CC
A 45-year-old male patient with alcohol abuse disorder and no other known medical conditions presents to the emergency department (ED), complaining “My face and neck are swollen and hurt; they blew up overnight, and it hurts to swallow. This started when my tooth started hurting 3 days ago.”
HPI
The patient’s clinical examination progressively worsened with increased facial and neck swelling bilaterally and difficulty tolerating his secretions over the past 2 days. The patient reports he has bad teeth, and several of his teeth cause him pain intermittently. The patient has not seen a dentist in several years. The patient reports chills in the preceding days, dysphagia (difficulty swallowing) and odynophagia (painful swallowing), but he denies any changes to his voice (dysphonia, which is usually present with edema of the vocal cords and upper airway).
PMHX/PDHX/medications/allergies/SH/FH
The patient is a poor historian, only reporting alcohol use and denying any other known medical conditions.
Examination
General. The patient is sitting slouched slightly forward with his jaw hanging slightly open, with obvious saliva pooling in his anterior oral cavity. The patient appears to be having difficulty tolerating his secretions and is holding a Yankauer suction to help manage his saliva. He appears to be in mild respiratory distress, but no stridor is present.
Airway. It is difficult to examine the airway given the patient’s extremely limited mouth opening (trismus, or “locked jaw,” which is restriction of the movement of the jaw). The anterior neck over the trachea is edematous and indurated to palpation. A computed tomography (CT) scan of the face and neck would be useful in evaluating the airway in terms of edema and any deviation or narrowing of the airway caused by surrounding edema. Flexible nasopharyngoscopy could be considered to assess for discharge in the supraglottic larynx or oropharynx, which could complicate anesthetic management.
Vital signs. The patient’s blood pressure is 145/90 mm Hg (hypertensive), heart rate is 115 bpm (tachycardic), respirations are 30 breaths per minute (tachypnea), temperature is 40°C (febrile), and oxygen saturation is 96% on room air.
Maxillofacial. The patient has severe facial swelling and edema with induration of the bilateral face in the mandibular regions and submandibular regions with a slightly greater prominence on the right side ( Fig. 23.1 ). There is marked submandibular and submental induration, and the mandibular border is not palpable in its full extent bilaterally. The swelling is warm to touch and erythematous over the mandibular and submandibular regions bilaterally. No subcutaneous crepitus (indicative of subcutaneous air from gas-producing organisms) is present. Unable to palpate any appreciable cervical lymphadenopathy, although this may be masked by significant edema in these regions.
Intraoral. The patient has trismus as mentioned, leading to a limited intraoral examination. Maximum interincisal opening is approximately 15 mm. The floor of the mouth and tongue are elevated, and the floor of mouth is indurated and edematous bilaterally (indicative of sublingual space involvement). Unable to visualize the oropharynx.
Cardiovascular. The patient is tachycardic and hypertensive consistent with pain and clinical examination.
Pulmonary. Lungs are clear to auscultation bilaterally, without any wheezing, rales, or rhonchi.
Imaging. A panoramic radiograph is the initial screening study of choice because it provides an excellent overview of the dentition, identifying any odontogenic sources of infection. However, many times in ED cases, panoramic imaging modality is not readily available. CT scans of the neck with contrast material are indicated when evaluating deep space neck infections. (Chest CT should be included if there is a suspicion of descending mediastinitis.) This study can help determine the anatomic spaces involved, localize any fluid collections (loculations of purulence), and determine whether the airway is deviated or compromised. A CT scan is the gold standard for evaluation and treatment planning for deep space infections of the head and neck, and CT scans should be performed with intravenous (IV) contrast to be accurate for diagnosing and visualizing a fluid collection or abscess. When chest CT is deemed unnecessary, chest radiographs (posteroanterior and lateral views) can be an important screening tool to detect a widened mediastinum, which may be indicative of descending mediastinitis.
This patient was deemed to be too unstable to undergo imaging without a secure airway; therefore, the patient was intubated before obtaining CT scan of the face and neck. A CT scan of the face and neck with IV contrast was obtained ( Fig. 23.2 ) and revealed extensive rim-enhancing fluid collections in the bilateral submandibular and sublingual spaces and the right pterygomandibular, lateral pharyngeal, and parapharyngeal spaces. There was diffuse soft tissue edema consistent with cellulitis in the involved spaces and surrounding fat stranding. No subcutaneous emphysema was seen in the cervical tissues. (Subcutaneous gas collection is considered a hallmark of cervical necrotizing fasciitis and is seen in up to 46%–67% of cases.) The endotracheal tube was visualized with significant edema around the airway, and the airway was deviated to the right postintubation even though most edema was present on the right side. This patient did not initially undergo CT chest imaging because the most inferior extent of the fluid collection was visualized and did not violate the mediastinum.
Labs
A complete blood count and complete metabolic panel are indicated during the workup of patients with severe odontogenic infections. The presenting white blood cell (WBC) count is a marker of infection severity, and this value should be followed during the course of treatment. C-reactive protein (CRP) is an acute-phase reactant released in response to inflammation and can be used to monitor the response to therapy. Studies have also suggested that a remarkably high CRP level at the time of admission is a predictor of a complicated hospital course. Electrolyte disturbances (sodium, potassium, magnesium, calcium) are common among patients with severe head and neck infections, especially when the patient is not able to tolerate oral intake because of swelling or pain. Blood urea nitrogen (BUN) and creatinine levels are useful to evaluate for prerenal azotemia caused by hypovolemia. Blood cultures are indicated in patients who meet sepsis criteria or with persistent fever. An electrocardiogram should be obtained when there is suspicion of mediastinitis. Arterial blood gas measurement is warranted in critically ill patients presenting with septic shock. The current patient presented with these lab values: WBC count of 21,000 cells/mm 3 with a 35% bandemia, BUN of 30 mg/dL (reference range, 7–18 mg/dL), and creatinine of 1.2 mg/dL (reference range, 0.6–1.2 mg/dL). The BUN-to-creatinine ratio was 25. (A ratio >20 is indicative of prerenal azotemia.) The remainder of his electrolyte values were within normal limits.
Assessment
Angina is typically used to refer to a type of chest pain that is associated with reduced blood flow to the cardiac musculature, yet Ludwig’s angina has nothing to do with the heart. Angina is derived from Latin and Greek words meaning “choke” or “strangle,” which refers to the feeling of asphyxiation that these patients may experience. Ludwig’s angina was first described in 1836 by the German physician Karl Friedrich Wilhelm von Ludwig. It was described as a rapidly progressing, gangrenous cellulitis in the submandibular region. The definition has evolved over time to mean any infections that simultaneously affect the bilateral submandibular, sublingual, and submental spaces. Classically, Ludwig’s is secondary to a carious or infected mandibular second or third molar with 70% to 90% of all cases being of odontogenic origin.
Treatment
Death in patients with Ludwig’s angina is almost always from airway compromise. At the time of its initial description, patients would succumb to their disease process more than 50% of the time. Improvements in quality, access to care, and antibiotics have decreased this incidence to less than 10%.
Treatment must begin with evaluation and stabilization of the patient’s airway. Airway evaluation begins the moment the patient walks in. Is the patient in distress, or are they resting comfortably? Anyone in distress, with stridulous respiration, must be considered at high risk for airway embarrassment. Physical examination must include both through intra- and extraoral exams. The oral cavity examination can be exceedingly difficult to examine because patients often have significant trismus and discomfort. Patients with Ludwig’s angina typically have elevation and fullness of the tongue and floor of the mouth with limited space between the soft palate and tongue. Pharyngeal wall edema may also be seen.
A fiberoptic nasopharyngoscopy can augment the oral examination, especially in patients with limited opening. This also allows for direct visualization of the vocal cords and any potential airway obstruction in the posterior oropharynx. If the patient is not stable, a definitive airway should be obtained as soon as possible. Intubation may be extremely difficult or impossible. Awake fiberoptic nasal intubation may be required. Videolaryngoscopy (e.g., GlideScope) has also been shown to decrease the difficulty of intubation and increase the chance of success for experienced and inexperienced providers. A surgical team should be on standby to convert to an emergency front of neck access (cricothyroidotomy or tracheostomy; see Chapter 22 on surgical airways) if a nonsurgical airway cannot be obtained.
Supportive measures should be initiated right away. Many of these patients are hypovolemic because of the combination of decreased oral intake and sepsis or septic shock. Standard monitors of fluid resuscitation, such as heart rate, blood pressure, and urine output, should be used. Patients who continue to have hemodynamic instability with adequate fluid resuscitation may require vasopressor therapy. Tight glycemic control (blood glucose, 90–110 mg/dL) has also been shown to improve overall survival in patients with sepsis.
Patients with Ludwig’s angina have a mixed aerobic–anaerobic polymicrobial infection, and broad empiric antimicrobial therapy should be initiated immediately. Coverage with Zosyn (piperacillin tazobactam 3.375 g given intravenously every 6 hours) and vancomycin (1 g given intravenously every 12 hours) are appropriate empiric antibiotic selections for these patients. In non–critically ill patients, penicillin-based drugs are the treatments of choice. Because of high incidence of beta-lactamase (or other mechanism of resistance to beta-lactam antibiotics), a penicillin with a beta-lactamase inhibitor should be used. Unasyn (ampicillin sulbactam 3 g given intravenously every 6 hours) has excellent coverage with minimal side effects. Clindamycin (clindamycin 900 mg given intravenously every 8 hours) was previously thought to be the antibiotic of choice in penicillin-allergic patients, but because of increasing amount of resistance in the population and a poor side effect profile, it should be avoided if possible. As soon as possible, antibiotics should be narrowed using cultures and sensitivity results.
These patients require early aggressive surgical drainage and source control. Patients with delays in definitive treatment have worse outcomes. Cultures should be taken by aspiration before definitive drainage to prevent contamination from normal skin flora. It is unnecessary to make large incisions unless there is concurrent necrotizing fasciitis. Incisions 1 to 2 cm in size should be made in the submandibular and submental areas, at least 2 cm from the inferior border of the mandible for protection of the marginal branch of the facial nerve. Blunt dissection used to explore all involved spaces, first with an instrument and then with finger dissection to break up any loculations. All infected teeth should be removed, and a subperiosteal dissection should be completed in these areas, with connection to the neck debridement to allow for dependent drainage. The wounds should be irrigated with copious amounts of normal saline. Red rubber catheters or Penrose drains should then be placed. It has been shown that there is no benefit to irrigating surgical drains over nonirrigating drains. Drains can be slowly advanced out or removed outright after drainage ceases. If patients do not improve, repeat CT scan or repeat surgical drainage in the operating room (OR) may be necessary.
The current patient was given 8 mg of dexamethasone intravenously in the ED, IV fluid resuscitation was initiated, and empiric intravenous antibiotics were administered. Antibiotic therapy consisted of ampicillin–sulbactam (Unasyn) 3 g every 6 hours. The patient was urgently taken to the OR for incision and drainage of the involved anatomic spaces of the neck via intra- and extraoral spaces and via multiple surgical incisions and extraction of carious teeth #1, 2, 17, 18, and 19. The patient was already intubated before entering the OR. An 18-gauge needle was used to aspirate purulent exudate from the submandibular space, which was sent for Gram stain, aerobic and anaerobic cultures, and antibiotic sensitivity studies. The surgical drainage consisted of three incisions, which were 1.5 to 2 cm in length 2 cm below the inferior border of the mandible anterior to the antegonial notch bilaterally and an incision anteriorly in the submental area. Consideration should be given to placement of the incisions to allow dependent drainage and within existing skin creases when possible. Blunt dissection with a hemostat and a Kelly clamp was carried out to explore all involved spaces. Copious amounts of purulence and necrotic tissue were expressed from the surgical sites. Teeth #1, 2, 17, 18, and 19 were elevated and extracted. Elevation of the gingival cuff was completed, and subperiosteal dissection was carried out along the lingual and buccal aspects of the mandible to enter the sublingual and submandibular spaces from multiple approaches. All the incisions were connected to each other in the subplatysmal and subperiosteal planes. Irrigation was performed with copious amounts of sterile saline, and Penrose drains were placed in the submandibular, sublingual, and submental spaces ( Fig. 23.3 ). All drains were irrigated with copious amounts of antibiotic irrigation, normal saline irrigation, or both. The patient was kept intubated postoperatively because of surgical and airway edema. The patient was taken back to the OR for two subsequent washouts and further incision and drainage. The patient eventually required tracheostomy. After tracheostomy, the patient continued to have thick secretions around the trach and was failing pressure support trials. A repeat CT face and neck with contrast was obtained ( Fig. 23.4 ), revealing significant fluid collection within the trachea above the tracheostomy tube. Patient was taken to the OR for direct laryngoscopy, bronchoscopy, debridement of previous surgical sites, and tracheal toileting. After significant resolution of the infection and edema and weaning from ventilatory support, he had a positive cuff leak test result and subsequently passed a capping trial. He was decannulated before discharge from the hospital to a subacute rehabilitation facility.
