Trends and Outcome of Aggressive Fascial Space Infections.

Background: Odontogenic infections are common and self-limiting in most cases; however, they can lead to severe consequences, considerable morbidity and can even be fatal despite modern medical therapy. Patients and Methods: This retrospective study included patients with severe deep fascial space infections treated in the Maxillofacial Surgery Unit, General Surgery Department, Faculty of Medicine, Sohag University, Sohag Governorate, Egypt, and the Department of Oral and Maxillofacial Surgery, King Fahd Specialist Hospital (tertiary referral center), Burayda City, Qassim Province, Saudi Arabia, from June 2017 to June 2022. Results: This study included 296 patients, 161 (54.4%) males, 135 (45.6%) females. The fifth decade of life was the most common vulnerable age group. Forty-three percent of patients had diabetes mellitus, 26.6% were hypertensive, and 13.3% were on long-term steroid therapy. In 83% of patients, the offending tooth was identified but in 17% of patients no dental cause was identified. The lower third molar tooth was most commonly involved. Sixty-nine (23.3%) patients had submandibular space infections. Fifty-three (17.9%) patients had canine space infections. Thirty (10.1%) patients had submasseteric space infection. Twenty-eight (9.5%) patients had submental space infections. Twenty-three (7.8%) patients had combined infection of the submasseteric, submandibular, and pterygomandibular spaces, whereas 19 (6.4%) patients presented with Ludwig's angina. Conclusions: Odontogenic infections are common. The submandibular space is the most commonly affected single space. These infections could lead to lethal complications in immunocompromised patients, especially patients with diabetes mellitus. These infections require urgent surgical intervention to decrease hospital stays and avoid potentially lethal complications.

Ketamine-Induced Spontaneous Breathing Intubation With Airway Topicalization: A Case Report of Airway Obstruction in Retrieval Care.

A LifeFlight Retrieval Medicine air medical team was tasked to a rural facility 200 km away to manage and retrieve a 73-year-old woman with evolving airway obstruction. Resources at the referring site included a general practitioner with anesthetic skills training but no access to otorhinolaryngology (ear, nose, and throat) or flexible fiberoptic airway devices. On arrival of the LifeFlight Retrieval Medicine, the patient became agitated, with deterioration in her airway patency. A clinical diagnosis of Ludwig's angina with evolving airway obstruction was made. Using a technique of ketamine-facilitated, spontaneous breathing tracheal intubation with a video laryngoscope, the retrieval team was able to safely secure the patient's airway before transporting her to a regional hospital with ear, nose, and throat surgical services. Computed tomographic imaging revealed an oropharyngeal abscess with spread into the larynx, which subsequently underwent surgical drainage. This case report outlines the technique of awake laryngoscopy with relevance to the retrieval physician and discusses some of the challenges and potential complications associated with it.

Decompression of Ludwig's angina in a pregnant patient under bilateral superficial cervical plexus block.

Ludwig's angina is defined as a potentially lethal, rapidly spreading cellulitis, involving the sublingual and submandibular spaces, and is manifested by a brawny suprahyoid induration, tender swelling in the floor of the mouth, and elevation and posterior displacement of the tongue. During a life-threatening infection such as Ludwig's angina, the mother and foetus are vulnerable to septicemia and asphyxia. We describe a case of decompression of Ludwig's angina in a 28 weeks pregnant patient under bilateral superficial cervical plexus block. The block, coupled with bilateral mandibular nerve block, provided ample anaesthesia to perform a thorough incision and drainage, including transection of mylohyoid with lowering of the floor of mouth and rapid relief of respiratory obstruction.

Ludwig's angina in Nigeria: The disease of the poor and health inequality!

AIM: highlight the health inequality and identify opportunities to improve the care delivered to the patients who suffer from Ludwig's angina which could have national and international clinical impact. MATERIALS AND METHODS: Data was collected from three major oral and maxillofacial centers, in Nigeria including Benin, Lagos and Kano. A protocol was developed for data collection which included demographic details, socio-economic status, management of the air way, the associated morbidities and mortalities. RESULTS: Forty-nine were managed in Benin, 57 in Lagos and 66 in Kano. Diabetes was the most prevalent underlying systematic condition, affecting 21% of the Ludwig's angina patients in Lagos. Poverty was a common denominator, 90% of the patients from Kano were unemployed compared to 23% and 8% from Lagos and Benin respectively. For most of the patients, the airway was monitored. Incision and drainage were carried out in most of the cases at Benin and Lagos, but it was only considered in 50% of the cases in Kano. Mortality ranged from 4% in Benin to 12% in Lagos and it was as high as 19% in Kano. CONCLUSION: poor access to oral healthcare, unemployment and low socio-economic status are important predisposing factors of Ludwig's angina.

Ludwig's Angina in Pregnancy: A Case Report.

BACKGROUND: Physiologic changes in pregnancy may predispose pregnant women to oral health problems. However, most women are not counselled on oral health during pregnancy. Lack of proper oral health care predisposes pregnant women to odontogenic infections, which can lead to severe complications. CASE: A 34-year-old multiparous woman presented at 400 weeks gestation with a 3-day history of severe, progressive neck swelling, jaw pain, and trismus. She was diagnosed with Ludwig's angina secondary to an untreated dental cavity. She required emergency fiberoptic intubation to secure her airway, urgent delivery via cesarean section, and subsequent surgical drainage performed by otolaryngology. CONCLUSION: Ludwig's angina during pregnancy is associated with severe morbidity. Dental care should not be denied or postponed due to pregnancy, and dental infections should be treated promptly. Health care providers should counsel women on the importance of maintaining good oral health during pregnancy.

Ludwig's angina and steroid use: A narrative review.

BACKGROUND: Ludwig's angina, a rapidly progressive cellulitis causing airway obstruction, has traditionally been managed with antibiotics and surgical intervention. More controversial is the use of steroids in the management of patients with this condition. This article summarizes the literature of steroid use in the management of Ludwig's angina. METHODS: The study used a narrative review method alongside the PRISMA guidelines for systematic reviews. PubMed, Ovid Medline, Cochrane, and Web of Science were searched for cases of Ludwig's angina with documented steroid use in patient management. Inclusion criteria were articles in the English language with direct patient outcomes. There were 17 articles selected with 31 patient cases. RESULTS: Most reports of steroid use in Ludwig's angina in the literature are case reports, with one retrospective review, and one letter to the editor. Dexamethasone was the steroid of choice in most cases reviewed. All patient cases reported used antibiotics alongside their steroid use, and 27 out of 31 patient cases required surgery. Most patients recovered with no further sequelae or complications. Three (9.68%) patients suffered mortality due to unrelated causes. CONCLUSIONS: Primary literature reporting the use of steroids in the management of Ludwig's angina includes few cases. While the role steroids have in these cases remains uncertain, the articles summarized do not suggest an adverse influence, and may suggest a benefit.

Ludwig's angina: A diagnostic and surgical priority.

Ludwig's angina has been known for two centuries as a rapidly and frequently fatal progressive gangrenous cellulitis or necrotizing fasciitis of the neck and the floor of the mouth. The management of the usually young patients affected requires a trained team combining medical skills in surgery, antibiotic therapy, and resuscitation. The prognosis is directly related to early surgical debridement and the experience of the team managing these patients. We present four cases of severe necrotizing cervical cellulitis notably associated with concomitant self-medication with non-steroidal anti-inflammatory drugs. Through these cases, we conclude that several surgical steps could be required, combined with broad-spectrum antibiotic therapy. An optimal surgery, draining all collections and excising all necrotic tissues, seems to be a condition needed for antibiotic efficacy and finally healing.

Comparison of Outcomes in Conservative versus Surgical Treatments for Ludwig's Angina.

OBJECTIVE: To compare the treatment outcomes in patients with early stage Ludwig's angina who received intravenous antibiotics alone with those who received surgical decompression and intravenous antibiotics. SUBJECTS AND METHODS: Individuals with early stage Ludwig's angina were studied using a retrospective cohort study design from August 1997 to September 2017. Data were collected from case notes and logbooks. Appropriate statistical tests were chosen to analyze both the independent and outcome variables. Using 2-tailed test, a level of significance of 0.05 was chosen. RESULTS: A total of 55 patients comprising 38 (69.1%) males and 17 (30.9%) females were studied. The conservative group had a higher number of cases that developed airway compromise (26.3%) when compared to those with surgical approach (2.9%). There was an association between the treatment approach and the development of airway compromise (χ2[1] = 4.83, p = 0.03). CONCLUSION: There was a higher incidence of airway compromise in patients treated with intravenous antibiotics alone than in those treated with surgical decompression and intravenous antibiotics.

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.

Mucormycosis Causing Ludwig Angina: A Unique Presentation.

Mucormycosis is a rare fungal infection with a yearly incidence of 1.7 cases per million in the United States. It usually occurs in patients with metabolic abnormalities or who are immunocompromised with prolonged neutropenia. However, it can also occur in patients without any underlying disease process. The treatment of choice is surgical debridement of necrotic tissue and systemic antifungal therapy, including amphotericin B. A dilemma for the surgeon when faced with head and neck mucormycosis is the morbidity of surgical debridement from both a functional and cosmetic standpoint. There have been multiple case reports of a form of cutaneous mucormycosis in the head and neck involving the oral mucosa and the mandible, but no reports in the literature of a fungal infection causing Ludwig angina. This report describes one such case. The morbid clinical implications of mucormycosis causing Ludwig angina become apparent when considering the defect caused by adequate surgical debridement.

Anesthetic Management of Advanced Stage Ludwig's Angina: A Case Report and Review With Emphasis on Compromised Airway Management.

Ludwig's angina, although uncommon, remains a potentially life-threatening condition because of the risk of impending airway obstruction. Effective treatment is based on early recognition of the clinical process, with the appropriate use of parenteral antibiotics, securing the airway, and formal surgical drainage of the infection. Awake fiberoptic intubation under topical anesthesia may be the preferred method to secure the airway. Flexible nasotracheal intubation requires skill and experience. When fiberoptic bronchoscopy is not feasible, not available, or has failed, an elective awake cricothyrotomy and tracheostomy are the options. Furthermore, the introduction of newer advanced airway techniques, such as video-assissted laryngoscopy, may allow the clinician additional flexibility in nonsurgical airway management. We present a recent case of a patient with Ludwig's angina, successfully managed at our hospital, with a brief review of airway management options.

Does surgical decompression in Ludwig's angina decrease hospital length of stay?

INTRODUCTION: Ludwig's angina (LA) is an uncommon and potentially life-threatening condition of the upper aero-digestive tract that often requires the coordinated efforts of the surgical, anesthetic and intensive care teams to optimize management. The purpose of the present study was to investigate the documented clinical features and the surgical and airway management of LA at Alice Springs Hospital for the purpose of assessing surgical outcomes with particular reference to length of stay (LOS). METHODS: Retrospective chart review from January 1998 to January 2008 examined patients admitted with LA at Alice Springs Hospital. Documented clinical features, interventions, and operative findings including floor of mouth swelling, Mallampati score, and airway compromise were collected. Outcomes, with particular respect to LOS, for those who received intravenous (IV) or inhalational induction and those that received awake fibre-optic intubations were compared. RESULTS: Of 30 patients with LA, 28 (93%) were managed with operative drainage with a LOS in the intensive care unit (ICU) of 2 days and a hospital LOS of 5 days. Seven received awake fibre-optic intubation and 21 had IV or inhalational anesthesia with none requiring tracheotomy. There was no statistical difference in LOS between those patients whose microbiological culture results showed no growth and those whose cultures had positive growth. DISCUSSION: Management was generally operative decompression with IV antibiotics. LOS is not affected by the presence or absence of culture positive infection. It is proposed that operative intervention is safe, effective, and is associated with shorter patient stays in the intensive care unit and the hospital overall.

Is surgical airway necessary for airway management in deep neck infections and Ludwig angina?

BACKGROUND: Deep neck infections are potentially life-threatening conditions because of airway compromise. Management requires early recognition, antibiotics, surgical drainage, and effective airway control. The Surgical Education and Self-Assessment Program 12 states that awake tracheostomy is the treatment of choice for these patients. HYPOTHESIS: With advanced airway control techniques such as retrograde intubation, GlideScope, and fiberoptic intubation, surgical airway is not required. DESIGN: A retrospective analysis of all deep neck abscesses treated from December 1999 to July 2006 was performed. METHODS: All patients who underwent urgent or emergent surgery for Ludwig angina and submental, submandibular, sublingual, and parapharyngeal abscesses (Current Procedural Terminology codes 41015, 41016, 41017, 42320, and 42725) were included in our review. Charts were studied for age, presence of true Ludwig angina, presence of airway compromise, airway management, morbidity/mortality, and the requirement for surgical airway. RESULTS: Of 29 patients, 6 (20%) had symptoms consistent with true Ludwig angina. Nineteen (65.5%) had evidence of airway compromise. Eight (42%) of these 19 patients required advanced airway control techniques. No patient required a surgical airway, and no mortality resulted from airway compromise. Advance airway control techniques were required more often in patients with airway compromise (P < .05). CONCLUSION: Treatment of Ludwig angina and deep neck abscesses requires good clinical judgment. Patients with deep neck infections and symptoms of airway compromise may be safely managed with advanced airway control techniques.

Pregnancy complicated by Ludwig's angina requiring delivery.

At 33 weeks of gestation, a 24-year-old developed Ludwig's angina that worsened despite aggressive therapy. This is the first reported case of Ludwig's Angina in pregnancy that required an emergent cesarean section for fetal indications. Delivery may have contributed to improvement in the mother's health status.

Comparison of maxillofacial space infection in diabetic and nondiabetic patients.

INTRODUCTION: Orofacial space infections are common presentations in maxillofacial clinics even in the post-antibiotic era. One of the main factors determining the spread of infection is the host defense mechanism. Diabetes is one of the most common systemic illness suppressing the immunity of an individual and increasing their susceptibility to infections. This study was carried out to compare the spaces involved, the severity of infection, the virulent organism, the efficacy of empirical antibiotics, the length of hospital stay, and the complications encountered in the management of maxillofacial space infection of odontogenic origin in diabetic patients as compared with nondiabetic patients. METHODOLOGY: A 4-year prospective study was carried out on patients with maxillofacial space infection of odontogenic origin. The patients were divided into 2 groups on the basis of presence or absence of diabetes. RESULTS: A total of 111 patients were identified out of which 31 were diabetic. The organisms commonly isolated were Streptococcus species with submandibular space being the most common space involved in both the groups. The empirical antibiotic used was amoxicillin plus clavulanic acid combined with metrogyl in 70.27% cases. CONCLUSION: Streptococcus species is still the most common causative pathogen irrespective of the diabetic status of the patient. The same empirical antibiotic therapy of amoxicillin plus clavulanic acid combined with metrogyl along with hyperglycemia control and surgical drainage of infection yielded satisfactory resolution of infection in the diabetic patients as well.

Angina de Ludwig: revisão de literatura e relato de caso / Ludwig?s Angina: Literature Review and a Case Report

Descrita inicialmente em 1836, por Wilhelm Friedrich Von Ludwig, a angina de Ludwig tem como sintomas mais relatados a sua evolução rápida, o desconforto respiratório e a dor. Outro fator de grande relevância é o alto risco de mortalidade a que os pacientes estão expostos devido aos riscos de obstrução das vias aéreas e ao comprometimento de estruturas nobres. Os autores relatam um caso de angina de Ludwig, discutindo sua etiologia, aspectos clínicos, diagnóstico, seleção de antibióticos, cultura e antibiograma, manutenção de vias aéreas, drenagem e tratamento cirúrgico.

Initially described by Wilhelm Friedrich Von Ludwig in 1836, the most commonly reported symptoms of Ludwigïs angina are rapid progression, respiratory discomfort and pain. Another factor of great importance is its high mortality due to respiratory obstruction and the compromising of noble structures. The authors report a case of Ludwig?s angina and discuss its etiology, clinical findings, choice of antibiotics, culture and antibiogram, maintenance of the airways, drainage and surgical treatment.