Ludwig's Angina

Ludwig's angina is a serious, potentially life-threatening cellulitis or connective tissue infection of the submandibular space. It typically arises from infections of the teeth, particularly the second or third molars, and can lead to airway obstruction due to swelling. This condition is named after the German physician Wilhelm Friedrich von Ludwig, who first described it in the 19th century.

Etiology

• Common Causes:

  • Dental infections (especially from the lower molars)
  • Infections from the floor of the mouth
  • Trauma to the submandibular area
  • Occasionally, infections can arise from other sources, such as the oropharynx or skin.

• Microbial Agents:

  • Mixed flora, including both aerobic and anaerobic bacteria.
  • Common organisms include Streptococcus, Staphylococcus, and Bacteroides species.

Pathophysiology

• The infection typically begins in the submandibular space and can spread rapidly due to the loose connective tissue in this area.
• The swelling can lead to displacement of the tongue and can obstruct the airway, making it a medical emergency.

Clinical Presentation

• Symptoms:

  • Swelling of the submandibular area, which may be bilateral
  • "Brawny induration" (firm, non-fluctuant swelling)
  • Pain and tenderness in the submandibular region
  • Difficulty swallowing (dysphagia) and speaking (dysarthria)
  • Fever and malaise
  • Possible elevation of the floor of the mouth and displacement of the tongue

• Signs:

  • Swelling may extend to the neck and may cause "bull neck" appearance.
  • Trismus (limited mouth opening) may be present.
  • Respiratory distress due to airway compromise.

Diagnosis

• Clinical Evaluation: Diagnosis is primarily clinical based on history and physical examination.
• Imaging:
  • CT scan of the neck may be used to assess the extent of the infection and to rule out other conditions.
  • X-rays may show air in the soft tissues if there is a necrotizing infection.

Management

Initial Management

• Airway Management:
  • Ensure the airway is patent; this may require intubation or tracheostomy in severe cases.

Medical Treatment

• Antibiotics:
  • Broad-spectrum intravenous antibiotics are initiated to cover both aerobic and anaerobic bacteria. Common regimens may include:
    • Ampicillin-sulbactam
    • Clindamycin
    • Metronidazole combined with a penicillin derivative

Surgical Intervention

• Drainage:
  • Surgical drainage may be necessary if there is an abscess formation or significant swelling.
  • Incisions are typically made in the submandibular area to allow for drainage of pus and to relieve pressure.

Complications

• Airway Obstruction: The most critical complication, requiring immediate intervention.
• Sepsis: Can occur if the infection spreads systemically.
• Necrotizing fasciitis: Rare but serious complication that may require extensive surgical intervention.
• Thrombosis of the internal jugular vein: Can occur due to the spread of infection.

Prognosis

• With prompt diagnosis and treatment, the prognosis is generally good. However, delays in management can lead to significant morbidity and mortality due to airway compromise and systemic infection.

Walsham�s Forceps

Walsham�s forceps are specialized surgical instruments used primarily in the manipulation and reduction of fractured nasal fragments. They are particularly useful in the management of nasal fractures, allowing for precise adjustment and stabilization of the bone fragments during the reduction process.

1. Design:

   • Curved Blades: Walsham�s forceps feature two curved blades�one padded and one unpadded. The curvature of the blades allows for better access and manipulation of the nasal structures.
   • Padded Blade: The padded blade is designed to provide a gentle grip on the external surface of the nasal bone and surrounding tissues, minimizing trauma during manipulation.
   • Unpadded Blade: The unpadded blade is inserted into the nostril and is used to secure the internal aspect of the nasal bone and associated fragments.

2. Usage:

   • Insertion: The unpadded blade is carefully passed up the nostril to reach the fractured nasal bone and the associated fragment of the frontal process of the maxilla.
   • Securing Fragments: Once in position, the nasal bone and the associated fragment are secured between the padded blade externally and the unpadded blade internally.
   • Manipulation: The surgeon can then manipulate the fragments into their correct anatomical position, ensuring proper alignment and stabilization.

3. Indications:

   • Walsham�s forceps are indicated for use in cases of nasal fractures, particularly when there is displacement of the nasal bones or associated structures. They are commonly used in both emergency and elective settings for nasal fracture management.

4. Advantages:

   • Precision: The design of the forceps allows for precise manipulation of the nasal fragments, which is crucial for achieving optimal alignment and aesthetic outcomes.
   • Minimized Trauma: The padded blade helps to reduce trauma to the surrounding soft tissues, which can be a concern during the reduction of nasal fractures.

5. Postoperative Considerations:

   • After manipulation and reduction of the nasal fragments, appropriate postoperative care is essential to monitor for complications such as swelling, infection, or malunion. Follow-up appointments may be necessary to assess healing and ensure that the nasal structure remains stable.

Intubation

Intubation is a critical procedure in airway management, and the choice of technique�oral intubation, nasal intubation, or tracheostomy�depends on the clinical situation, patient anatomy, and specific indications or contraindications. 

Indications for Each Intubation Technique

1. Oral Intubation

Oral intubation is often the preferred method in emergency situations and when nasal intubation is contraindicated. Indications include:

• Emergent Intubation: Situations such as cardiopulmonary resuscitation (CPR), unconsciousness, or apnea.
• Oral or Mandibular Trauma: When there is significant trauma to the oral cavity or mandible that may complicate nasal access.
• Cervical Spine Conditions: Conditions such as ankylosis, arthritis, or trauma that may limit neck movement.
• Gagging and Vomiting: In patients who are unable to protect their airway due to these conditions.
• Agitation: In cases where the patient is agitated and requires sedation and airway protection.

2. Nasal Intubation

Nasal intubation is indicated in specific situations where oral intubation may be difficult or impossible. Indications include:

• Nasal Obstruction: When there is a blockage in the oral route.
• Paranasal Disease: Conditions affecting the nasal passages that may necessitate nasal access.
• Awake Intubation: In cases where the patient is cooperative and can tolerate the procedure.
• Short (Bull) Neck: In patients with anatomical challenges that make oral intubation difficult.

3. Tracheostomy

Tracheostomy is indicated for long-term airway management or when other methods are not feasible. Indications include:

• Inability to Insert Translational Tube: When oral or nasal intubation fails or is not possible.
• Need for Long-Term Definitive Airway: In patients requiring prolonged mechanical ventilation or airway support.
• Obstruction Above Cricoid Cartilage: Conditions that obstruct the airway at or above the cricoid level.
• Complications of Translational Intubation: Such as glottic incompetence or inability to clear tracheobronchial secretions.
• Sleep Apnea Unresponsive to CPAP: In patients with severe obstructive sleep apnea who do not respond to continuous positive airway pressure (CPAP) therapy.
• Facial or Laryngeal Trauma: Structural contraindications to translaryngeal intubation.

Contraindications for Nasal Intubation

• Severe Fractures of the Midface: Nasal intubation is contraindicated due to the risk of further injury and complications.
• Nasal Fractures: Similar to midface fractures, nasal fractures can complicate nasal intubation and increase the risk of injury.
• Basilar Skull Fractures: The risk of entering the cranial cavity or causing cerebrospinal fluid (CSF) leaks makes nasal intubation unsafe in these cases.

• Contraindications for Oral Intubation

  1. Severe Facial or Oral Trauma:

     • Significant injuries to the face, jaw, or oral cavity may make oral intubation difficult or impossible and increase the risk of further injury.

  2. Obstruction of the Oral Cavity:

     • Conditions such as large tumors, severe swelling, or foreign bodies that obstruct the oral cavity can prevent successful intubation.

  3. Cervical Spine Instability:

     • Patients with unstable cervical spine injuries may be at risk of further injury if neck extension is required for intubation.

  4. Severe Maxillofacial Deformities:

     • Anatomical abnormalities that prevent proper visualization of the airway or access to the trachea.

  5. Inability to Open the Mouth:

     • Conditions such as trismus (lockjaw) or severe oral infections that limit mouth opening can hinder intubation.

  6. Severe Coagulopathy:

     • Patients with bleeding disorders may be at increased risk of bleeding during the procedure.

  7. Anticipated Difficult Airway:

     • In cases where the airway is expected to be difficult to manage, alternative methods may be preferred.

Contraindications for Tracheostomy

1. Severe Coagulopathy:

   • Patients with significant bleeding disorders may be at risk for excessive bleeding during the procedure.

2. Infection at the Site of Incision:

   • Active infections in the neck or tracheostomy site can increase the risk of complications and should be addressed before proceeding.

3. Anatomical Abnormalities:

   • Significant anatomical variations or deformities in the neck that may complicate the procedure or increase the risk of injury to surrounding structures.

4. Severe Respiratory Distress:

   • In some cases, if a patient is in severe respiratory distress, immediate intubation may be prioritized over tracheostomy.

5. Patient Refusal:

   • If the patient is conscious and refuses the procedure, it should not be performed unless there is an immediate life-threatening situation.

6. Inability to Maintain Ventilation:

   • If the patient cannot be adequately ventilated through other means, tracheostomy may be necessary, but it should be performed with caution.

7. Unstable Hemodynamics:

   • Patients with severe hemodynamic instability may not tolerate the procedure well, and alternative airway management strategies may be required.

1 Cellulitis: a non-suppurative inflammation of subcutaneous tissue, extending along connective tissue planes and across intercellular spaces.

Spreading inflammation in the tissue planes is called cellulitis. There is wide spread swelling, redness and pain without definite localization.

Caused by Streptococcus pyogenes.. If general condition of the patient is undermined, as in diabetes, cellulitis spreads rapidly and leads to Septicemia (infection in the blood).Redness, itching and stiffness is present in the site of inoculation (where the bacteria enter the skin), local Gangrene (death of the tissue) may occur. The appearance of skin creases or wrinkles, indicates resolution (healing).

Treatment

1. Rest , Appropriate antibiotics.

Cellulitis of the neck: Is a complication of wounds tonsillitis or mastoiditis Ludwig’s angina is the term applied to sub-maxillary cellulitis. The two dangers of cervical cellulitis are:

1. Oedema of glottis - with possible asphyxia (respiratory obstructon )

2. Mediastinitis - In ludwig’s angina the floor of the mouth become oedematous. The tongue can be seen displaced, turned upwards by swelling and oedema. The patient is unable to close the mouth owing to oedema of the tongue and the floor of the mouth. This can also CCC when the tongue is bitten by a wasp.

Ludwig’s angina: Ludwig - characterized by a brawny (non pitting) swelling of the sub-mandibular region, corn with inflammatory oedema of the mouth. It is the combined cervical and intrabuccal signs that constitute the characteristic feature of the lesion. The cause of the condition is virulent, usually streptococcal infection of the cellular tissue surrounding the sub-mandibular salivary gland.

Clinical features

 The swollen tongue is pushed towards the palate and forwards through the open mouth, while the cellulitis extends down the neck.

The most dangerous plane, is deep to the deep fascia.

Ludwig’s angina is an infection of closed fascial space and if .untreated, the inflammatory exudate often passes via, the tunnel occupied by stylohyhoid to the submucosa of glottis, in which event the patient is in immediate danger of death from oedema of the glottis.

Treatment

1. antibiotics on Early Diagnosis

2. In cases where the swelling, both cervical and intrabuccal, does not subside rapidly with such treatment, a curved incision, beneath the jaw is made and this decompresses the closed fascial space. The incision is deepened and after displacing the superficial lobe of the sub-mandibular salivary gland, the mylohyoid muscle are divided. This decompresses the closed fascjal space referred to. The wound is lightly sutured and drained. The operation can be conducted with greatest safety under local anaesthesia.

Bacteraemia and  Septicemia

Bacteraemia and septicaemia means the organisms are present in the blood. Clinical features are those of severe infection and shock: , Pyrexia is intermittent , Rigors ,  Jaundice is due to liver damage,  Acute renal failure may occur , Peripheral circulatory failure,  lntravascular coagulation indicates a fatal outcome

 causative focus found and treated surgically .g., Appendicetomy in perforated appendix

2. Blood culture taken

3. Broad spectrum antibiotic is given

4. Blood transfusion is given.

5. Injection hydrocortisone is given.

Pyaemia

Pyaemia is due to infected emboli circulating in blood stream. Pyaemia is characterized by: -

1. Rigors

2. Intermittent fever

3. Formation of abscess in vital organs like heart or brain.

Treatment

1. Is to prevent emboli reaching the blood stream

2. Broad spectrum antibiotic is given.

3. Abscess are incised and drained

If not treated portal pyaemia with multiple abscesses in liver occur, which is a dangerous condition.

Acute Abscess :  An abscess a collection of pus.

Bacteria which cause pus formation is called pyogenic organisms. Bacteria reach the infected area by:

1. Direct route: eg. Penetrating wound

Local extension: From adjacent focus of infection

2 Lymphatics

4. Blood stream

Pyogenic membrane surrounds the abscess and is infiltration with (leukocytes and bacteria.

Pus: Pus contains dead leukocytes and bacteria. It reaches the surface of the body or is discharged into a hollow viscous.

Symptoms: patient feels ill., Throbbing pain is characteristic of suppuration. Pain becomes more severe in the dependent position. E.g. infected finger,

Classical signs

Temperature is elevated , Rigors, inflammation

Fluctuation: Present in the later stages, and reveals the presence of pus. Prevention

1. An abscess can sometimes be aborted by antibiotics in the early stage.,. Rest,  Elevation of the affected part.

Treatment

Is incision and drainage of abscess

Hilton’s method of opening an abscess:

It is used where important anatomical structures like the blood vessels and nerves are preesnt, as in the neck, axilla and groin. The skin and superficial fascia is incised. A sinus forceps is thrust into the abscess  cavity. The blades are opened and the pus is drained. A gloved finger is introduced and loculi are broken. A ribbon gauze is lightly packed and antibiotics are given. This is done under surface anaesthesia i.e., ethyl chloride spray.

Antibioma

 If antibiotic is given the pus in the abscess frequently becomes sterile and a large brawny edematous swelling remains which takes many weeks to resolve.

Treatment: explore the mass with a wide-bore aspirating needle

 Most antibiornas are due to late, inadequate, and ineffective antibiotics.

CANCRUM ORIS

Is an infective gangrene of cheek and lip.

may occur as a complication of kala azar, enteric fever and  children with poor oral hygiene.

The lesion starts as an acute inflammatory patch on oral mucosa which is seen ulcerated.

The affected part of the cheek or the lip gradually becomes gangrenous.

Focal vascular thrombosis and sepesis occur.

When slough separates, a part of the cheek or lip sloughs out to form a buccal fistula with ugly deformity. The adjacent jaw may be infected too.

Various organisms are found - specially Fusiform bacillus and_Borrellia vincenti.

The foetid odour, gangrenous patch of cheek or lip, purulent discharge from the mouth, fever and toxaemia are the characteristic features. The patient is unable to open the mouth properly.

Treatment

1. Antibiotics, multivitamins and repeated mouth washes

2 Neostibamine in kala-azar. Sequestrectomy in chronic osteomyelitis of the mandible.

4. Plastic reconstruction of the lip or cheek for unsightly deformity undertaken.

CARBUNCLE

Is an infective gangrene of the subcutaneous tissue. It is due to staphylococcal aureus infection. It is uncommon before the age of 40. Males are the usual sufferers. Diabetes may be present. It often occurs on the nape of the neck.

Clinical features

Subcutaneous tissue becomes painful and indurated. Ove skin is red. Unless treated promptly, extension will occur and late softening. The skin gives way and thick pus and slough are discharged.

Usually, there is one central large slough, surrounded by smaller areas of necrosis. Infection extends widely and fresh openings appear

Treatment

1. Many carbuncles are aborted, if penicillin is used adequately in the early stage.

2. Local treatment consists of hygroscopic dressings being given ie. magsulph-glycerin dressing Later the carbuncle is excised with a cruciate incision.

3. If the gap is large and when the granulation tissue comes to the surface, skin grafting is done.

Neuromuscular Blockers in Cardiac Anesthesia

In  patient on β-blockers, the choice of neuromuscular blockers (NMBs) is critical due to their potential cardiovascular effects. Here�s a detailed analysis of the implications of using fentanyl and various NMBs, particularly focusing on vecuronium and its effects.

Key Points on Fentanyl and β-Blockers

• Fentanyl:

  • Fentanyl is an opioid analgesic that can cause bradycardia due to its vagolytic activity. While it has minimal hemodynamic effects, the bradycardia it induces can be problematic, especially in patients already on β-blockers, which reduce heart rate and blood pressure.

• β-Blockers:

  • These medications reduce heart rate and blood pressure, which can compound the bradycardic effects of fentanyl. Therefore, careful consideration must be given to the choice of additional medications that may further depress cardiac function.

Vecuronium

• Effects:

  • Vecuronium is a non-depolarizing neuromuscular blocker that has minimal cardiovascular side effects when used alone. However, it can potentiate decreases in heart rate and cardiac index when administered after fentanyl.
  • The absence of positive chronotropic effects (unlike pancuronium) means that vecuronium does not counteract the bradycardia induced by fentanyl, leading to a higher risk of significant bradycardia and hypotension.

• Vagal Tone:

  • Vecuronium may enhance vagal tone, further predisposing patients to bradycardia. This is particularly concerning in patients on β-blockers, as the combination can lead to compounded cardiac depression.

Comparison with Other Neuromuscular Blockers

1. Pancuronium:

   • Vagolytic Action: Pancuronium has vagolytic properties that can help attenuate bradycardia and support blood pressure. It is often preferred in cardiac anesthesia for its more favorable hemodynamic profile compared to vecuronium.
   • Tachycardia: While it can induce tachycardia, this effect may be mitigated in patients on β-blockers, which can blunt the tachycardic response.

2. Atracurium:

   • Histamine Release: Atracurium can release histamine, leading to hemodynamic changes such as increased heart rate and decreased blood pressure. These effects can be minimized by slow administration of small doses.

3. Rocuronium:

   • Minimal Hemodynamic Effects: Rocuronium is generally associated with a lack of significant cardiovascular side effects, although occasional increases in heart rate have been noted.

4. Cis-Atracurium:

   • Cardiovascular Stability: Cis-atracurium does not have cardiovascular effects and does not release histamine, making it a safer option in terms of hemodynamic stability.

Types of Head Injury

1. Extradural Hematoma (EDH)

Overview

• Demographics: Most common in young male patients.
• Association: Always associated with skull fractures.
• Injured Vessel: Middle meningeal artery.
• Common Site of Injury: Temporal bone at the pterion (the thinnest part of the skull), which overlies the middle meningeal artery.
• Location of Hematoma: Between the bone and the dura mater.

Other Common Sites

1. Frontal fossa
2. Posterior fossa
3. May occur following disruption of major dural venous sinus.

Classical Presentation

• Initial Injury: Followed by a lucid interval where the patient may only complain of a headache.
• Deterioration: After minutes to hours, rapid deterioration occurs, leading to:
  • Contralateral hemiparesis
  • Reduced consciousness level
  • Ipsilateral pupillary dilatation (due to herniation)

Imaging

• CT Scan: Shows a lentiform (lens-shaped or biconvex) hyperdense lesion between the brain and skull.

Treatment

• Surgical Intervention: Immediate surgical evacuation via craniotomy.
• Mortality Rate: Overall mortality is 18% for all cases of EDH, but only 2% for isolated EDH.

2. Acute Subdural Hematoma (ASDH)

Overview

• Location: Accumulates in the space between the dura and arachnoid.
• Injury Mechanism: Associated with cortical vessel disruption and brain laceration.
• Primary Brain Injury: Often associated with primary brain injury.

Presentation

• Consciousness: Impaired consciousness from the time of impact.

Imaging

• CT Scan: Appears hyperdense, with hematoma spreading diffusely and having a concavo-convex appearance.

Treatment

• Surgical Intervention: Evacuation via craniotomy.
• Mortality Rate: Approximately 40%.

3. Chronic Subdural Hematoma (CSDH)

Overview

• Demographics: Most common in patients on anticoagulants and antiplatelet agents.
• History: Often follows a minor head injury weeks to months prior.
• Pathology: Due to the tear of bridging veins leading to ASDH, which is clinically silent. As the hematoma breaks down, it increases in volume, causing mass effect on the underlying brain.

Clinical Features

• Symptoms may include:
  • Headache
  • Cognitive decline
  • Focal neurological deficits (FND)
  • Seizures
• Important to exclude endocrine, hypoxic, and metabolic causes in this group.

Imaging

• CT Scan Appearance:
  • Acute blood (0�10 days): Hyperdense
  • Subacute blood (10 days to 2 weeks): Isodense
  • Chronic (> 2 weeks): Hypodense

Treatment

• Surgical Intervention: Bur hole evacuation rather than craniotomy.
• Anesthesia: Elderly patients can often undergo surgery under local anesthesia, despite comorbidities.

4. Subarachnoid Hemorrhage (SAH)

Overview

• Causes: Most commonly due to aneurysms for spontaneous SAH, but trauma is the most common cause overall.
• Management: Conservative treatment is often employed for trauma cases.

5. Cerebral Contusions

Overview

• Definition: Bruising of the brain tissue due to trauma.
• Mechanism: Often occurs at the site of impact (coup) and the opposite side (contrecoup).
• Symptoms: Can range from mild confusion to severe neurological deficits depending on the extent of the injury.

Imaging

• CT Scan: May show areas of low attenuation (hypodense) or high attenuation (hyperdense) depending on the age of the contusion.

Treatment

• Management: Depends on the severity and associated injuries; may require surgical intervention if there is significant mass effect.