Ludwig Angina: A Review of Current Airway Management [Clinical Challenges In Otolaryngology] Marple, Bradley F. MD Volume 125(5) - PowerPoint PPT Presentation

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Ludwig Angina: A Review of Current Airway Management [Clinical Challenges In Otolaryngology] Marple, Bradley F. MD Volume 125(5)

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Airway maintenance The need for immediate artificial airway: ... a review of current airway management. Archives of Otolaryngology -- Head & Neck Surgery. – PowerPoint PPT presentation

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Title: Ludwig Angina: A Review of Current Airway Management [Clinical Challenges In Otolaryngology] Marple, Bradley F. MD Volume 125(5)


1
??????
  • ?????????

2
  • 25 ??? 12532225
  • 94.2.20 747pm
  • ????
  • ????
  • TRIAGE ???? II
  • T39C,P 94/min,R18/min,BP128/60 mmHg
  • Chief complaint ?? Neck swelling ???? for 2
    days
  • Present illness ??? ?????? fever
  • cough
    with yellowish sputum for 2 days

  • sorethroat for 2 days

  • dyspnea

  • general soreness
  • no
    rhinorrhea
  • Past history Denied allergy
  • Denied
    systemic disease

3
Physical Examination
  • Cons clear
  • HN conjnot pale
  • submental swelling ??, tender
  • Chest coarse
  • Abd soft
  • Ext freely movable

4
Impression ?
5
Order
  • 750pm
  • Neck soft tissue view
  • WBC/DC, Hb, Plt
  • CRP
  • N/S run 80 ml/h
  • Keto 1 amp IM st
  • Consult ENT
  • 820 pm
  • PCT ( ) If negative, Augmentin 1.2g st q8h iv
  • Bun/Cre
  • Keto, Danzen 1 qid po 2 days
  • OPD f/u

6
Result
  • WBC 25550 Seg 89 Band 4
  • Hb 16.4
  • Platelet 197000
  • CRP 10.1
  • Bun/Cre 9/1.1
  • Neck soft tissue view
  • ENT Mild injected throat
  • Patent vocal cord
  • Imp neck cellulitis
  • r/o submandibular
    sialadenitis
  • Oral Voren, Augmentin, Simagel,
    Danzen
  • OPD f/u.

7
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8
Order
  • 2/21 am
  • Genta-C 80mg ivd st q8h
  • 225 am
  • Neck CT s c contrast
  • Metronidazole 1 g st iv then 500mg q6h iv
  • B/C II
  • VBG
  • Reconsult ENT
  • 940 am
  • Admission and OP

9
Result
  • Neck CT

10
Ludwig angina a review of current airway
management. Archives of Otolaryngology -- Head
Neck Surgery. Marple BF. 125(5)596-9, 1999
May.Ludwig's angina a clinical review.
European Archives of Oto-Rhino-Laryngology.
Srirompotong S. Art-Smart T. 260(7)401-3, Aug
2003.
  • Ludwigs Angina

11
Background
  • Hippocrates in 1836, a postmortem findings, Karl
    Friedrich Wilhelm von Ludwig
  • A rapidly progressive gangrenous cellulitis
    originating in submandibular gland.
  • Inflammatory distention of the fascial planes of
    the neck can lead to respiratory tract
    obstruction and death.
  • It extends by continuity rather than lymphatic
    spread.
  • Mortality rate exceeds 50 during the
    preantibiotic era, attributed to overwhelming
    sepsis.
  • But in the early 1900s the deadly role of
    mechanical respiratory obstruction was realized.

12
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13
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14
Etiology
  • gt 90 odontogenic in origin
  • Peritonsillar absecess
  • Parapharyngeal abscesses
  • Oral lacerations
  • Mandibular fractures
  • Submandibular sialadenitis

15
Presentation
  • Neck swelling
  • Tooth pain
  • Protruding or elevated tongue
  • Fever
  • Dysphagia
  • Trismus
  • Difficulty breathing
  • Asphyxia

16
Pathogens
  • Bacterial isolates are often mixed, comprising
    both aerobes and anaerobes.
  • Mostly alpha-hemolytic streptococci,
    staphylococci and bacteroides.

17
Treatment
  • Primary goal
  • Preserve the oropharyngeal airway.
  • Secondary goal
  • Antibiotic agent or incision and drainage

18
Airway maintenance
  • Question When, How ?
  • Airway compromise develops insidiously.
  • Early s/s of obstruction may be very subtle to
    neglect.
  • Whereas actual obstruction is abrupt.
  • Limited cases and experience?
  • Routine endotracheal intubation or tracheotomy?
  • Recommendations vary throughout literature.
  • The trend is toward airway observation as
    antimicrobial therapy has emerged.

19
Airway maintenance
  • The need for immediate artificial airway
  • Stridor
  • Cyanosis
  • Retractions
  • difficulty managing secretions.
  • Rapid progression of edema
  • Comorbid health problems, DM

20
Airway maintenance
  • Airway maintenance may be difficult
  • Endotraclear intubation
  • Supraglottic edema
  • Nuchal rigidity
  • Trismus
  • Nasal intubation
  • Requires careful awake
  • Flexible endoscope
  • Patient in an upright position.
  • Last resort
  • Cricothyroidotomy
  • Tracheotomy.

21
Antibiotic agent
  • Early aggressive antibiotic therapy
  • largely replaced surgical decompression
  • frequently circumvents artificial control of the
    airway.
  • Determine the source of infection
  • High-dose penicillin G.
  • Sometime combined with metronidazole.
  • In penicillin-allergic patients, use clindamycin.
  • IV dexamethasone, given for 48 h, has been
    beneficial in reducing edema.

22
Surgical intervention
  • Decompression
  • sublingual and submandibular spaces.
  • Incision and drainage
  • Debridement

23
Complication
  • Deep neck infection
  • Mediastinitis
  • Sepsis
  • Pneumonia
  • Empyema
  • Asphyxia
  • Pneumothorax

24
Conclusion
  • The very name angina, meaning spasmodic
    suffocative pain when not treated.
  • Tracheotomy may eliminate the decision-making
    burden, but
  • Early aggressive antimicrobial therapy has
    reduced the need for airway intervention.
  • The treatment plan for each patient should be
    individualized.

25
Conclusion
  • The condition of the patient and comorbid health
    problems, physician experience, available
    resources, and personnel are all crucial factors
    in this decision-making process.
  • Examinations performed at regular intervals allow
    the physician to monitor the progression of the
    disease or its response to therapy.
  • Routine use of SpO2 helps to monitor the
    patient's oxygenation, but does not replace the
    role of the caregiver.
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