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A 32-year-old man (Figure 26-1) presented to the emergency department with dysphagia, dysphonia, and dyspnea. Further inquiry revealed a 1-week history of right-sided jaw pain. This was initially treated with oral antibiotics and analgesics by his family doctor while awaiting an appointment with his dentist. He saw his dentist the previous day and had an abscessed molar tooth extracted from his right mandible. Unfortunately, his pain continued and he developed swelling and fever, prompting him to present to the emergency department. His past medical history was unremarkable, and aside from his remaining prescription of the penicillin and hydromorphone, he was on no medications. He had no known allergies.
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26.2.1 Discuss the Incidence and Etiology of Deep-Neck Infections in Adults
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The management of the patient whose airway is compromised due to a deep-neck infection is a challenge for even the most experienced practitioner. Fortunately for all, these are relatively rare. A typical ENT referral center may see one to three adult cases per year requiring airway management. As in this case, the deep-neck infection is often odontogenic. Intravenous drug abuse is another important cause. However, many cases of deep-neck infections do not have an identifiable etiology.1 Diabetes mellitus may also be a risk factor and its presence tends to be associated with more aggressive infection.2,3
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26.2.2 Do All Deep-Neck Infections Require Airway Intervention?
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Most patients with deep-neck infections can be managed conservatively without surgical intervention and do not require intervention to maintain the patient's airway.4,5 This conservative approach is similar to the management of adenotonsillar hypertrophy secondary to infectious mononucleosis, which will typically respond to steroids with or without antibiotics. Even epiglottitis in the adult population only rarely will require airway manipulation in the form of intubation or tracheotomy. Early deep-neck infections present usually as a cellulitis that can be successfully treated with antibiotics alone. Small, localized abscesses, such as peritonsillar abscesses, can often be treated with needle aspiration followed by antibiotics.
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26.2.3 What Is Ludwig's Angina and How Does It Differ from Retropharyngeal Abscess?
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This life-threatening infection of the floor of the mouth was first described in 1836 by Wilhelm Frederick von Ludwig. The condition has also been called "morbus strangulatorius", "angina maligna", and "garotillo" (Spanish for "hangman's loop"). These older terms reflect the high mortality, typically by total airway obstruction, in the days before antibiotics.
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Ludwig's angina is defined as severe bilateral cellulitis and edema of the submandibular and sublingual spaces. Woody swelling of the submandibular area in a febrile ...