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.

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.

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.

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.

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.

Deep space neck infection: principles of surgical management.

Knowledge of the management of infections of the deep spaces of the neck is essential to the daily practice of oral and maxillofacial surgery. Timely decisions must be made through the acute course of the disease. Interventions must be performed with the appropriate surgical skill. The surgeon must decide on medical and surgical management, including antibiotic selection, how to employ supportive resuscitative care, when to operate, what procedures to perform, and how to secure the airway. To make these decisions the surgeon must understand the anatomy of the region and the etiology of infection, appropriate diagnostic workup, and medical and surgical management. This article provides a review of these pertinent topics.

Deep neck infection.

Deep neck infections present significant morbidity and mortality, particularly when associated with predisposing factors that impair a functional immunologic response. Familiarity with deep neck spaces and fascial planes is critical, because these form the basis for the emergent nature of the disease process. Common and potentially life-threatening complications include airway obstruction, jugular vein thrombosis, descending mediastinitis, sepsis, acute respiratory distress syndrome, and disseminated intravascular coagulation. The most common primary sources of deep neck infection are odontogenic, tonsillar, salivary gland, foreign body, and malignancy. Microbiology typically reveals mixed bacterial flora, including anaerobic species, that can rapidly progress to a fulminating necrotizing fasciitis. The treatment cornerstone remains securing the airway, providing efficient drainage and appropriate antibiotics, and improving immunologic status. A prolonged hospital stay should be anticipated.

Submandibular cellulitis (Ludwig's angina) associated to a complex odontoma erupted into the oral cavity. Case report and literature review.

The clinical presentation of Ludwig's angina consists in a severe expanding cellulitis causing swelling of the floor of the mouth, tongue and submandibular region, thus resulting in a possible obstruction of the airway and in a rapid progress in deep neck soft tissue infection and mediastinitis with potentially fatal consequences. Frequently, submandibular cellulitis develops from an acute infection spreading from the lower molar teeth. Mandibular fractures, traumatic laceration of the floor of the mouth, and peritonsillar abscesses are other concomitant clinical features. A case of Ludwig's angina associated with a large erupted odontoma and with a deeply impacted third molar displaced to the border of the mandible is described. The patient was affected by enlargement of submandibular space, marked face swelling causing an evident face deformity, tenderness and redness of the neck and limited movement of the neck and mouth. In the past, Ludwig's angina was frequently fatal, however aggressive surgical and medical therapy have significantly reduced the mortality rate. The reported case can be considered as important, not only because of the rarity of the odontoma eruption in the oral cavity, but mainly for the extent of the clinical manifestation of a lesion usually described in literature as asymptomatic.

Surgical management of Ludwig's angina.

BACKGROUND: Ludwig's angina (LA) is a dangerous surgical condition that can cause severe airway compromise and death. There is controversy regarding the best way to manage the airway of patients with LA. Options range from conservative management involving close observation and i.v. antibiotics to airway intervention, including tracheostomy and endotracheal intubation using fibre-optic nasoendoscopy. We present evidence supporting a role for conservative airway management in a select subset of patients. METHODS: This paper reviews 9 years' experience of treating patients with LA at Liverpool Hospital. RESULTS: Twenty-one out of 29 (72%) of our patients were treated conservatively following initial clinical assessment. One of these patients subsequently deteriorated requiring emergency intubation. Of those treated non-conservatively at initial presentation, seven patients were able to be intubated using fibre-optic nasoendoscopy and one patient required tracheostomy under local anaesthesia. CONCLUSION: A general discussion of issues related to the management of LA is presented. Based on our experience we conclude that there is a subset of patients with LA who can be managed safely with conservative management.

Angina de Ludwig: tratamento cirúrgico minimamente invasivo e guiado por ultra-sonografia cervical / Ludwig´s angina: minimally invasive surgical treatment guided by cervical ultrasonography

A angina de Ludwig é um processo infecto-inflamatório que acomete o assoalho da boca e o pescoço, com marcado edema tecidual, ocasionando dificuldades respiratórias e de deglutição, trismo e toxemia, podendo ter evolução fatal. A etiologia é predominantemente associada a infecções dentárias, exodontias ou traumas orais, sendo de bacteriorlogia polimicrobiana. O diagnóstico é clínico e a avaliação por imagem geralmente feita por radiografias simples e pela tomografia computadorizada, sendo a ultra-sonografia pouco utilizada. O tratamento constitui-se na manutenção de via áerea patente, antibioticoterapia precoce, hidratação e eventualmente procedimentos cirúrgicos agressivos, em casos de evolução desfavorável.

Management of Ludwig's angina with small neck incisions: 18 years experience.

OBJECTIVE: To review Ludwig's angina medical and surgical approach with small incisions. STUDY DESIGN: Retrospective, open, noncomparative, longitudinal. METHODS: All patients with Ludwig's angina who received medical, metabolic, airway management, and surgical treatment from January 1, 1983 to December 31, 2000. STUDIED PARAMETERS: Antibiotic treatment, surgical treatment, hospitalization time, associated diseases, etiologic factors, recuperation time. RESULTS: Age range was 18 to 87 years, with a female-to-male ratio of 1.1:1 (68 females, 53 males). Thirty patients belonged to middle or high socioeconomic status. The primary site of infection was odontogenic in 107 of the patients. All the patients were managed with surgical drainage made within the first 12 hours after hospital admission. The most common antibiotic treatments were the combination of clindamycin with crystalline penicillin G. The hospital stay for more than half of patients was 6 days or less. In 62 patients we found extension into the parapharyngeal space and in 32 cases we found retropharyngeal extension of the Ludwig's angina. Forty-six patients had or were diagnosed as having diabetes mellitus. Tracheotomy was required in 34 patients. The airway of the rest of patients was controlled with nasotracheal intubation. Only 33 patients had major complications, such as mediastinitis, sepsis, or death. CONCLUSIONS: Drainage using small incisions is a safe and effective method as part of treatment of Ludwig's angina.

Otolaryngologic critical care.

In this chapter we have reviewed the complicated medical conditions that exist in many head and neck surgical patients. Common surgical procedures that frequently require postoperative monitoring and several infectious disorders requiring intensive care unit admission were also reviewed. Intensivists need to be familiar with these procedures and diseases. Collaboration with the surgical specialist is required to optimize patient care.