Category Archives: ENT

The daily educational pearl – Ludwig’s angina

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 Ludwig’s angina

With thanks to Yusuf.

= progressive cellulitis of the floor of the mouth and neck that begins in the submandibular space

– potentially fatal disease – can progress to death within hours, usually by sudden asphyxiation

Cause: usually dental cause, such as an extraction or dental abscess; it can also complicate mandibular fractures, foreign body or laceration of the floor of the mouth, tongue piercings

Signs / symptoms: dysphagia, odynophagia, neck pain and swelling, drooling; bilateral submandibular swelling, “wooden” consistency of the floor of the mouth, tongue swelling, elevation and protrusion; a tense oedema and induration of the neck may occur – the “bull neck” sign; trismus, fever; in severe cases – dysphonia, stridor, respiratory distress

Imaging: CT with IV contrast or MRI

Management :
– potential airway emergency – DIFFICULT AIRWAY that might need urgent airway management in ED; seek early help from the Anaesthetics department – preferred method is fiberoptic naso- or orotracheal intubation; crycothyroidotomy will be difficult due to the disrupted anatomy, and also increases the risk of spreading the infection into the mediastinum

– IV antibiotics – same regimen as for peritonsillar abscesses

– urgent Maxillo-facial or ENT consult

Definitive management is still debated, whether these patients should be managed surgically with incision and drainage or medically only with antibiotics.

The daily educational pearl – retropharyngeal abscess

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Retropharyngeal abscess

Common in children younger than 4 years of age because the retropharyngeal space contains lymph nodes that atrophy after the age of 6, but there is an increasing incidence in adults (different pathophysiology – initial cellulitis of the retropharyngeal space spreads rapidly to form an abscess).

Causes:

pharyngitis / otitis media / parotitis / tonsillitis / Ludwig’s angina

dental infections / dental procedures

extension from vertebral osteomyelitis / discitis

upper airway instrumentation / endoscopy

trauma + foreign bodies (e.g. fish bones)

haematologic spread

Pathogens: usually polymicrobial with a mixture of aerobic bacteria (Beta-hemolytic Streptococcus, Staphylococcus spp., anaerobic bacteria (Bacteroides), Gram-negative bacteria (Haemophillus). Mycobacterium tuberculosis can cause retropharyngeal abscesses as well, but they are “cold” abscesses, that rarely present with fever or systemic features.

Signs / symptoms: fever, drooling, sore throat, dysphagia, odynophagia, neck pain and stiffness, dysphonia (“duck quack” or “cri du canard” voice), stridor, trismus or respiratory distress; tenderness on moving the trachea and larynx sideways (“tracheal rock sign”).

These patients prefer to remain supine (to prevent the oedematous retropharynx from occluding the airway), as opposed to the patients with epiglottitis / severe croup who prefer to sit forward / tripod position.

Complications: airway obstruction, mediastinitis, abscess rupture + aspiration pneumonia, epidural abscess, sepsis, jugular venous thrombosis

Imaging options:

Xray lateral soft tissues neck: prevertebral soft tissue swelling (>1/2 vertebral body width at C2-C4 or > 1 vertebral body width at C6-C7); rarely gas, or air-fluid levels.

CT of the neck with IV contrast or MRI: definite diagnosis + size of abscess + local complications

Treatment: IV antibiotics (same regimen as for peritonsillar abscesses), with or without surgical drainage.

They all need urgent ENT review / management and admission to intensive care unit due to the potential for airway obstruction.