Sublingual Space Research Articles

Developmental studies of the sublingual and mandibular salivary glands in Japanese quails (Coturinx coturinx japonica)

BackgroundThe Japanese quail (Coturinx coturnix japonica) has a crucial role in the lives of humanity since the 12th century and continues to play main roles in our industry and scientific research. The advantages that the Japanese quail has, such as heavy egg production and high-quality meat with low cholesterol and fat contents, Moreover, the Japanese quail is easily managed, with high feeding conversion, low cost of investment, and high rate of returns. Salivary glands are a part of the lingual apparatus that secretes serios and mucous saliva. Whereas, the saliva secretions have different roles in the food variation, apprehension, and moisture of food bolus. The morphological and cytochemical analysis are done on 20 healthy Japanese quail embryos of 6th, 10th, 11th, and 13th days of incubation and 25 healthy quail chicks at hatching day old, 7th, 14th, 30th, and 60th days old. These samples are investigated histologically, histochemically, and scanned by electron microscopy serially. Our purpose of the study is to highlight the area of the oropharyngeal salivary glands and their role in food variation, as few studies spoke about that in Japanese quail.ResultsThe primordia of the sublingual and mandibular salivary glands were noticed at the 6th and 10th days of the prehatching respectively as an epithelial bud. After hatching, both primordia were elongated and differentiated into secretory units. These glands were mucous polystomatic tubulo-alveolar paired glands, which were situated in the submucosa of the oropharyngeal floor (sublingual floor and paralingual grooves). The sublingual glands consisted of 3–5 lobes extended from the two Os ceratobranchial by their wide ends caudally, to beyond the median sulcus of the prefrenular part of the sublingual space rostrally. The taste buds were variable in size and position. The mandibular glands lay on the paralingual groove, which arose at the 10-day old embryo. The mandibular glands were located dorsomedial to the sublingual glands and extended longitudinally from the rostral border of the frenulum linguae to the caudal tips of the sublingual glands. The taste buds decreased in volume and number with advancing age.ConclusionOverall, salivary glands increase in their alcianophilic activity of the secretions with advancing age, which indicates low PH within the secretory end pieces.

Acute upper airway obstruction caused by mouth floor cellulitis in a patient of advanced age: a case report and literature review.

Mouth floor cellulitis is a type of diffuse cellulitis involving the submandibular, submental, and sublingual spaces. This condition may cause asphyxia due to elevation and posterior deviation of the tissues of the floor of the mouth. The severity of submandibular gland infection often escalates in the presence of underlying comorbidities. Advanced age, hyperglycemia, and an immunocompromised status often lead to the rapid development of infection, resulting in complications such as acute upper airway obstruction. These complications increase treatment difficulty and the risk of mortality. We herein report a case involving an older adult with diabetes who developed mouth floor cellulitis secondary to a submandibular gland infection. Despite the severity of the submandibular gland infection, a timely, effective, and multidisciplinary approach improved the patient's prognosis.

Anatomy, Diagnosis, and Clinical Management of Deep Neck Space Infections

Any surgeon providing care to patients with congenital, oncologic, infectious, or traumatic processes impacting the head and neck should have an intimate knowledge of the local anatomy. The complex fascial system in this region results in a series of loosely and tightly bound spaces that can both harbor and/or facilitate the rapid spread of infections through these fascial planes and potential spaces. Deep neck space infections may occur spontaneously from cutaneous, lymphatic, odontogenic, otologic, salivary gland, sinus, and hematogenous sources or develop as the result of surgical/iatrogenic manipulation. These infections are typically polymicrobial, involving a mixture of Gram-positive cocci, Gram-negative rods, and beta-lactam-resistant anaerobes commonly found in the oropharyngeal flora. Other populations, such as immunocompromised or hospitalized patients, are particularly vulnerable to infection by certain opportunistic and antibiotic-resistant pathogens. Understanding the deep neck anatomy is crucial for predicting the spread of infection and guiding treatment strategies. The superficial and deep cervical fascial planes form a series of compartments and spaces including the retropharyngeal, danger, prevertebral, carotid, parapharyngeal, submandibular, sublingual, parotid, masticator, temporal, and infrahyoid spaces. Despite their rarity in the post-antibiotic era, deep neck space infections pose a significant threat as they progress rapidly and can quickly lead to life-threatening complications. Delayed clinical presentation is common due to the compartmentalization by fascial planes, therefore early recognition requires a high index of suspicion, thorough clinical examination, and diagnostic imaging studies, typically contrast-enhanced computed tomography (CECT). Treatment requires a multidisciplinary approach, including advanced airway management, administration of empirical broad-spectrum antibiotics, and surgical drainage when indicated. This review provides a comprehensive overview of deep neck space anatomy and its defining fascial planes, as well as discussions on epidemiology, specific microbiology, clinical presentation, diagnosis, antibiotic selection, and surgical treatment options.

Are Deep Odontogenic Infections Associated With an Increased Risk for Sepsis?

Quick Sequential Organ Failure Assessment (qSOFA) is recommended to identify sepsis. Odontogenic infection (OI) can progress to sepsis, causing systematic inflammatory complications or organ failure. The purpose of the study was to measure the association between OI location and risk for sepsis at admission. This retrospective cohort study included subjects treated for OI at Baylor University Medical Center in Dallas, TX, from January 9, 2019 to July 30, 2022. Subjects > 18years old who were treated under general anesthesia were included. OI limited to periapical, vestibular, buccal, and/or canine spaces were excluded from the sample. The primary predictor variable was OI anatomic location (superficial or deep). Superficial OI infection includes submental, submandibular, sublingual, submasseteric, and/or superficial temporal spaces. Deep OI includes pterygomandibular, deep temporal, lateral pharyngeal, retropharyngeal, pretracheal, and/or prevertebral. The primary outcome variable was risk for sepsis measured using a qSOFA score (0 to 3). A higher score (>0) indicates the patient has a high risk for sepsis. Covariates were demographics, clinical, laboratory, and radiological findings, antibiotic route, postoperative endotracheal intubation, tracheostomy, intensive care unit, admission, and length of stay. Descriptive and bivariate analyses were performed. A χ2 test was used for categorical variables. The Mann-Whitney U test was used for continuous variables. Statistical significance was P<.05. The sample was composed of 168 subjects with a mean age of 42.8±21.5 and 69 (48.6%) subjects were male. There were 11 (6.5%) subjects with a qSOFA score > 0. The relative risk of a qSOFA > 0 for a deep OI is 5.4 times greater than for a superficial OI (136 (95.8) versus 21 (80.8%): RR (95% confidence interval): 5.4 (1.51 to 19.27), P=.004). After adjusting for age, sex, American Society of Anesthesiologists score, and involved anatomical spaces, there was a significant correlation between laterality and the number of involved anatomical spaces and qSOFA score (odd ratio=9.13, 95% confidence interval: 2.48 to 33.55, adjusted P= <.001). The study findings suggest that the OI location is associated with the qSOFA score >0.

ENHANCING ORTHODONTIC TREATMENT FOR PATIENTS WITH SWALLOWING AND SPEECH DISORDERS

Introduction. At the modern level, disorders of the functions of the tongue are considered by scientists in close relationship with the condition of the cranio-mandibular structures, posturological changes and various general somatic disorders of the human body.&#x0D; The purpose of this study was to improve the effectiveness of orthodontic treatment outcomes for patients with disorders of tongue functions based on data obtained from the systematic review of revelant literature and own clinical experience.&#x0D; Materials and Methods. The research involved an analysis of contemporary national and international literature spanning from 2000 to the present. Additionally, the study summarized the clinical experience gained from examining and treating 1024 patients with swallowing and speech disorders over the past 8 years.&#x0D; Results. The "Algorithm for investigating the state and position of the tongue during swallowing and speech functions" has been formulated. This algorithm encompasses stages of clinical and paraclinical analysis, evaluating factors such as the tongue position, the condition of supra- and sublingual spaces, pharyngeal airways, hyoid bone position, as well as using techniques such as photopalatography, electropalatography, and electromyography. The corrective method we offer for addressing improper tongue positioning during swallowing and speech involves enhancing the patient's overall somatic condition through recommendations for a healthy diet, an active lifestyle, and specific myogymnastics. It further focuses on normalizing the myodynamic balance between the external and internal muscle circles of the dento-jaw area. Controlled myogymnastics for the tongue is facilitated using a specially designed device.&#x0D; Conclusion. The developed algorithm for studying the condition and position of the tongue during swallowing and speech functions, along with the proposed corrective method, promises to enhance the effectiveness of diagnosing malocclusion associated with or caused by tongue function disorders. This approach contributes to the objectification of results in orthodontic treatment.

Ludwig's Angina, Clinical Challenge in Pediatrics. – A Case Report

BACKGROUND: Ludwig's angina is a rapidly progressing cellulitis that occurs in the sublingual, submandibular, and submental spaces, with a high mortality rate due to its potential to obstruct the airway. Its primary cause is odontogenic, with polymicrobial infection being the most common scenario. The occurrence of this condition is less common in the pediatric population, but children are more susceptible to life-threatening complications. THE CASE: A two-year-old male preschooler, with no significant medical history, presented with a clinical picture evolving over six days. This was characterized by recurrent fever spikes (up to a maximum of 38.7 degrees Celsius) and a growing, stony, painful mass in the right cervical region measuring 5cm x 5cm. The patient had not shown improvement despite self-medication with amoxicillin at home. Upon admission to a regional hospital, a fixed, painful, stony mass was found in the right submandibular region. Blood tests revealed leukocytosis with a left shift, positive acute-phase reactants, and a neck ultrasound indicating upper cervical adenitis without abscess formation. Antibiotic treatment was initiated for six days. However, the fever persisted, and there was an increase in the size of the lesion, along with the formation of an abscess and limited neck rotation. Consequently, on the 12th day of illness, the patient was referred to a tertiary-level hospital where a large, fixed, stony lesion was observed in neck regions II and III, with no exclusion of a neoplastic process. The patient also experienced difficulty swallowing, necessitating a liquid diet. It was decided to perform drainage under sedation and a biopsy, which revealed a stony mass in the right neck region II extending into the submental space and midline. There were severe inflammatory changes in the subcutaneous tissue, necrotic lymph nodes, but no abscess was found. Pathological examination showed inflammatory infiltrate, recent hemorrhage and vascular congestion, with the initial suspicion being an infectious process. Flow cytometry of the cervical lymph node showed no alterations in the lymphoid series but an elevation of neutrophils. However, due to the characteristics and location of the lesion, a consultation with pediatric hematologic-oncology was sought, and they considered a low likelihood of malignancy. A tuberculin test was requested and returned negative results. A culture of the lesion also yielded negative results. During hospitalization, the condition was considered Ludwig's angina, and the patient continued to show a progressive reduction in temperature and adenitis. On the 21st day, the patient exhibited a reduction of approximately 90% in the size of the lesion, leading to the discontinuation of antibiotic treatment and subsequent medical discharge. CONCLUSION: Ludwig's angina is an infection that primarily affects the floor of the mouth, progressing rapidly and potentially compromising the patient's airways, thus warranting a medical emergency status. It is uncommon and can be mistaken for neoplastic diseases or other infections, highlighting the need for knowledge about this condition and a high degree of suspicion due to its potentially life-threatening consequences. The goal is to establish appropriate management through a multidisciplinary team, given the complexity of its manifestations.

A retrospective study of ludwig’s angina at the maxillofacial unit of the komfo anokye teaching hospital-kumasi, Ghana.

Introduction: Ludwig’s angina is a potentially life-threatening diffuse cellulitis involving the sublingual, submental, and submandibular spaces bilaterally and causing progressive airway obstruction. The microbiology of Ludwig’s angina is polymicrobial, but commonly isolated is Streptococcal spp. Aim: The current study aimed to retrospectively evaluate the prevalence of Ludwig’s angina at the Maxillofacial Unit of the Komfo Anokye Teaching Hospital, Ghana. Materials &amp; Methods: A 2-year retrospective analysis of patient records from January 2012 to December 2013 was undertaken. The studied variables included the aetiology, symptoms, signs, and treatment modalities. Descriptive analysis was done using charts, frequency, and tables.Results: The total number of admissions for maxillofacial space infections was 224, comprising 128 males and 96 females. The number of patients with Ludwig’s angina was 56, giving a prevalence rate of 25.0%. The commonest source of infection was of odontogenic origin (94.6%), and the teeth most involved were the first lower molars (37.5%). The predominant microorganisms isolated were E.coli, Klebsiella, and Pseudomonas spp. The majority of patients (94%) were managed medically and surgically with incision, drainage, and insertion of drains as well as extraction of affected teeth. The commonest antibiotic combination was amoxicillin/clavulanate potassium with metronidazole (65.5%), followed by crystalline penicillin with metronidazole (12.7%). Conclusion: The commonest cause of Ludwig’s angina was odontogenic, and the microorganisms cultured were E. coli, Klebsiella, and Pseudomonas. The commonest antibiotic combination used for treatment was amoxicillin/clavulanate potassium with metronidazole.

Structural analysis of the mylohyoid muscle as a septum dividing the floor of the oral cavity for the purposes of dental implant surgery: variety of muscle attachment positions and ranges of distribution

ObjectivesThe objective was to investigate the details of the attachments of the mylohyoid muscle to the mandible anterior to the hyoid and mylohyoid lines to understand the positional relationship between the sublingual space and the mylohyoid, knowledge that is essential for dental implant surgery in the incisal region, as well as the routes of communication between the sublingual space and other spaces.MethodsWhile evaluating the presence or absence of an anterior mylohyoid muscle fiber attachment to the mandible, sublingual gland herniation, spaces between muscle fascicles were also recorded as sites of penetration. The mean muscle thickness in each of these areas was also calculated.ResultsIn all specimens, the mylohyoid originated not only from the mylohyoid line but also from the lingual surface of the center of the mandibular body (the mandibular symphysis) below the mental spines. The mylohyoid muscle fascicles were thickest in the posterior region, and further anterior to this, they tended to become thinner. Sublingual gland herniations passing through the mylohyoid were noted in the anterior and central regions, but not in the posterior region. Penetration between the muscle fascicles was most common in the central region, and no such penetration was evident in the posterior region.ConclusionsThese results suggest that the mylohyoid functions only incompletely as a septum, and that routes of communication from the sublingual space to the submandibular space may be present in both the anterior and central muscle fascicles of the mylohyoid. Therefore, bleeding complications during dental implant placement in the anterior mandible can be serious issues. There is a potential for sublingual hematoma that could compromise the airway by pressing the tongue against the soft palate into the pharynx.

Ludwig’s Angina – A Case Report

Ludwing angina is defined as progressive cellulitis of the submandibular space. It is a deep neck space infection. The two compartments affected are the sublingual and sub mylohyoid space. It progresses rapidly and needs to be addressed urgently. Early identification and initiating treatment will aid in reducing morbidity and mortality.

Aggressive abscesses in the head and neck region of probable odontogenic origin – two case reports

Odontogenic infections are the most common type of infections of the head and neck among adults. They usually spread continuously from the mandible and/or maxilla into the sublingual, submandibular or masticatory spaces, then directly into the parapharyngeal space. They require comprehensive diagnostic and therapeutic management, as they may potentially lead to life-threatening complications. We present two clinical manifestations of aggressive abscesses in the head and neck region of probable odontogenic origin and discuss different therapeutic approaches. The first patient, a 31-year-old man, was admitted because of a tumor-like lesion within the right maxillary sinus. He complained of purulent nasal discharge of two weeks duration despite antibiotic therapy. In the Caldwell-Luc operation a cyst filled with puss was displayed, the sac of the cyst and the polypoid mass were removed. The second patient, a 28-year-old man, was admitted due to an abscess of the left half of the neck and viscerocranium, with a large edema of this area, neck pain, fever, dyspnea and lockjaw. The patient was qualified for surgery. During intubation, a purulent collection emptied into the oral cavity and throat. In both cases, simultaneously with the surgery, an empirical broad-spectrum antibiotic therapy was administered. Microbiological analysis of the material collected during the operations revealed Prevotella melaninogenica in the first case, and Streptococcus group C in the second. Treatment of aggressive odontogenic infections must take a comprehensive approach, including both surgical intervention and antibiotic therapy covering Gram-positive as well as Gram-negative aerobic and anaerobic pathogens.

Story of a Displaced Tooth – A Case Report

Various iatrogenic complication may be seen during extraction of mandibular 3rd molar. Displacement of mandibular 3rd molar into pterygomandibular space is usual but displacement into an unusual space like submandibular space or sublingual space is very rare. This can cause significant physical and psychological problems for the patient. The treatment for this kind of complications may vary from a conservative treatment to surgical procedure, what will depend on clinical features, symptoms, the location of the tooth, and its relation to adjacent structures. The present case report illustrates a rare complication of extraction of impacted mandibular third molar that was displaced into the sublingual region. Upon locating the tooth, successful removal of tooth was performed. Healing was uneventful after a 3 month of follow up.

AB175. SOH23ABS_026. An unusual case of thyroglossal duct cyst carcinoma presenting in the sublingual space, and its multidisciplinary management

Background: Thyroglossal duct cysts (TGDCs) are the most common congenital anomaly of thyroid gland development, with a <1% risk of malignancy occurring within them. It's rare for a TGDC to be located in floor of the mouth region or the sublingual space since both these areas are not part of the typical embryological migration route of the thyroid gland.

Ludwig’s angina in a child: a case report and literature review

BackgroundLudwig’s angina is a diffuse cellulitis in the sub-mandibular space, which extends to the sublingual space. It is an emergency that often occurs in adults as a complication of oral infections. It is rare in children and is particularly life-threatening due to the smaller size, as well as the characteristics in these spaces in a child. This is the case of Ludwig’s angina in a 2-year-old boy, with rapid onset of signs of respiratory discomfort, no dental or systemic etiology, and great evolution.Case presentationA little boy was brought by his mom to the emergency room for the onset a firm swelling in the sub-mental region along with pain and fever, which appeared 3 days prior to the consultation. He was first examined by a pediatrician who prescribed oral broad-spectrum antibiotics (amoxicillin). The symptoms worsened over 48 h, as the little boy presented respiratory discomfort in supine position.He was admitted in the emergency department. Without dysphagia or respiratory distress.The clinical examination showed swelling in the sub-mental and sub-mandibular region with/without trismus or signs of oral infection. The laboratory investigations showed hyper-leukocytosis with a microcytic hypochromic anemia.CRP = 300; HIV test was negative.The computed tomography (CT scan) showed a diffuse abscess in the sub-mental and sub-mandibular and sub-lingual regions.No mediastinal collection was found.The diagnosis of Ludwig’s angina was established.The patient underwent percutaneous surgical drainage of 15 ml of pus, which alleviated his symptoms, the treatment was carried out through broad-spectrum antibiotics, analgesics, and daily cleaning of the wound and change of surgical dressing. Bacteriological exam found gram-positive cocci in chains. The culture showed a Staphylococcus aureus. The patient presented clinical and biological improvement and was discharged after 7 days.Six months follow-up showed a healthy child, without signs of infection or any other complication.ConclusionLudwig’s angina in children -however rare- is a potentially life-threatening, rapidly spreading, bilateral swelling of the sub-mandibular. Its management is based on airway control, drainage of the collection and broad-spectrum intravenous antibiotics, as well as surveillance of the biological parameters.Early diagnosis and appropriate management enhances outcome and decreases mortality significantly.

Lemierre syndrome associated Cavernous Sinus Thrombosis and Development of Internal Carotid Artery Narrowing: A Case Report and Review of Literature (P2-5.005)

<h3>Objective:</h3> To report a case of Lemierre syndrome complicated by cavernous sinus thrombosis (CST) and bilateral internal carotid artery (ICA) stenosis without cerebral infarction in a young woman and summarize the literature on Lemierre syndrome with arterial involvement. <h3>Background:</h3> Lemierre syndrome is a complication of oropharyngeal infection characterized by thrombosis of the internal jugular vein (IJV) with septic thrombophlebitis followed by bacteremia and septic emboli dissemination to distal organs, but arterial involvement is extremely rare. <h3>Design/Methods:</h3> A 24-year-old previously healthy woman presented to the hospital with one week of progressive jaw pain and neck swelling after recent tooth extraction. Physical examination showed left ptosis without other neurologic deficits. Computer tomography (CT) of the neck found multiple anterior neck abscesses. The patient underwent emergent incision and drainage of abscess at the left lateral pharyngeal, left masticator, and bilateral sublingual space. Vascular imaging revealed findings of non-occlusive thrombus in the left IJV, bilateral cavernous sinus thrombosis (CST), and septic emboli in bilateral apical lungs, consistent with Lemierre syndrome. Neuroimaging showed no cerebral infarction even though a digital subtraction angiogram (DSA) demonstrated bilateral ICA severe stenosis (&gt;70%) in both extracranial and intracranial segments. Cultures of abscess samples proved positive for <i>Candida albicans</i> and <i>Streptococcus constellatus</i>. The patient received treatment with full-coverage antibiotics and anticoagulation therapy resulting in an excellent outcome. <h3>Results:</h3> A literature search yielded 29 cases of Lemierre syndrome with arterial complications, which manifested as ICA occlusion or stenosis, or mycotic aneurysm development. Despite variable clinical symptoms, most patients developed CST and were all treated with antibiotics. Anticoagulation therapy is controversial given scarce and inconsistent evidence. <h3>Conclusions:</h3> The presented case and literature review emphasize the variability of the clinical course of Lemierre syndrome. Septic CST can be a rare cause of ICA occlusion, stenosis, or pseudoaneurysms because of arteritis, and thus expedited workup is necessary. <b>Disclosure:</b> Dr. Zhou has nothing to disclose. Dr. Malik has nothing to disclose.

Infectious Disease

Infectious Disease

UPPER AIRWAY OBSTRUCTION: DELAYED COMPLICATION OF WARFARIN THERAPY

AIM- Report an unusual presentation of delayed complication of warfarin therapy leading to airway compromise. Warfarin is a BACKGROUNDwell-known oral anticoagulant and its major adverse side effect is bleeding (1-10%).Spontaneous hematoma of the sublingual and lingual space is an extremely rare and life threatening complication of warfarin sodium use and can lead to upper airway obstruction from elevation of the oor of mouth and tongue. -The case of a 40 year old male with complaints of swelling be CASE DESCRIPTION low chin and oor of mouth pushing the tongue backwards since 2 days and difculty speaking and swallowing since 1 day and difculty breathing since the past few hours is reported here. History revealed prolonged warfarin therapy. It was managed conservatively with withdrawal of warfarin and administration of Vitamin K and FFP. Prolonged warfarin therapy can lead to hematoma formation in the oor of mouth a CONCLUSION- nd neck swelling which can mimic Ludwig angina. The case can be managed conservatively with careful observation to avoid sudden upper airway obstruction.CLINICAL SIGNIFICANCE- Reporting of such case is warranted due to the need to create awareness of this life threatening complication of warfarin therapy, to preclude any diagnostic dilemma and to share our management of this dreaded complication.

An Observational Study on the Anatomical Characteristics of Acupoint CV23 (Lianquan) with Ultrasonography

Background: Acupoint CV23 is one of the most commonly used acupoints for the treatment of post-stroke dysphagia and tongue pain. However, care must be taken during the procedure to consider the position of glands and blood vessels in the subcutaneous space of the acupoint. Needling depths to the geniohyoid muscle reportedly range from 0.4 to 3.3 cm. Using ultrasound imaging, we aimed to observe the anatomical characteristics around acupoint CV23 to derive a safe needling depth.Methods: Ultrasound images of acupoint CV23 accessed from the Standard Ultrasound Image of Acupoint database were retrospectively analyzed for 30 participants aged in their 20s and 30s (15 male, 15 female), and the depth from the skin to the geniohyoid muscle was measured. Correlations between the needling depth and anthropometric factors (such as neck circumference) were analyzed.Results: The average needling depth to the geniohyoid muscle was 1.59 ± 0.49 cm (male; 1.43 ± 0.52 cm, female, 1.75 ± 0.42 cm, &lt;i&gt;p&lt;/i&gt; = 0.03). The geniohyoid muscle, anterior digastric muscles, and genioglossus muscle were observed in the subcutaneous area of acupoint CV23, and a risk of sublingual gland damage needs to be considered for oblique insertion of the acupuncture needle. No statistically significant correlations between the needling depth and anthropometric factors were observed.Conclusion: Acupoint CV23 has a relatively shallow needling depth, and considering the presence of blood vessels and glands in the sublingual space, visualizing the surrounding anatomical structures using ultrasound was helpful to ensure safe needling practice.

Sudden Death Due to Undiagnosed Ludwig’s Angina: An Autopsy Case Report

Ludwig’s angina is a rapidly progressive and gangrenous cellulitis in the submandibular, sublingual spaces, and neck. It is characterized by an elevated tongue and laryngeal edema, resulting in airway compromise and, rarely, in sudden death. The most common cause is an odontogenic infection of a molar tooth. Infection can spread to the superior mediastinum and buccal area through anatomical structures. Herein, we report the sudden death of a 45-year-old male who was not diagnosed with Ludwig’s angina. He died in the emergency room 20 minutes after loss of consciousness. Intubation was impossible owing to severe laryngeal edema. The C-reactive protein level was 33.81 mg/dL. On autopsy, a diffuse light green abscess of the submandibular space was detected, along with severe edema of the epiglottis, aryepiglottic fold, and vocal cords. Subsequently, we confirmed that the airway obstruction was caused by Ludwig’s angina based on a literature review. In conclusion, this report emphasizes the need to identify the infection source and perform a detailed dissection according to the anatomical structure in the autopsy procedure for Ludwig’s angina.

A rare case of paediatric sublingual keratinous cyst

The occurrence of keratinous cyst in the oral cavity is extremely rare. Keratinous cyst in the floor of the mouth is painless, doughy or fluctuant lesion and causes no symptoms until it is large enough to interfere with speech or eating. Cyst generally presents as slow and progressive growth and often not diagnosed until the second or third decade of life.We report an uncommon presentation of keratinous cyst of the sublingual space in a 6year old female child. The swelling was mimicking ranula on inspection. On complete examination, the swelling appeared as epidermoid cyst. After a routine evaluation of the sublingual mass, surgical excision was performed under general anaesthesia. This case report addresses novel information regarding simple yet effective way of managing a sublingual keratinous cyst in a paediatric patient.

Retrospective Cohort Study on the Management of Diffuse Deep Neck Space Infections Using a Modified Submental Approach and Placement of Wound Vacuum

Diffuse deep neck space infection (DDNSI) is an emergent condition that requires efficient surgical and airway management. A novel surgical approach has been developed to enhance access and improve visualization of the involved deep neck spaces, which allows for better evaluation of the extent of tissue necrosis. This study will compare the treatment of DDNSI with traditional incision and drainage with drain placement (Conventional) versus the new incision and drainage design with the use of a wound vacuum (VAC). This retrospective cohort study was performed on DDNSI cases treated with the VAC versus Conventional techniques from July 2014 to September 2020 at Memorial Hermann Hospital by the oral and maxillofacial surgery service. To be categorized as a DDNSI, the patient had to demonstrate radiographic evidence of an infection bilaterally in a minimum of four spaces, such as bilateral submandibular, sublingual, and submental spaces. Primary predictor variable was treatment method for DDNSI, Conventional versus VAC. Primary outcome variables were hospital length of stay (LOS), number of washouts, and days of intubation. Covariates were age, sex, number of spaces involved, presence of necrotic tissues, comorbidities, and mortality. Appropriate uni- and bi-variate statistics were calculated. Statistical significance was set a P < .05. Fifty-one patients (17 female and 34 male) aged 18 to 65years were treated for DDNSI. Twenty-eight patients were treated using the VAC approach and 23 patients were treated with the conventional approach. The average LOS 8.3± 0.8days (P-value=.0001), number of days intubated 3± 0.3 (P-value=.0001), and number of required washouts 2± 0.2 (P-value=.004) were statistically lower in the VAC group compared to the Conventional group. There were significant improvements encountered with overall length of hospital stay, number of days intubated, and the number of required wash outs. There were significant differences in outcomes between patients with comorbidities when compared to those who had none.