Abstract Introduction Ludwig angina is a rapidly progressing, life-threatening cellulitis that affects the soft tissues of the floor of the mouth. The critical clinical threat is airway compromise. There is no universal agreement on the proper approach to airway management in patients with LA because of the wide variety of presentation and mitigating factors. Here we report a case of a 28-year-old woman who developed Ludwig’s angina with mediastinal involvement. Case presentation 28 y/o female without significant past medical history, presented to the ED with complaints of right mandible pain for 3 days. Her pain began in the right lower second molar area, and was associated with facial swelling. Upon arrival, the patient was tachycardic, febrile, with bilateral tenderness, swelling, warm and redness in the submandibular region. An initial maxillo-facial CT revealed generalized soft tissue reticulation at the floor of the mouth compatible with cellulitis. The patient was admitted and underwent treatment with broad spectrum IV antibiotics and steroids. On hospital day 4, the patient developed trismus, muffled voice and worsening swelling. Repeat CT showed a significant increase in soft tissue inflammatory changes and subcutaneous gas involving the floor of mouth and deep spaces of the neck extending inferiorly into the superior mediastinum. The patient was urgently transported to the OR for incision and drainage and dental extraction 31. Her airway was secured via Fiberoptic intubation thru right nares and 1/2” Penrose drains were placed into bilateral neck. Patient was extubated after passing cuff leak test 2 days post-procedure, and was discharged home after an additional week of medical management. Discussion Descending necrotizing mediastinitis (DNM) is a severe infection that originates from oropharyngeal or cervical infections and spreads downward into the mediastinum. It is an uncommon disease with a mortality rate of about 20-40%. This high mortality is mainly attributed to delays in diagnosis and treatment and poor drainage of the mediastinum. In our case the progression to trismus, muffled voice and soft-tissue gas and mediastinal extension represented warning signs of impending airway collapse. Corticosteroid are controversial in the setting of LA. Certain studies have shown decreased need for intubation while others failed to find difference. In patients with Ludwig’s angina, the development of deep neck space infection with signs of mediastinal involvement should raise immediate suspicion for descending necrotizing mediastinitis. Early CT imaging, multidisciplinary airway-surgical coordination, and rapid surgical drainage are key to preventing catastrophic outcomes. This abstract is funded by: None
Acosta et al. (Fri,) studied this question.