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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




Infant
Hemangioma
Lymphangioma
Branchial cleft cyst
Rhabdomyosarcoma
Child
 Reactive
lymphadenopathy
 Branchial cleft cyst
 Thyroglossal duct
cyst
Tintinalli table 243-2
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
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
WBC
9.4
RBC
4.62
Hemoglobin
13.1
Hematocrit
38.7
MCV
83.8
MCH
28.4
MCHC
33.9
RDW
11.9
Platelets
228
Segment
65.8
Lymphocyte
24.3
Monocyte
9.4
Eosinophil
0.3
Basophil
0.2
單位
H/L
1000/uL
million/uL
g/dL
L
%
L
fL
pg/Cell
g/dL
%
1000/uL
%
%
%
%
%
參考值
M3.9-10.6, F3.5-11
M4.5-5.9, F4.0-5.2
M13.5-17.5 F12-16
M41-53 F36-46
80-100
26-34
31-37
11.5-14.5
150-400
42-74
20-56
0-12
0-5
0-1
檢驗項目
Sugar
Creatinine(B)
Amylase (B)
ALT/GPT
Na
K
CRP
檢驗值
105
0.6
14
9
137
3.9
92.0
單位
H/L
參考值
mg/dL H 70-105
mg/dL
M:0.4-1.4,F:0.6 -1.2
U/L
L 27-137
U/L
0-36
meq/L
134-148
meq/L
3.0-4.8
mg/L
H <5
CXR
Neck- lateral view
ED diagnosis
Sublingual abscess R/O Ludwig's angina
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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