1. PED Case presentation
R1 林中仁

2. 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

3. 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

4. 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(-)

5. What’s your initial impression?

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

7. 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

8. What’s your order for this patient?

9. 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 )

10. 檢驗項目 檢驗值 單位 H/L 參考值
WBC /uL M , F3.5-11
RBC million/uL M , F
Hemoglobin g/dL L M F12-16
Hematocrit % L M41-53 F36-46
MCV fL
MCH pg/Cell
MCHC g/dL
RDW %
Platelets /uL
Segment %
Lymphocyte %
Monocyte %
Eosinophil %
Basophil %

11. 檢驗項目 檢驗值 單位 H/L 參考值
Sugar mg/dL H
Creatinine(B) mg/dL M: ,F:
Amylase (B) U/L L
ALT/GPT U/L
Na meq/L
K meq/L
CRP mg/L H < 5

12. CXR

13. Neck- lateral view

14. ED diagnosis
Sublingual abscess R/O Ludwig's angina

15. 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

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

17. 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

20. 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.

21. 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.

22. 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.

23. 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.

24. 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.

25. 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.

27. 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.

28. 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

29. 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.

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

31. 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.

32. 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

33. 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.

34. 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.

35. 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.

36. Thanks for your listening!