2. Ludwig’s Angina
• Rapidly progressing polymicrobial cellulitis of the
submandibular space that can result in life
threatening airway compromise
• Angina - Strangling
• Mortality
– Before the advent of antibiotics : 50%
– Nowadays : 8–10%
– Most common cause of death is respiratory
compromise ( encircling of the upper airway)
6. • Causative organisms
– Group A beta-hemolytic streptococcal species
(streptococcus pyogenes)
– Alpha-hemolytic streptococcal species (streptococcus
viridans, streptococcus pneumoniae)
– Staphylococcus aureus
– Fusobacterium , Bacteroides melaninogenicus and oralis
– Peptostreptococcus, Actinomyces ,Neisseria species
– Occasional : Pseudomonas species, Escherichia coli, and
Haemophilus influenzae
7. Clinical Features
• Highest prevalence seen in young adults
• Pain in any involved teeth, with severe tender localized
swelling in the submandibular region
• Drooling (due to dysphagia) , halitosis, trismus , stridor ( from
laryngeal edema and elevation of the posterior tongue against
the palate)
• Fever, chills, tachycardia
• Boardlike firmness of the floor of the mouth and brawny
induration of the suprahyoid soft tissues
• Airway obstruction within hours !!
8.
9. Criteria for diagnosing Ludwig's angina (Grodinsky)
- Rapidly spreading cellulitis with no specific tendency to form
abscess
- Involvement of both submaxillary and sublingual spaces,
usually bilaterally
- Spread by direct extension along facial planes and not
through lymphatics
- Involvement of muscle and fascia but not submandibular
gland or lymph nodes
- Originates in the submaxillary space with progression to
involve the sublingual space and floor of the mouth
10. Investigations
• Routine blood investigations
• Pus culture
• Plain radiographs to assess the
degree of soft tissue swelling
and airway obstruction
• CT - most useful imaging tool
11. Treatment
• Frequent assessment
– To assess the risk of progression and airway
compromise
• Empirical therapy
– High-dose intravenous antibiotics : Cefuroxime
and metronidazole
12. • Incision and drainage : intraoral and external
– Transverse incision across the midline from one
angle of jaw to the other Muscles of the tongue
opened vertically Myelohyoid muscle sectioned
longitudinally
– Drains placed in all fascial spaces
• Tracheostomy to maintain an airway
15. Acute retropharyngeal Abscess
• Common in children below 5 yrs
• Predisposing factors
–Suppuration of retropharyngeal lymph node
of Rouviere
–Penetrating FB eg. Fish bones
–Post surgical
17. Signs
• Ill looking, febrile, drooling of saliva
• Hyperextension of the head
• Hot potato (muffled )voice
• Neck swelling and tenderness
• Bulge on posterior pharyngeal wall - usually unilateral
• Tracheal rock sign : pain while gently moving the
larynx and trachea from side to side
18. Investigations
• Complete blood count
• Plain X- Ray soft tissue neck Lateral view
– At the level of C2 : Distance from the anterior
border of the cervical vertebrae to the posterior
border of the airway : ≤ 7 mm regardless of the
patient's age
– At C6 : ≤14 mm in children younger than 15 years
and up to 22 mm in adults
19. • Widened prevertebral soft tissue shadow more than
normal in all ages or more than 2/3 of corresponding
cervical vertebral body signifies retropharyngeal
abscess
• CT scan of neck : Plain and contrast
– Extent of abscess, involvement of other spaces
22. Treatment
• Adequate hydration : I.V. Fluids
• Systemic antibiotics : Ceftriaxone/metronidazole
• Incision and Drainage
– Transoral : No anesthesia, supine with head low ,
incision and suction of pus
– Transcervical : Through lateral neck incision
• Tracheostomy
23.
24. Chronic Retropharyngeal abscess
• Causes
– Caries of cervical spine
– Tubercular infection of retropharyngeal LN
– Post traumatic
• Clinical Features
– Chronic discomfort in throat
– Dysphagia
– Bulge of posterior pharyngeal wall with fluctuant
swelling
25. Forms
• Lateral type :
– Koch's infection of the cervical lymph node
spreading to retropharyngeal nodes and forming a
cold abscess
– Seen in children below 5 years of age
– Swelling seen intra orally is classically on the sides
and not in the midline (as there is a central raphe)
– Swelling is fluctuant and with minimal signs of
inflammation
26. • Central type
– Pott’s tuberculous cervical spine
– Abscess present between the body of vertebra and
the prevertebral fascia
– Begins in the midline and spreads to both sides
– On oral examination there is a swelling in the
midline in the posterior pharyngeal wall, which is
fluctuant with less signs of inflammation
27. • Investigations
− As in acute retropharyngeal abscess
− ZN stain of the pus after aspiration
• Treatment
− IV antibiotics
− Incision and drainage : Per-oral / external
− Antitubercular chemotherapy
− Neck exploration
30. Clinical Features
• Fever, sore throat, odynophagia, torticollis
• Anterior Compartment
– Tonsils pushed medially
– Induration along the angle of the mandible
– Trismus
– External swelling behind the angle of jaw
31. • Posterior compartment
– Bulge of pharynx behind the posterior pillar
– Paralysis of IX, X, XI, XII cranial nerves and
cervical sympathetic chain
– Erode into the carotid artery or cause septic
thrombophlebitis of the internal jugular vein
(Lemierre syndrome)
32.
33.
34.
35. Treatment
• Systemic antibiotics
–Ceftriaxone 1 gm. iv BD
–Amoxyclav 1.2 gm. iv TDS
–Metronidazole 500mg iv TDS
• Incision & drainage
–Intraoral drainage from tonsillar fossa
–External incision from the neck
36. Surgical approaches to Parapharyngeal Space
a) Transoral
– Small benign lesions of the prestyloid space
presenting as an oropharyngeal mass
– Problems -- limited exposure, increased risk of
tumor spillage, possibility of neurovascular injury
b) Cervical with or without mandibulotomy
– A transverse incision at the level of the hyoid bone
with removal or displacement of the
submandibular gland
– Tracheostomy necessary with this approach
37. - Tumors in the lower parapharyngeal space
extending to the neck
c) Cervical - parotid
– Extension of the cervical approach incision
superiorly in front of the ear
– Tumours in the midparapharyngeal space without
extension superiorly into the skull base or
posteriorly around the petrous internal carotid
artery
d) Transparotid
e) Infratemporal fossa