Ludwig’s Angina an Emergency with Difficult Intubation: A Case Report

Abstract

Deep neck space infections are really challenging to the otothinolaryngologist, intensivist and to the anesthetist for managing at a tertiary care center. Proper handling of such cases is needed in time to save the life of such patient. We reported a case 65 year female patient present with sudden onset of huge submental and submandibular swelling admitted in ICU with difficult intubation.

Introduction

The neck is very delicate region of the body as it secure aero digestive pathway any infection in in superficial or deep space of the neck may lead to the serious effect on life of the patient. Submental and submandibular swelling of the neck with diffuse inflammatory rapidly progressive swelling around the neck is called Ludwig’s angina. While described as far back as the writings of Hippocrates and Galen, the necrotizing fasciitis Ludwig’s angina was first detailed by the German surgeon Wilhelm Friedrich von Ludwig in 1836 [1]. Ludwig’s angina is a rapidly progressive, potentially fulminant cellulites involving the sub-lingual, sub-mental, and sub-mandibular spaces [2]. It typically originates from an infected or recently extracted tooth, most commonly the lower second and third molars. Ludwig’s angina is a known, yet a rare surgical emergency that is potentially life threatening unless early recognized and aggressively treated. Airway management is the main foundation in these cases. Despite that, no specific guidelines exist and management is largely dependent on clinical judgment and experience.

Case Reports

A 65 yr case of neck swelling present to the ENT OPD at a tertiary care center in emergency with complaining of difficulty in breathing since 2 days with sudden onset of rapidly developing swelling in last 24 h. Immediately we got admitted this patient to the surgical ICU.

With our intensivist we made the difficult oral intubation of this patient with great difficulty with a silicon endotracheal tube of no. 7 using LMA as shown in Fig. 1. Respiratory rate was 26 per minute and oxygen saturation was 92% before intubation after intubation tachypnea reduced and oxygen saturation come to the 98%. Breathing pattern becomes normal after intubation. ABG shows acidosis.

Fig. 1.

Image showing huge submental swelling

Further detail history shows patient was known case of diabetes mellitus with hypertension on medical treatment. In that patient is having uncontrolled diabetes which was monitored though fasting and postprandial blood sugar level in ICU. In past history 5 days back the patient consulted with the dentist doctor for right sided lower molar dental caries, they are given treatment for same and advised dental extraction of lower right side second molar teeth.

On clinical examination there was diffuse swelling over the anterior neck involving the right submandibular and sublingual space with the submental region extending to the opposite side of lingual and submandibular region. There were erythema and redness present with increase localizes temperature with tenderness on palpation. Swelling size approx. 10 cm × 8 cm there was difficulty in opening the mouth because of trismus. Only one finer, mouth opening was there, with forceful opening it just increased by one more figure. So that we have done oral intubation for such difficult situation, because there were lots of laryngeal edema so no proper laryngeal inlet opening seen for intubation so used LMA.

All the routine blood investigation of patient done to check the all values is normal or deranged to monitor the patient status for further management. Blood group was Rh B positive, Hb 11 gm/dL, CBC shows thrombocytopenia, blood urea 28 mg/dL, Sr creatine 0.90 mg/dL, and blood urea nitrogen 13 mg/dL. Mildly elevated CRP in the initial period with normal PT INR.

Patients ECG was normal with sinus tachycardia and 2 D ECHO shown concentric LVH with good ejection fraction with no MR, TR and Pulmonary report were normal. USG neck showing the swelling over the bilateral submandibular and submental region. Chest X-ray P A view was normal. Incision and drainage of the swelling is not done as the patient was hemodynamically not stable and patient condition was deteriorating so it’s postponed.

We started the patient on higher intravenous antibiotics to cover all the bacteriological spectrum that is gram positive and gram negative bacteria. Also, given analgesic and antacid to the patient with close monitoring of all the parameters of the patient. Before trying for the emergency tracheostomy of this patient situation getting worsen due to the sever sepsis patient become hypotensive we started the patient with noradrenalin titrated dose max up to 1mcg/kg/min. The patient received 4 lit. Of crystalloids and 4unit of FFP Transfusion for hypovolemia for the survival of the patient. As lastly the patient develops disseminated intravascular coagulation with multiorgan failure and succumbs to death.

Discussion

Now a day number of cases of Ludwig’s angina are reduced due to the use of higher antibiotics and proper oral hygiene by the patient with total advancement in dental care in the early stages of dental caries. In spite of this care some time patient with diabetes mellitus and uncontrolled diabetics with immunocompromised status present with huge sublingual, submental and submandibular swelling causing difficulty in breathing for the patient. This is the Ludwig’s angina which is medical emergency.

It is a potentially life-threatening cellulites, or connective tissue infection, of the neck and the floor of the mouth, which is characterized by progressive submandibular swelling with elevation and posterior displacement of the tongue [3, 4].

Odontogenic infections account for the majority of cases [5]. The most commonly cultured organisms include Staphylococcus, Streptococcus, and Bacteroides species [5].

Early antibiotic treatment should be broad spectrum to cover Gram-positive and Gram-negative bacteria as well as anaerobes. A Combination of penicillin, clindamycin, and metronidazole is commonly used. We used broad spectrum antibiotics with third generation cephalosporin with penicillin in this case on admission.

Larawin et al. retrospectively studied a total of 103 patients with deep neck space infections from 1993 to 2005. Ludwig’s angina was the most commonly encountered infection seen in 38 (37%) patients of treatment. 13 (34%) patients managed successfully with medical therapy and only 4 (10%) patients required a tracheostomy tube [6].

Kurien et al. reported a 13-year review of patients with Ludwig’s angina between 1982 and 1995. Patients were either admitted to the ENT or pediatric surgical units. There were 41 patients, 24% being children and 76% adults. In children, 70% were controlled with conservative medical management while 81% of adults required incision and drainage. Tracheostomy was necessary in 10% of the children and in 52% of the adults. The mortality rate was 10% in both groups [7].

Conclusion

Ludwig’s angina is a surgical emergency if not treated within time it will lead to serious respiratory obstruction and death of the patient. Every neck abscess is challenging to the ENT surgeon. Early intervention in such case is key for patient survival. Airway management is priority in such case it must be secured conservatively and if needed surgically without thinking twice for it. Improved imaging modalities, antibiotic therapy, surgical skills, and clinical experience are the key factors behind this change in practice.

Funding

No funding sources.

Compliance with Ethical Standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical Approval

This study approved by the institutional ethical committee.

Informed Consent

Well informed consent of patient taken as this article involve human being.