Table Demonstration Poster Board Instructions

• This template will help you design your presentation for the Table Demonstration, which we will create for each project. Your board will be 44” x 28” and placed on a tripod. When you arrive to present on Sunday, November 28th, 2010 at the Javits Center, please locate your board in the Table Demonstration Area.

• The first slide will be the Title of your presentation with your name, co-presenters names (if applicable) and school or hospital affiliation. Please include your school logo or hospital logo if available.

• Each slide you create will be a section on the board. Please keep it to a maximum of 8 slides. Please insert all your text and photos.

• Once the completed PowerPoint presentation is received, you will be emailed the final proof for your approval.

• Each presentation must be received by September 15, 2010.

• Only one board per presentation will be accepted. NO material submitted after September 15 will be accepted for the 2010 program.

This Poster Board is a sample of what yourproject will look like once we have created it.

Please contact Ms. Kersing Yam at 212.398.6922 or email

Kersing@gnydm.com if you have anyquestions.

Ludwigs Angina: Case report and management

David R. Telles, DDS

Ghazal Mahjoubi, DMD

Earl Clarkson, DDS (attending)

Antonio Chua, MD (General Surgery)

Woodhull Medical Center

Management of Orofacial Infection

• Eight steps :– Determine the severity of

infection.– Evaluate host defenses.– Decide on the setting of care.– Treat surgically.– Support medically.– Choose and prescribe antibiotic therapy.– Administer the antibiotic properly.– Evaluate the patient frequently

Species of Bacteria responsible for Odontogenic infection

Organism Percent

Aerobic 25%

Gram positive cocci 85%

Strep sp. 90 %

Strep. (group D) spp. 2 %

Staphylococcus spp. 6 %

Eikenella 2 %

Gram-negative cocci (Neisseria spp.) 2 %

Gram-positive rods (Cornyebacterium spp.) 3 %

Gram-negative rods (Haemophilus spp.) 6 %

Misc. 4 %

Anaerobic 75 %

Gram-positive cocci 30 %

Streptococcus spp. 33 %

Peptostreptococcus spp. 33 %

Peptococcus 33 %

Gram-negative cocci (Veillonella spp.) 4 %

Gram-positive rods 14 %

Eubacterium spp.

Lactobacillus spp.

Actinomyces spp.

Clostridia spp.

Gram-negative rods 50 %

Bacteroides spp. 75 %

Fusobacterium spp. 25 %

Misc 6 %

Microbial Incidence for Orofacial infection

Incidence of microbial isolate in Woodhull vs. gen. population

Woodhull General

Streptococcus 53.12% 76.5 %

Staphylococcus: 25% 1.275 %

Other: 21.88% ------

Haemophilus spp. 3.125 % 1.5%

Peptostreptococcus 3.125 % 24.75%

Fusiform spp. 3.125% 9.375 %

No Growth (from Flynn) 18 % 8%

Anaerobic ---- 75%

Aerobic ---- 25%

Table from Telles et. al. 2009 and Flynn et. al. 2006

Case report

• CC: “I was seen by a general dentist 3 days ago for tooth pain and given an antibiotic”

• HPI: 20 yo M with pain associated with lower wisdom tooth approximately 1 week. Pt presented to ER with severe pain, difficulty talking, diaphoretic. Pt stated that since he started the antibiotic and since then infection has been getting worse.

• Vitals: Pulse: 120, BP: 140/95, Temp: 101.5 F • Labs: WBC – 17.3• Meds: PenVK 500 mg, Ibuprofen• NKDA• SocHx: + tobacco use 5 pack yr Hx, denies drugs/alcohol

Case Report• PE

– Severe trismus MIO 10 mm– Bilateral submandibular edema and submental edema– Gross caries # 17– Tenderness to palpation submental region down to anterior neck to

superior aspect of sternum– Uvula deviated to the right

• Assessment: – Ludwigs Angina involving the submental space, L

sublingual/L pterygomandibular/L lateral pharyngeal spaces with air emphysematous changes noted throughout anterior neck indicative of rapidly progressive infection by gas producing anaerobe

Case report

• Radiology

• Cultures

Clinical Case

• Hospital Course– Day 1: Pt admitted and received awake tracheostomy

• Then Incision and drainage performed of L submandibular, submental and L lateral pharyngeal/L lateral pterygoid spaces

• Pt placed on XXXX Antibiotic for XXX days

• Pt received daily irrigation of wounds of the affected spaces bid

– Day 7: Pt received exploration of L lateral pharyngeal space due to persistent leukocytosis and abscess noted on new neck soft tissue CT

– At Day 20 patient was discharged after having tracheostomy placed on fenestrated trach

Ludwigs Angina• Condition exhibiting bilateral swelling of the submental, sublingual, and

submandibular spaces. • Characterized by extreme hardness of the floor of the mouth, "brawny",

"indurated" swelling (no give or fluctuation due to pus formation) of the neck centering about the floor of the mouth and by the ensuing elevation of the mucosa of the mouth and tongue.

• Interstitial spaces are filled with fluid. • Infection may eventually extend to the lateral pharyngeal space and

enter the retropharyngeal space and even descend to the mediastinum. • Death from Ludwig's angina occurs as a result of suffocation due to

edema of the mouth, tongue, and the glottis, from mediastinitis due to spread, or from septicemia or pneumonia

• Trismus – a significant result of infection involving the masticator spaces• Extraction of a lower molar tooth and subsequent infection precedes

Ludwig's angina in a majority of cases. • Roots of the second and third molar teeth reach downward to the

level of the attachment of the mylohyoid muscle and typically below it– most first molar teeth are located above this level

Potential spread of orofacial infection

Conclusions

• Trismus is a significant finding in orofacial infection – most likely involving the masticator space

– Indicates infections spreading posteriorly

• Spread of infection is based on location, spaces involved, co-morbidities/host, effectiveness of antibiotic

• For severe orofacial infection – always consider referral to OMFS/Hospital for Incision/drainage with admission for IV Antibiotics

• Empirical Antibiotics for severe orofacial infection is Clindamycin 300 mg qid x 7d

– Always C&S studies should be followed and Antibiotics adjusted based on sensitivity results

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