An unusual case of life-threatening airway compromise complicating a neck dissection

Abstract

Sir, The potential complications associated with neck dissection classically include damage to important neurovascular structures within the dissection parameters. However, there are no documented cases within the literature that describe severe delayed airway compromise as a result of unilateral or bilateral neck swelling in the perioperative period. A degree of post-operative swelling is to be expected, but delayed airway compromise requiring intubation and intensive care unit support following neck dissection is uncommon. We report an unusual case of severe unilateral neck swelling developing secondary to an elective neck dissection together with a discussion of current diagnostic and management strategies. A 64-year-old male underwent a left modified radical neck dissection (levels I–V) following previous excision of a 2.4 mm Breslow thickness melanoma on the left shoulder and subsequent cytology-confirmed metastatic lymphadenopathy in the left posterior triangle. Pre-operative intravenous augmentin was administered, and three drains were placed at the conclusion of surgery. Following an uncomplicated recovery, all drains were removed and the patient was discharged 6 days later. He subsequently presented 48 h post-discharge with rapid onset swelling of the left side of the neck. A CT scan suggested a collection in the submandibular region causing moderate airway compromise and midline airway shift (Figs. 1a, b and 2a, b). Re-exploration of the neck dissection identified marked swelling of the anterior belly of the digastric and myoglossus muscles, but no collections or haematoma. Microbiology swabs of the neck sent from theatre confirmed the presence of Staphylococcus aureus in the wound. Intravenous tazocin and clindamycin were commenced, and the patient returned to intensive care intubated. The patient was extubated after 36 h following clinical improvement and discharged the following day with no further episodes of neck swelling or long-term sequelae. Ludwig’s angina was the initial diagnosis in this patient, but given that the infection was unilateral, it did not fit the classical diagnostic criteria of bilateral neck swelling. Ludwig’s angina is a life-threatening cellulitis, usually originating in the submandibular space. This condition typically occurs secondary to odontogenic infections [1], with the most common pathogens identified as Streptococcus viridans, S. aureus and Staphylococcus epidermidis, and group B streptococcus [1, 2]. Other recognised causes include parapharangeal abscesses, mandibular fractures, oral piercings, submandibular gland sialadenitis and oral malignancy [1]. Those suffering from dental caries and systemic illnesses such as diabetes mellitus, malnutrition, alcoholism and immunosuppression are also at risk [2, 3]. Ludwig’s angina often begins as a mild infection which rapidly progresses to bilateral swelling of the neck and floor of the mouth with associated trismus, tongue elevation, and stridor, ultimately leading to airway compromise and asphyxia [1–4]. The presence of cellulitis helps to differentiate this condition from others such as haematoma [5]. Without treatment, Ludwig’s angina carries a high mortality of 50 %, although this figure is markedly reduced to 10 % by antibiotics and supportive treatment [1, 2, 6, 7]. * Philip Rubin Philip.Rubin@cddft.nhs.uk