. Behind the lower bifurcation of the thymic glands, the thymic capsule was firmly fixed to the pericardium around the anterior aortopulmonary trunk. It thickened locally, formed a small white stripe, and occasionally deformed the pericardium by pulling it anteriorly. No other tendon-like structure was observed.

Conclusions

Our observation of the SPL showed differences from classical descriptions. The SPL is a sagittal fibrous collection showing a unique figure. Part of the SPL is thickened behind the thymus, anchoring the thymus to the pericardium in the midline. The SPL is part of the bottom of Grodinsky's Space 3 in the thorax. The SPL is visible in radiologic images, such as the anterior junction line on a plain chest radiograph.

A three-component model of the spinal nerve ramification: Bringing together the human gross anatomy and modern Embryology

Due to its long history, the study of human gross anatomy has not adequately incorporated modern embryological findings; consequently, the current understanding has often been incompatible with recent discoveries from molecular studies. Notably, the traditional epaxial and hypaxial muscle distinction, and their corresponding innervation by the dorsal and ventral rami of the spinal nerve, do not correspond to the primaxial and abaxial muscle distinction, defined by the mesodermal lineages of target tissues. To resolve the disagreement between adult anatomy and embryology, we here propose a novel hypothetical model of spinal nerve ramification. Our model is based on the previously unknown developmental process of the intercostal nerves. Observations of these nerves in the mouse embryos revealed that the intercostal nerves initially had superficial and deep ventral branches, which is contrary to the general perception of a single ventral branch. The initial dual innervation pattern later changes into an adult-like single branch pattern following the retraction of the superficial branch. The modified intercostal nerves consist of the canonical ventral branches and novel branches that run on the muscular surface of the thorax, which sprout from the lateral cutaneous branches. We formulated the embryonic branching pattern into the hypothetical ramification model of the human spinal nerve so that the branching pattern is compatible with the developmental context of the target muscles. In our model, every spinal nerve consists of three components: (1) segmental branches that innervate the primaxial muscles, including the dorsal rami, and short branches and long superficial anterior branches from the ventral rami; (2) plexus-forming intramural branches, the serial homolog of the canonical intercostal nerves, which innervate the abaxial portion of the body wall; and (3) plexus-forming extramural branches, the series of novel branches located outside of the body wall, which innervate the girdle and limb muscles. The selective elaboration or deletion of each component successfully explains the reasoning for the standard morphology and variability of the spinal nerve. Therefore, our model brings a novel understanding of spinal nerve development and valuable information for basic and clinical sciences regarding the diverse branching patterns of the spinal nerve.

The carotid sheath: Anatomy and clinical considerations

Objectives

The distinctive bilateral carotid sheaths (CS) reside in the neck region and form part of the deep cervical fasciae. Aspects of the CS anatomy are controversial, most notably its specific attachment sites and fascial makeup, which are key determinants for the spread of tumours and infections and surgical planning. This review aimed to organise the pertinent aspects relating to CS anatomy and pathology, explore their clinical relevance and highlight areas of disagreement in the literature.

Methods

A narrative review identified key papers relating to CS anatomy, histology, embryology, pathology and clinical and surgical significance using PubMed and Google Scholar. This was supported by a systematic review focused on the fascia forming the CS which was conducted using PubMed, Web of Science and Core Collection which yielded 22 papers.

Results

and Discussion: The CS surrounds the internal carotid artery, internal jugular vein, cranial nerves IX - XII, lymph nodes and nervous plexuses as they course from the jugular foramen superiorly down along into the mediastinum inferiorly. There are contradicting descriptions regarding the CS attachments at the extracranial skull base and within the mediastinum. Author descriptions of the CS fasciae are complex, varied and incongruent. Pathologies affecting the CS include malignancies of the nerves, vascular lesions and utilisation of the CS space as a corridor for the spread of deep neck infections.

Conclusion

This paper collates and presents pertinent anatomical and clinical aspects regarding the CS. A proper knowledge of the CS anatomy and structural relationships will optimise surgical approaches and orientation when operating within the region.

Lingual lymph nodes: Anatomy, clinical considerations, and oncological significance

Lingual lymph nodes are an inconstant group of in-transit nodes, which are located on the route of lymph drainage from the tongue mucosa to the regional nodes in neck levels I and II. There is growing academic data on the metastatic spread of oral cancer, particularly regarding the spreading of oral tongue squamous cell carcinoma to lingual nodes. These nodes are not currently included in diagnostic and treatment protocols for oral tongue cancer. Combined information on surgical anatomy, clinical observations, means of detection, and prognostic value is presented. Anatomically obtained incidence of lingual nodes ranges from 8.6% to 30.2%. Incidence of lingual lymph node metastasis ranges from 1.3% to 17.1%. It is clear that lymph nodes that bear intervening tissues from the floor of the mouth should be removed to improve loco-regional control. Extended resection volume, which is required for the surgical treatment of lingual node metastasis, cannot be implied to every tongue cancer patient. As these lesions significantly influence prognosis, special efforts of their detection must be made. Reasonably, every tongue cancer patient must be investigated for the existence of lingual lymph node metastasis. Lymphographic tracing methods, which are currently implied for sentinel lymph node biopsies, may improve the detection of lingual lymph nodes.

Early stages of development of the alar fascia (human specimens at 6-12 weeks of development)

In recent years, there has been much discussion concerning the cervical fasciae. The aim of this study is to confirm and to describe the development of the alar fascia as well as its relationship with nearby structures. Histological preparations of 25 human embryos (6-8 weeks of development) and 25 human fetuses (9-12 weeks of development) were studied bilaterally using a conventional optical microscope. Our study confirms the existence of the alar fascia and permits three stages to be established during its development. The initial stage (1st), corresponding to the 6th week of development (Carnegie stages 18-19), is characterized by the beginning of the alar fascia primordium in the retroesophageal space at the level of C7-T1. In the formation stage (2nd), corresponding to the 7th and 8th weeks of development (Carnegie stages 20-23), the alar fascia primordium grows upwards and reaches the level of C2-C3. In the maturation stage (3rd), beginning in the 9th week of development, the visceral, alar and prevertebral fasciae can be identified. The alar fascia divides the retrovisceral space (retropharyngeal and retroesophageal) into two spaces: one anterior (between the alar fascia and the visceral fascia and extending from C1 to T1, named retropharyngeal or retroesophageal space according to the level) and the other posterior (between the alar fascia and the prevertebral fascia, named danger space). We suggest that this latter space be named the retroalar space. This study suggests that alar fascia development is related to mechanical factors and that the alar fascia permits the sliding of the pharynx and the oesophagus during swallowing.

The Retaining Ligament of the Anterior Digastric Muscle

The anterior belly of the digastric muscle (ABDM) is important in numerous esthetic surgeries including rhytidectomy, alteration of the cervicomental angle via partial resection of the ABDM muscle belly, and suprahyoid muscular medialization and suspension. Recently, the connection between the ABDM and the mylohyoid muscle (MH) has been proposed as important for the mechanism of the digastric corset procedure. This report refers to the connection between the ABDM and the MH as a type of retaining ligament of the anterior digastric muscle (RLAD). This report is the first to directly demonstrate the existence of the RLAD, via photograph and video, and document variation in its attachment sites, its composition, and its behavior when traction forces are applied. In addition to the importance of the RLAD in plastic surgery, the RLAD may affect neurovascular structures between the ABDM and MH and serve as a physical barrier separating the submental fascial space from the submandibular fascial space and, therefore, influence the spread of infection.

SMAS Fusion Zones Determine the Subfascial and Subcutaneous Anatomy of the Human Face: Fascial Spaces, Fat Compartments, and Models of Facial Aging

BACKGROUND

Fusion zones between superficial fascia and deep fascia have been recognized by surgical anatomists since 1938. Anatomical dissection performed by the author suggested that additional superficial fascia fusion zones exist.

OBJECTIVES

A study was performed to evaluate and define fusion zones between the superficial and the deep fascia.

METHODS

Dissection of fresh and minimally preserved cadavers was performed using the accepted technique for defining anatomic spaces: dye injection combined with cross-sectional anatomical dissection.

RESULTS

This study identified bilaminar membranes traveling from deep to superficial fascia at consistent locations in all specimens. These membranes exist as fusion zones between superficial and deep fascia, and are referred to as SMAS fusion zones.

CONCLUSIONS

Nerves, blood vessels and lymphatics transition between the deep and superficial fascia of the face by traveling along and within these membranes, a construct that provides stability and minimizes shear. Bilaminar subfascial membranes continue into the subcutaneous tissues as unilaminar septa on their way to skin. This three-dimensional lattice of interlocking horizontal, vertical, and oblique membranes defines the anatomic boundaries of the fascial spaces as well as the deep and superficial fat compartments of the face. This information facilitates accurate volume augmentation; helps to avoid facial nerve injury; and provides the conceptual basis for understanding jowls as a manifestation of enlargement of the buccal space that occurs with age.

[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.

Necrotizing fasciitis of the head and neck: a case report

Necrotizing fasciitis (NF) is an infection that spreads along the fascial planes, causing subcutaneous tissue death characterized by rapid progression, systemic toxicity, and even death. NF often appears as a red, hot, painful, and swollen wound with an ill-defined border. As the infective process continues, local pain is replaced by numbness or analgesia. As the disease process continues, the skin initially becomes pale, then mottled and purple, and finally, gangrenous. The ability of NF to move rapidly along fascial planes and cause tissue necrosis is secondary to its polymicrobial composition and the synergistic effect of the enzymes produced by the bacteria. Treatment involves securing the airway, broad-spectrum antimicrobial therapy, intensive care support, and prompt surgical debridement, repeated as needed. Reducing mortality rests on early diagnosis and prompt aggressive treatment.

Review article: Maxillofacial emergencies: oral pain and odontogenic infections

Oral pain and odontogenic infections are common reasons for patients to present to EDs and general medical practice in Australia. Although most odontogenic infections can be managed on an outpatient basis, because of their proximity to the airway, infections in this region can be life threatening, requiring urgent surgical intervention and ICU management. This article focuses on the emergency assessment, triage and non-specialist management of oral pain and odontogenic infections.

Anatomic-histologic study of the floor of the mouth: the lingual lymph nodes

OBJECTIVE

The lingual lymph nodes are inconstant nodes located within the fascial/intermuscular spaces of the floor of the mouth. Oral tongue squamous cell carcinoma has been reported to recur and metastasize in lingual lymph nodes with poor prognosis. Lingual lymph nodes are not currently included in basic tongue squamous cell carcinoma surgery.

METHODS

Twenty-one cadavers (7 males, 14 females) were studied, aged from 57 to 94 years (mean age 76.3 years). The gross specimen of the floor of the mouth was divided into blocks: A (median nodes), B, B' (parahyoid), C, C' (paraglandular). Serial histological microslides were cut and stained with hematoxylin-eosin. Frequency of lingual lymph nodes in each block and their microscopic features were assessed.

RESULTS

The lingual lymph nodes in overall number of 7 were detected in 5 of the 21 cadavers (23.8%). The total incidence of lingual lymph node was 33.3% (7 nodes/21 cadavers). Block A failed to demonstrate any lymph nodes (0%); Blocks B, B'-2 nodes (9.5%) and 2 nodes (9.5%), respectively; Blocks C, C'-1 node (4.8%) and 2 nodes (9.5%), respectively. The mean lingual lymph node length was 4.1 mm (from 1.4 to 8.7 mm), the mean thickness was 2.8 mm (from 0.8 to 7.5 mm). Five cadavers (23.8%) revealed mucosa-associated lymphoid tissue. Atrophic changes appeared in 4 (57.1%) lingual lymph nodes.

CONCLUSION

The presence of lymph node-bearing tissue in the floor of the mouth is demonstrated. In account of resection radicalism and better local control the fat tissue of the floor of the mouth should be removed in conjunction to glossectomy. Further anatomic and clinical research is required to establish the role of lingual lymph node in oral squamous cell carcinoma recurrence and metastasis.

Level IIb CTV delineation based on cervical fascia anatomy in nasopharyngeal cancer

We carefully reviewed magnetic resonance (MR) images from 100 consecutive NPC patients and analyzed the lymph node distribution status at level IIb. We proposed several modifications of the existing consensus guidelines for determining the level IIb clinical target volume (CTV) in NPC patients.

Diversified and Unusual Presentations of Neck Space Infections: Still a Big Concern for Physicians

The aim of this clinical study was to find similarities; dissimilarities of neck space infections along with challenges faced by treating physician for their diversified clinical presentations and complications. Patients with neck space infections were compared for the purpose. The classic manifestations of these infections, such as high fever, systemic toxicity, and local signs were not present in all cases leading to dilemma in physician's decision making. They progress towards fatality very fast. Prompt recognition, diagnosis and management of such cases and complications are of paramount importance to reduce morbidity and mortality. In addition to broad spectrum antibiotic therapy along airway protection, surgical drainage is necessary in nearly all cases. Neck space infections still continue to be a well prevalent health problem in poor socioeconomic group in developing countries having significant morbidity as well as mortality.

Head and neck fascia and compartments: no space for spaces

An accurate understanding of the arrangement of cervical fascia and its associated compartments is essential for differential diagnosis, predicting the spread of disease, and surgical management. The purpose of this detailed review is to summarize the anatomic, clinical, and radiological literature to determine what is known about the arrangement of cervical fascia and to highlight controversies and consensus. The current terminology used to describe cervical fascia and compartments is replete with confusing synonyms and inconsistencies, creating important interdisciplinary differences in understanding. The term "spaces" is inappropriate. A modified nomenclature underpinned by evidence-based anatomic and radiologic findings is proposed. This should not only enhance our understanding of cervical anatomy but also facilitate clearer interdisciplinary communication.

Patterns of cervicofacial infections: analysis of the use of computed tomography

OBJECTIVE

The aim of this study was to determine which clinical, microbiological and radiological factors contribute to the need for repeated computed tomography (CT) imaging and surgical drainage.

METHODS

In this retrospective study, medical records of all patients who underwent surgical drainage of cervicofacial infections between January 2006 and August 2010 at a London tertiary referral centre were analysed. Patients who underwent CT due to a clinical suspicion of deep cervicofacial infection were divided into two groups: (1) single CT only and (2) repeated CT imaging. These groups were then compared using Fisher's exact test. Patients requiring return to theatre for additional exploration and drainage of collection were also analysed.

RESULTS

Four hundred and forty-five patients were admitted with cervicofacial infections, of whom 78 patients had a CT scan. The most frequent site of infection was the submandibular space, involving 54 % of patients. Among the patients who underwent repeated imaging compared to those who underwent a single CT scan, the parapharyngeal space was involved significantly more frequently (5/24 vs 2/54, p = 0.03), as was the presence of multiple-space infections (13/24 vs 15/54, p = 0.04) and osteomyelitis (4/24 vs 0/54, p = 0.007). Multiple-space infection was also more frequent in the group who required repeat visits to theatre as compared to those who had a single drainage (7/9 vs 23/69, p = 0.02).

CONCLUSIONS

The majority of cervicofacial infections are managed without the need for CT scanning. Presence of infection in multiple cervicofacial spaces and in the parapharyngeal space and presence of osteomyelitis result in persistent sepsis necessitating repeat imaging and drainage.

Ludwig's angina in the pediatric population

As many as 1 in 3 of cases of Ludwig's angina occur in children and adolescents, and pediatricians are therefore ideally situated to detect these individuals at an early stage of their potentially life-threatening disease. The early identification and referral of children afflicted with Ludwig's angina to tertiary care centers allows for the rapid initiation of medical therapy and the consultation of those emergency services critical to providing such patients with optimal diagnostic and therapeutic interventions. This review provides an overview of the anatomical and pathophysiological considerations in Ludwig's angina and describes practical management principles to assist pediatricians in the diagnosis and treatment of this disease. Included in this review is an evidence-based algorithm for airway management.

Necrotizing fasciitis of the head and neck: 34 cases of a single institution experience

We analyzed 34 patients with necrotizing fasciitis (NF) of the head and neck. According to the clinical presentation, we classified NF into the cervical and cranial type. Infection can spread along the superficial lamina or along the pretracheal lamina of the deep cervical fascia. In the first type, skin necrosis is the main sequelae, while in the second case, descending infection and mediastinitis are the main complications. Of the 34 patients, in 17 the infection progressed in the mediastinum. Due to aggressive surgical therapy and postoperative intensive care, the mortality rate remained low (1/17; 6%). In this analysis, we emphasize the importance of an accurate and fast diagnosis, followed by aggressive surgical therapy and a multidisciplinary approach.

Clinical aspects, diagnosis and treatment of the phlegmons of maxillofacial area and deep neck infections

INTRODUCTION

The problem of maxillofacial and neck tissue inflammatory diseases constantly draws attention of otolaryngologists and maxillofacial surgeons in assosiation with steady frequency of pathology. Despite a modern antibiotic therapy, there still exist cases in which an initial delay in diagnosis and treatment may result in a life-threatening situation.

MATERIAL AND METHODS

We have analyzed a clinical picture of 219 patients aged from 5 up to 91 years. The patients have been distributed according to the spread of purulent process and the laboratory research data into the following groups.

RESULTS AND DISCUSSION

In inoculations from a wound during the primary surgical treatment in 67.6% of patients 1 microorganism has been revealed, in 7.9%--2 microorganisms, in 5%--3 and more microorganisms, in 19.4% of patients microorganisms have not been revealed. The most frequent cultures extracted from wound contents, were staphylococci and streptococci (61.2%). The presence of mixed (aerobic and anaerobic) microflora in the inflammation center has been marked recently. We have analyzed 64 MRI and X-CT at suspicion on diffusion of purulent process in deep neck cellular space. In 52 patients the process was localized within the limits of neck spaces and in 12 patients--the pyoinflammatory process extended on mediastinum though the clinical suspicion on mediastinitis was only in 10 patients.

CONCLUSIONS

The treatment of maxillofacial and neck pyoinflammatory diseases and their complications remains a complex and difficult problem. Alongside with clinical methods of diagnosis of maxillofacial and neck pyoinflammatory diseases it is necessary to use accessory methods such as X-CT and MRI which clinical-diagnostic efficiency is very high. An antimicrobial therapy plays a significant role in the treatment of maxillofacial phlegmons. Antimicrobial regiments have been recommended and should cover the polymicrobial etiology.

Necrotizing fasciitis of the chest wall with a retropharyngeal abscess: case report and literature review

We herein report a case of a diabetic 49-year-old woman with anterior chest wall necrotizing fasciitis that caused a retropharyngeal abscess and discuss the literature surrounding necrotizing soft tissue infections of the chest wall. The patient was treated with serial wound debridements, antibiotic therapy, and percutaneous drainage and serial irrigation of the retropharyngeal abscess with a silicone catheter. The resulting defect was grafted with a split thickness skin graft.

Sudden death by laryngeal polyp: a case report and review of the literature

Sudden unexpected death in the context of bizarre or unusual behavior usually relates to acute drug intoxication or excited delirium. We report the case of a man who died suddenly while running naked on a public street. Although the initial death investigation was indicative of excited delirium or drug intoxication, autopsy revealed glottic obstruction by an inflammatory laryngeal polyp. Toxicologic studies were negative and investigation revealed presentation at a hospital the day before death with stridor. It is believed he developed airway obstruction while dressing at home and ran out on the street to find assistance. This case illustrates the importance of a thorough death investigation and a broad differential diagnosis when approaching a forensic autopsy.

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.

[Diffuse cervical cellulites and descending necrotizing mediastinitis]

OBJECTIVES

To give a report on the progress in physical examination, investigations and treatment of diffuse cervical cellulites (DCC) associated with descending necrotizing mediastinitis.

MATERIALS AND METHODS

A Retrospective study (1995-2005) of patients presenting DCC with mediastinitis was made. All had a cervical and thoracic Computed tomography (CT) scan. The references were collected by a Medline search.

RESULTS

Six men and 2 women, average ages 53 years were treated. Four had an immunodeficient status. Two had had an anti-inflammatory drug treatment without antibiotic treatment. The average for diagnosis and treatment was 4 days. In 2 cases we found a dental origin and in 6 cases a pharyngeal origin. The most frequently identified germs were streptococcus beta haemolytic group A and Prevotella. In 4 cases, no physical sign of mediastinitis was noted. The diagnosis of mediastinitis was made thanks to the thoracic CT scan. All the patients were treated by broad-spectrum antibiotic therapy. All had cervical and thoracic surgical drainage. Mediastinal drainage was made by cervical way in 3 cases and by thoracotomy in 5 cases. One patient died.

CONCLUSIONS

The DCC with mediastinum extension are serious infectious emergencies with a high mortality rate. Clinical diagnosis of mediastinitis is difficult. A thoracic CT scan should be performed systematically. Performing thoracotomy best controls mediastinal drainage.

Surgical management of Ludwig's angina

BACKGROUND

Ludwig's angina (LA) is a dangerous surgical condition that can cause severe airway compromise and death. There is controversy regarding the best way to manage the airway of patients with LA. Options range from conservative management involving close observation and i.v. antibiotics to airway intervention, including tracheostomy and endotracheal intubation using fibre-optic nasoendoscopy. We present evidence supporting a role for conservative airway management in a select subset of patients.

METHODS

This paper reviews 9 years' experience of treating patients with LA at Liverpool Hospital.

RESULTS

Twenty-one out of 29 (72%) of our patients were treated conservatively following initial clinical assessment. One of these patients subsequently deteriorated requiring emergency intubation. Of those treated non-conservatively at initial presentation, seven patients were able to be intubated using fibre-optic nasoendoscopy and one patient required tracheostomy under local anaesthesia.

CONCLUSION

A general discussion of issues related to the management of LA is presented. Based on our experience we conclude that there is a subset of patients with LA who can be managed safely with conservative management.

Bedside ultrasound of the soft tissue of the face: A case of early Ludwig’s angina

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.

A Review of Ludwig's Angina for Nurse Practitioners

PURPOSE

To discuss the causative factors, clinical course, and current treatment modalities for Ludwig's angina, a submandibular cellulitis, and to raise nurse practitioners' (NPs') awareness of this condition.

DATA SOURCES

Recent clinical articles, research, case studies, and medical texts.

CONCLUSIONS

Ludwig's angina may be fatal. Early diagnosis, aggressive antibiotic therapy, and management involving a multidisciplinary team approach are imperative for the patient to progress without complications.

IMPLICATIONS FOR PRACTICE

Education and awareness are crucial for successful diagnosis of and management of treatment for Ludwig's angina. Although NPs have a limited role in the treatment of Ludwig's angina, their ability to recognize the signs and symptoms will prompt emergency care and treatment and facilitate better outcomes for their clients.

Bilateral Submandibular Gland Infection Presenting as Ludwig's Angina: First Report of a Case

We diagnosed and treated a case of Ludwig's angina in a 45-year-old man who had edema of the floor of mouth and the tongue along with bilateral submandibular sialadenitis and sialolithiasis. We secured the patient's airway via nasal fiberoptic intubation in the surgical intensive care unit and administered intravenous antibiotics. The edema subsided, and the patient was extubated on the third postoperative day and discharged shortly thereafter. To our knowledge, this is the first reported case of a patient with bilateral submandibular sialadenitis and sialolithiasis presenting as Ludwig's angina. Despite the decreasing incidence of this disease, Ludwig's angina remains an important disease process because a failure to control the airway can have disastrous consequences. Proper diagnosis, airway control, antibiotic therapy, and occasionally surgical management are essential to ensure the safety of the patient.

Cervical necrotizing fasciitis of odontogenic origin: a report of 11 cases

PURPOSE

Although most cases of cervical necrotizing fasciitis (CNF) are odontogenic in origin, reports of this disease in the dental literature are sparse. The purpose of this study was to review the cases treated on our service, and to analyze the features of this disease and the responses to management, to supplement the understanding of this relatively rare and life-threatening disease.

PATIENTS AND METHODS

All cases of infection admitted to the OMS service in a period of 10.5 years were studied retrospectively. The diagnosis of CNF was established by the findings on surgical exploration and histologic examination. The patients' age, sex, medical status, causes of the infection, bacteriology, computed tomography scan findings, surgical interventions, complications, survival, and other clinical parameters were reviewed.

RESULTS

A total of 422 cases of infection were admitted, and 11 cases of cervical necrotizing fasciitis were found. The incidence of CNF was 2.6% among the infections hospitalized on the OMS service. There were 7 male and 4 female patients. Eight patients were older than 60 years of age. Seven patients had immunocompromising conditions, including diabetes mellitus in 4, concurrent administration of steroid in 2, uremia in 1, and a thymus carcinoma in 1. All patients showed parapharyngeal space involvement; four also showed retropharyngeal space involvement. Gas was found in the computed tomography scan in 6 patients, extending to cranial base in 3 of them. Anaerobes were isolated in 73% of the infections, whereas Streptococcus species were uniformly present. All patients received 1 or more debridements. Major complications occurred in 4 patients, including mediastinitis in 4, septic shock in 2, lung empyema in 1, pleural effusion in 2, and pericardial effusion in 1. All major complications developed in the immunocompromised patients, leading to 2 deaths.

CONCLUSION

The mortality rate in this study was 18%. Early surgical debridement, intensive medical care, and a multidisciplinary approach are advocated in the management of CNF.

Ludwig's angina in the pediatric population: report of a case and review of the literature

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.

Acute suppurative parotitis with spread to the deep neck spaces

This report describes the case of an elderly, diabetic woman who became dehydrated and developed acute suppurative parotitis, which caused marked swelling of her left face and neck. The parotid infection also extended by continuity into the lateral pharyngeal space and contiguous deep neck spaces, causing airway-threatening, extensive inflammation and swelling of the epiglottis and parapharyngeal soft tissues. The differential diagnosis and diagnostic rationale is discussed. The anatomy of the stylomandibular area is reviewed to explain how infection of the parotid can spread to the pharynx.

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.

Ludwig's angina: case report and review

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.

Computerized axial tomography to define the distribution of solution after stellate ganglion nerve block

STUDY OBJECTIVE

To define the spread of local anesthetic after C6 stellate ganglion nerve block using computerized axial tomography (CAT).

DESIGN

Prospective, open descriptive study.

SETTING

Outpatient pain consult center.

PATIENTS

10 ASA status I patients undergoing stellate ganglion nerve blocks for sympathetically maintained pain.

INTERVENTIONS

Radiocontrast and local anesthetic was given in 5 ml increments to 20 ml total volume for C6 stellate ganglion nerve blocks in eight patients and C7 in two patients.

MEASUREMENTS AND MAIN RESULTS

CAT scanning was performed at baseline and after 5, 10, 15, and 20 ml of injectate was administered. Cervical level and pattern of injectate spread was recorded after each increment. Neck pressure above C6 did not promote caudal spread. One half of the injections were beneath prevertebral fascia. Injections on top of the fascia spread more diffusely around C6. All injections in high volume reached the medial aspect of T1 around the head, not neck, of the first rib.

CONCLUSIONS

Solutions injected for C6 stellate ganglion nerve block concentrate medial to the stellate ganglion at T1. Thus, they must produce upper extremity sympathectomy by a mechanism other than contact with the ganglion.

Esthetic contour analysis of the submental cervical region: a study based on ideal subjects and surgical patients

A cephalometric analysis of the submental-cervical region was carried out by examining and comparing 16 white adults who had ideal submental-cervical esthetics with 16 adult orthognathic surgery patients who were treated by submental lipectomy or liposuction and various orthognathic surgical procedures. A normative data base of the submental-cervical region was derived from the ideal subject group. The submental-cervical morphology of the preoperative patients differed significantly from the ideal subjects. The submental-cervical angle (Sm-Ce) and the submental soft tissue thickness at C point (IBM-Sm) presented the greatest disparity between the ideal subjects (118.0 degrees, 28.0 mm) and the preoperative patients (158.3 degrees, 42.1 mm, each P < .001). After surgery, Sm-Ce and IBM-Sm decreased to 132.8 degrees (P < .001) and 28.7 mm (P < .001), respectively. By the end of 6 months postoperative, the mean values of Sm-Ce and IBM-Sm were 131.1 degrees and 28.6 mm. The submental soft tissue thickness of the patients 6 months after surgery was not statistically different from the ideal subjects (each P > .05). Orthognathic surgical procedures with concomitant submental lipectomy or liposuction had a significant effect on the contour of the submental and cervical soft tissues.

Cervical and mediastinal emphysema secondary to mandible fracture: case report and review of the literature

Cervical and mediastinal emphysema is a rare but serious, life-threatening complication associated with mandibular fractures secondary to high-impact trauma. A case is reported in which a 24-year-old white man involved in a motor vehicle accident presented with an isolated mandibular fracture, cervical emphysema, and pneumomediastinum. A review of the literature is presented, and relevant anatomy and management are discussed.

Thoracic complications of deeply situated serous neck infections

Nine cases of complicated deep neck infections, occurring during a period of twelve years are presented. Complications observed were cervico-thoracic necrotizing fasciitis in 3 cases, purulent pleural effusion in 6 cases, pericardial effusion in 2, mediastinitis in 8 cases, jugular vein thrombosis and rupture of the innominate artery in one case each. Although 2 cases were managed initially with blind endotracheal intubation, all cases finally required tracheostomy. A cervico-mediastinal approach was useful for the early mediastinal involvement. Two patients died because of inadequacy of the multiple surgical procedures resulting in persistent infection and multi-organ failure and one because of uncontrollable bleeding after innominate artery rupture.

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.

Tissue movement--a macrobiomechanical approach

The surgical movement of skin involves both a respect for the biological integrity of the involved tissues and an understanding of its mechanical properties. The interaction of tissue biology and mechanics on the level of the organism therefore represents a macrobiomechanical approach to tissue movement. An understanding of anatomy and tissue movement dynamics is key in the performance of successful cutaneous surgery.

Effects of upper dorsal sympathectomy on esophageal motility in humans

To evaluate the role of the sympathetic nervous system in modulating esophageal motility, esophageal manometry was performed on two groups of patients who underwent upper dorsal sympathectomy for relief of palmar hyperhydrosis. In six patients sympathectomy was done by the supraclavicular approach, with removal of T2 and T3 ganglia. Manometry was performed before the operation and three weeks after it. In seven other patients sympathectomy was done by the axillary approach, with removal of T2-T4 ganglia. Manometry in this group was performed 28.4 +/- 22.4 months after the operation. Fifteen individuals with an intact sympathetic system served as controls. Manometric parameters evaluated were esophageal contraction amplitude and duration and lower esophageal sphincter pressure. The difference between the results obtained in the pre- and postoperative periods in the first group was not statistically significant. The differences between the two patient groups and between the patient groups and the control group were not statistically significant either. We conclude that upper dorsal sympathectomy does not affect esophageal motility in man.