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An Otolaryngologic Perspective
Aaron R. Morrison, Nicole L. Bryan, MD ;
1 Garth T. Olson, MD ;
1 MD1

University of New Mexico Health Sciences Center


ƒ /XGZLJ¶VDQJLQDLVDVHULRXV ƒ /XGZLJ¶VDQJLQDZDVRULJLQDOO\GHVFULEHGE\ Of the 22 patients in this study, 7 (32%) received an ƒ A logical approach to the management of
infection in which airway Wilhelm Friedrich von Ludwig in 1836. The term awake tracheostomy, 4 (18%) were fiberoptically /XGZLJ¶VDQJLQDPXVWEHLQSODFHIRURSWLPDO
management is the first priority to angina was used to describe the sensation of intubated and then a tracheostomy was performed, outcomes (please see suggested algorithm in
prevent respiratory compromise. choking and suffocation patients often suffer 5 (23%) were fiberoptically intubated, and 6 (27%) Figure 2).
from with this infection. were observed without airway intervention.
ƒ There are four possible routes Therefore 11 (50%) of the patients in this sample ƒ ,QHDUO\/XGZLJ¶VDQJLQDREVHUYDWLRQLQD
of airway management in patients ƒ /XGZLJ¶VDQJLQDLVGHILQHGDVDVHYHUHDQG received a tracheostomy for airway control. monitored environment is safe and appropriate.
SUHVHQWLQJZLWK/XGZLJ¶V$QJLQD rapidly spreading cellulitis involving the following Average length of stay for patients receiving a
spaces: tracheostomy was 8.8 days versus 6.0 days for ƒ %HFDXVH/XGZLJ¶VDQJLQDFDQEHUDSLGO\
1) awake tracheostomy Ɠ submandibular space fiberoptically intubated patients and 3.3 days for progressing, a plan to establish a safe airway
2) fiberoptic intubation followed ƕ Superior border: mylohyoid muscle & inferior border of mandible patients who were observed (Figure 1). One must be in place throughout the hospital
ƕ Anterior border: anterior belly of digastric muscle
by tracheostomy ƕ Posterior border: posterior belly of digastric muscle patient who underwent tracheostomy was unable to course of conservatively treated patients.
3) fiberoptic intubation or ƕ Inferior border: hyoid bone be decannulated secondary to obstructive sleep
ƕ Superficial border: platysma muscle & investing layer of deep
4) airway observation without cervical fascia apnea and tracheomalacia. None of the patients in ƒ As the majority of patients will require
intubation. Ɠ sublingual space the observation group underwent additional invasive airway management, protocols should
ƕ Superior border: oral mucosa procedures during their hospital stay. All patients in be established with anesthesiology to facilitate
ƕ Inferior border: mylohyoid muscle
ƒ There is currently no widely a group in which airway intervention was performed rapid and safe airway management.
Ɠ submental space
accepted protocol to provide ƕ Superior border: deep cervical fascia, platysma muscle, underwent incision and drainage (I&D) and/or
guidance when managing a superficial cervical fascia, & skin dental extractions. Two patients in the awake
ƕ Deep border: mylohyoid muscle
ƕ Lateral borders: anterior bellies of the digastric muscles tracheostomy JURXSUHTXLUHGPXOWLSOH, '¶V CONCLUSIONS
the decision falls to the
experience and preference of the ƒ The precipitating cause of infection is ƒ There are clearly a small subset of patients
otolaryngologist, often in odontogenic in 85% of cases (Wasson). Other ZLWK/XGZLJ¶VDQJLQDLQZKRPREVHUYDWLRQLVD
conjunction with the causes include trauma, peritonsillar abscess, 9
safe and appropriate treatment algorithm
anesthesiologist. parapharyngeal abscess, epiglottitis, and 8
sialadenitis. 7

ƒ A review of the literature has 5
ƒ Our experience reflects that those who

found discussions from the point ƒ &RPPRQSUHVHQWLQJV\PSWRPVRI/XGZLJ¶V 4 present early in the course of the infection can
of view of the anesthesiologist, angina include: 3 safely be treated in a monitored setting.
but a review from the Ɠ odynophagia Ɠ dysphagia 2

otolaryngology community is Ɠ drooling Ɠ trismus 1

ƒ In our series, the majority of patients
lacking. Ɠ toothache Ɠ fever (16/22) required invasive airway management.
Ɠ induration of the entire floor of Observation Awake Fiberoptic
Intubation Tracheostomy
ƒ We reviewed 22 cases of mouth with tongue elevation ƒ The form of management depended upon
/XGZLJ¶VDQJLQDVHHQDWRXU Ɠ tender induration and erythema of the Airway Management the preference of the attending surgeon and
institution over the last 6 years anterior neck the comfort level of the anesthesiologist with
and evaluated the airway Figure 1: Length Of Hospital Stay fiberoptic airway intubation.
ƒ Tachypnea,stertor, increased work of
management strategy of each
breathing, and respiratory distress are late, and
patient. We present each ƒ Half of our patients required a tracheostomy
worrisome findings. Progression through the
strategy in the context of our as the final form of airway control.
above symptoms is rapid and complete airway
otolaryngologic patient
obstruction and death can occur within hours of
experience. ƒ Therefore, the possibility and preparation
for tracheostomy should be considered when
ƒ Due to the rapid progression and life- HYDOXDWLQJDQ\SDWLHQWZLWKVXVSHFWHG/XGZLJ¶V
threatening nature of airway obstruction, the angina.
overriding priority when evaluating a patient
VXVSHFWHGWRKDYH/XGZLJ¶VDQJLQDLVWKDWRI ƒ Tracheostomy as the final form of airway
airway management. control was associated with a longer

METHODS AND MATERIALS ƒ In our series, airway management with

observation and awake fiberoptic intubation,
A retrospective chart review was undertaken when appropriate, can result in a shorter
over a six year period at our institution. hospitalization.
deep neck infections were used to identify
patients to be included in the study. Each chart
CONTACT was reviewed for confirmation of the diagnosis ƒ Cummings: Otolaryngology: Head and Neck Surgery, 4th
and twenty-two patients were identified as having edition. 2005:2517.
UNM Health Sciences Center Ludwig?. The Journal of Laryngology and Otology 2006:
information, airway management strategy, length
Email: 120:363-365.
Phone: 505-272-6451 of hospital stay, surgeries performed, and ƒ Marple BF. Ludwig Angina, A Review of Current Airway
complications were gathered from the patient Management. Arch Otolaryngol Head Neck Surg/Vol 125,
charts. Figure 2: /XGZLJ¶V$QJLQD$LUZD\$OJRULWKP May 1999. Pg 596-598.