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.

Isolation of Staphylococcus aureus and black-pigmented bacteroides indicate a high risk for the development of Ludwig's angina.

OBJECTIVE: The aim of this study was to compare clinical, microbiological, enzymatic, and host immune response variables between subjects hospitalized with facial cellulitis, with Ludwig's angina (LA) and without Ludwig's angina (WOLA). STUDY DESIGN: Microbiological and enzymatic tests on pus, and hematological and immunological assessments on blood samples of 15 patients with LA and 42 patients with WOLA were performed. Laboratory findings of both groups were compared using the Student t test. Multiple logistic regression analysis was performed and significant differences identified by univariate analysis. RESULTS: Patients with LA demonstrated increased levels of white blood cell counts, urea, and CRP levels, and decreased levels of CIC compared with patients WOLA. However, only CRP and urea were found to be significantly raised in the LA group. A greater population of Staphylococcus aureus and black-pigmented bacteroides were isolated from patients with LA. CONCLUSION: Elevated levels of CRP and urea could indicate the severity of infection in patients with LA. This could be because of the highly virulent and fast-spreading organisms, S. aureus and black-pigmented bacteroides, which may be a factor indicative of LA.

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.

Death from overwhelming odontogenic sepsis: a case report.

A case of fatal Ludwig's angina from an odontogenic origin complicated by chronic lymphocytic leukaemia is presented. This case highlights that death from odontogenic infection is a reality, particularly in those with systemic disease causing immunocompromise. Early surgical intervention, aggressive intravenous antimicrobial therapy and supportive care is imperative.

Use of interventional radiology in the management of mediastinitis of odontogenic origin.

Descending necrotising mediastinitis is a rare complication of odontogenic infection. The key to diagnosis is to maintain a high index of suspicion when antibiotics and adequate surgical drainage do not lead to resolution of symptoms. Open thoracic operation to drain mediastinal collections is potentially lethal and interventional radiological techniques are thought to reduce mortality. We report the use of interventional radiology in the diagnosis, monitoring and treatment of this condition and illustrate our experience with three case reports.

Ludwig's angina: a clinical review.

Ludwig's angina is caused by a rapidly expanding cellulitis of the floor of the mouth and is characterized by a brawny induration of the floor and suprahyoid region (bilaterally), with an elevation of the tongue potentially obstructing the airway. In the pre-antibiotic era, Ludwig's angina was frequently fatal; however, antibiotics and aggressive surgical intervention have significantly reduced mortality. We reviewed nine patients with Ludwig's angina between July 1996 and June 2002, all of whom presented with fever, neck swelling, bilateral submandibular swelling and elevation of the tongue. In eight patients (89%) a dental infection appeared to be the underlying cause. High-dosage intravenous antibiotics directed towards the suspected causative microorganisms were given to all of the patients: two were treated successfully with conservative medical management, while seven underwent surgical drainage (a tracheotomy was necessary in one patient). Routine aerobic cultures were done on samples of drained material and the predominant microorganisms were Streptococcus species in two patients; there were none in the other five. Two patients had post-operative complications, but all recovered.

Bacterial infections of oral soft tissues.

Bacterial infections of the oral soft tissues are not particularly common. When they occur, they can often be rapidly progressive and even fatal without prompt diagnosis, drainage, and antibiotic therapy. Most infections are caused by endogenous oral bacteria that have overcome the host immune system as a result of surgery or, more frequently, because of underlying defects in the innate or specific immune systems. The role of oral anaerobes in these infections is increasingly being realized, and empirical antibiotic therapy should always take account of the possibility of anaerobic involvement in any infection. More research is required into infected mucositis in patients with hematologic malignancies and the possible importance of enterobacteria in infections of the oral mucosa in debilitated patients. Surveillance cultures may help improve management of therapy.

[Report of 16 cases of Ludwig's angina: 5-year review]. / Informe de 16 casos de angina de Ludwig: revisión de cinco años.

Ludwig's angina es a bilateral gangrenous induration of the connective tissues of the neck and floor of the mouth. It causes rapid airway obstruction and affects the submandibular, sublingual and submental spaces. The main causes of infection are usually the second and third molars. In severe or difficult cases, an early surgical procedure is often necessary. According to our experience on this entity, as gathered in five years (16 cases), the process has a dental origin. Two deaths were reported. Most cases were treated with crystalline penicillin G, metronidazole, dicloxacillin or amykacin; tracheotomy was performed on 12 patients, four other cases were treated with controlled breathing. The authors suggest antibiotic therapy, early surgery when needed, with a careful monitoring of airway symptoms to lessen the need of tracheotomy and reduce the death rate. Ludwig's angina should by no means go unnoticed in its early stages; early diagnosis should always be considered.