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.

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.

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.

Severe soft tissue infections of the head and neck: a primer for critical care physicians.

Patients with severe infections of the potential spaces of the head and neck are commonly managed in the ICU. These infections may present with devastating complications such as airway obstruction, jugular septic thrombophlebitis, lung abscess, upper airway abscess rupture with asphyxiation, mediastinitis, pericarditis, and septic shock. A thorough understanding of the anatomy and microbiology of these infections is essential for proper management of these patients. Retropharyngeal, danger, prevertebral, lateral pharyngeal, and submandibular space infections and their site-specific clinical manifestations, complications, and therapeutic interventions are discussed.

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.

Deep head and neck infections: outcome following empirical therapy with early generation antibiotics.

In order to study the bacteriological profile, antibiotic sensitivity and outcome following empirical therapy with early generation antibiotics in patients with deep head and neck infection, a retrospective review of 42 patients admitted for drainage and intravenous antibiotic therapy was performed. Ludwig's angina was the commonest infection, with the most common organisms isolated being Group F ß-haemolytic (15%) and non-haemolytic (12.5%) streptococcus. All streptococci and anaerobic gram-positive cocci were susceptible to penicillin. S. aureus isolates were oxacillin-sensitive and enterococcus isolates were ampicillin-sensitive. All 42 patients received empirical therapy with either intravenous penicillin or its derivatives. In only three patients was a change of antibiotic required based on culture and sensitivity results. Early generation antibiotics appear ideal as empirical therapy for deep head and neck infection.

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 by Salmonella Typhi: a clinical dilemma.

Salmonella Typhi has rarely been associated with focal abscesses; and in literature, there is no evidence of its association with abscesses in the neck spaces. Ability of Salmonella Typhi to invade and localise in the neck spaces not only poses a diagnostic challenge but also underscores the necessity to understand the mechanisms that facilitate Salmonella Typhi to establish infections at sites completely non-traditional to the organism.

Streptococcal submandibular cellulitis in young infants.

Six infants with streptococcal submandibular cellulitis and bacteremia were managed in our institution during a seven-month period. Five uncomplicated cases were caused by group B beta-hemolytic Streptococcus, and one rapidly progressive case of Ludwig's angina was caused by group A Streptococcus. Recognition of this characteristic clinical presentation of group B streptococcal infection may be beneficial in the management of such patients.

Role of anaerobic bacteria in perimandibular space infections.

This review includes 44 patients with perimandibular space infections admitted to Johns Hopkins Hospital during a 5-year period. The most frequent spaces involved were the submandibular, peritonsillar, and parapharyngeal spaces. As expected, 1) peritonsillar abscesses were invariably associated with pharyngitis, 2) submandibular and buccal space infections generally represented complications of dental infections, and 3) parapharyngeal space infections were associated with both portals of entry. Most patients were treated with drainage procedures, and all received antimicrobial agents, the most common being penicillin. Serious complications included potential airway obstruction requiring tracheostomy in six patients with Fusobacterium bacteremia and two patients with septic emboli to the lung. All patients survived, and most had a relatively brief hospitalization with no sequelae.

How serious are oral infections?

Life-threatening conditions following dental infections have been rare since antibiotics were introduced into the world of medicine. However, infections spreading through the soft tissues of the head and neck are encountered occasionally and mortality is still reported as a result of sepsis or airway embarrassment. A case of Ludwig's angina from odontogenic infection that progressed into mediastinitis and pericarditis is presented. The steps adopted in the management of this case highlight the significance of early recognition and diagnosis of the source of deep cervical infections, the importance of securing the airway, effecting surgical drainage and aggressive intravenous antibiotic therapy.

[Ludwig's angina]. / Angine de Ludwig.

Ludwig's angina is a rare infectious condition originating in the oropharyngeal region, most commonly from the teeth. The principal symptoms consist of cervical pain, dyspnea, dysphagia, symmetrical neck swelling and fever. Serious complications include respiratory collapses, mediastinitis, pleural empyema, pericarditis and pericardial tamponade, and may result in the death of the patient. The most useful investigations in patients with suspected Ludwig's angina are clinical assessment, a cervico-thoracic CT-scan to determine the extent of the lesions, microbiological examination and panoramic radiography to detect possible dental focuses of infection. Treatment consists of ensuring adequate ventilation by securing the upper airways, broad spectrum antibiotic therapy, eradication of the source of infection, and often early surgical decompression may be necessary. Rapid diagnosis and appropriate treatment can reduce the mortality rate to 10%.

Descending necrotizing mediastinitis associated with spinal cord abscess.

A 58-year-old man with a history of Ludwig's angina was admitted with a spinal cord abscess at the level of C2-T1 and associated osteomyelitic destruction of vertebral bodies, spinal cord compression, and secondary quadriparesis, followed by descending mediastinitis. A right posterolateral thoracotomy and a cervicotomy drained purulent exudates. A tracheostomy was performed, and the patient was discharged after 84 days.

Odontogenic maxillofacial space infections at a tertiary care center in North India: a five-year retrospective study.

OBJECTIVE: Odontogenic infections contribute to a significant proportion of maxillofacial space infections (MSI) across the world. MSI can cause several life-threatening complications despite skillful management. The objective of this study was to review the clinical characteristics, management, and outcome of odontogenic MSI treated at a tertiary care center, and to identify the factors predisposing to life-threatening complications. METHODS: A retrospective chart review of all patients treated for MSI from January 2006 to December 2010 at the Christian Medical College Hospital in Ludhiana, North India, was conducted. RESULTS: Out of 137 patients identified, 66.4% were men. Mean patient age was 40 years, and 24.1% of the patients were diabetic. The most common origin was pulpal (70.8%), the most common space involved was the submandibular space, and the most common teeth responsible were the lower third molars. Twenty patients (14.6%) developed complications. Diabetes, multiple space involvement, and a total leukocyte count of ≥15×10(9)/l were associated with complications. CONCLUSIONS: Patients with MSI who present with multiple space involvement, a high leukocyte count, and those with diabetes are at higher risk of developing life-threatening complications and need to be closely monitored.

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.

Head and neck infection and inflammation.

This article discusses the imaging manifestations of infectious and inflammatory conditions of the head and neck. Special attention is paid to the sites, routes of spread, and complications of neck infections. Because the clinical signs and symptoms and the complications of these conditions are often determined by the precise anatomic site involved, anatomic considerations are stressed. Familiarity with the fascial layers, spaces of the neck, and the contents of each space is helpful for this discussion. The fascial layers of the neck are important barriers to infection, and once infection is established, the fascial layers play a part in directing its spread.