Author:
PaulBlackburn
Chelsea C.Bonfiglio
Description
- Named for German physician Wilhelm Friedrich von Ludwig, who 1st described this in 1836 as a rapidly progressive, gangrenous cellulitis and edema of soft tissues of the neck, floor of the mouth
- Gangrene is serosanguineous infiltration with little or no frank pus or primary abscesses
- Contiguous spread may encircle the airway or involve the mediastinum
- Emergent interventions rarely include surgical or aspiration techniques
- Most deaths are due to airway compromise, occlusion, and resultant asphyxia
- Mortality exceeded 50% in preantibiotic era, currently <8%
Etiology
- Odontogenic in 90% of adult cases, usually from 2nd, and 3rd mand ibular molars
- Less commonly: Mand ibular fractures, oral lacerations, contiguous infections, sialadenitis, errant drug injections, tongue piercings
- Polymicrobial: β-hemolytic strep commonly associated with anaerobes such as peptostreptococcus, pigmented bacteroides
- Microbiologic analyses may guide therapy
Factors Increasing Morbidity and Mortality
- Comorbid illness
- Diabetes mellitus - specifically shown to independently increase life-threatening complications above other comorbidities
- Pregnancy
- Large body habitus
- Involvement of more than one neck space
- Anterior visceral space involvement (hyoid bone → superior mediastinal space)
Pediatric Considerations |
- Frequently no clear etiology or site of origin
- Ideally, a destination facility will have specialty expertise available (surgery and subspecialties, anesthesia) and be properly equipped to provide emergent intervention
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Signs and Symptoms
History
- Nonspecific constitutional symptoms: Fever, malaise, anxiety, SOB
- Pain: Tongue, throat, jaw, chest, neck stiffness
- Dysphagia, dysphonia
- Dentition, dental care suboptimal
Physical Exam
- Febrile, toxic, tripod “sniffing” posture
- Stridor, “hot potato” voice
- HEENT:
- Tongue progressively displaced upward in both posterior, anterior directions at unpredictable rate
- Airway rapidly and increasingly compromised
- Drooling, salivary incontinence
- Trismus impedes diagnosis and complicates treatment measures, airway interventions
- Physical exam findings beyond those of the head and neck area are often noncontributory or unrelated
Essential Workup
- The diagnosis is usually clinically evident
- No study or procedure needed to confirm the diagnosis
- Loss of airway patency can be unexpected, precipitous, and calamitous
- Securing airway patency and initiating treatment take precedent over workup considerations
Diagnostic Tests & Interpretation
Lab
No test will establish the diagnosis; assess severity or direct therapy
Imaging
Contrast-enhanced CT:
- CT of the neck with IV contrast enhancement is the study of choice:
- Stand ard cross-sectional imaging extends from skull base to aortic arch
- Best for evaluating the mediastinum, deep space infection location and extent, degree of airway involvement
- Findings include streaky or “dirty” fat in areas of inflammation; adenopathy (submand ibular, submental, anterior and posterior cervical chains); perhaps pus or gas formation
- Potential limitations:
- Patient must remain supine for the study duration
- Scanning location often away from optimal resuscitation, intervention capability
Plain radiographs:
- Soft tissue lateral neck x-ray may demonstrate altered anatomy, especially in the upper airway
- CXR of little utility, including detecting presence and extent of mediastinal involvement
- Panorex may detect odontogenic or mand ibular pathology, but of no use imaging soft tissue
Contrast-enhanced MRI:
- Information obtained is the same, of no greater value than contrast-enhanced CT:
- Potential limitations: Same as CT
Ultrasound:
- Detects gas in tissues, abscesses, reactive lymphadenopathy
- May locate, outline the airway among edematous, distorted tissues of the anterior neck
- A guide for abscess or fluid aspiration
- Assess degree of airway involvement, measure glottic opening
- Accurately mark cricothyroid membrane before and after airway manipulation
Diagnostic Procedures/Surgery
No surgery or invasive procedure will establish the diagnosis, assess severity, or direct therapy
Differential Diagnosis
- Infectious: Cellulitis, epiglottitis, tracheitis, peritonsillar abscess
- Traumatic: Penetrating injury, sublingual hematoma from fracture, soft tissue injury
- Angioneurotic edema
- Neoplasia
Prehospital
- Transport in position of comfort
- Allow adult tripod “sniffing” position, to suction themselves
- Allow pediatric transport on parent's lap
- Simple interventions (blow-by O2, nebulizer treatments)
- Maximize oxygenation:
- FIO2 of 100%
- Consider concurrent O2 delivery systems, such as facemask and nasal cannula
- Jet insufflation: An infrequently used temporizing rescue device for oxygenation
- Potential limitations: Few experienced with device assembly or use
- Newer rescue devices easier to place and use
Pediatric Considerations |
- Minimize patient upset, agitation
- Transport with parent
- Question the necessity for any interventions: IV access, blood draws, O2 mask, monitor leads
- Transport to facility best able to care for this complex patient if possible
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Initial Stabilization/Therapy
Airway Measures
- Maximize oxygenation
- Maintain in position of comfort
- Gather supplies/personnel for back-up airway techniques
- See “Airway Management” below
Vascular Access
- Vascular access: Provides rapid, titratable, predictable medication delivery
- Intraosseous (IO) access useful with:
- Poor peripheral access
- Resuscitations
- Pediatric access
- Adverse prehospital conditions
- 2nd IV access recommended
ED Treatment/Procedures
- Immediate priorities are to secure the airway and to institute medical treatment
- Diminishing consensus on need for acute surgical intervention other than airway related
- Infrequently see treatable abscess formation, fluid collections on initial presentation
Airway management:
- Rescue airway devices may be difficult to place, altered effectiveness due to anatomy distortion, trismus, excessive secretions
- Avoid blind intubation techniques to reduce laryngospasm, iatrogenic injury, bleeding, further tissue distortion
- Consider use of US to assess airway involvement, mark the cricothyroid membrane, measure glottic diameter to choose the correct ETT size and increase 1st-pass success
- Equipment considerations:
- Smaller ET tubes
- Prelubricate with gel or viscous lidocaine
- Use stylet or bougie for tube support
- Bend distal tube into “hockey stick” shape
- Fiberoptic naso or orotracheal intubation
- Use videolaryngoscopy
- Rapid-sequence intubation (RSI) agents may cause abrupt loss of muscle tone, airway architecture, or precipitate airway compromise
- Concern for impending respiratory failure increases with stridor, voice change, trismus, tripod posture, sialorrhea
Definitive management:
- Traditional surgical gold stand ard: Tracheostomy using local anesthesia:
- Potential difficulties: Surgeon, specialist availability, facility capabilities not uniform
- Traditional nonsurgical gold stand ard awake intubation using fiberoptic guidance:
- Allows for intubation attempt without compromising the patient's airway protection
- Potential difficulties:
- Provider comfort
- Short scopes often lack suction or irrigation ports
- Visualization easily impaired
- Best management option “double setup”
- Patient in an operating theater equipped, prepared to establish surgical airway
- Nonsurgical intervention attempted
- Immediate surgical intervention if unsuccessful or clinical deterioration
- Intubation: Anticipate distorted anatomy:
- Sitting, awake a preferred option
- Sequential topical applications
Medication
- IV administration: Preferred route of administration as previously outlined
- IO considerations:
- Lidocaine flush reduces infusion pain
- Flow rates same as IV for routine fluids, medication administration
- Avoid hyperosmolar agents, potential marrow injury
- Antibiotics: Empiric use of broad-spectrum antibiotics justifiable until return of culture and antibiogram results, which should direct further therapy:
- Ampicillin/sulbactam: 1.5-3 g IM/IV q6h (peds: 300 mg/kg/d div. q6 if <1 yr, <40 kg; 1.5-3 g IV q6h if >1 yr, >40 kg); max. 12 g/d
- Cefoxitin: 1-2 g IV q6-8h (peds: 80-160 mg/kg/d div. q4-6h); max. 12g/d
- Clindamycin: 600-900 mg IM/IV q8h (peds: 15-25 mg/kg/d div. q6-8h)
- Piperacillin/tazobactam: 3.375 g IV q6h (peds: If >9 mo, <40 kg; 300 mg/kg/d IV div. q8h)
- Ticarcillin/clavulanate: 3.1 g IV q4-6h (peds: If >3 mo, <60 kg; 200-300 mg/kg/d div. q4-6h)
- Analgesia: Pain control should be a primary concern
- Antiemetics: Proactive, prophylactic use for medication-related or condition-induced symptoms
- Steroids: Recommend empiric use of longer-acting steroids to reduce:
- Swelling
- Inflammation
- Systemic stress dose replenishment
- Hyperbaric oxygen: Consider if mediastinitis or necrotizing fasciitis
ICD9
528.3 Cellulitis and abscess of oral soft tissues
ICD10
K12.2 Cellulitis and abscess of mouth
SNOMED