Morning Report

Morning Report: Infections of the Neck and Upper Airway

 

HPI: 49 year old male with a hx of recent flu-like symptoms (fever, cough, rhinorrhea, myalgias) presenting with neck pain, swelling and erythema. 1 week PTA, he was diagnosed with Ludwig’s angina and treated with IV antibiotics and steroids, followed by PO Clindamycin and Medrol pack, but returns now with continuing/worsening symptoms.

BP 100/66 | HR 53 | Temp 98 °F | Resp 18 | SpO2 98%

Pertinent Labs: WBC 18.2

CT:  Progression of abscess in the midline floor of mouth 3.6 x 2.4 x 2.3 cm. Secondary myositis of the mylohyoid and anterior belly of digastric muscle. Normal sublingual spaces b/l. Inflammatory change within the subcutaneous tissues of the submandibular and submental spaces.

Think about the etiology of submandibular space infections, complications that may arise, components of a thorough physical exam and workup, and appropriate management.

Learning Points:

  1. Submandibular space infections are most commonly polymicrobial, caused by extension of dental infections
  2. Airway obstruction and spread of infection to mediastinum are most concerning complications
  3. Manage cellulitis and small abscesses with antibiotics (usually PCN+beta lactamase inhibitor) for 48 hours and assess response to treatment. Severe/complicated infections managed by open surgical I&D with antibiotics.

EBM Article:

  1. Boscolo-Rizzo, P and Da Mosto, M. Submandibular Space Infection: A Potentially Lethal Infection. International Journal of Infectious Disease, Nov. 2008
  2. 2. Hamza, S. et al. Deep Fascial Space Infection of the Neck. South Med J. 2003;96(9)
  3. Tintinalli. 7th Edition. Infections and Disorders of the Neck and Upper Airway
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