LUDWIG angina is a potentially lethal, rapidly spreading cellulitis involving the floor of the mouth and neck. 1Without aggressive management it often results in life threatening upper airway obstruction. 2Prompt airway management is critical, but the presence of swelling of the neck, glottic edema, elevation of the tongue, trismus, or pharyngeal edema create formidable problems. 1There is no consensus in the literature regarding airway management. The published recommendations vary and are based on each author's personal experience and available resources. We report a patient with Ludwig angina and severe airway compromise who presented at a remote field hospital. We successfully relieved airway obstruction by surgical decompression alone, using a cervical plexus block.
A 42-yr-old woman from a remote border village was brought to our field hospital in respiratory distress. She had a 5-day history of increasing pain and swelling in the left submandibular region associated with fever and dysphagia. For the last 24 h she had been unable to speak and had respiratory difficulty. Treatment using indigenous medicines and balms had been ineffective. The patient weighed 45 kg, had a respiratory rate of 44 breaths/min with intercostal retraction and stridor. Her blood pressure record was 110/70 mmHg with pulse rate of 110 beats/min and temperature of 38.8°C. Examination showed a marked brawny edema over the left submental and submandibular spaces, extending across to the right and down to the anterior chest. There was significant trismus with protrusion of the grossly edematous and elevated tongue. Examination of the oropharynx was not possible (fig. 1). Administration of oxygen was started immediately with a Bain breathing system and a facemask using a flow rate of 6 l/m and further investigations were undertaken. She had leucocytosis (WBC 18,600/mm3) and normal hemoglobin of 11 g/dl. Soft tissue radiograph of the neck showed a narrowed glottic opening. Intravenous antibiotics were started (cefotaxime, amikacin, and metronidazole). In view of her respiratory distress and stridor, urgent surgical decompression was deemed necessary. She was taken to the operating room for airway control as she became increasingly restless with increase in tachypnea to 60 breaths/min. At this time, her Spo2was 86% by pulse oximetry. Due to gross trismus and swelling of the tongue and oropharyngeal tissues, an orotracheal or awake blind nasotracheal intubation was not considered feasible. It was thus decided to attempt a trial of decompression under cervical plexus block. Complete preparations for an emergency tracheostomy were also made.
She was given 0.2 mg of intravenous glycopyrrolate and standard monitors were placed. An intradermal wheal was raised over the left C3 and C4 transverse processes after preparing the area aseptically. Deep cervical plexus was blocked with single injection over C4 using 4 ml of 1% lignocaine. A needle was introduced through the skin over C3 transverse process and 6 ml of 1% lignocaine was injected both cephalad and caudal along the posterior inferior border of sternocleidomastoid. By this method, superficial cervical plexus was blocked.
Dense anesthesia was established in about 7 min. A rapid decompression of the left submandibular region was done and the mylohyoid transected with resultant lowering of the floor of mouth. There was little discharge from the wound, which was lightly packed and dressed. The patient was observed for 30 min in the operating room where her stridor and respiratory distress showed remarkable improvement. Her respiratory rate stabilized to 24 breaths/min after 1 h of observation in the acute ward. Her subsequent convalescence was rapid and uneventful and she resumed oral diet on the second postoperative day.
The danger of airway obstruction from soft tissue swelling in the head and neck has been appreciated since antiquity, with specific references being made by Hippocrates, Galen, Aretius, and Paulus of Aegin. Wilhelm Frederich von Ludwig in 1836 described “repeated recent occurrence of a certain type of inflammation of the throat, which, despite the most skillful treatment, is almost always fatal.”3It was known as Morbus Strangulatorius and Garotillo (Spanish for hangman's loop); all names alluding to the respiratory obstruction so prominent in disease morbidity. 4Ludwig angina is defined as a potentially lethal, rapidly spreading cellulitis, involving the sublingual and submandibular spaces, and is manifested by a brawny suprahyoid induration, tender swelling in the floor of the mouth, and elevation and posterior displacement of the tongue. 5
Oral or dental infections are implicated in up to 70% of cases. Poor dental hygiene, gingivitis, and periapical abscesses are commonly involved in the pathogenesis. The organisms most commonly cultured from oral infections include Streptococcus viridans and Staphylococcus aureus, as well as anaerobic B melaninogenicus and peptostreptococcus. 6Isolation of gram-negative organisms like H influenza, E. coli , Pseudomonas, and Neisseria are not frequent.
In an exhaustive review of the literature, from 1945 to 1979, 75 cases of Ludwig angina were found, and the authors strongly advocate elective tracheostomy under local anaesthesia. 8However, there may be good reason to avoid tracheostomy. Cellulitis of the neck with involvement of the tracheostomy site makes it a more difficult procedure. Moreover, surgical dissection of the fascial planes in the neck may actually open and contaminate the pathways, leading to life-threatening mediastinal invasion. 6More recent reviews of anesthesia management report good results without the use of tracheostomy. 2,3Other options for airway management may include orotracheal, blind nasotracheal, and fiber optic intubation or cricothyroidotomy with jet insufflation.
Incision and drainage provides some decompression and can result in immediate relief of airway obstruction. 9Patients, however, must be closely monitored for signs of airway obstruction, and if increasing symptoms are evident an artificial airway must be created. The problem of anesthesia when using incision and drainage is not addressed by most authors advocating an artificial airway, where general anesthesia is an obvious option. Local infiltration is unlikely to be fully effective in cellulitis, is cumbersome in an obviously sick and restless patient, and does not permit a thorough exploration. We chose to employ a cervical plexus block as anesthesia for surgical decompression. The block permitted a thorough incision and drainage, including transection of mylohyoid with lowering of the floor of mouth and rapid relief of respiratory obstruction. The patient's respiratory status rapidly improved, and hence, tracheostomy was not required. However, we are inclined to believe that superficial cervical plexus block alone would suffice.
While more sophisticated airway management methods may be advisable, cervical plexus block permits a surgical decompression. In remote hospitals with limited resources it should be considered as an option in selected cases. In case the airway compromise is not relieved, emergency tracheostomy remains a lifesaving procedure.