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CASE REPORT Drainage of Ludwigs Angina in a Pregnant Patient under Superficial Cervical Plexus loc!

2 Arun Kumar Gupta*, V.K.Dhulkhed*, B.M.Rudagi**, Ana Gupta* *Dept of Anesthesiology ** Dept of ral ! Ma"illofa#ial $urgery Rural Medi#al %ollege, &oni, Maharashtra, '(ndia). *+,-,. Correspondence" Dr.Arun Kumar Gupta, Assistant /rofessor, Dept of Anesthesiology, Rural Medi#al %ollege, &oni, Maharashtra '(ndia). *+,-,.0 /hone no1 23+342,2.2-550 6mail1 guptaarun-+7gmail.#om

A STRACT
&ud8ig9s angina is rapidly spreading #ellulitis that may result in potentially lethal upper air8ay o:stru#tion. ;here is <ery little pu:lished literature regarding this #ondition in the pregnant patient. =e present a #ase report of a 25 years old female patient admitted at ,5 8eeks gestation 8ith tooth pain, su:mandi:ular s8elling, se<ere trismus and dysphagia, #onsistent 8ith &ud8ig9s angina. >er planned treatment in#luded in#ision and drainage of asso#iated spa#es, teeth e"tra#tion, and anti:ioti# therapy. During a life threatening infe#tious #ondition su#h as the one 8e des#ri:e, risks to the mother and the :a:y in#lude septi#emia, hypo"ia and?or asphy"ia. =e su##essfully relie<ed air8ay o:stru#tion :y surgi#al de#ompression alone, using a #er<i#al ple"us :lo#k. #e$words1 /regnan#y0 &ud8ig9s angina0 %er<i#al ple"us :lo#k. Citation" Gupta AK, Dhulkhed VK, Rudagi BM, Gupta A. Drainage of &ud8ig9s angina in a pregnant patient under superfi#ial #er<i#al ple"us :lo#k. Anaesth /ain ! (ntensi<e %are 25530+,'2)1.4@-5

%&TROD'CT%O&
&ud8ig9s angina is defined as a potentially lethal, rapidly spreading #ellulitis, in<ol<ing the su:lingual and su:mandi:ular spa#es, and is manifested :y a :ra8ny suprahyoid induration, tender s8elling in the floor of the mouth, and ele<ation and posterior displa#ement of the tongue.+ ;he most #ommon #ause of &ud8ig9s angina is an odontogeni# infe#tion from one or more grossly de#ayed, infe#ted teeth, and is usually as a result of nati<e oral strepto#o##i or a mi"ed aero:i#@anaero:i# oral flora.2 /rompt air8ay management is #riti#al, :ut the presen#e of s8elling of the ne#k, glotti# edema, ele<ation of the tongue, trismus, or pharyngeal edema #reate formida:le pro:lems.,

(t is a life threatening #ondition, yet an e"tensi<e literature sear#h did not yield mu#h pu:lished information regarding its o##urren#e in the pregnant patients.

CASE REPORT
A 25@year old primigra<ida, at ,5 8eeks gestation, presented to our hospital 8ith #omplaints of fa#ial s8elling. $he des#ri:ed that her pregnan#y had :een une<entful, e"#ept for a se<en@ day history of lo8er left Auadrant tooth pain, and a three@day history of fe<er and #hills. >er #lini#al e"amination re<ealed a large soft tissue s8elling under her mandi:le, e"tending :ilaterally to the angles of the mandi:le and inferiorly up to her hyoid :one. n presentation, her <ital signs 8ere1 temperature ,4.-B%, :lood pressure +2C?C*, pulse ++.?min, respiratory rate +3?min, o"ygen saturation on room air 3.D, and 8hite #ell #ount of +.455?E&. ;he diagnosis of &ud8ig9s angina 8as made. (t 8as diffi#ult to perform an adeAuate oral e"am due to pain, s8elling, and se<ere trismus 8hi#h allo8ed her to open her mouth to only +C mm 'a<erage range *5F*C mm). ;he patient had diffi#ulty in #ontaining her o8n sali<ary se#retions :e#ause of dysphagia, :ut had no dyspnea. $in#e in similar situations patients may desaturate <ery Aui#kly, e<en though her o"ygen saturation 8as re#orded to :e 3.D on room air, she 8as gi<en supplemental o"ygen and a pulse o"imeter 8as atta#hed. An emergent #ri#othyrotomy kit 8as kept a<aila:le at the patient9s :edside at all times. =e formally #onsulted the Department of :stetri#s and Gyne#ology, understanding that in administering medi#ations and?or undergoing any surgi#al treatment in pregnan#y, one must #onsider the risks and the :enefits :oth to the mother and the un:orn, it 8as determined that the :enefits of pro#eeding 8ith emergent and immediate surgi#al inter<ention out8eighed the risks. (igure )" Li*ited *out+ opening

$e#uring an air8ay <ia an a8ake fi:eropti# nasal intu:ation 8as risky1 a fi:eropti# tu:e inserted into the pharyn" might pun#ture an a:s#ess and #ause pus aspiration or s8allo8ing. (t 8as thus de#ided to attempt a trial of de#ompression under superfi#ial #er<i#al ple"us :lo#k. %omplete preparations for an emergen#y tra#heostomy 8ere also undertaken.

$tandard monitors 8ere atta#hed. ;he patient 8as pla#ed in a supine position, 8ith her head turned to the right side. Gnder asepti# te#hniAue, lido#aine +D 8as infiltrated at the midpoint of the line #onne#ting the mastoid pro#ess 8ith %hassaigna#9s tu:er#le of %. trans<erse pro#ess. ;hen inH.:u<ipa#aine 5.CD 4ml 8as inHe#ted after negati<e aspiration using a fan te#hniAue along the posterior :order of sterno#leidomastoid mus#le 8hi#h redu#ed the pain and ena:led the patient to open mouth more 8idely. An inferior al<eolar ner<e :lo#k 8as then performed :y ma"illofa#ial surgeon intraorally. Dense anesthesia 8as esta:lished in a:out - min. A rapid de#ompression of the left su:mandi:ular region 8as done and the mylohyoid transe#ted 8ith resultant lo8ering of the floor of mouth, the :lunt disse#tion #ontinued through the mylohyoid mus#le to the su:lingual areas to a##ess all lo#ulations. &o8er left three molars 8ere then e"tra#ted sin#e it 8as :elie<ed that these grossly #arious and partially impa#ted teeth 8ere the primary sour#e of the infe#tion. Gpon remo<al, purulen#e 8as e"pressed through the e"tra#tion so#ket. ;here 8as little dis#harge from the 8ound, 8hi#h 8as lightly pa#ked and dressed. /ost op fetal heart sound 8as monitored :y fetal Doppler. After four days, she 8as dis#harged, to :e follo8ed up at Departments of ral ! Ma"illofa#ial $urgery and :stetri#s ! Gyne#ology.

D%SC'SS%O&
;he uniAue anatomy of the floor of the mouth plays an important role in the de<elopment and e"tension of intraoral infe#tions. ;he usual infe#tious #ourse :egins 8ith a periapi#al dental a:s#ess of the se#ond or third mandi:ular molar. ;he roots of these teeth e"tend inferior to the insertion of the mylohyoid mus#le, so that if untreated, the infe#tion may #ontinue from primary spa#es to penetrate the thin inner #orte" of the mandi:le and 8ill in<ol<e the posterior margin of the mylohyoid mus#le to the su:mandi:ular spa#e. At this point, the infe#tion may de<elop and progress at su#h an alarming rate that spe#ial pre#autions regarding air8ay maintenan#e must :e taken. * (t is estimated that a:out C5,555 8omen reAuire anesthesia and a surgi#al inter<ention ea#h year at some time during gestation for indi#ations unrelated to the pregnan#y. C (n su#h situations, 8hen medi#al and surgi#al treatments for pregnant 8omen are #onsidered, :oth the physiologi# #hanges of pregnan#y and the perinatal effe#ts of the treatment must :e #onsidered.. /regnan#y is a##ompanied :y physiologi#al #hanges 8hi#h pla#e the mother at a higher risk of infe#tion or of doing 8orse on#e infe#ted. Iirst, the immune response is greatly diminished during pregnan#y, thus resulting in rapid progression of an infe#tion. $e#ondly, there is de#reased neutrophil #hemota"is, #ell mediated immunity, and natural killer #ell a#ti<ity.-,4 Moreo<er, appro"imately C5D of pregnant 8omen #omplain of some degree of dyspnea :y +3th 8eek of gestation- and there is some depletion in the o"ygen reser<e of the gra<id patient. ;his #ould in#rease fetal hypo"ia during periods of hypo<entilation.. Irom an oral perspe#ti<e, as pregnan#y asso#iated hormonal #hanges :egin to affe#t a 8oman9s :ody, the gingi<al tissues are affe#ted as 8ell. ;hey :e#ome mu#h more sensiti<e and thus sus#epti:le to irritation from soft plaAue. ;he plaAue a##umulates, :e#omes hard #al#ulus deposits on the teeth, and har:ors :a#teria in large num:ers resulting in a #onstant, lo8@grade intraoral infe#tion. Maternal infe#ti<e pro#esses sustained espe#ially :y gram negati<e anaero:i# :a#teria, su#h as those leading to &ud8ig9s angina, ha<e :een demonstrated to #ause physiologi# im:alan#e through inflammatory #ytokine produ#tion, sometimes resulting in preterm la:or, premature rupture of mem:ranes, and lo8 :irth 8eight.3 During pregnan#y, 8omen tend to ha<e freAuent meals and sna#ks, 8hi#h augment plaAue a##umulation, as 8ell as an in#rease in de#ay or rapid progression of pre<iously present de#ay. A remote infe#tion

#an at times infe#t the pla#enta, uterus, and possi:ly the fetus, #ausing fetal septi#emia. During a life threatening infe#tious situation su#h as the one des#ri:ed, the risk of maternal and fetal mor:idity may o<ershado8 potential teratogeni# side effe#ts during early pregnan#y.+5 (n an e"hausti<e re<ie8 of the literature, from +3*C to +3-3, -C #ases of &ud8ig9s angina 8ere found, and the authors strongly ad<o#ate ele#ti<e tra#heostomy under lo#al anaesthesia.++ %ellulitis of the ne#k 8ith in<ol<ement of the tra#heostomy site may make it a more diffi#ult option. Moreo<er, surgi#al disse#tion of the fas#ial planes in the ne#k may a#tually open and #ontaminate the path8ays, leading to life@threatening mediastinal in<asion.+2 ther options for air8ay management in#lude orotra#heal, :lind nasotra#heal, and fi:er opti# intu:ation or #ri#othyroidotomy 8ith Het insufflation. =e #hose to employ a #er<i#al ple"us :lo#k as anesthesia for surgi#al de#ompression. ;he :lo#k permitted a thorough in#ision and drainage, in#luding transe#tion of mylohyoid 8ith lo8ering of the floor of mouth and rapid relief of respiratory o:stru#tion. &ing et al also re#ommended the #onsideration of superfi#ial #er<i#al ple"us :lo#k, and if ne#essary an auri#ulotemporal ner<e :lo#k to manage sele#ted patients 8ith diffi#ult air8ays 8ho present for drainage of dental a:#esses.+, Moshe et al ad<o#ated superfi#ial #er<i#al ple"us :lo#k 8ith #on#omitant mandi:ular ner<e :lo#k 8ith a high su##ess rate, lo8 #ompli#ation rate and high patient a##eptan#e rate for the drainage of su:mandi:ular and su:mental a:s#esses.+* &ud8ig9s angina is life threatening :e#ause of risks of septi#emia and asphy"ia. Iurthermore, in pregnan#y, the #ondition itself as 8ell as possi:le therapies may put the mother and her un:orn #hild at in#reased risk.

CO&CL'S%O&
$uperfi#ial #er<i#al ple"us :lo#k #om:ined 8ith mandi:ular ner<e :lo#k #an safely :e employed for the surgi#al de#ompression in a #ase of pregnant patient 8ith &ud8ig9s angina.

RE(ERE&CES
+. /atterson >, Kelly J>, $trone M1 &ud8ig9s angina1 An update. &aryngos#ope +3420321,-5. 2. ;opaKian RG, Gold:erg M>, >upp JR. ral and Ma"illofa#ial (nfe#tions. *th ed. /hiladelphia, /a1 =. B. $aunders0 2552. ,. Allen D, &oughnan ;6, rd RA1 A ree<aluation of the role of tra#heostomy in &ud8ig9s angina. J ral Ma"illofa# $urg +34C0*,1*,.@3. *. Marple BI. &ud8ig angina1 a re<ie8 of #urrent air8ay management. Ar#hi<es of tolaryngology F >ead and Le#k $urgery. +3330+2C'C)1C3.F.55. C. Aroesty J>, &anKa J;, &u#ente I6. tolaryngology and pregnan#yMdiffi#ult management de#isions. tolaryngology F >ead and Le#k $urgery. +33,0+53'.)1+5.+F+5.3. .. Barron =M. Medi#al e<aluation of the pregnant patient reAuiring nono:stetri# surgery. %lini#s in /erinatology. +34C0+2',)1*4+F*3..

-. $il<er RM, /eltier MR, Bran#h D=. ;he immunology of pregnan#y. (n1 %reasy RK, Resnik R, editors. Maternal@Ietal Medi#ine1 /rin#iples and /ra#ti#e. /hiladelphia, /a1 =. B. $aunders0 255*. pp. 43F+53. 4. &a8renK DR, =hitley BD, >elfri#k JI. %onsiderations in the management of ma"illofa#ial infe#tions in the pregnant patient. J ral Ma"illofa# $urg. +33.0C*'*)1*-*F*4C. 3. $#annapie#o IA, Bush RB, /aHu $. /eriodontal disease as a risk fa#tor for ad<erse pregnan#y out#omes. A systemati# re<ie8. Annals of /eriodontology. 255,041-5F-4. +5. Moore /A. $ele#ting drugs for the pregnant dental patient. Journal of the Ameri#an Dental Asso#iation. +3340+23'3)1+24+F+24.. ++. >ought R;, IitKgerald B6, &atta J6, Nallen RD1 &ud8ig9s angina1 A report of t8o #ases and re<ie8 of the literature from +3*C to January +3-3. J ral $urg +3450,414*3@CC. +2. $no8 L, &u#as A6, Grau M, $teiner M1 /urulent mediastinal a:s#ess se#ondary to &ud8ig9s angina. Ar#h tolaryngol +34,0+531 C,@C. +,. &ing KG, >asan M$, >a K , =ang %O. $uperfi#ial #er<i#al ple"us :lo#k #om:ined 8ith auri#ulotemporal ner<e :lo#k for drainage of dental a:s#ess in adults 8ith diffi#ult air8ays. Anaesth (ntensi<e %are 25530,-'+)1+2*@.. +*. $hteif M, &esmes D, >artman G, Ruffino $, &aster N. ;he use of the superfi#ial #er<i#al ple"us :lo#k in the drainage of su:mandi:ular and su:mental a:s#essesFan alternati<e for general anesthesia. J ral Ma"illofa# $urg. 2554 De#0..'+2)12.*2@C.