Anaesthetic management of case of Ludwig’s angina: forewarned is forearmed.

Abstract

While described as far back as the writings of Hippocrates and Galen, the necrotizing fasciitis Ludwig's angina was first detailed by the German surgeon Wilhelm Friedrich von Ludwig in 1836 as a rapidly and frequently fatal progressive gangrenous cellulitis and oedema of the soft tissue of neck and floor of mouth 1 .It originates in the region of the submandibular gland with elevation and displacement of the tongue and rapidly progresses to involve the sub-lingual, sub-mental, and sub-mandibular spaces 2. Airway compromise is always synonymous with the term Ludwig's angina and it is the leading cause of death. Therefore, airway management is the primary therapeutic concern. 3 The treatment plan for each patient should be individualised and based on a number of factors. The stage of disease and comorbid conditions at the time of presentation, physician experience, available resources, and personnel are all crucial factors in the decision making. 4 2. Case report A 20-year old female, weighing 48 kgs and 153 cms in height, presented to our hospital with complaints of facial and neck swelling. She gave history of difficulty in breathing, swallowing, and inability to open the mouth since 2 days. She described a five-day history of lower left quadrant tooth pain, and a three-day history of fever and chills. On presentation, her vital signs were: temperature 39.7°C, blood pressure 100/54mm of Hg, pulse 128/min, respiratory rate 24/min, oxygen saturation on room air 90%, and haemoglobin of 4 g%, white cell count of 18,000/μL. Her clinical examination revealed severe pallor, severe facial oedema, large soft tissue swelling under her mandible, extending bilaterally to the angles of the mandible and inferiorly up to suprasternal area. On airway examination mouth-opening was restricted, with an interincisor gap of 1 cm. She had respiratory distress on sleeping and was uncomfortable because of pain and intra-oral drainage of pus. Neck extension was very painful and extremely limited. Both the nares were patent and the trachea was not palpable. She was nil by mouth for more than 8 hours. (Figure 1). Soft tissue neck x-rays showed an increase in the submandibular and pretracheal space. Ultrasonography (USG) reported fluid collection in the submandibular region and neck, anterior to the thyroid and between the strap muscles of neck, bounded laterally by the carotids, tracking deep along the lateral border of the thyroid.