Diagnosis and management of Ludwig's angina: An evidence-based review

Effectiveness of negative pressure wound therapy in Ludwig's angina: a retrospective study of 18 cases

OBJECTIVE

To investigate the effectiveness of negative pressure wound therapy (NPWT) for Ludwig's angina (LA).

METHODS

We retrospectively reviewed 18 patients with LA admitted to the 82nd Group Army Hospital of PLA between October 2014 and October 2021. All patients underwent surgical drainage and debridement within 6 h after admission. A minimally invasive approach involving bilateral small incisions in the submandibular area was used to perform the procedure. An NPWT device was applied for positive drainage of the involved spaces after debridement. Postoperatively, the patients received the appropriate supportive care and antibiotic therapy. Data collection encompassed sex, age, systemic diseases, dressing change frequency, NPWT duration, wound healing time, and ICU stay length. Follow-up was performed to evaluate recurrence, scarring, and neck mobility. For comparative analysis, control data were obtained from LA patients treated with conventional surgical drainage between January 2008 and September 2014. Descriptive statistics and Student's t-test were employed for statistical analysis.

RESULTS

In the NPWT group, all patients had uneventful courses during hospitalization and were discharged upon complete wound healing. Fifteen patients required only a single session of surgical debridement with NPWT, while the remaining three underwent two procedures. Upon NPWT device removal, all infectious cavities exhibited clean wounds with mature granulation tissue formation. Compared to the conventional surgery group, the NPWT group demonstrated a significantly shorter wound healing time (15.33 ± 3.93 vs. 19.50 ± 2.17 days; p = 0.025), reduced ICU stay duration (0.61 ± 0.61 vs. 2.17 ± 0.75 days; p < 0.001) and markedly fewer dressing changes (2.17 ± 0.38 vs. 17.00 ± 3.16; p < 0.001).

CONCLUSIONS

NPWT demonstrated excellent effectiveness in the management of LA. Compared to conventional surgical debridement and drainage, it offers several distinct clinical advantages, including accelerated wound healing, shortened ICU stays, and reduced dressing change frequency. These benefits are clinically linked to both reduced postoperative pain perception and decreased nursing workload. Additionally, smaller incisions result in less surgical trauma and improved cosmetic outcomes. NPWT should be considered as a viable approach in the management of LA. Future randomized controlled trials are needed to confirm NPWT's superiority in larger cohorts.

CLINICAL TRIAL NUMBER

Not applicable.

From Routine to Ruin: An Astonishing Computed Tomography Scan Reveals Catastrophic Ludwig's Angina and Necrotizing Mediastinitis after a Simple Dental Procedure

Ludwig's angina is a rare, life-threatening cellulitis of the submandibular space, if unchecked, can rapidly progress to severe complications such as necrotizing mediastinitis, a condition with significant morbidity and mortality. We report the case of a 32-year-old male who developed this rare complication following wisdom tooth extraction. The patient presented with throat swelling and hematemesis, and contrast-enhanced computed tomography (CT) imaging had a decisive role in capturing the full extent of the infection, revealing severe airway narrowing, mediastinal free air, and a suspected superior vena cava thrombus. These imaging findings shaped critical clinical decisions, leading to urgent surgical drainage performed jointly by thoracic and ear, nose and throat teams along with aggressive therapy. CT not only guided treatment but also provided a roadmap for tracking disease resolution and detecting complications. Despite severe systemic involvement, including sepsis and hypotension, the patient responded well to a targeted antimicrobial regimen and supportive care. This case highlights the importance of multidisplinary work in such extensive cases, and emphasizes how radiology is more than a diagnostic tool and is an active force in shaping the management and outcome of complex infections, allowing for precise intervention before irreversible complications arise.

LEARNING POINTS

Ludwig's angina can rapidly progress to necrotizing mediastinitis, even after a routine dental procedure, making early recognition and timely intervention critical.Computed tomography is essential in assessing the extent of infection, identifying airway compromise and mediastinal involvement, which directly influence management decisions.A multidisciplinary approach, including early surgical intervention and aggressive antibiotic therapy, is crucial for optimizing outcomes in complex infections like necrotizing mediastinitis.

Putting the mouth back in the body - the neglected area of dental and oral travel health

The lack of dental travel health care has been deplored for some time. Travel medicine's remit is to prepare people for travel. People travel with their mouth firmly in their body, yet the mouth's wellbeing does not rate a mention. This article represents the first exploration of a range of topics relevant to an until now neglected, yet potentially highly important, area of health care. A range of dental mishaps can occur while away from home, from simple toothache to accidents, serious emergencies, or restoration failures. Other problems originate in unwise behaviour, including holiday-inspired body modifications.Unless there is pain, teeth are typically not thought about much. However, examining the practical side of dental hygiene during travels, several overlooked and perhaps surprising topics emerge that - through the travel lens - take on a different and important role: the oral microbiome, toothbrush hygiene, the toilet plume, and traveller diarrhoea. Based on this discussion, recommendations are made for clinical practice, education, and further research.The historical chasm between dentistry and medicine, despite long-standing calls for change, does not seem to go away and impairs holistic high quality travel health care. Travel medicine can bypass this unproductive division. It has the unique opportunity to be the first medical specialty cooperating closely with dentists to bridge this gap by providing quality travel health care to travellers with all their body parts attached.

Effective blind bilateral superficial cervical plexus block for tracheostomy tube insertion in a geriatric patient with Ludwig angina with hypertension in resource constrained area: a case report

INTRODUCTION

Ludwig angina is a rare, rapidly spreading submaxillary, submandibular, and sublingual necrotizing life-threatening widespread cellulitis of the soft tissue on the floor of the mouth that can cause fatal complications because of airway obstruction. Currently, there are few published studies assessing the efficacy of superficial cervical plexus block for airway surgery and there is no agreement in the literature about airway management. The published recommendations differ and are based on the authors' own experiences and available resources. This report aimed to provide insight into critical patient management by performing regional anesthesia with fewer complications to the cardiovascular and respiratory systems.

CASE PRESENTATION

We report the case of a 70 year-old hypertensive Black Ethiopian woman with American Society of Anesthesiologist-Physical Status class III and hypertension, who was admitted to the hospital for treatment by her surgeon. The surgeon diagnosed her with Ludwig angina. After adequate physical examination and laboratory investigation, she arrived at the operation room for exploration and drainage of the abscess with a superficial cervical plexus block. She arrived safely at the adult intensive care unit for frequent suctioning. The block was effective until 6 h after the procedure with visual analogue scale (2/10), her vital signs remained stable throughout the postoperative period, and then the tracheostomy tube was removed by the surgeon after 10 days. The patient's hemodynamic status and breathing effort were satisfactory, and she was discharged 15 days later.

CLINICAL DISCUSSION

Proper airway management is critical for the survival of patients diagnosed with Ludwig angina. According to recent studies, an increasing number of patients with Ludwig angina require intensive care unit admission for tracheal intubation and mechanical breathing. However, it is uncertain whether intensive care reduces the death rate in patients with Ludwig angina. Finally, it is suggested that studies with large sample sizes and strong levels of evidence be conducted to conclude the effectiveness of superficial cervical plexus block for airway emergency surgeries.

CONCLUSION

Management of the airway in patients with Ludwig angina is challenging. Clinicians must take precautions and make sharp decisions on the basis of a variety of circumstances, including the availability of equipment at medical facilities, such as fiberoptic intubation equipment; the anesthetist's level of experience, such as performing superficial regional block and good mask ventilation; and the patient's medical status at the time of presentation. As a result, intervention needs to be quick so as to avoid airway obstruction and further complications.

Importance of the Physical Exam in Diagnosing Ludwig's Angina Without Access to Modern Imaging Modalities in the Developing World

Ludwig's angina (LA) is a rapidly progressive cellulitis-causing airway obstruction that can spread through fascial planes to the floor of the mouth and into the mediastinum. Early recognition and treatment are essential for preventing potentially fatal complications. Diagnosis is based on clinical suspicion and confirmed through CT and ultrasound (US). In areas lacking access to imaging modalities, clinicians must rely on a thorough physical examination. Reporting this case is to raise awareness for LA in underserved areas with a higher risk for infection. The case describes a 54-year-old female with a two-day history of an untreated throat infection that likely developed LA. She presented with a sore throat, progressively worsening shortness of breath, and submandibular swelling accompanied by self-reported fever, chills, and night sweats. With the limited resources available at the rural clinic, she was treated with oral metronidazole, amoxicillin, as well as prednisone. She was referred to the nearest hospital for an immediate surgical consultation.

Predictors of Emergency Interventions in Acute Airway Obstructive Diseases: A Retrospective Single-Center Observational Study

BACKGROUND

The factors related to emergency intervention for internal medicine conditions leading to airway obstruction are not clear.

OBJECTIVE

We aimed to identify factors associated with emergency interventions in acute airway obstructive diseases (AAODs).

METHODS

This is a retrospective observational single-center study. We defined AAODs as acute epiglottitis, peritonsillar abscess, tonsillitis, pharyngitis, oral floor abscess, neck abscess, angioedema, Lemierre's syndrome, hemoptysis, and airway foreign body. We compared the group required airway interventions (intubation, cricothyroidotomy, tracheostomy) with the group treated conservatively admitted to Yokosuka Kyosai Hospital, Japan (tertiary referral hospital) for AAOD between April 2012 and March 2022.

RESULTS

Two hundred fifty-five patients were admitted for AAOD, 104 patients were excluded, and 150 patients (39 intervention group, 111 conservative group) were analyzed. Univariate analysis revealed significant age differences (74(61-78) vs 67(31-76), p<0.01), Glasgow Coma Scale (15(14-15) vs 15(15-15), p<0.01), respiratory rate (24(20-30) vs 20(16-22), p<0.01), National Early Warning Score (NEWS) (6(3-9) vs 3(1-5), p<0.01), Sequential Organ Failure Assessment (SOFA) score (2(1-4) vs 0(0-2), p<0.01), stridor (26% vs 2%, p<0.01), dysphagia (41% vs 21%, p=0.02), drooling (18% vs 3%, p<0.01), frequent suctions (6% vs 0%, p<0.01), airway examination abnormalities (AEAs) (69% vs 32%, p<0.01) and diagnosis (p<0.01). Multivariate logistic regression analysis indicated AEA (OR=9.41, 95%CI 3.66-24.2), upper airway diseases (OR=5.74, 95%CI 2.12-15.6), and SOFA score (OR=2.88, 95%CI 1.06-7.83) were predictors for intervention. However, the sensitivity and specificity of AEA were 0.69 (95%CI 0.52-0.83) and 0.69 (95%CI 0.59-0.77), respectively.

CONCLUSIONS

AEAs were associated with a high risk of airway interventions in AAOD. Nevertheless, the sensitivity and specificity were insufficient.

Pediatric Odontogenic Infections

Odontogenic infections are a broad group of head and neck conditions that arise from the teeth and surrounding periodontium. These largely preventable infections disproportionately affect members of ethnic and racial minorities and low-income/uninsured groups, and result in significant costs to our health care system. Left untreated, odontogenic infections can spread to deep spaces of the head and neck and can result in life-threatening complications. The mainstay of treatment includes timely treatment of the affected teeth. These infections are a global public health concern that could be diminished with improved access to routine dental care.

Acute upper airway obstruction caused by mouth floor cellulitis in a patient of advanced age: a case report and literature review

Mouth floor cellulitis is a type of diffuse cellulitis involving the submandibular, submental, and sublingual spaces. This condition may cause asphyxia due to elevation and posterior deviation of the tissues of the floor of the mouth. The severity of submandibular gland infection often escalates in the presence of underlying comorbidities. Advanced age, hyperglycemia, and an immunocompromised status often lead to the rapid development of infection, resulting in complications such as acute upper airway obstruction. These complications increase treatment difficulty and the risk of mortality. We herein report a case involving an older adult with diabetes who developed mouth floor cellulitis secondary to a submandibular gland infection. Despite the severity of the submandibular gland infection, a timely, effective, and multidisciplinary approach improved the patient's prognosis.

Submandibular Sialolithiasis Mimicking Ludwig's Angina: A Case Report and Brief Clinical Review

The "double tongue sign" is a characteristic finding in patients with Ludwig's angina, a potentially life-threatening infection due to airway compromise. Management primarily focuses on early airway protection and antibiotic administration. Submandibular sialolithiasis, on the other hand, could present with the double tongue sign without symptoms suggestive of airway involvement. Unlike Ludwig's angina, conservative treatment is usually the first-line approach for sialolithiasis. The importance of rapidly recognizing and distinguishing between the 2 conditions is emphasized through effective triage and risk stratification, particularly in rural areas where physicians are not readily available.

Case Report: Ludwig's angina - 'The Dangerous Space'

Background: Ludwig's angina is a potentially life-threatening disease characterized by diffuse bilateral cellulitis with an odontogenic origin. This unique infection is now rare owing to the antibiotic era. Case: This patient presented to the emergency room with trismus, jaw and neck swelling, mild respiratory distress with tachypnea, hyperthermia, and panic. Clinical examination and radiographic evaluation confirmed the diagnosis of Ludwig's angina. As it is a quickly spreading infection, the patient was taken up for immediate surgical decompression leading to pus drainage, removal of the offending tooth, bacterial culture and sensitivity, and administration of empirical antibiotics. As we had operated promptly, there was no need for emergency airway intervention, and the patient had immediate relief from airway distress. Conclusions: Early accurate diagnosis with conservative surgical decompression, thereby negating the need for airway intervention, was vital to avoiding mortality which is always possible in such an expeditious infection.

Potentially Fatal Ludwig's Angina: A Case Report

Ludwig's angina is a condition that could be fatal, causing severe diffuse cellulitis bilaterally that affects the submandibular, sublingual, and submental areas. It has an acute onset and progresses rapidly. A common and potentially deadly complication is airway impairment. Prompt diagnosis and treatment planning have the opportunity to save lives. An elective tracheostomy is recommended for the patient to maintain an open airway, followed by addressing potential affected spaces due to a widespread odontogenic infection. This infection has extended to the neck, causing elevation of the ventral surface of the tongue and floor of the mouth, leading to airway obstruction and the manifestation of stridor. In the latter stages of the illness, additional attention should be paid to maintaining the airway before surgical decompression and antibiotic treatment. In advanced cases, the usual protocol of care still includes surgical drainage of the infection, judicious administration of parenteral antibiotics, and airway management. A case report's objectives are to improve clinical knowledge, facilitate better diagnosis and treatment, and add to the body of medical research by offering a thorough and educational description of a particular patient's experience with this illness.

Ludwig's Angina: Higher Incidence and Worse Outcomes Associated With the Onset of the Coronavirus Disease 2019 Pandemic

Background: Ludwig's angina (LA) is a diffuse cellulitis of the submandibular space and adjacent tissues. During the coronavirus disease 2019 (COVID-19) pandemic, odontogenic treatments were often delayed because of the implementation of safety measures to avoid the spread of the virus. We hypothesized that delayed odontogenic treatments associated with the onset of the COVID-19 pandemic would be associated with an increase in the incidence of LA and worse outcomes related to these infections. Patients and Methods: Patients from June 2018 to June 2022 with computed tomography images suggestive of LA and confirmed by ear, nose, throat (ENT) consult were included. We abstracted demographics, outcomes, clinical management, and microbiology. Patients were stratified into pre-COVID and COVID-onset. Our primary outcome, incidence of LA, was defined as: (new LA cases) ÷ (ED evaluations of oral or dental infections × 1.5 years). Results: In the pre-COVID group, we identified 32 of 1,301 patients with LA for an incidence of 0.02 per year. The COVID-onset group consisted of 41 of 641 patients, with an incidence of 0.04 per year. In the COVID-onset group, progression to necrotizing fasciitis was more likely (0% vs. 15%; p < 0.024), and they returned to the operating room for repeated debridement (3% vs. 22%; p < 0.020). Likewise, hospital length of stay, intensive care unit (ICU) length of stay, and ventilator days were higher (4.3 ± 3.5 vs. 9.5 ± 11.3; 1.1 ± 1.2 vs. 9.5 ± 7.1; 0.3 ± 1 vs. 3.6 ± 7.1; p < 0.001). Conclusions: Although the prognosis for dental infections diagnosed early is generally favorable, we observed a notable increase in the incidence of LA after the onset of the COVID-19 pandemic. Moreover, complications stemming from these infections became more severe in the COVID-onset era. Specifically, the likelihood of necrotizing fasciitis showed a substantial increase, accompanied by an increased risk of respiratory failure and mediastinitis.

Life-Threatening Airway Obstruction and Septic Shock Due to Submandibular Space Infection: A Case Report

Submandibular space infection, a rare and aggressive form of cellulitis, affects the floor of the mouth and neck, potentially leading to life-threatening complications. Although commonly associated with oral trauma and contiguous abscesses, the severity of these odontogenic infections often escalates due to underlying comorbidities. This report presents a unique case of a 74-year-old man who developed severe complications following an outpatient oral procedure. The patient exhibited fever and mouth swelling within a short time, which quickly advanced to impending airway compromise and septic shock. Diagnostic imaging revealed extensive swelling from the left submandibular region extending to the anterior neck and parapharyngeal space, effacing the airway. This necessitated immediate nasotracheal intubation and mechanical ventilation. Medical management comprised emergent antibiotic administration, airway protection, and admittance to the intensive care unit. This case underscores the potential severity of complications arising from an odontogenic infection in the presence of multiple comorbidities following an oral procedure. It emphasizes the need for prompt symptom recognition, emergency airway management, and the initiation of antibiotic therapy. Furthermore, this case illustrates the critical role of various imaging modalities and the choice of intubation technique in patients with an anticipated difficult airway. Despite the severity of submandibular space infection, a timely, effective, and multidisciplinary approach can mitigate fatal outcomes and improve patient prognosis.

The empirical use of aminoglycosides in Ludwig's angina based on bacterial analysis of 63 cases

PURPOSES

To determine if the empirical use of aminoglycosides is justified in Ludwig's angina based on microscopy, culture and sensitivity results.

METHODS

A retrospective analysis was done on patients that presented with Ludwig's angina to the Maxillofacial and Oral surgery department at the University of Pretoria. Demographical data was extracted from patient files. Pus specimens that were submitted as part of the initial surgical intervention were analysed.

RESULTS

Sixty-three patients were included in the study with the majority, 76.19% (n=48/63), comprising males. The mean patient age was 38.6 years (range 6 months to 78 years). The majority of infections (87.3%) had an odontogenic aetiology (n=55/63). Forty-four percent of the patients had immunosuppressive co-morbidities (n=28/63). Streptococci contributed 71.26% (n=62/87) of the cultured bacteria. Similar bacteria were cultured in the immunocompromised and the immunocompetent patients (p=0.672). Ninety-two percent (n=57/62) of the streptococci cultured were sensitive to penicillin. The addition of aminoglycosides to the study sample would not have made a statistically significant difference (p=0.1556).

CONCLUSION

Based on the findings of this study, the empirical use of aminoglycosides is not warranted in either immunocompromised or immunocompetent patients with Ludwig's angina.

An Awake Flexible Scope Intubation for a Patient With Trisomy 21, COVID-19, and Ludwig's Angina

For patients with known or suspected atlantoaxial instability, awake flexible scope intubation is often an attractive option for safely securing the airway. Due to the challenges of consent and cooperation, patients with trisomy 21 are generally considered to be poor candidates for this technique. However, in rare instances, such as the case of this patient with co-existing Ludwig's angina and COVID-19 pneumonia, the benefits of proceeding with an awake flexible scope intubation may outweigh the potential risks.

Persistent Pancytopenia as a Long-COVID Manifestation in a Patient with Adult-Onset Still's Disease: A Case Report

Background: Adult-onset Still's disease (AOSD) is a rare rheumatic inflammatory condition with an extremely heterogeneous clinical presentation and systemic impairment. Uncommon manifestations may be challenging to manage, especially in patients with previous severe acute SARS-CoV-2 infection. For the first time, we report the case of a patient affected by refractory AOSD presenting with severe pancytopenia as a long-COVID manifestation. The purpose of this case report is to illustrate the clinical presentation, diagnostic and therapeutic management of this unusual manifestation. Moreover, we examine the mechanisms that are potentially responsible for the onset of the pancytopenia observed in our patient. Case presentation: We describe the case of a 40-year-old male who presented with a history of fever for 2 years, arthralgia, maculopapular salmon-pink rash and a previous SARS-CoV-2 infection which required admission to intensive care. The patient's laboratory results revealed elevated inflammatory markers levels (erythrocyte sedimentation rate and C-reactive protein), hyperferritinemia and severe pancytopenia that needed multiple transfusions. A diagnosis of AOSD was made based on clinical and laboratory presentation after excluding neoplastic, infectious and other rheumatic diseases. The previous empirical treatment was not adequate to control the condition; therefore, treatment with high-dose steroids, canakinumab and epoetin alfa was started and led to the resolution of the man's symptoms and a reduction in inflammatory marker levels, whereas blood cell count remained stable without a need for further blood transfusions. The patient is currently under rheumatologic and hematologic follow-up every month. Conclusions: Neither AOSD nor SARS-CoV-2 infection usually manifests with pancytopenia, except in hemophagocytic syndrome or immunodeficient patients, respectively. Identifying the underlying etiology of pancytopenia is mandatory to establish a prompt treatment that generally resolves the disorder. However, in our case, all common causes of pancytopenia were excluded, suggesting a potential manifestation of the long-COVID syndrome. Despite the resolution of the acute infection and the remarkable treatment of AOSD, pancytopenia persists. Herein, we propose for refractory AOSD patients with previous SARS-CoV-2 infection a novel approach to the diagnosis and treatment of pancytopenia.

Ludwig's angina and mask use

Ludwig angina cases that could only be recognized by unmasking.

Facial Swelling After Dental Work Done: A Case of Ludwig's Angina

Ludwig's angina is a fast-spreading cellulitis located on the floor of the oropharynx and neck (Tami, Othman, Sudhakar, & McKinnon, 2020). Patients may present with a wide range of symptoms depending on the severity of the condition (Reynolds & Chow, 2007). Emergency nurse practitioners need to promptly identify, diagnose, and treat patients with this problem, with close attention to the patient's airway. A compromised airway is the leading cause of mortality from this condition (McDonnough et al., 2019). The diagnosis is generally made with a comprehensive history and physical examination, laboratory values, and imaging studies such as computer tomography (Bridwell, Gottlieb, Koyfman, & Long, 2021). Management includes admission to the hospital, broad-spectrum antibiotics, and specialist surgical consultation (Bridwell et al., 2021).

Extrapulmonary tuberculosis and COVID-19 infection coexisting in concurrent necrotising fasciitis with deep space infection of neck: an unusual presentation

Ludwig’s angina is a rapidly spreading, potentially fatal infection of deep fascial spaces of the neck leading to airway oedema and death. This, in recent times when associated with COVID-19 infection, possess treatment challenges making the patient susceptible to opportunistic infections with reduced healing potential. Owing to the multifactorial aetiology in our case and addressing them at the earliest, it is important to achieve favourable outcomes. The space infection that seeded with untreated trivial dental caries progressed to necrotising fasciitis of neck with mycobacterial growth on cartridge-based nucleic acid amplification test for tuberculosis testing. The presence of Mycobacterium organisms should be speculated in patients with pulmonary signs of tuberculosis (TB) because a suppurative TB lymphadenitis of neck could also have the same presentation. The decisive moment in successful outcome was identification of mycobacteria in COVID-19 infected patient, thereby allowing to initiate the antitubercular therapy along with surgical debridement. Thus, medical management of patient with cohabiting infections is difficult task and needs appropriate addressal.

Anatomical variations of the anterior belly of the digastric muscle in Thai cadavers: A cross-sectional study

Aim:

Because the digastric muscle is considered as an anatomical landmark, its variations may emphasize clinicians to be cautious during surgery. However, previous studies from different ethnicities reported a wide range of occurrence and several types of this muscle variation, pointing the necessity of the data from local population to better treatment decisions. Thus, this study aimed to explore the variations of the anterior belly of the digastric muscle in Thai cadavers.

Materials and Methods:

This cross-sectional study investigated the submental region of 91 cadavers by convenient sampling method. The characteristics of the variation in the anterior belly were recorded in accordance with sex and side of the cadavers. Multiple logistic regression was calculated for determining the association of occurrence of muscle variation with sexes and sides (α = 0.05).

Results:

Among 91 cadavers, the accessory bundles were observed in 16 cadavers (10 males and 6 females). The presence of the additional belly was sex and side independent. Three variation types were observed; the arrowhead type and the double-headed type have been previously reported, whereas the asymmetrical fan-shaped type is the new variant that has never been described before.

Conclusions:

The variation of the anterior belly of the digastric muscle including the new variant can be seen in Thais with low occurrence. To our knowledge, the present study is the first report of the aberrations of the digastric muscle in the Southeast Asian population. Therefore, our study provides the basis for anatomical study of muscular variants and helps surgeons plan the operation to prevent iatrogenic injuries.

Images in Primary Care Medicine: Point-of-Care Ultrasound in Gout

Gout is the most common crystal arthropathy and is frequently diagnosed and managed by primary care physicians. Point-of-care ultrasound (POCUS) is a valuable tool to aid in the diagnosis of gout via the identification of the double contour sign, aggregates of crystals, tophi, and erosions. In addition, POCUS can aid in the management of gout by recognizing early signs of gout, monitoring the effectiveness of urate-lowering therapy, and guiding aspiration and corticosteroid injection.

Fatal airway obstruction due to Ludwig's angina from severe odontogenic infection during antipsychotic medication: A case report and a literature review

Ludwig's angina is characterized by inflammation of the sublingual and submandibular spaces and is mainly caused by odontogenic infection, which leads to cellulitis of the soft tissues of the floor of the mouth and the neck. This causes asphyxia due to elevation and posterior deviation of the tissues of the floor of the mouth. We report a fatal case of airway obstruction due to Ludwig's angina. A woman in her forties who had no physical complications, but had a mental illness, was undergoing outpatient dental treatment for caries in the first premolar of the left mandible. She was admitted to a psychiatric hospital because of insomnia caused by pain, where she developed cardiopulmonary arrest while sleeping and died 14 days after onset of the dental infection. Postmortem computed tomography (PMCT) prior to autopsy showed swelling of the soft tissues-from the floor of the mouth to the oropharyngeal cavity, the supraglottic larynx, and the prevertebral tissue. Autopsy revealed a markedly swollen face and neck, an elevated tongue, and a highly edematous epiglottis and laryngopharyngeal mucosa. There was also cellulitis and abscess of the facial, suprahyoid, and neck musculature, which suggested that the cause of death was asphyxiation due to airway obstruction. This was an alarming case, with mental illness leading to risk of severe odontogenic infection, and in which obesity and use of antipsychotic medication might have acted synergistically leading to airway obstruction. This is also a case of Ludwig's angina captured by PMCT, which has rarely been reported.