A Case of Ludwig's Angina in an Adolescent
1
BACKGROUND • Ludwig’s angina is a serious form of cellulitis with a diffuse, acute, rapid spread of an abscess through the submandibular, sublingual, and submental soft tissue fascial planes • Sublingual space involvement results in elevation, posterior enlargement, and protrusion of the tongue (woody tongue) and can lead to airway compromise • Submandibular space involvement results in neck enlargement and tenderness (bull neck) • Additional signs include restricted neck movement, dysphagia, dysphonia, dysarthria, tachycardia, drooling, sore throat, trismus, voice change, elevation of the floor of the mouth, posterior and superior displacement or protrusion of the tongue, chills, fever, malaise, and dehydration • About 1 in 3 cases occur in children and adolescents, of which 50% are of odontogenic origin • 16-year-old male presented to the Emergency Department (ED) with bilateral facial swelling • Non-contributory medical history • Dental history: • Fracture of #30 restoration 1 year ago • Intense pain when eating which began 1 week prior • Treated by private practice dentist 2 days prior for mild intraoral swelling localized to #30 • Started penicillin with plan for #30 root canal therapy • Symptoms in ED: worsening bilateral neck swelling, dysphagia, mild shortness of breath when supine, voice changes, low- grade fever, pain level 7/10, and drooling • Had not eaten in two days but was tolerating liquids • Extraoral examination: bilateral indurated sublingual, submandibular and submental space swelling with diffuse erythema extending to neck and clavicles and labored breathing when supine with posturing • Intraoral examination: slight trismus with limited opening, elevated floor of the mouth, #30 recurrent caries with fractured restoration and with pain upon palpation and percussion, no vestibular obliteration or abscess noted • Consulted ENT and OMFS • ENT consultation: bedside fiberoptic scope revealed larynx visualization normal, not concerned for airway obstruction due to airway edema, tongue edema or retrusion, or obstructing masses or swelling • OMFS consultation: CT neck with contrast ordered, recommended IV ampicillin-sulbactam stat and plan for emergency surgery • CT report: ill-defined multiloculated abscess containing air measuring 44 mm x 40 mm x 28 mm in the submental region extending superiorly toward right mandibular angle, edema present above the hyoid bone, along right pharyngeal wall, and in the anterior right sublingual space extending to the right mandibular angle, displacement of the lingual fatty septum midline leftward, and bilateral lymphadenopathy near the hyoid bone A Case of Ludwig's Angina in an Adolescent Danesh DO, Hammersmith KJ, Laxer KR The Ohio State University and Nationwide Children’s Hospital, Columbus, OH REFERENCES AND ACKNOWLEDGEMENTS CONCLUSIONS CASE REPORT • Extraction of #30 under general anesthesia • Incisions at right submandibular and submental area below inferior border of mandible • Two extraoral penrose drains: one placed into the submandibular space and one placed through-and-through from right submandibular incision to midline incision in submental space • Moderate amount of purulence and serosanguinous drainage from submandibular and submental spaces noted • Surgical laboratory cultures taken of the right neck abscess: revealed many Streptococcus anginosis group isolates present (susceptible to vancomycin, penicillin, clindamycin, ceftriaxone, and ampicillin) • Cultures negative to Group A Streptococcus, Staphylococcus aureus, fungal elements, anaerobe, and acid fast bacilli isolates CLINICAL FINDINGS AND IMAGING PROCEDURES COMPLETED 1. Lin, H., O'Neill, A., & Cunningham, M. (January 01, 2009). Ludwig's Angina in the Pediatric Population. Clinical Pediatrics, 48, 6, 583-587. 2. Neville, B. W., Damm, D. D., Allen, C. M., & Chi, A. C. (2016). Oral and maxillofacial pathology. Acknowledgements: Dr. Ashok Kumar and the providers involved for guiding this patient’s management • Severe cases of facial swelling may progress to Ludwig’s angina and/or lead to complications, including post-operative respiratory failure • Management of significant facial swelling in adolescent and pediatric patients requires interdisciplinary collaboration and treatment • Following awake extubation, had respiratory failure secondary to upper airway obstruction with stridor and hypoxia • Jaw thrusts, oral airway, and repeat suctioning were attempted • Re-intubation completed with difficulty, and patient was sent to PICU • Patient was intubated until transitioned to BiPAP on post- operative day (POD) 1 • Transitioned to nasal cannula on POD 3 without further complications • Remained on IV ampicillin-sulbactam until discharge • Both extraoral drains were removed on POD 4, patient was discharged with oral amoxicillin-clavulanate for ten days and outpatient follow-up with OMFS
Transcript of A Case of Ludwig's Angina in an Adolescent
BACKGROUND
• Ludwig’s angina is a serious form of cellulitis with a diffuse, acute, rapid spread of an abscess through the submandibular, sublingual, and submental soft tissue fascial planes
• Sublingual space involvement results in elevation, posterior enlargement, and protrusion of the tongue (woody tongue) and can lead to airway compromise
• Submandibular space involvement results in neck enlargement and tenderness (bull neck)
• Additional signs include restricted neck movement, dysphagia, dysphonia, dysarthria, tachycardia, drooling, sore throat, trismus, voice change, elevation of the floor of the mouth, posterior and superior displacement or protrusion of the tongue, chills, fever, malaise, and dehydration
• About 1 in 3 cases occur in children and adolescents, of which 50% are of odontogenic origin
• 16-year-old male presented to the Emergency Department (ED) with bilateral facial swelling
• Non-contributory medical history• Dental history:• Fracture of #30 restoration 1 year ago• Intense pain when eating which began 1 week prior• Treated by private practice dentist 2 days prior for mild
intraoral swelling localized to #30• Started penicillin with plan for #30 root canal therapy
• Symptoms in ED: worsening bilateral neck swelling, dysphagia, mild shortness of breath when supine, voice changes, low-grade fever, pain level 7/10, and drooling
• Had not eaten in two days but was tolerating liquids• Extraoral examination: bilateral indurated sublingual,
submandibular and submental space swelling with diffuse erythema extending to neck and clavicles and labored breathing when supine with posturing
• Intraoral examination: slight trismus with limited opening, elevated floor of the mouth, #30 recurrent caries with fractured restoration and with pain upon palpation and percussion, no vestibular obliteration or abscess noted
• Consulted ENT and OMFS
• ENT consultation: bedside fiberoptic scope revealed larynx visualization normal, not concerned for airway obstruction due to airway edema, tongue edema or retrusion, or obstructing masses or swelling• OMFS consultation: CT neck with contrast ordered, recommended IV ampicillin-sulbactam stat and plan for emergency surgery• CT report: ill-defined multiloculated abscess containing air measuring 44 mm x 40 mm x 28 mm in the submental region extending superiorly toward right mandibular angle, edema present above the
hyoid bone, along right pharyngeal wall, and in the anterior right sublingual space extending to the right mandibular angle, displacement of the lingual fatty septum midline leftward, and bilateral lymphadenopathy near the hyoid bone
A Case of Ludwig's Angina in an AdolescentDanesh DO, Hammersmith KJ, Laxer KR
The Ohio State University and Nationwide Children’s Hospital, Columbus, OH
REFERENCES AND ACKNOWLEDGEMENTS
CONCLUSIONS
CASE REPORT
• Extraction of #30 under general anesthesia• Incisions at right submandibular and submental area below
inferior border of mandible• Two extraoral penrose drains: one placed into the
submandibular space and one placed through-and-through from right submandibular incision to midline incision in submental space
• Moderate amount of purulence and serosanguinous drainage from submandibular and submental spaces noted
• Surgical laboratory cultures taken of the right neck abscess: revealed many Streptococcus anginosis group isolates present (susceptible to vancomycin, penicillin, clindamycin, ceftriaxone, and ampicillin)
• Cultures negative to Group A Streptococcus, Staphylococcus aureus, fungal elements, anaerobe, and acid fast bacilli isolates
CLINICAL FINDINGS AND IMAGING
PROCEDURES COMPLETED
1. Lin, H., O'Neill, A., & Cunningham, M. (January 01, 2009). Ludwig's Angina in the Pediatric Population. Clinical Pediatrics, 48, 6, 583-587.
2. Neville, B. W., Damm, D. D., Allen, C. M., & Chi, A. C. (2016). Oral and maxillofacial pathology.
Acknowledgements: Dr. Ashok Kumar and the providers involved for guiding this patient’s management
• Severe cases of facial swelling may progress to Ludwig’s angina and/or lead to complications, including post-operative respiratory failure
• Management of significant facial swelling in adolescent and pediatric patients requires interdisciplinary collaboration and treatment
• Following awake extubation, had respiratory failure secondary to upper airway obstruction with stridor and hypoxia
• Jaw thrusts, oral airway, and repeat suctioning were attempted
• Re-intubation completed with difficulty, and patient was sent to PICU
• Patient was intubated until transitioned to BiPAP on post-operative day (POD) 1
• Transitioned to nasal cannula on POD 3 without further complications
• Remained on IV ampicillin-sulbactam until discharge• Both extraoral drains were removed on POD 4, patient
was discharged with oral amoxicillin-clavulanate for ten days and outpatient follow-up with OMFS
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