Medical Image of the Month: Ludwig’s Angina

Figure 1.  A coronal reconstruction of the patient’s initial post-contrast maxillofacial CT demonstrates swelling of the soft tissues of the floor of the mouth consistent with phlegmonous changes and early abscess formation (blue arrows).  There is also swelling in the region of the vallecula and epiglottis (red arrow).

Figure 2.  A coronal reconstruction of the patient’s follow-up post-contrast maxillofacial CT after placement of a tracheostomy tube demonstrates marked progression of the swelling of the soft tissues of the floor of the mouth with development of a large, ill-defined abscess in the floor of the mouth (blue circle). Note the marked, progressive narrowing of the oropharynx (red arrow) over a period of approximately 24 hours.

Case Presentation: A 65-year-old gentleman with a history of insulin-dependent diabetes mellitus presented to the emergency room with a chief complaint of two days of difficulty swallowing and jaw pain.  Four days prior to presentation, he had extensive dental work performed to address multiple dental caries.  On arrival to the emergency room, he was noted to be tachycardic with difficulty swallowing his saliva and liquids.  On physical examination, he had difficulty opening his mouth with marked swelling of his tongue.  He also had marked swelling of the soft tissues of the floor of the mouth with palpable adenopathy.  A maxillofacial CT with contrast (Figure 1) was performed which demonstrated extensive edema and early abscess formation in the floor of the mouth.  He was initially admitted to the general medicine floor and started on broad-spectrum antibiotics.  Over the course of the next 12 hours, he began to have increased difficulty breathing and was unable to swallow his own secretions.  He was promptly transferred to the ICU where a fiberoptic nasotracheal intubation was attempted at bedside but was unable to be performed given the extensive soft tissue swelling in the posterior oropharynx.  An emergent awake tracheostomy was subsequently performed by ENT.  A repeat maxillofacial CT with contrast (Figure 2) demonstrated marked progression of the inflammatory changes and abscess formation in the floor of the mouth consistent with progressive Ludwig's angina.  The combination of prompt surgical drainage and broad-spectrum antibiotics resulted in marked clinical improvement over the next 72 hours. The patient's final tissue cultures grew Streptococcus viridans.

Ludwig's angina is a potentially life-threatening gangrenous cellulitis of the neck and floor of the mouth which is characterized by progressive submandibular swelling with elevation and posterior displacement of the tongue. Odontogenic infections are the cause for most cases. Pre-existing medical conditions which predispose patients to the development of Ludwig's angina include diabetes mellitus, malnutrition, alcoholism, and immunocompromised states (i.e. AIDS and organ transplantation).

In the early stages of the disease, patients may be managed with observation and intravenous antibiotics to cover for β-hemolytic streptococcus and anaerobic organisms. The most life-threatening complication of Ludwig's angina is airway obstruction.  Immediate involvement of an anesthesiologist and ENT are crucial in the management of this condition.  Blind nasotracheal intubation should not be attempted in these patients given the potential for bleeding and abscess rupture.  Flexible nasotracheal intubation requires skill and experience.  If flexible nasotracheal intubation is not possible, a cricothyrotomy and tracheostomy under local anesthesia can be performed in the emergent setting.  An elective awake tracheostomy is a safer and more logical method of airway management in patients with fully developed Ludwig's angina.

Lauren Estep, MD and Tammer El-Aini, MD

Department of Pulmonary, Critical Care, Allergy and Sleep

University of Arizona College of Medicine

Tucson, AZ USA

References

1. Hasan W, Leonard D, Russell J. Ludwig's Angina-A Controversial Surgical Emergency: How We Do It. Int J Otolaryngol. 2011;2011:231816. [CrossRef] [PubMed]
2. Candamourty R, Venkatachalam S, Babu MR, Kumar GS. Ludwig's Angina - An emergency: A case report with literature review. J Nat Sci Biol Med. 2012 Jul;3(2):206-8. [CrossRef] [PubMed]

Cite as: Estep L, El-Aini T. Medical image of the month: Ludwig’s angina. Southwest J Pulm Crit Care. 2019:18(4):74-5. doi: https://doi.org/10.13175/swjpcc013-19 PDF 

Medical Image of the Week: A Positive Sniff Test

Figure 1.  Image from thoracic CT scan shows persistent elevation of the right hemi diaphragm, complete right lower lobe and partial middle lobe atelectasis with patent airways on chest computed tomography.

Figure 2. Diaphragm fluoroscopy demonstrating the paradoxical upward movement of the right hemi diaphragm during inspiration confirming right hemi diaphragmatic paralysis.

A 66-year-old man with a history of hypertension, morbid obesity, emphysema, type 2 diabetes complicated by extensive peripheral neuropathy presented for evaluation of persistent fatigue, shortness of breath and increased oxygen requirements.

Approximately 18 months prior to presentation the patient required intubation for septic shock with multifocal pneumonia and right lower lobe collapse. The patient left the hospital after 10 days on 4 liters of oxygen and had been oxygen dependent since then with no improvement despite aggressive pulmonary rehabilitation. A pulmonary function test (PFT) demonstrated a moderate, restrictive ventilatory defect with low diffusion capacity; while his thoracic computed tomography showed persistent elevation of the right hemi-diaphragm with right lower lobe and partial middle lobe atelectasis (Figure 1). No evidence of endobronchial lesions, mediastinal or cervical masses, or enlarged lymph nodes seen.

The patient underwent a fluoroscopic sniff test that confirmed paralysis of the right hemi-diaphragm (Figure 2) (1). Phrenic nerve palsy has been associated with cardiac surgery due to both cooling and stretching mechanisms, cervical and thoracic compression of the phrenic nerve, trauma and iatrogenic injury, Herpes zoster, poliomyelitis, neurologic amyotrophic, brachial plexopathy have been associated with unilateral and bilateral diaphragmatic paralysis (2). In our patient, extensive history, physical exam, neurologic evaluation, laboratory tests and imaging failed to reveal a provoking insult to the right phrenic nerve. Therefore, diabetes related phrenic nerve palsy was entertained as a working diagnosis due to the patient’s extensive history of diabetes related neuropathy. The patient was started on noninvasive positive pressure ventilation with a BiPAP machine and showed remarkable symptomatic improvement at bedtime, but his functional status has been significantly limited during the day. He is currently being evaluated for possible diaphragmatic plication surgery.

Surgical plication of the paralyzed hemi diaphragm has shown very good results in appropriately selected patients (3). This included improvement in lung function, exercise endurance, and dyspnea post surgery.

Richard Young, MD*, Ateeli Huthayfa, MBBS**, Afishin Sam, MD**.

*Department of Internal Medicine. **Department of Pulmonology and Critical Care

Banner University Medical Center, University of Arizona, Tucson, Arizona

References

1. Nason LK, Walker CM, McNeeley MF, Burivong W, Fligner CL, Godwin JD. Imaging of the diaphragm: anatomy and function. Radiographics. 2012 Mar-Apr;32(2):E51-70. [CrossRef] [PubMed]
2. Gibson GJ. Diaphragmatic paresis: pathophysiology, clinical features, and investigation. Thorax. 1989 Nov;44(11):960-70. [CrossRef] [PubMed]
3. Hüttl TP, Wichmann MW, Reichart B, Geiger TK, Schildberg FW, Meyer G. Laparoscopic diaphragmatic plication: long-term results of a novel surgical technique for postoperative phrenic nerve palsy. Surg Endosc. 2004 Mar;18(3):547-51. [CrossRef] [PubMed]

Cite as: Young R, Huthayfa A, Sam A. Medical image of the week: a positive sniff test. Southwest J Pulm Crit Care. 2017;14(5):199-200. doi: https://doi.org/10.13175/swjpcc050-17 PDF 

Medical Image of the Week: Spontaneous Pneumomediastinum

Figure 1. Upright chest radiograph showing pneumomediastinum tracking into neck and small right apical pneumothorax (arrows).

Figure 2. Coronal slice of CT chest showing extensive pneumomediastinum and subcutaneous emphysema (arrows).

Figure 3. CT scan of chest showing the Macklin effect with air tracking along the bronchovascular sheath in the left lower lobe.

A 24-year-old man with a past medical history significant for type I diabetes mellitus presented to the emergency department with complaints of nausea and vomiting for several days. He reported he had been on drinking alcohol heavily 4 days prior to presentation and subsequently had multiple episodes of vomiting. Initial laboratory evaluation was consistent with diabetic ketoacidosis (DKA). A routine chest x-ray was obtained to evaluate for an infectious etiology of his DKA and revealed pneumomediastinum and a small right apical pneumothorax (Figure 1). A CT scan of the chest was done and showed extensive pneumomediastinum as well as air tracking along the bronchovascular sheaths in the left lower lobe (Figure 2 and 3). It did not reveal evidence of esophageal injury.

Spontaneous pneumomediastinum (SPM) refers to pneumomediastinum that is not associated with noticeable cause such as esophageal rupture or trauma. It is typically a benign condition thought to be due to alveolar rupture and subsequent air tracking along the bronchial tree (1). It has been associated with a number of conditions including asthma, DKA, anorexia nervosa, and other conditions that lead to excessive coughing or vomiting. The radiographic appearance of air dissecting through the pulmonary intersitium along the bronchovascular sheath is known as the Macklin effect and can be seen in Figure 3.

Spontaneous pneumomediastinum typically resolves without complications but must be differentiated from the much more serious diagnosis of esophageal rupture, or Boerrhaave’s syndrome. Boerrhaave’s syndrome is more likely to present with fever, hemodynamic instability, and hydropneumothorax. All patients presenting with suspected SPM should be evaluated for esophageal perforation with a radiographic contrast swallow (2). In our case it was negative for evidence of esophageal disruption and the patient recovered completely.

Lucie Griffin DO and Erik Kraai MD

Division of Pulmonary, Critical Car, and Sleep Medicine

University of New Mexico Health Sciences Center

Albuquerque, NM USA

References

1. Murayama S, Gibo S. Spontaneous pneumomediastinum and Macklin effect: Overview and appearance on computed tomography. World J Radiol. 2014 Nov 28;6(11):850-4. [CrossRef] [PubMed]
2. Kelly S, Hughes S, Nixon S, Paterson-Brown S. Spontaneous pneumomediastinum (Hamman's syndrome). Surgeon. 2010 Apr;8(2):63-6. [CrossRef] [PubMed] 

Cite as: Griffin L, Kraai E. Medical image of the week: spontaneous pneumomediastinum. Southwest J Pulm Crit Care. 2016 Mar;12(3):115-6. doi: http://dx.doi.org/10.13175/swjpcc015-16 PDF