RevBrasAnestesiol.2017;67(6):637---640
REVISTA
BRASILEIRA
DE
ANESTESIOLOGIA
PublicaçãoOficialdaSociedadeBrasileiradeAnestesiologiawww.sba.com.br
CLINICAL
INFORMATION
Airway
management
in
Ludwig’s
angina
---
a
challenge:
case
report
Roberto
Taboada
Fellini
a,b,
Daniel
Volquind
a,b,c,∗,
Otávio
Haygert
Schnor
d,
Marcelo
Gustavo
Angeletti
e,
Olívia
Egger
de
Souza
a,b,c,d,eaPropedêuticaCirúrgicaeAnestésicadaUniversidadedeCaxiasdoSul,UnidadedeEnsinoMédico,CaxiasdoSul,RS,Brazil bClínicadeAnestesiologiadeCaxiasdoSul,CaxiasdoSul,RS,Brazil
cComissãoExaminadoradoTítuloSuperioremAnestesiologia,PortoAlegre,RS,Brazil
dHospitalSantaRita,ComplexoHospitalarSantaCasadeMisericórdiadePortoAlegre,PortoAlegre,RS,Brazil eCursodeMedicinadaUniversidadedeCaxiasdoSul,CaxiasdoSul,RS,Brazil
Received17August2014;accepted8October2014
Availableonline21September2016
KEYWORDS
Airways; Ludwig’sangina; Mediastinitis
Abstract
Background: Ludwig’sangina(LA)isaninfectionofthesubmandibularspace,firstdescribed byWilhelmFrederickvonLudwigin1836.Itrepresentsanentitydifficulttomanageduetothe rapid progressionanddifficultyinmaintainingairwaypatency, amajorchallengeinmedical practice,resultinginasphyxiaanddeathin8---10%ofpatients.
Objective: DescribeacaseofapatientwithLudwig’sanginaundergoingsurgery,withemphasis onairwaymanagement,inadditiontoreviewingthearticlespublishedintheliteratureonthis topic.
Casereport: Male patient, 21 years, drug addict, admitted by the emergency department anddiagnosedwithLA.Difficultairwaywasidentifiedduringtheanestheticexamination.In additional tests,significantdeviation fromthetracheal axiswasseen.Undergoing bilateral thoracoscopicpleuraldrainage,weoptedforairwaymanagementthroughtrachealintubation usingfiberopticbronchoscopy,andbalancedgeneralanesthesiawasproposed.Therewereno complicationsduringthesurgical-anestheticact.Aftertheprocedure,thepatient remained intubatedandmechanicallyventilatedintheintensivecareunit.
Conclusions: AirwaymanagementinpatientswithLudwig’sangina remainschallenging.The choiceofthesafesttechniqueshouldbebasedonclinicalsigns,technicalconditionsavailable, andtheurgentneedtopreservethepatient’slife.
©2015SociedadeBrasileiradeAnestesiologia.Publishedby ElsevierEditoraLtda.Thisisan openaccessarticleundertheCCBY-NC-NDlicense( http://creativecommons.org/licenses/by-nc-nd/4.0/).
∗Correspondingauthor.
E-mail:danielvolquind@gmail.com(D.Volquind).
http://dx.doi.org/10.1016/j.bjane.2014.10.010
638 R.T.Fellinietal.
PALAVRAS-CHAVE
Viasaéreas; AnginadeLudwig; Mediastinite
ManejodaviaaéreanaanginadeLudwig---umdesafio:relatodecaso
Resumo
Justificativa:A angina de Ludwig (AL) constitui uma infecc¸ão do espac¸o submandibular, primeiramente descritapor Wilhelm Frederick von Ludwig em 1836. Representa uma enti-dadededifícilmanejodevidoàrápidaprogressãoedificuldadenamanutenc¸ãodaviaaérea pérvia,umimportantedesafionapráticamédica,queculminaemasfixiaemorteem8-10%dos pacientes.
Objetivo:DescreverocasoclínicodeumpacientecomanginadeLudwigsubmetidoa proced-imentocirúrgico,comênfasenomanejodaviaaérea,alémderevisarosartigosdisponíveisna literaturamédicaarespeitodessetema.
Relatodecaso:Pacientemasculino,21anos,drogadito,admitidopeloprontosocorroe diag-nosticado com AL. Na propedêutica anestésica constatou-se via aérea difícil. Nos exames complementaresfoipossívelobservarimportantedesviodoeixotraqueal.Submetidoà toraco-scopiabilateralcomdrenagempleural,optou-sepelomanejodaviaaéreaatravésdeintubac¸ão nasotraqueal por fibrobroncoscopia e foi proposta anestesia geral balanceada. Não houve intercorrênciaduranteo atocirúrgico-anestésico. Apósprocedimentopaciente permaneceu intubadoeemventilac¸ãomecânicanaUnidadedeTerapiaIntensiva.
Conclusões:OmanejodaviaaéreanospacientescomanginadeLudwigpermanecedesafiador. Aescolhadatécnicamaisseguradeveserembasadanoquadroclínico,nascondic¸õestécnicas disponíveisenanecessidadeprementedepreservac¸ãodavidadopaciente.
©2015SociedadeBrasileiradeAnestesiologia.PublicadoporElsevierEditoraLtda.Este ´eum artigoOpen Accesssobumalicenc¸aCCBY-NC-ND( http://creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction
Ludwig’sangina (LA)is an infection ofthe submandibular
space,firstdescribed byWilhelm FrederickvonLudwig in
1836.1Thepresenceofdentalcaries,oraltrauma,
immuno-suppression,andcontinuoususeofpsychoactivesubstances,
suchasalcoholanddrugabuse,arepredisposingfactorsfor
theonsetofthisinfection.2The infectionprogressionmay
causetheinvolvementoftheretropharyngealspace
delim-itedby thedeepcervical fascia,which startsat the skull
baseandextendstotheuppermediastinum.3
Itisanentitydifficulttomanageduetotherapid
progres-sionanddifficultyinmaintainingairwaypatency,resulting
inasphyxiationanddeathin8---10%ofpatients.4
Thechallengeofestablishingapatentairwayinhigh-risk
patientsmotivatedthiscasereport.
Case
report
Malepatient,white,21yearsold,cocaine andcrack user,
was admitted to the emergency room with dyspnea and
severe neck and jaw pain on the right, which worsened
whileattemptingtoopenthemouth.Physicalexamination
showedsepticteeth,swallowingpain,chestpain,edema,
hyperemia and subcutaneous emphysema in the anterior
cervical region and mandibular on the right, inspiratory
stridor,andrespiratoryeffort.Withfever(axillary
temper-ature 38◦C), blood pressure 80
×45mmHg, HR 113bpm,
RR25breaths.min−1,andSpO
288%inroomair.Computed
tomography of the neckand chest showed impairmentof
mediastinalregioninwhichtherewasanimportantamount
ofgas dissecting themuscleand fat planes,especiallyon
the right, and determining a significant deviation from
thetracheal axistothecontralateralside. Italsoshowed
gas dissecting the posterior space of the nasopharynx
and extending to the upper mediastinum. The vascular
structureswerepreserved.AfterthediagnosisofLudwig’s
angina, antibiotic therapy was started with ampicillin
and gentamicin at recommended doses and bilateral
thoracoscopywithpleuraldrainagewasproposed.
Thepatientwasmonitoredwithelectrocardiogram(DII
and V5), pulse oximetry, and noninvasive blood pressure.
Venouspuncturewasperformedwith18Gvenouscatheter.
Airway evaluation showed the impossibility of
oro-tracheal intubation due to the patient’s mouth opening
difficulty (<1cm), Mallampati score 4, and immobility
of the cervical region because of pain and swelling in
rightmandible.Weoptedfornasotrachealintubationusing
fiberopticbronchoscopy.
Anesthetic sedation was performed with midazolam
(2mg) associated with fentanyl (100mcg), both by
intra-venous route. Duringthe procedure, the patientreceived
O2vianasalcatheter(3L.min−1).
There were no complications during fiberoptic
intuba-tion.Aftercuffinflationandconfirmationofintubationby
capnography, propofol (150mg), fentanyl (350mcg), and
rocuronium (35mg) were infused. Controlled mechanical
ventilationwasstarted,withtidalvolumeof600mL,12
ven-tilationcycles.min−1,withainhalation/exhalationratioof
1:2 and PEEP of 5cmH2O.Capnography curve was
main-tainedrangingfrom35---40mmHg.
ItwasusedaFiO2of60%,whichwassufficienttoestablish
ahemoglobinsaturationin99---100%.Weoptedforusingthe
inhaled anesthetic sevoflurane in 2% concentration
AirwaymanagementinLudwig’sangina---achallenge:casereport 639
period.Aftersurgery,thepatientremainedintubatedand
on mechanical ventilation in the Intensive Care Unit but
evolved to death by septic shock on the sixth day after
surgery.
Discussion
Ludwig’s angina involves the submandibular, sublingual,
and submaxillary spaces, which communicate posteriorly.
Itaffectstheareabelowthemouthfloorandinvolves the
submental triangle and submandibular muscles limitedby
the deep cervical fascia. The infection progression may
causetheinvolvementofcervicalandmediastinalareaswith
severeairwayimpairment.1,3
Theestablishmentofapatentairwayisthemainconcern
and emergency tracheotomy may be requirede.5,6
Suspi-cion of difficult airwayinvolvement is a recommendation
forfiberopticintubationthroughnasalroute.7,8
Orotracheal ornasotrachealintubationmaybe
impossi-bleduetotheanatomicalimpairmentofinfection,airway
traumarisk,ruptureof pusintotheoral cavitywith
bron-chopulmonaryaspiration,aswellasthepotentialtoinduce
severelaryngospasm.9
Inthiscontext,SpitalnicandSucovreportedthecaseof
apatientwithLudwig’sanginainwhichtheairway
manage-ment throughintubation withfiberoptic laryngoscopywas
unsuccessful due tothe swellingand anatomy distortion.
Tracheostomywasthenrequired.3
Faced with the impossibility of fiberoptic intubation,
the indication for airway management is throughsurgical
tracheostomy, although some authors advocate
cricothy-roidotomy because it has fewer complications, such as
emergencyairway.8,10,12
In this report, the mouth opening difficulty with the
occurrenceof lockjawestablished thedifficult airway
sit-uation,andthesignsofairwayobstructionandrespiratory
failure were decisive for the airway management option
withfiberopticthroughfiberbronchoscope.Fiberoptic
bron-choscopy was performed by conscious sedation with no
trachea anesthetic blockade nor larynx innervation blunt
duetoanatomicalimpairmentbroughtbythedisease.
The studies, regardless of the recommended airway
approach,reinforcetheimportanceofcarefulclinical
eval-uationofthepatientwithrapiddecisionabouttheairway
management.
Brommelstroetetal.reportedtwocasesofpatientswith
necrotizingmediastinitisafterLudwig’sangina,whoseorigin
wasanodontogenicinfection.Inbothcases,tracheostomy
wasperformedtomaintaintheairwayduetoworseningof
generalconditionandtheneedforcervicaland
submandi-bularabscessdrainage.13
In 2002, Potter retrospectively studied the medical
records of 85 patients with infections in deep cervical
spaces and in hisconclusions hedid not recommend
tra-chealintubationinseverecasesbecausetheypresentrisks
ofunplannedextubationwithdifficultreintubationdueto
edemaandthepossibilityofinfectionspreadingduring
intu-bation. Thisauthorbelieves thata carefulanalysisof the
patientandtheavailabilityofequipmentarecrucialwhen
choosingtheairwaymanagementmethod.11
Despitetherisksoftrachealintubation(TI),Kassametal.
reportedacaseofapatientwithLAwhounderwentTIfor
dentalextraction anddecompression ofareas affectedby
infectionandremainedintubatedfor 72hafterthe
proce-dure.Inthisstudy,theauthorsemphasizetheimportanceof
maintainingtheTIforaperiodaftertheproceduretoreduce
swellingandconsequentlylowertheriskofairway
obstruc-tion postoperatively.9 In this case, the patient remained
intubatedvia nasotracheal during theearly postoperative
periodinordertoavoidcomplicationsrelatedtoairway
con-trol,asthedifficultiesremainuntilthediseaseresolution.9
Inaretrospectiveanalysisof29casesofthroatabscess,
Wolfe et al. showed that in 19 cases (65.5%) there was
evidence of respiratory involvement and in eight of the
19cases (42%) patients required advanced techniques for
airwaymanagement.Inthisstudy,nocase required
surgi-calcontroland therewasno mortalitydue toventilation
management.14
Theurgencyinestablishingourpatient’sairwayandthe
adverseconditions inthe managementof itdid notallow
theuse of double lumen tube (Carlens) aspreoperatively
planned. The possibilityof selective ventilation to
medi-astinaldrainagewassupplanted bytheneed fortherapid
establishmentof apatentandsafeairwayinthis patient.
Wecouldhaveusedabronchialblocker,butthehospitaldid
nothaveitatthetimeofservice.
Other techniques such as GlideScope®, AirTraq®, and
fiberoptic laryngoscopyallow betteraccess tothe airway
andpreventthesurgicalmanagement.14,15
In conclusion, airway management in patients with
Ludwig’s angina remains challenging. Choosing the safest
techniqueshouldbebasedonclinicalsigns,technical
con-ditions available, and the urgent need to preserve the
patient’slife.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
References
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