PED Case presentation R1 林中仁

急診兒科 2007/10/19 23:34 林 ○ ○ , 11 y/o boy Chief complaint: Progressed sublingual area swelling and pain noted for 3 days

Present illness Progressive swelling over sublingual and neck area for 3 days. Dysphagia and odynophagia in recent 2 days, intake with pudding only, drooling(+) No fever, no cough or rhinorrhea , No short of breathness No dental caries, no recent dental procedure, no recent trauma history activity: good ; appetite: poor Past history: denied Vaccination: as schedule Allergy history: denied Travel history: denied

Physical examination PAT: apperance: easy looking breath smooth, no retraction circulation stable Conscious clear Conjunctiva: not injected, not pale HEENT: Throat: injected(-), ulcers(-) Sublingual swelling, tenderness(+), induration(+) Neck supple, no LAP Kernig's sign(-); Brudzinski sign(-) Chest: breathing sounds clear RHB, no murmur Abdomen: soft and flat no tenderness Extremities: Freely movable, focal weakness(-) skin rash(-)

What’s your initial impression?

Differential diagnosis Infection: Ludwig’s angina Peritonsillar abscess retropharyngeal abscess Salivary gland infection Tumor Thyroid dysfuntion

Neck masses by age Young adult Reactive lymphadenopathy Mononucleosis Hodgkin disease Branchial cleft cyst Thyroglossal duct cyst Adult Salivary gland or parotid infection or neoplasm Oral cavity neoplasm Metastatic carcinoma Lymphoma Thyroid disorder Infant Hemangioma Lymphangioma Branchial cleft cyst Rhabdomyosarcoma Child Reactive lymphadenopathy Thyroglossal duct cyst Tintinalli table 243-2

What’s your order for this patient?

Initial order 10/19 23:34 IV WITH N/S RUN 150ML/HR CONSULT ENT CBC/DC CRP SUGAR ALT(GPT) Amylase Na, K Cr BLOOD CULTURE CHEST P-A VIEW Neck lateral view ( soft tissue )

檢驗項目 檢驗值 單位 H/L 參考值 WBC 9.4 1000/uL M3.9-10.6, F3.5-11 RBC 4.62 million/uL M4.5-5.9, F4.0-5.2 Hemoglobin 13.1 g/dL L M13.5-17.5 F12-16 Hematocrit 38.7 % L M41-53 F36-46 MCV 83.8 fL 80-100 MCH 28.4 pg/Cell 26-34 MCHC 33.9 g/dL 31-37 RDW 11.9 % 11.5-14.5 Platelets 228 1000/uL 150-400 Segment 65.8 % 42-74 Lymphocyte 24.3 % 20-56 Monocyte 9.4 % 0-12 Eosinophil 0.3 % 0-5 Basophil 0.2 % 0-1

檢驗項目 檢驗值 單位 H/L 參考值 Sugar 105 mg/dL H 70-105 Creatinine(B) 0.6 mg/dL M:0.4-1.4,F:0.6 -1.2 Amylase (B) 14 U/L L 27-137 ALT/GPT 9 U/L 0-36 Na 137 meq/L 134-148 K 3.9 meq/L 3.0-4.8 CRP 92.0 mg/L H < 5

CXR

Neck- lateral view

ED diagnosis Sublingual abscess R/O Ludwig's angina

Augmentin (Amoxicillin 500mg+Clavulanic acid 100mg) 10/20 00:13 Augmentin (Amoxicillin 500mg+Clavulanic acid 100mg) x 2 pc Stat & q8h IVF Arrange admission 發病危通知單: 舌下膿瘍,可能引發上呼吸道阻塞 氣切包stand by

Hospital course Admission: 10/20~10/24 Improved after antibiotics treatment Discharged on 10/24

Submandibular space infections (Ludwig's angina) In 1836, von Ludwig described indurated edema of the submandibular and sublingual areas with minimal throat inflammation but without lymph node involvement or suppuration

70~85% of cases follow infection of the second or third mandibular molar teeth. Predisposing factors include dental caries, recent dental treatment, sickle cell disease, a compromised immune system, trauma and tongue piercing. Ludwig's angina in children can occur de novo, without any apparent precipitating cause.

The submylohyoid space is initially involved, then extends to the sublingual space. If infection were spread via the lymphatics, involvement would be unilateral instead of bilateral.

Pathogen Polymicrobial Represent the normal resident flora of the contiguous mucosal surfaces from which the infection originated Anaerobes generally outnumber aerobes by a factor of 10:1.

Diagnosis The infection is always bilateral. Both the submandibular and sublingual spaces are involved. Rapidly spreading cellulitis without abscess formation or lymphatic involvement. The infection begins in the floor of the mouth. It is characteristically an aggressive, rapidly spreading "woody" or brawny cellulitis.

Disease course The tongue may enlarge to two or three times its normal size Immediate posterior extension will directly involve the epiglottis may spread into the parapharyngeal space via buccopharyngeal gap  the retropharyngeal space  the superior mediastinum.

Spread of process superiorly and posteriorly elevates floor of mouth and tongue. In anterior spread, the myoid bone limits spread inferiorly, causing a "bull neck" appearance.

Clinical features Febrile Poor dental hygiene, mouth pain, stiff neck, drooling, and dysphagia The mouth is held open by lingual swelling Leaning forward to maximize the airway diameter.

Physical findings A tender, symmetric and indurated swelling, may with palpable crepitus, is present in the submandibular area. Elevation and posterior displacement of the tongue Marked floor of mouth edema. Significant asymmetry of the submandibular area  may be indicative of extension to the parapharyngeal space

Imaging Radiographic views of the teeth may indicate the source of infection Lateral views of the neck will demonstrate the degree of soft tissue swelling around the airway and possibly submandibular gas.

Treament Most cases can be managed initially by close observation and intravenous antibiotics. Ampicillin- sulbactam is the antibiotic of choice.

Key points in ED Early sign and symptoms of imminent airway collapse may be subtle. Many patients will require awake fiberoptic intubation or awake tracheostomy. Stridor, difficulty managing secretions, anxiety and cyanosis are late signs and require emergency airway management.

Journal citation Ludwig’s angina in the pediatric population: report of a case and review of the literature J.C. 80 Britt et al. : Int. J. Pediatr. Otorhinolaryngol. 52 (2000) 79–87

The cornerstone of medical management is antibiotic agents active against streptococcus, staphylococcus, and anaerobic species. Penicillin remains the drug of choice. While there may be merit in the use of steroids for Ludwig’s angina, there is limited experience reported.

In the absence of respiratory compromise, pediatric patients can and have been managed successfully without an artificial airway providing they can be observed in an intensive care setting. In case with respiratory compromise, use of intubation rather than tracheostomy was the trend.

Surgical intervention is reserved for infections forming a localized abscess collection and those unresponsive to optimal medical therapy. The benefits of surgical intervention in the absence of abscess formation have not been demonstrated conclusively.

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