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Submandibular spaceinfection : a potentiallylethal infection

JOURNAL READING

Tutor :dr. Tris Sudyartono, Sp.THT-KLdr. Agus Sudarwi, Sp. THT-KLdr. Santo ranowo, Sp.THT-KL

Presented by :Gladys Hartono112012!Al"#"#n 112012$Ro%&y G#a'to 11201(0$)

*A+ULT, O* -EDI+INE

.RIDA /A+ANA +HRITIAN UNIERIT,

EAR NOE AND THROAT DEPART-ENT

-ARDI RAHA,U HOPITAL .UDU

21 De%e'ber 201(3 2) January 2014


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Abstract•

!b"ecti#es: The aims of this study were to re#iew the clinicalcharacteristics and management of submandibular spaceinfections and to identify the predisposing factors of life-threatening complications.

•

$esign and methods: This was a retrospecti#e study at atertiary academic center. %e retrie#ed and e#aluated therecords of all patients admitted to the &ni#ersity of adua!tolaryngology 'linic at Tre#iso (egional Hospital with thediagnosis of submandibular space infection for the period )**+/. The following #ariables were re#iewed: demographic

data, pathogenesis, clinical presentation, associated systemicdiseases, bacteriology, imaging studies, medical and surgicaltreatment, and complications. A multi#ariate logistic regressionanalysis was underta0en using a forward stepwise techni1ue


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Abstract

• (esults:

2ulti#ariate analysis identi3ed four ris0 factors for complications.Anterior #isceral space in#ol#ement and diabetes mellitus werethe most important predicti#e factors in the model.

• 'onclusions:

Airway obstruction and spread of the infection to themediastinum are the most troublesome. Therefore, themaintenance of a secure airway is paramount. atients withcellulitis and small abscesses can respond to antibiotics alone.

Surgical drainage should be performed in patients with largerabscesses, Ludwig4s angina, anterior #isceral space in#ol#ement,and in those who do not respond to antibiotic treatment.


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Introdu%t#on

DEEPNE+.

IN*E+TION

In%#densand

-ortal#ty5

+o'6le7 anato'y

and*atal %o'6l#%at#ons

8e%auseo9


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Anatomy


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Introdu%t#on

• The origins of $56s are odontogenicinfections.

• As well as occurring secondary todental infections, submandibularspace infections may be aconse1uence of submandibular gland

sialadenitis, lympha,trauma, orsurgery.


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Introdu%t#ons

• Ludwig4s angina is a potentially life-threatening bilateral di7usegangrenous cellulitis of the

submandibular and sublingual spaces


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• The "ournal was retrie#ed and e#aluatedfrom the records of all patients admittedto the &ni#ersity of adua !tolaryngology

'linic at Tre#iso (egional Hospital withthe diagnosis of submandibular spaceinfection for the period )**+/.

• 89clusion criterias: atients with headand nec0 cancer or post-traumaticsubmandibular space infections.

Pat#ents and'etods


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atients and methods

• The following #ariables were re#iewed: – $emographic data

– athogenesis

– 'linical presentation

– Associated systemic diseases

– acteriology

–

6maging studies – 2edical and surgical treatment

– 'omplications


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• All patients underwent contrast-enhancedcomputed tomography ;'8'T


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• The infection was categori>ed according to:character ;cellulitis #ersus abscess<

Side ;monolateral, bilateral<

The other in#ol#ed spaces ;lateral pharyngealspace, retropharyngeal space, pre#ertebralspace, parotid space, masticatory space,#isceral #ascular space, anterior #isceral space


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atient and methodsatient withintra#enousantibiotics

'linicallystable

'linicalimpro#ement

'8'T repeat

'ollection ofpus ;-< :surgical

inter#ention

5o clinicalimpro#ement

Surgicaldrainage

'linicallyunstable

6mmediatesurgicaldrainage

Obser"ed ! ours


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• atient characteristics REULT


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• atient characteristics REULT


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-ost%o''on

sy'6to's

5ec0 swelling?

$ysphagia

2ost commoncause

Dental#n9e%t#on

Pr#'arys#te o9

#n9e%t#on

Submandibular space

2ost commonsystemic

disease

D#abetes

'ell#tus


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Treat'ent and #n%#den%e o9%o'6l#%at#ons

• The most fre1uently usedtreatment regimen, alone or incombination, was

amo9icillinBcla#ulanate potassium

• Twenty-3#e patients ;@.*<underwent cer#ical surgical

drainage. Twel#e patients ;)C.+<de#eloped life-threateningcomplications


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redictors of complications

• Age D /E years, diabetes mellitus, otherscomorbidities, secondary submandibularinfection, bilateral submandibular swelling,

multiple space in#ol#ement and anterior#isceral space in#ol#ement signi3cantlycorrelate with the rate of complications.

• Anterior #isceral space in#ol#ement and

diabetes mellitus were the most importantpredicti#e factors in the model


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$iscussion

• The mainstay of treatment of $56sconsists of airway control, antibioticmedical treatment, and, if necessary,surgical drainage.

• 6n patients with bilateral submandibularswelling, an airway obstruction can bethe result of the tongue pushing againstthe roof of the mouth and the posterior

pharyngeal wall, or be a conse1uence ofanterior #isceral space in#ol#ement withlaryngeal edema.


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D#s%uss#on

• The microbiological pattern of $56s isgenerally polymicrobial, including aerobes;group A streptococcus, #iridans

streptococci, Staphylococcus aureus, andHaemophilus in=uen>ae< and anaerobes;re#otella, orphyromonas, Fusobacterium,and eptostreptococcus spp<

• The most eGcacious antimicrobial agentscomprise the combination of a penicillin anda beta-lactamase inhibitor.


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• 'oagulase-negati#e Staphylococcus

was the most common isolate foundand was identi3ed in @+.) ofpositi#e cultures.

• Staphylococcus aureus was thesecond most common isolatedmicroorganism in this series. 5o

methicillin-resistant strains ;2(SA


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• ancomycin, trimethoprimBsulfametho9a>ole,rifampin, and line>olid in di7erent associations shouldbe the options considered for the treatment of 2(SA

in addition to surgical drainage of the abscess

• Treatment planning re1uires a clear di7erentiationbetween cellulitis and abscess. '8'T has a critical role

in the identi3cation of $56s, in the di7erentiation ofdeep nec0 abscesses from cellulitis, in delineation of

the in#ol#ed spaces, in the diagnosis of complications,and in chec0ing the e#olution of the infection.


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• A scalloped contour of the ring-enhancing, was recently pro#ed to behighly predicti#e of the presence of

pus ;positi#e predicti#e #alue *C,sensiti#ity /C, and speci3city +<

• !pen surgical incision and drainage

are considered the mainstay oftreatment for submandibular spaceabscesses and Ludwig4s angina


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• 6n patients with Ludwig4s angina, a moreaggressi#e approach is "usti3ed. Thesepatients are reported to be more at ris0 thanothers for ad#erse complications

• $ata showing that patients with diabetesmellitus and other comorbidities areparticularly susceptible to $56s and tend toha#e a higher rate of life-threatening

complications is con3rmed. particularattention should be paid to diabetics, and anearly surgical drainage should also beconsidered in apparently less se#ere cases.


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• Submandibular space infections are

potentially lethal infections. 'linicalstatus may 1uic0ly and une9pectedlyworsen.

•

Airway obstruction and spread ofinfection to the mediastinum are themost troublesome complications.

Therefore, the maintenance of asecure airway is paramount and anaggressi#e treatment is "usti3ed.


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• A surgical drainage should be performed inpatients with larger abscesses, Ludwig4s

angina, anterior #isceral space in#ol#ement,and in those who do not respond to antibiotictreatment.

• The clinical assessment in patients with

comorbidities, especially diabetes mellitus,re1uires a high le#el of suspicion for potentiallife-threatening complications. 8arly surgicaldrainage should always be considered, e#en in

seemingly less critical cases.


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