Ludwig's Angina Research Articles

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

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

Variation of the mylohyoid: implications for Ludwig angina, cervical contouring, and digastric muscle transfer

The mylohyoid (MH) musculature separates the sublingual and submandibular spaces and is, therefore, important with regard to the spread of infection and space occupying lesions. Moreover, the MH may be elevated and included in the myocutaneous submental island flap or sutured in conjunction with the platysmas and the anterior bellies of the digastric muscles (ABDMs) to add stability to submental muscular medialization procedures. Therefore, variation in the anatomy of the MH musculature must be considered in the management of the spread of infection and space occupying lesions as well as in surgical planning. This report reviews mylohyoid variations and documents a unique case in which several suprahyoid muscular variations occurred concurrently. The variations included isolated anterior bellies of the mylohyoid inserting into the geniohyoid thereby forming mylo-geniohyoid muscles as well as isolated posterior bellies of the mylohyoid inserting into the ABDM and the intermediate tendon of the digastric muscle thereby forming mylo-digastric muscles. Surgeons operating in the suprahyoid region should be aware of potential anatomical variation of the mylohyoid to develop contingency plans.

Ludwig's angina: an analysis of sixteen cases at Hasan Sadikin Hospital, Bandung, Indonesia

Ludwig's angina: an analysis of sixteen cases at Hasan Sadikin Hospital, Bandung, Indonesia

Ludwig's Angina: Report of 40 Cases and Review of Current Concepts in Emergency Management in a Rural Tertiary Facility Teaching Hospital

ABSTRACT Objective To review the current protocols and assess their efficacy in the emergency management of cases presenting with Ludwig's angina. Materials and methods A retrospective study of patients diagnosed with Ludwig's angina, admitted and treated in our institution between November 2007 and December 2012. Results There were 40 cases with 24 males (60%) and 16 females (40%), ages ranged between 16 and 80 years. Duration of symptoms was between 3 days and 2 weeks. The most common cause was dental infections seen in 23 cases (57.5%), one of them was a pregnant lady. Six were due to habitual tooth pricking with a broom stick (15%). In 3 patients it was due to submandibular duct stenosis secondary to calculi (7.5%). Five patients had diabetes as underlying disease (12.5%). Facial trauma contributed in 2 patients (5%) and in 1 patient it was due to carcinoma buccal mucosa (2.5%). All the patients were treated with systemic broad spectrum antibiotics, intravenous fluids, and analgesics. Twenty patients (50%) underwent tracheostomy with surgical decompression through small incisions under local/ general anesthesia. Ten patients (25%) were subjected to incision and drainage with subsequent removal of the diseased teeth. Ten patients (25%) were managed conservatively with antibiotics, analgesics, and under close supervision for airway compromise. There were no complications recorded and no mortality. Conclusion Ludwig's angina is a life-threatening surgical emergency. Early diagnosis and immediate surgical intervention can save lives. The appropriate use of parenteral antibiotics complemented with airway protection and surgical decompression remains the standard treatment protocol in advanced cases of Ludwig's angina. How to cite this article Ambikavathy M, Kumar S. Ludwig's Angina: Report of 40 Cases and Review of Current Concepts in Emergency Management in a Rural Tertiary Facility Teaching Hospital. Int J Head Neck Surg 2017;8(1):11-14.

Ludwig's angina in pregnancy and puerperium: Case series in an academic hospital, Sokoto, Northwest Nigeria

Ludwig's angina (LA) otherwise known as angina ludovici is a potentially life-threatening diffuse cellulitis of the neck, the floor of the mouth and submandibular regions bilaterally leading to airway obstruction. This condition during pregnancy and puerperium is rare. Many physiological changes occur through pregnancy and puerperium that place the mother at a higher risk of infection or deteriorating condition once infected. This change includes, reduced immune response resulting in potential faster progression of an infection. We report two cases of LA in third trimester of pregnancy and two cases during peurperium within 5 months at the Departments of Dental and Maxillofacial Surgery and Obstetrics and Gynaecology, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria. Treatment modalities and challenges involved in their management were also discussed. Overall, three patients survived the disease, two cases of LA in pregnancy and one case of LA in the puerperium, one patient in the puerperium died due to overwhelming sepsis. The babies of both patients in the puerperium survived, although they came in with very low birth weight and failure to thrive. They were managed in the special care baby unit of the hospital. Management of LA in a resource and personnel scarce setting is demanding especially in special group of patients such as pregnancy and puerperium. Multidisciplinary approach in management is essential, especially in the antenatal period of the patient.

Group B Streptococcus Infection Presenting as Ludwig's Angina Beyond Infancy

Ludwig’s angina is a serious and rapidly progressive cellulitis of the floor of the mouth which involves the submandibular, sub-maxillary, and sublingual spaces of the face. It uncommonly occurs in adults and children and its early recognition is paramount. With early diagnosis, airway observation and management, aggressive intravenous antibiotic therapy, and judicious surgical intervention, this disease should resolve without any complications. Here we report a case of an immunocompetent adolescent who developed Ludwig’s Angina due to Group B Streptococcus (GBS) infection who was successfully treated with surgical intervention and antibiotics therapy. To our knowledge this is the first reported case of GBS infection beyond infancy presenting as Ludwig’s Angina in an immunocompetent adolescent. There are other reported cases in the literature of GBS infection presenting beyond infancy but none of the cases presented with Ludwig’s Angina.

Odontogenic phlegmon of the mouth floor: a case report

Odontogenic phlegmon of the mouth floor—Ludwig's angina (phlegmonae fundi cavi oris seu angina Ludovici)—is a rare, life-threatening, local complication in most cases of odontogenic inflammation. This study presents the case of a patient treated in the Department of Maxillofacial and Plastic Surgery of the University Hospital in Białystok due to phlegmon of the mouth floor resulting from odontogenic inflammation with a dynamic course. Quick diagnostics, surgical intervention as well as antibiotic therapy contributed to its efficient and successful treatment.

Pregnancy Complicated By Odontogenic Facial Space Infection; A Study

Introduction: Odontogenic neck space infections represent a severe disease with possible life-threatening complications. Therapy of severe neck infections is even more crucial during pregnancy because of the possible life-threatening situation for both the mother and the foetus. Aim: The study was done to describes the course of a deep neck space infection in pregnant patients, commencing with typical symptoms of localized odontogenic infection and ending in a critical, life-threatening condition for the patient. Study Design /Material & Methods: The 14 pregnant females were randomly selected to describes the course of a deep neck space infection in pregnant patients, commencing with typical symptoms of localized odontogenic infection and ending in a critical, life-threatening condition for the patient. Implications for dental and medical treatment during pregnancy, especially regarding odontogenic infections, are presented and discussed with findings in the international literature. Conclusion: Infections are common in pregnancy due to hormonal changes and altered immunological activity aggravating response to plaque accumulation and caries resulting in serious life threatening condition, like Ludwigs Angina. So Every mother should be closely examined by her dentist before and during pregnancy to avoid any deleterious complications for herself and the foetus.

Dental Caries: A Review

Dental caries, a chronic disease is unique among human and is one of the most common important global oral health problems in the world today. It is the destruction of dental hard acellular tissue by acidic by-products from the bacterial fermentation of dietary carbohydrates especially sucrose. It progresses slowly in most of the people which results from an ecological imbalance in the equilibrium between tooth minerals and oral biofilms which is characterised by microbial activity, resulting in fluctuations in plaque pH due to bacterial acid production, buffering action from saliva and the surrounding tooth structure. The microbial community of caries is diverse and contains many facultatively and obligately-anaerobic bacteria. S. mutans is the most primary associated with it. Dental caries can affect the human in various ways i.e. presence of tooth pain, infection or dysfunction of the stomatognathic system can limit the necessary ingestion of energetic foods, affecting the growth in children and adults as well as their learning, communication skills and recreational activities. Moreover, oral and pharyngeal cancers and oral tissue lesions are also significant health concern. Cavernous sinus thrombosis and Ludwig angina can be life-threatening. Due to this, treatment is needed for dental diseases which cost is normally high and is not feasible for all community due to limited resources such as time, person and money. Therefore, prevention is more affordable. Personal hygiene cares and dietary modification should be recommended.

Ludwig's angina complicated by fatal cervicofascial and mediastinal necrotizing fasciitis

A 54-year-old man, with a history of poorly controlled diabetes mellitus, presented to the emergency room with a three-day history of severe, progressive swelling of his neck associated with odynophagia. Oral cavity examination was remarkable for trismus with mouth opening limited to two fingers, edematous floor of the mouth, drooling and a carious second lower molar tooth. Physical exam was consistent with bilateral swelling of the neck, severe tenderness and symmetric induration in the submandibular area consistent with Ludwig's angina. On admission, leukocyte count was 7300/μL increasing to 26,000. Neck CT displayed gas in the fascial planes and musculature consistent with necrotizing fasciitis descending into the mediastinum and anterior chest (Fig. 1, Fig. 2). Blood cultures were negative and wound cultures were positive for an alpha-hemolytic streptococcus not further speciated and Actinomyces meyeri. Fig. 1 CT showing presence of gas in the anterior cervical space. Fig. 2 CT showing air dissecting into the anterior mediastinum. Broad-spectrum antimicrobials with Vancomycin and Imipenem/cilastatin were initiated; emergent surgical debridement and tracheostomy were performed (Fig. 3). During the hospital course he required multiple debridements and extraction of an infected second lower molar tooth. The clinical course was complicated by septic shock, acute respiratory distress syndrome and acute renal failure. Despite aggressive medical and surgical intervention, the patient expired from multisystem organ failure on day thirteen. Fig. 3 Extensive debridement with exposed sternomastoids and tracheostomy in situ. Ludwig's angina is an aggressive, potentially fulminant, deep neck infection often caused by dental infection/abscess from polymicrobial organisms [1]. It presents with fever, chills, mouth pain, drooling and dysphagia. Cervicofascial necrotizing fasciitis is rarely seen in patients with Ludwig's angina [2]. Clinical course and prognosis of patients with both conditions is determined by their immune status. Ludwig's angina superimposed by cervicofascial necrotizing fasciitis is a surgical emergency with a mortality rate of approximately >50%. The cornerstone of the treatment is securing the airway, providing efficient drainage, appropriate antimicrobials, and improving immunologic status [3]. Clinical presentation of Ludwig's angina can be subtle even in immunocompromised individuals with extensive underlying tissue destruction as seen in our case. It is important to maintain a high index of suspicion for necrotizing fasciitis in the setting of Ludwig's angina. Delay in the diagnosis and treatment is associated with a high mortality and morbidity [4].

Ludwig′s angina: Analysis of 28 cases seen and managed in Sokoto, Northwest Nigeria

Objectives: To determine the prevalence, seasonal presentation, and management of Ludwig's angina in Northwest Nigerian Tertiary Health Facility. Patients and Methods: Cases of Ludwig's angina that presented and managed by the Dental and Maxillofacial Surgery Unit of the Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria, between 2013 and 2015 were retrieved. Data were stored and analyzed using IBM SPSS (IBM Corp., Armonk, NY, USA) Statistics for windows version 20. Results: Over the review period, 36 patients presented with clinical features of Ludwig's angina. Only 28 cases were analyzed and 8 cases had incomplete data and were excluded from the analysis. Of the 28 patients, 23 (82.1%) were males while 5 (17.9%) were females with a male: female ratio of 4.6:1. The mean age of the sample was 32.3 ΁ 11.6, range 18-60 years. A majority of the patients were in low socioeconomic group with 11 (39.3%) patients being peasant farmers. Odontogenic infection was responsible for the disease in 27 (96.4%) cases while only 1 (3.6%) case was idiopathic. Of those with odontogenic etiology, 18 (64.3%) were due to sequelae of caries. Microbiology, culture, and sensitivity in few cases revealed Streptococcus species, Pseudomonas aeruginosa, and Staphylococcus aureus. Most of the cases recorded no bacterial growth after 24 h incubation period. Twenty-five patients (89.3%) survived the disease while 3 (10.7%) died. Conclusions: Management of Ludwig's angina in a resource- and personnel-scarce setting can be very challenging. Early surgical decompression, aggressive empirical antibiotics, and nutritional support have contributed to the low mortality in our series.

Acute Suppurative Sialadenitis Secondary to Excisional Ranula Biopsy in Child

ABSTRACT Introduction Ranulas are lesions that affect the salivary glands, and they are generally treated by excision; however, they can recur in some cases where the gland is not removed and they may progress to acute suppurative sialadenitis, yet such cases are rare, especially in children. Aims To report clinical management of occurrence of acute suppurative sialadenitis secondary to excisional biopsy of ranula in a child. Case report An 11-year-old female patient was diagnosed with ranula where excisional biopsy was performed. Subsequently, the patient developed infection, suggesting Ludwig's angina, after reevaluation, she was diagnosed with acute suppurative sialadenitis in the right mandibular gland; during the follow-up period, antibiotic therapy was introduced. Conclusion The close relationship of the biopsy site with the submandibular space and other structures of the neck required the completion of antibacterial prophylaxis associated with preoperative care, transoperative care, and postoperative care to combat opportunistic infections and their subsequent complications. Clinical Significance Suppurative sialadenitis and its subsequent complications may be considered, although rare, as a complication in cases of ranula. How to cite this article Pinheiro TN, Arid J, Maciel AP, Machado AFM, Monteiro ML, de Oliveira Daltoé M, de Carvalho FK. Acute Suppurative Sialadenitis Secondary to Excisional Ranula Biopsy in Child. Int J Experiment Dent Sci 2016;5(2):123-126.

Facial cellulitis and Ludwig's angina associated with calcium hydroxylapatite injection in an immunocompetent patient

Facial cellulitis and Ludwig's angina associated with calcium hydroxylapatite injection in an immunocompetent patient

Successful management of difficult airway: A case series

Management of difficult airway is widely recognized as one of the important tasks of an anesthesiologist. The problems related to it are known to be primary causes of life-threatening consequences. Herewith, we present a case series of difficult airway scenarios managed successfully with different techniques and airway gadgets. The following cases were managed successfully with appropriate airway techniques: 1) Ludwig's angina for drainage with awake fiberoptic intubation, 2) temporomandibular joint (TMJ) ankylosis for bilateral gap arthroplasty with fiberoptic intubation, 3) burn contractures for the release managed with intubating laryngeal mask airway (ILMA). Airway management is one of the vital aspects of clinical care provided by an anesthesiologist. The airway-related complications have significantly decreased due to better knowledge, skills of the anesthesiologist, and an array of airway gadgets. The three case scenarios of difficult airway were successfully managed with the appropriate airway gadgets suitable for each case without any untoward complication. Most airway problems can be solved with available gadgets and techniques, but clinical judgement borne of experience and expertise is crucial in implementing the skills in any difficult airway scenario.

Knowledge and awareness of medical doctors, medical students and nurses about dentistry in Nigeria

IntroductionVarious studies have reported poor awareness and knowledge of dentistry in the Nigerian population. There is, however, paucity of information assessing the knowledge and awareness of medical doctors/students and nurses about dentistry. The present study is aimed at determining the knowledge and awareness of medical doctors/students and nurses about dentistry.MethodsSelf-administered questionnaires were randomly distributed among medical doctors/students, and nurses of Obafemi Awolowo Teaching Hospitals’ Complex, Ile-Ife, Nigeria. Information collected using the questionnaire included participants’ biodata, questions evaluating dental awareness, knowledge of systemic and oral health connections as well as referral practices. The data analysis was done with STATA version 11 software.ResultsA total of 300 questionnaires were randomly distributed among doctors/students and nurses, 206 were returned (response rate of 69%). Of the returned questionnaires, 129(63%) were males and 77(37%) were females. There were 42 medical doctors, 49 nurses and 115 medical students. The mean age of the participants was 26.7 years (SD 5.2). Majority (99.5%) was aware of dental profession, but 92% had never referred patients for dental consultation. One third (31%) of medical doctors believed that Ludwig angina was a cardiac disease. A large proportion of the respondents (61%) see no need for routine dental visit while 27% would want to visit the dentist only when they had a dental complaint.ConclusionAlthough a large percentage of the participants claimed to be aware of dentistry, our findings revealed low level of knowledge and attitude to Dentistry. Efforts should be made towards closing this knowledge gap to achieve efficient oral health.

“Cannot Intubate, Cannot Ventilate” Scenario and Failed Tracheostomy in a Patient with Massive Neck Swelling: A Case Report

Introduction: Neck swelling associated with airway obstruction is a significant challenge in airway management. When the neck swelling is very large and the airway anatomy is grossly distorted, even surgical tracheostomy may prove impossible. Case report: We present a case of massive neck swelling causing airway compromise, complicated by difficult ventilation, intubation and failed tracheostomy. A 53-year-old woman presented with a submandibular swelling, diagnosed as Ludwig's angina. However she refused surgical intervention and only agreed to antibiotics. Six weeks later, she came in again with airway compromise. Endotracheal intubation was attempted in the operating theatre with otorhinolaryngology (ENT) surgeon backup. Intubation was difficult by direct laryngoscope and Glidescope video laryngoscope. Mask-ventilation and Proseal ventilation later became impossible. Emergency tracheostomy also failed because the trachea could not be located. She developed hypoxic cardiac arrest. Conclusion: Acute airway obstruction from massive neck swelling should be jointly managed by the anaesthetist, surgeon and a well-informed team in the operating theatre. Conscious sedation using dexmedetomidine or remifentanil infusion may allow the use of fibreoptic intubation in un-cooperative patients.

Deep Neck Space Infections: A Study of 76 Cases.

Deep neck space infections (DNSI) are serious diseases that involve several spaces in the neck. The common primary sources of DNSI are dental infections, tonsillar and salivary gland infections, malignancies, and foreign bodies. With widespread use of antibiotics, the prevalence of DNSI has been reduced. Common complications of DNSI include airway obstruction, jugular vein thrombosis, and sepsis. Treatment principally comprises airway management, antibiotic therapy, and surgical intervention. This study was conducted to investigate the age and sex distribution of patients, symptoms, presentation, sites involved, bacteriology, and management and complications of DNSI. This retrospective study was performed from October 2010 to January 2013, and included 76 patients with DNSI. Patients of all age groups and gender were included. All parameters including age, gender, co-morbidities, presentation, site, bacteriology, complications, and required interventions were studied. In our study, the majority of patients were in the 31-50-year age group. Males accounted for 55.26% of the sample and females for 44.74%, with a male:female ratio of 1.23. Most of the patients were from a rural background. Diabetes was found as a co-morbid condition in 10.52% cases. Neck pain was the most common symptom, identified in 89.47% cases. The most common etiological factor was odontogenic infection (34.21%), followed by tonsillar and pharyngeal infection (27.63%). The most common presentation was Ludwig's angina (28.94%), followed by peritonsillar abscess and submandibular abscess. In 50% of cases, Streptococcus and Staphylococcus were found in the culture. Surgical intervention was carried out in 89.47% cases. Emergency tracheotomy was required in 5.26% cases. DNSI can be life-threatening in diabetic patients, the immunocompromised, and elderly patients, and special attention should therefore be given to these groups. Early diagnosis and treatment is essential to prevent complications. All patients must be treated initially with intravenous antibiotics, with treatment subsequently updated based on a culture and sensitivity report. Due to poor oral hygiene, lack of nutrition, smoking and chewing of beetle nut and tobacco, odontogenic infections are the most common cause of DNSI. Thus, DNSI could be prevented by making the population aware of dental and oral hygiene and offering regular check-ups for dental infections.

Clinical features of deep neck infection: analysis of 77 patients.

This retrospective study aims to detect the prognostic factors which affect the duration of hospital stay and evaluate the complications which develop in patients with deep neck infection. The study included 77 patients (40 males, 37 females; mean age 42.4±20.1 years; range 11 to 88 years) treated with a diagnosis of deep neck infection in our clinic between November 2006 and November 2012. Patients' demographic and clinical features were analyzed to detect their associations with development of complications and hospitalization time. Odontogenic origin and submandibular localization were the most frequently observed clinical appearance. Of eight patients (10.4%) who developed serious complications, two (2.6%) died. Age, comorbidity, presence of anemia alone, Ludwig's angina and retropharyngeal involvement were associated with increased rate of complications (p<0.05); while sex, antibiotic usage prior to admittance and primary location of infection were not related (p>0.05). Submandibular localization and absence of leucopenia reduced the risk of complications (p<0.05). The mean duration of hospital stay was 12.9±8.7 days (range 2-59 days). Age, presence of comorbidity and development of complications extended the hospitalization period (p<0.05). In spite of the improvements in diagnosis and treatment, deep neck infection may be an important cause of mortality if complications develop. Comorbid anemia, Ludwig's angina and retropharyngeal involvement were identified as the strongest predictors in terms of development of complications. Duration of hospital stay extended in patients who developed complications.

Ear, Nose and Throat Emergencies and Anesthesia

ABSTRACT Ear, nose and throat (ENT) emergency procedures demand significant anesthetic challenges. Variety of emergency conditions like deep neck space infections (Ludwig's angina, retropharyngeal, parapharyngeal abscess), acute onset of stridor, epiglottitis, laryngotracheobronchitis, inhaled foreign bodies, facial injuries, etc. are a challenge to both the surgeon and the anesthesiologist and communication and cooperation is vital. Priority in emergency is to clear and secure the airway and consider requirement of ‘shared airway’. Preferred anesthesia and airway technique include awake flexible fiberoptic (FOB) guided intubation in cooperative patients’ and an inhalational induction in uncooperative patient or tracheostomy. Anticipation, vigilance, readiness for difficult intubation, emergency tracheostomy and team work is essential while managing ENT emergency procedures. How to cite this article Harde M, Bawankar T, Bhadade R. Ear, Nose and Throat Emergencies and Anesthesia. Int J Otorhinolaryngol Clin 2015;7(1):28-34.

Factors influencing Ludwig’s Angina

Introduction: Ludwig‘s angina is a rapidly progressive, potentially fulminant cellulitis involving the sub-lingual, submental and sub-mandibular spaces. It typically originates from an infected or recently extracted tooth, most commonly the lower second and third molars. Besides, poor nutritional status, lack of proper medical supports are still major predisposing factors in developing Ludwig‘s angina in countries like Bangladesh. Aim: Our study aimed to observe etiological factors, clinical presentations, causative agents and treatment response. Method: We carried out a cross sectional study among 26 patients with Ludwig‘s angina admitted in the department of ENT and Head-neck surgery in Mitford Hospital from January- December-2012. Results: In this study we found that males are predominantly affected than females (22 males and 4 females, ratio-5.5:1) with odontogenic infection (15, 57%) as source. We found history of recent tooth extraction in 5 cases (19.2%) &amp; organism was isolated from pus culture, Klebsiella in 5 cases (19.2%) out of 13 cases. In this study we found tooth cleaning habit of patients by tooth brush18 cases (69.2%). We elicited underlying systemic disease mainly Diabetes Mellitus in 4 cases (15.3%) and Chronic renal failure in some of our cases but could not reach in a conclusion as to whether systemic illness predisposes to Ludwig‘ angina. Conclusion: Our study suggests that prompt and thorough clinical evaluation and definitive care will considerably improve patient condition and reduce morbidity and mortality. DOI: http://dx.doi.org/10.3329/bjo.v20i1.22010 Bangladesh J Otorhinolaryngol; April 2014; 20(1): 5-7