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Mpilo Medical Journal

Volume 1, No 3, January 1999.
Editor: Predrag M. Maksimovic, M!, !!", EN#.
$n tis %nline Journal &e &ill pu'lis various articles,
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possi'le, translation to Englis &ill 'e provided.
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Predrag M. Maksimovic
famona@email.com
.ocus
0ud&ig1s )ngina 2)ngina 0udovici3
4ellulitis o* te .loor o* te Mout
24ompiled 'y Predrag Maksimovic3
!e*inition
) rapidly spreading, 'ilateral, indurated cellulitis occurring in te *loor
o* te mout &itout a'scess *ormation or lympatic involvement.
5istory
#e disease process re*erred to as 0ud&ig1s angina &as *ormally descri'ed in
163, 'y (ilelm .riedric von 0ud&ig &en e reported on *ive patients in
&om a rapidly progressive so*t tissue in*ection developed, involving te
su'mandi'ular space and *loor o* te mout. "everal o* tese patients died o*
acute air&ay o'struction and aspy7iation. )ltoug is original description
accurately descri'ed te disease process and relevant *indings, e
erroneously *elt tat e &as dealing &it a ne& *orm o* neck in*lammation
tat &as in*ectious and occurring in an epidemic *asion.
0ud&ig1s angina, &it its potential *or air&ay o'struction, as pro'a'ly 'een
kno&n since anti8uity &it re*erences 'y 5ippocrates, 9alen, 4aelsius, and
oters under a variety o*terms suc as cyance, car'unculus gangraenosus,
mor'us strangulatorius, and angina maligna.
)natomy
0ud&ig1s angina is an in*ection o* te *loor o* te mout. .loor o* te mout
is comprised o* su'lingual space, su'mandi'ular space and su'mental space.
#e su'lingual and su'mandi'ular spaces are separated 'y te myloyoid muscle
and are connected via te myloyoid cle*t 2containing te tail o* te
su'mandi'ular gland, (arton1s duct, lingual nerve, ypoglossal nerve,
lympatics, and several arteries and veins3. #e *loor o* te su'mandi'ular
space is *ormed 'y te super*icial layer o* te deep cervical *ascia
attacing *rom te yoid 'one to te mandi'le. #e roo* is te myloyoid
muscle &ile te &alls are inner sur*ace o* te 'ody o* mandi'le, anterior
and posterior 'ellies o* te digastric muscles. #ere is ready communication
across te midline &it te opposite su'lingual or su'mandi'ular spaces. #e
su'mental space is 'ounded 'y te anterior 'ellies o* te digastric muscle
laterally, te mandi'le anteriorly, myloyoid superiorly and te yoid 'one
in*eriorly. #us, in*ection may readily spread *rom te main portion o* te
su'mandi'ular space to te su'mental space and *rom tere to te opposite
side. #e space located a'ove te myloyoid muscle is re*erred to as te
su'lingual space and consists o* loose connective tissue surrounding te
tongue and su'lingual gland and, again, tis space readily communicates &it
its counterpart on te opposite side. $t is &ort mentioning tat according
to te old anatomical nomenclature te su'mandi'ular space &as descri'ed as
'eing *ormed 'y te su'lingual, su'ma7illary and su'mental spaces. #oday, te
term su'ma7illary space is o'solete and is replaced 'y te term su'mandi'ular
space &ile te region *ormerly termed su'mandi'ular space is no& descri'ed
as *loor o* te mout.
#e *loor o* te mout as a &ole is 'ounded 'y te oral mucosa and tongue
superiorly and medially, te mandi'le anteriorly and laterally, te
super*icial layer o* te deep cervical *ascia &it its tigt attacment to
te mandi'le and yoid 'one laterally and in*eriorly, and te yoid 'one
in*eriorly. #e su'mandi'ular space, or one o* its components, is peraps te
space most commonly involved 'y signi*icant primary in*ections o* te ead
and neck. $n*ections may arise *rom in/uries to te *loor o* te mout,
su'lingual or su'mandi'ular gland sialoadenitis, or in*ections *rom te roots
o* te mandi'ular teet.
0ud&ig1s angina is a rapidly spreading cellulitis tat usually 'egins in te
su'mandi'ular space, resulting *rom an in*ected molar, and ten rapidly
spreads to involve te su'lingual space, usually on a 'ilateral 'asis. (it
te mandi'le and super*icial layer o* te deep cervical *ascia presenting
relatively unyielding 'arriers superiorly and laterally, te tongue is *orced
up&ard and posteriorly, giving rise to te severe air&ay o'struction
associated &it tis condition. "u'mandi'ular space in*ections may also
spread posteriorly to te carotid seat or retroparyngeal space, or 'ot,
'y crossing te lateral paryngeal space.
)s &ill 'e seen, te ma/ority o* cases o* 0ud&ig1s angina are o* dental
origin, &it te development o* a su'mandi'ular in*ection tat ten
progresses to involve te su'lingual space. 4rucial to tis process is te
relationsip o* te mandi'ular dentition to te attacment o* te myloyoid
muscle along te myloyoid ridge. #e anterior teet and *irst molars
regularly attac superior to te myloyoid insertion, and in*ection arising
*rom tese toot roots commonly results in a relatively limited su'lingual
a'scess. #e second and tird molar roots are routinely 'elo& te myloyoid
ridge, and in*ection presenting on te lingual sur*ace &ill enter te
su'mandi'ular space. )dditionally, it is important to recogni:e tat te
roots o* te anterior teet and *irst molar appro7imate te lateral
mandi'ular sur*ace, &ereas te second and tird molar roots approac te
lingual sur*ace o* te mandi'le.
0ud&ig1s angina usually develops *rom dental or periodontal in*ection,
especially o* te ;nd and 3rd mandi'ular molars. $t may occur in association
&it pro'lems caused 'y poor dental ygiene 2i.e. gingivitis and dental
sepsis3, toot e7tractions, or trauma 2i.e. *ractures o* te mandi'le,
lacerations o* te *loor o* te mout, peritonsillar a'scess3.
)ltoug not a true a'scess, 0ud&ig1s angina resem'les one clinically and is
treated similarly. <ntreated, it may 'e *atal.
#e ma/or mani*estations are pain in te area o* te involved toot= severe,
tender induration o* te su'mandi'ular region= trismus= dysponia= drooling
and ina'ility to s&allo&= and dyspnea and stridor *rom laryngeal edema and
tongue elevation. .ever, cills, and tacycardia are usually present. >+rays
o* te ead and neck are use*ul to assess te degree o* so*t+tissue s&elling
and air&ay o'struction.
Etiology
0ud&ig1s angina occurs most commonly in young adults &it periodontal
disease. .ormerly, 0ud&ig1s angina ad 'een ascri'ed to an in*ectious source
&it an epidemic occurrence. 5o&ever, it no& appears tat te reported
occurrences o* clusters o* 0ud&ig1s angina are most likely te result o*
pseudo+0ud&ig1s anginas secondary to suppurative lympadenitis in cases o*
scarlet *ever, dipteria, or measles. #sciassny, in an e7tensive revie& o*
te literature and detailed anatomic studies, demonstrated tat te ma/ority
o* 0ud&ig1s angina cases are te result o* a'scesses second or tird molar
teet &it penetration into te su'ma7illary space 'elo& te myloyoid ridge
and initiation o* a cellulitis. 5e *ound tat a dental cause &as responsi'le
in ?@ to 6- per cent o* cases, *ollo&ed 'y penetrating in/ury o* te *loor o*
te mout 2sta' &ound, gunsot &ound, orse kick, and so on3, &it mandi'ular
*ractures accounting *or te rest o* te cases. $t is interesting to note
tat e7traction o* a diseased molar &ill o*ten initiate te in*ection, and
#sciassny speculated tat te in/ection o* local anaestetic may seed te
su'mandi'ular space. Patterson noted tat 6@ per cent o* teir cases &ere
related to a dental patological condition, &it A- per cent o* te cases
*ollo&ing e7traction o* a diseased molar. #e remaining cases &ere in
cildren younger tan 3 years o* age in &om no clear cause could 'e
demonstrated.
#e in*ection is o*ten caused 'y a emolytic streptococcus, altoug te
in*ection may 'e a mi7ture o* aero'ic and anaero'ic organisms, &ic may
account *or te presence o* gas in te tissues. 4ills, *ever, increased
salivation, sti**ness in tongue movements, and an ina'ility to open te mout
erald te in*ection. #ickness is *ound in te *loor o* te mout, and te
tongue is elevated. #issues o* te neck 'ecome 'oardlike.
#e patient develops a to7ic condition, and respiration 'ecomes di**icult.
#e laryn7 is edematous.
Micro'iological .eatures
"ince most cases o* 0ud&ig1s angina are related to a dental cause, it is not
surprising tat te 'acterial cultures mirror te oral *lora. #e compilation
o* accurate micro'iologic data as 'een complicated 'y te *act tat most
patients ave ad at least several doses o* anti'iotics 'y te time surgical
treatment is per*ormed and te additional *act tat a num'er o* in*ections
resolve &it conservative treatment and no surgical drainage and, tus, no
specimen is o'tained. $t is clear tat tese in*ections are almost al&ays te
result o* mi7ed *lora, involving 'ot aero'es and anaero'es. #e most
commonly reported aero'es are alpa+emolytic streptococci, *ollo&ed 'y
"tapylococcus. #e data on anaero'ic cultures are more di**icult to
interpret 'ecause o* te presence o* prior anti'iotic terapy and te
di**iculty in culturing anaero'ic organisms. #e normal oral *lora typically
contains Peptostreptococcus, Peptococcus, .uso'acterium nucleatum,
Bacteroides melanogenicus, B. oralis, Veillonella, and "pirocaeta. #is
com'ination o* aero'ic and anaero'ic organisms gives rise to a synergistic
e**ect caused 'y te production o* endoto7ins suc as collagenase,
yaluronidase, and proteases, te com'ination o* &ic promotes a rapidly
progressive in*ection &it te clinical *eatures o* tissue necrosis, local
trom'ople'itis, putrid odor, and gas *ormation. )s a rule, gram+negative
organisms do not play a signi*icant role in 0ud&ig1s angina, altoug
5aemopilus in*luen:a, Escericia coli, and Pseudomonas ave all 'een
reported.
4linical .eatures
#e clinical picture o* 0ud&ig1s angina is typically tat o* a young man &it
poor dentition tat presents &it a istory o* increasing oral or neck pain
and s&elling. .re8uently, te patient1s symptoms are unilateral, 'ut tey
soon progress to involve 'ot sides. )s te in*ection progresses, tere is
increasing edema and induration o* 'ot te e7ternal perimandi'ular region
and te *loor o* te mout. #e so*t tissues o* te *loor o* te mout 'ecome
tremendously s&ollen and, as a result o* te relatively unyielding
super*icial layer o* te deep cervical *ascia and mandi'le, te e7pansion
progresses superiorly and posteriorly. #is e7pansion as te e**ect o*
trusting te tongue posteriorly and superiorly &it appro7imation o* te
palatal vault. #ere is increasing neck rigidity, trismus, odynopagia and,
eventually, drooling. #e temperature is typically elevated in te 1-- to 1-;
. range, and 1-A . is not uncommon.
)s te s&elling progresses, tere is increasing encroacment upon te air&ay,
and te patient assumes an erect posture &it tacypnoea. !yspnea and stridor
signal te imminent danger o* air&ay o'struction. #is is truly a desperate
situation 'ecause visuali:ation o* te laryn7 'y conventional tecni8ues is
impossi'le, and attempts at intu'ation may actually precipitate air&ay
o'struction. "imilarly, a traceostomy is e7tremely di**icult 'ecause o* te
ina'ility o* te patient to lie supine and te presence o* signi*icant neck
edema. #e point to stress is te rapidity &it &ic tis process may occur=
many case reports detail a progression *rom onset o* symptoms to respiratory
o'struction &itin te space o* 1; to ;A ours.
Pysical E7amination
#e pysical e7amination typically so&s *ever, tacycardia, and varia'le
degrees o* respiratory o'struction &it dyspagia and drooling.
#e su'mandi'ular and su'mental regions are tense, s&ollen, and tender. #e
*loor o* te mout is tense and indurated, &it massive mucosal s&elling and
pouting o* so*t tissue over te edges o* te lo&er teet. .luctuance is
unusual. #e tongue is pused superiorly, and tere is marked trismus.
$ndirect e7amination o* te laryn7 is, at 'est, di**icult and usually
impossi'le. Nasoparyngeal *i'eroptic e7amination &ill reveal te presence o*
a greatly enlarged 'ase o* te tongue pusing te epiglottis posteriorly= te
supraglottis and endolaryn7 are normal in appearance.
0a'oratory and Cadiologic E7amination
#e diagnosis and treatment o* 0ud&ig1s angina are 'ased on te clinical
parameters outlined= la'oratory and radiologic studies o**er only supporting
evidence. #ypically, te &ite 'lood cell count is moderately to markedly
elevated in te range o* 1@,--- to ;-,---, &it a marked si*t to te le*t.
>+ray studies &ill so& so*t tissue edema, occasionally gas, and posterior
displacement o* te tongue &it air&ay encroacment. Because o* te *act tat
tese in*ections are o*ten odontogenic, panoramic tomograpy may 'e elp*ul
in determining te site o* origin *or te in*ection and may aid in planning
te treatment regimen.
!iagnosis
"ince 0ud&ig1s original description, a variety o* in*lammatory conditions
related to te *loor o* te mout ave 'een la'eled 0ud&ig1s angina 2#a'le
13, 'ut in reality many &ould most appropriately 'e termed pseudoangina
ludovici. #ese pseudo+0ud&ig1s angina are more limited in*ections tat
involve only te su'lingual space, te su'mandi'ular lymp nodes, te
su'mandi'ular gland, or te su'mental space, or tey are a'scesses involving
one or more o* tese spaces. 0ud&ig1s original description &as o* a disease
process tat &as a Dgangraenous induration o* te connective tissues o* te
neck &ic advances to involve te tissues &ic cover te small muscles
'et&een te laryn7 and te *loor o* te moutD. #ere is a general consensus
in te literature tat to 8uali*y as a true 0ud&ig1s angina, te *ollo&ing
*eatures sould 'e present: 213 a spreading cellulitis &it no speci*ic
tendency to *orm a'scesses, 2;3 involvement o* 'ot su'ma7illary and
su'lingual spaces, usually 'ilaterally, 233 spread 'y direct e7tension along
*ascial planes and not lympatics, 2A3 involvement o* muscle and *ascia 'ut
not su'mandi'ular gland or lymp nodes, and 2@3 origination in te region o*
te su'ma7illary space &it progression to involve te su'lingual space and
*loor o* te mout.
#a'le 1. 4riteria *or !iagnosis o* 0ud&ig1s )ngina
Capidly progressive cellulitis= not an a'scess
!evelops along *ascial planes &it direct e7tension= does not involve
lympatic spread
!oes not involve su'mandi'ular gland or lymp nodes
$nvolves 'ot su'lingual and su'ma7illary spaces and is usually 'ilateral
0ud&ig1s angina may 'e descri'ed as an over&elming, generali:ed septic
cellulitis o* te su'mandi'ular region. )ltoug not seen o*ten, 0ud&ig1s
angina, &en it does occur, usually is an e7tension o* in*ection *rom te
mandi'ular molar teet into te *loor o* te mout, since teir roots lie
'elo& te attacment o* te myloyoid muscle. $t is usually o'served a*ter
e7traction.
#is in*ection di**ers *rom oter types o* poste7traction cellulitis in
several &ays. .irst, it is caracteri:ed 'y a 'ra&ny induration. #e tissues
are 'oardlike and do not pit on pressure. No *luctuance is present. #e
tissues may 'ecome gangrenous, and &en cut, tey ave a peculiar li*eless
appearance. ) sarp limitation is apparent 'et&een te involved tissues and
te surrounding normal tissues.
"econd, tree *ascial spaces are involved 'ilaterally: su'mandi'ular,
su'mental, and su'lingual spaces. $* te involvement is not 'ilateral, te
in*ection is not considered a 0ud&ig1s angina.
#ird, te patient as a typical open+mout appearance. #e *loor o* te
mout is elevated, and te tongue is protruded, making respiration di**icult.
#&o large potential *ascial spaces are at te 'ase o* te tongue, and eiter
or 'ot are involved. #e deep space is located 'et&een te genioglossus and
genioyoid muscles= te super*icial space is located 'et&een te genioyoid
and myloyoid muscles. Eac space is divided 'y a median septum. $* te
tongue is not elevated, te in*ection is not Econsidered a true 0ud&ig1s
angina.
Patognomonic *or 0ud&ig1s angina is te sign o* cock1s crest. "ometimes
unilaterally 'ut usually 'ilaterally te *loor o* te mout is red and
s&ollen and a streak o* yello& *i'rin covers su'lingual carunculae so tat it
looks as i* a cock is protruding is red ead &it a yello& crest *rom 'elo&
te tongue. $t can 'e stated sa*ely tat i* te mucosa o* te *loor o* te
mout is normal tere is no 0ud&ig1s angina.
#reatment
#reatment o* 0ud&ig1s angina depends on te stage o* disease &en te patient
presents. )ctually, 0ud&ig1s angina is a spectrum o* conditions, ranging *rom
a periapical a'scess and mild cellulitis in its early stage to massive sepsis
&it air&ay o'struction later on. #reatment may 'e tailored to te status o*
te individual patient, &it te understanding tat tis disease may progress
very rapidly, and i* initial steps are not success*ul, more radical means
must 'e employed. $n te early stages o* 0ud&ig1s angina, &it unilateral
mild s&elling and edema, simple intravenous anti'iotics and supportive
measures may 'e su**icient. #is is o*ten coupled &it e7traction o* te
inciting toot, i* it is identi*ia'le. $* te patient presents &it more
advanced disease or te disease progresses to 'ilateral s&elling, dyspagia
&it drooling, or any symptoms o* air&ay compromise, early air&ay
intervention, in a controlled *asion, is advocated rater tan &aiting until
emergency procedures are re8uired.
"urgical treatment is directed at securing an air&ay and providing surgical
drainage. #e coice o* air&ay management rests on te e7perience and
availa'ility o* te treating personnel. )ltoug air&ay management 'y
nasotraceal intu'ation, &it or &itout *i'eroptic assistance, is &ell
descri'ed in te literature, it sould 'e 'orne in mind tat air&ay
manipulation may precipitate acute o'struction and, tus, a traceostomy set
sould al&ays 'e availa'le. Because o* te possi'ility o* postoperative
e7tu'ation, and te di**iculty o* reintu'ation, conversion to a traceostomy
is generally advocated *or postoperative air&ay management. $* intu'ation is
not possi'le, a traceostomy under local anaestesia, o*ten &it te patient
sitting uprigt, is re8uired. #is may 'e complicated 'y te presence o*
signi*icant edema in te neck. #ose patients &it a rapidly deteriorating
air&ay may re8uire a cricotyroidotomy.
%nce te air&ay is esta'lised, surgical drainage is per*ormed.
!rainage consists o* a &ide surgical decompression o* te suprayoid region.
9enerally, te in*ectious process is 'ilateral, and te approac is troug a
median, ori:ontal incision tree to *our *inger'readts 'elo& te mandi'ular
margin. #e lengt o* te incision may 'e varia'le, 'ut generally it crosses
to te su'mandi'ular region 'ilaterally. #e myloyoid muscle is split in te
midline, and drainage is esta'lised 'ot medially and laterally. %*ten, te
side on &ic te in*ection started needs to 'e e7plored &it decompression
o* te su'mandi'ular capsule and 'lunt dissection to te mandi'ular margin.
#e tissues ave 'een descri'ed as aving a peculiar Dsalt porkD appearance,
&it &oody induration, &atery edema, and little 'leeding. 9ross purulence is
rarely encountered at te time o* e7ploration 'ut &ill o*ten drain *rom te
&ound several days a*ter decompression. Multiple drains are placed, and te
&ounds are le*t open.
#e coice o* anti'iotics must 'e tailored to te individual patient, 'ut
ig+dose penicillin 21; to 1, million unitsFday3 is considered te drug o*
coice. 4lorampenicol and clindamycin are alternate possi'ilities,
especially in penicillin+allergic patients. $n immunocompromised patients,
consideration sould 'e given to providing 'roader coverage *or te
possi'ility o* gram+negative anaero'ic organisms and penicillin+resistant
stapylococci.
4omplications
0ud&ig1s original description reported a ,- per cent mortality rate, &ereas
Patterson1s recent report ad a - per cent mortality rate. #e ma/or cause o*
deat in 0ud&ig1s angina is acute air&ay o'struction, and te most e**ective
means o* preventing it include care*ul monitoring o* te patient &it
intervention at te earliest sign o* air&ay compromise.
#raceostomy 2eiter initially or a*ter intu'ation3 is generally considered
te sa*est means o* maintaining an air&ay. .ollo&ing acute air&ay
o'struction, te ne7t ma/or potential complication o* 0ud&ig1s angina is
e7tension o* te in*ection to te carotid seat or retroparyngeal space
&it in*erior e7tension into te mediastinum. )ltoug e7tension to te
mediastinum &as *ormerly common, it is some&at unusual &it present+day
surgical drainage and anti'iotics. E7tension o* 0ud&ig1s angina sould 'e
suspected i* tere is persistent or increasing neck edema, spiking
temperatures, or persistent leukocytosis. 0ater *indings o* mediastinal
e7tension include increasing signs o* septic sock &it tacycardia and
decreasing 'lood pressure, crepitation o* te lo&er neck, or development o*
mediastinal crepitation or a mediastinal crunc. #e patient &it
mediastinitis &ill o*ten report increasing neck pain, cest tigtness, and
increasing dyspnea. #e cest 7+ray *ilm may so& a &idened mediastinum,
pericardial air, pulmonary in*iltrates, and e7trapleural *luid. )s mentioned,
in te acute pase o* 0ud&ig1s angina, tere is little or no purulence
'ecause o* te *act tat te in*ection is developing so rapidly tat tere is
no time *or pus to develop= later it is common *or purulence to drain *rom
te &ounds. $t is also possi'le tat isolated, undrained pockets o* pus may
develop, &ic may give rise to continuing signs o* sepsis. ) 4# scan o* te
neck &it contrast medium may 'e most elp*ul in detecting tese residual
pockets and directing surgical drainage.
%ter complications can include aspy7iation, aspiration pneumonia, lung
a'scesses, and metastatic sepsis.
Ce*erences
1. Paparella, M.: %tolaryngology G 5ead and Neck "urgery.
;. Hruger, 9.: #e7t'ook o* %ral and Ma7illo*acial "urgery.
3. Merck Manual.
A. McMinn, C. M. 5.: 0ast1s )natomy.
4ase Ceports
"everal oter patients.
4ystadenocarcinoma o* te C# su'mandi'ular gland.
Cecurrence one year a*ter te *irst operation.
4ystadenocarcinoma gro&ing *or a'out *our years. Notice te optalmoplegia.
#e patient immediately a*ter 0# emimandi'ulectomy &it e7articulation *rom
te second 0# premolar toot *or carcinoma involving 0# trigonum retromolare,
anterior 0# tonsil and 0# angle o* te mandi'le. Notice te deviation o* te
mandi'le to te le*t.
$ntraoral &ound ealing mainly per secundam. %ne vicryl sutur is still
visi'le.
Cecurrence in te 0# ceek one year a*ter te *irst operation. Cemoved &it
radical parotidectomy.
"tate a*ter removal o* te tumor o* te 0# lo&er eyelid and :ygomatic area
&it reconstruction &it local rotational *lap. Notice te de*ect o* te
eyelid, ektropion and scar.
"8uamocellular carcinoma destructing te nos and e7tending per continuitatem
to te upper lip, 'ot ceeks and 'ot peri+ and su'mandi'ular regions.
)*ter partial amputation o* te nose and upper lip.
"8uamocellular carcinoma destructing almost &ole o* te 'ody o* te mandi'le.
Primary reconstruction acieved &it transpositional regional *lap *rom te
neck. 0o&er corte7 o* te mandi'le &as retained to keep te space.
Epulis.
) patient *rom te rural areas treated *or a long time *or an Deye
in*ectionD. )lleggedly, eye glo'e &as removed.
)n or'ital e7enteration &as per*ormed. ) structure similar to a srunken eye
glo'e &as also removed. 5istology: carcinoma.
"ome si7 monts a*ter te *irst operation a local recurrence in te temporal
region is evident.
0# parotid cystadenocarcinoma.
"car is visi'le a*ter a 'iopsy 2sicIII3 per*ormed in oter ospital.
"uper*icial parotidectomy &as done &it preservation o* te *acial nerve and
te scar &it te surrounding skin &as included &it te specimen.
4# scan so&ed a lesion te si:e o* a *ist in te anterior C# *rontal lo'e.
!uring te *irst operation, 'lack masses &ere removed.
5istology: 'lastomycosis.
!uring te second operation te neurosurgeon removed te tume*action *rom te
anterior lo'e.
"arcoma ma7illae.
)*ter te *irst operation.
"i7 monts later te patient appeared &it even greater tumour.
)*ter te second operation.
Paryngeal *istula a*ter irradiation and total laryngectomy *or laryngeal
carcinoma.
Ceconstruction &it )riyan1s pectoralis ma/or musculo+cutaneous *lap. Notice
te elevation o* te Bakam/ian1s delto+pectoral *lap *or possi'le *uture use.
$ncipient necrosis o* te *lap a'ove te traceostomy.
#erminal stage o* te laryngeal carcinoma &it *ungi*orm recurrences.
Plasmacytoma undergoing 2unsuccess*ul3 radioterapy.
)melo'lastoma.
Ne& Num'er o* te Mpilo Medical Journal.
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