A 32-year-old man (Figure 28–1) presented to the emergency department (ED) 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 preceding 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 ED. 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.

Discuss the Incidence and Etiology of Deep Neck Infections in Adults

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 acute care providers, these present relatively infrequent. A typical ENT referral center may see only 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. Most patients are aged 40 to 60 and there is a predominance of males.¹ Many cases of deep neck infections do not have an identifiable etiology.² Diabetes mellitus may also be a risk factor and its presence tends to be associated with more aggressive infection.^3,4

Do All Deep Neck Infections Require Airway Intervention?

Most patients with deep neck infections can be managed conservatively without surgical intervention and do not require intervention to maintain the patient’s airway.^5,6 A conservative approach with antibiotics and depending on the etiology, steroids may be all that is required. Even epiglottitis in the adult population only rarely will require airway manipulation in the form of intubation or tracheotomy. The most common deep space neck infections seen in the ED are tonsillar or peritonsillar and usually represent a cellulitis that can be successfully treated with antibiotics alone. Small, localized abscesses, such as peritonsillar abscesses, are often treated with needle aspiration or incision and drainage, followed by antibiotics. Although patients may present with altered phonation and upper airway dyspnea, airway compromise is very rare. Postoperative neck infections may present acutely and can be associated with an airway distorting neck hematoma. The diagnosis is usually obvious clinically; however, CT allows further delineation of the pathology.

Interestingly, there has been a case report of an over-inflated King Laryngeal Tube mimicking Ludwig’s angina that actually resulted in a tracheotomy.⁷ With the increasing popularity of extra-glottic devices, airway practitioners should be aware of this potential problem.

There has also been a case report of a warfarin-induced sublingual hematoma mimicking Ludwig’s angina.⁸ Fortunately in this case there was no airway compromise and the patient was successfully managed by reversing the coagulopathy.

What Is Ludwig’s Angina?

This potentially 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.

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 patient with a history of jaw pain is the classic presentation. The infection may cause swelling of the tongue and epiglottis that will then impair the ability to swallow and clear secretions. Total airway obstruction may result from progressive swelling or from laryngospasm secondary to aspiration of pus secretions, or both.⁹ While most cases of deep neck infections can be managed conservatively with antibiotics alone, true cases of Ludwig’s angina typically require more aggressive intervention, including surgical drainage and definitive airway management. Treatment of Ludwig’s angina is three-pronged and involves: airway management, antibiotic therapy, and surgical drainage.

Why Might Airway Management be Difficult in Patients with Ludwig’s Angina?

Patients with Ludwig’s angina or a retropharyngeal abscess frequently have the potential to create difficulty with all aspects of airway management: bag-mask-ventilation (BMV), ventilation using extraglottic devices (e.g., LMA), laryngoscopy and tracheal intubation, and performing a surgical airway.

The oropharyngeal and sublingual swelling leads to displacement of the tongue. With progression, deep space infection may track and involve periglottic region. Stridor represents a late presentation with impeding airway collapse. BMV if required would be a challenge and necessitate high airway pressures to produce adequate gas flow. High-flow nasal oxygenation would be better tolerated and may bypass the obstructive oropharyngeal pathology. These patients are often dependent on position for airway patency and so maintaining an upright posture and avoiding sedation if possible is prudent. It may prove difficult or impossible to open the airway of the sedated or unconscious patient due to loss of muscle tone and the resultant further narrowing of the airway. Copious secretions may increase the risk of laryngospasm and tongue swelling may preclude use of an oral airway. A nasal airway is an option but bleeding could possibly trigger laryngospasm.

Upward displacement of the tongue by the infection can make insertion of any of the extraglottic rescue devices difficult or impossible. Although Brimacombe et al.¹⁰ reported the successful use of a small Laryngeal Mask Airway (#2) as a rescue device for a hypoxic adult patient with quinsy, extraglottic “rescue devices” for failed BMV may be ineffective due to glottic edema.

Secretions and edema, particularly tongue swelling, will make direct laryngoscopy more difficult regardless of the type of blade chosen. Nuchal rigidity, trismus, or both may be improved with sedation or muscle relaxants but there is no guarantee that these agents will be effective. Blind intubation techniques, such as the Intubating Laryngeal Mask Airway and lighted stylets (such as the Trachlight™, which sadly is no longer produced) would not generally be considered for first-line use in these patients as these techniques run the risk of disrupting infected tissue and potentially soiling the airway. Furthermore, these nonvisual intubating techniques could result in laryngospasm during the intubation attempt. Typically these patients have heavy secretions and occasionally some bleeding, limiting the use of indirect visual techniques such as the flexible and rigid fiberscopes and video-laryngoscopes. In true cases of Ludwig’s angina, oral intubation with any instrument is frequently not an option due to limited oral access. Most experts would advocate either a nasal intubation or a surgical approach.

Unfortunately, performing a surgical airway in this patient population is difficult. The anatomy is often distorted due to swelling and hyperemic tissues may increase the likelihood of bleeding. In some patients, the abscess may involve the area surrounding the trachea. Supine positioning of the patient to perform a surgical airway may worsen dyspnea and reduce the patient’s cooperation.

To add to the difficulty of airway management in these patients, all possible options of ventilation and oxygenation are fraught with danger. The ultimate decision will be made based on the urgency of the clinical circumstance, the available resources, the careful setting of priorities, and the skill and experience of the airway team (anesthesia practitioner and surgeon).

Discuss the Role of Diagnostic Imaging in Assessing These Patients

A lateral neck x-ray is often performed in these situations and may demonstrate submandibular and retropharyngeal edema but seldom provides enough information to direct management.

The advent of the CT scan has revolutionized the ability to accurately assess the swollen, inflamed neck. In addition to determining the severity of the infection involving different tissue planes and neck spaces, the resolution of the CT scan can help to differentiate between a cellulitis and an abscess. The CT scan can also determine the presence or absence of jugular vein thrombosis. Unfortunately, in the presence of a rapidly deteriorating airway, it will usually be necessary to proceed with emergency airway management before a CT examination of the neck becomes available. Even in patients with “stable” airways, a CT scan may not be possible prior to definitive airway management because the patient may be unable to lie flat. In these cases, the CT scan is done to better determine the extent of the infection only after securing an airway.

As technology and skills improve, some authors have suggested that bedside ultrasonography play more of a role in management of these patients.¹¹ This could potentially alleviate the problems of positioning associated with CT, and provide faster useful information.

Discuss the Technique of Nasopharyngoscopy and Its Role in the Management of Patients with Deep Neck Infections

Nasopharyngoscopy is a safe and simple technique which should become familiar to anesthesia practitioners, otolaryngologists, and emergency specialists. Following the application of topical vasoconstrictor and topical anesthetic (4% lidocaine), the flexible nasopharyngoscope is passed into the nasopharynx. The glottis should not be anesthetized as this could trigger laryngospasm. With the flexible nasopharyngoscope, the glottis can be viewed from above without the risk of provoking laryngospasm. The technique is usually first done in the ED as part of the initial evaluation, and repeated at the bedside or in the operating room as required to provide an ongoing evaluation of the airway. Serial nasopharyngoscopic assessments become particularly important if conservative airway management is decided upon.

How Was This Patient Assessed?

On examination, he appeared anxious and in severe discomfort. He was febrile with a temperature of 38.7°C. His respiratory rate was 26 breaths per minute. His heart rate was 104 beats per minute and his blood pressure was 132/76 mm Hg. His oxygen saturation was 91% on a non-rebreather face mask. He had a marked decrease in the range of motion of his neck. Significant swelling and erythema was observed extending from the right submandibular region, crossing the midline, and down the neck to include his left upper chest.

A lateral x-ray of the neck was remarkable for submandibular and retropharyngeal swelling along with a diminished airway caliber (Figure 28–2). Although potentially helpful, a CT scan was not done as it was felt that the patient could not tolerate lying flat, even for a short period of time.

Nasopharyngoscopy was performed in the ED by the ENT resident and revealed right lateral pharyngeal swelling and posterior displacement of the epiglottis obscuring the vocal cords.

How Do You Assess the Severity of Airway Obstruction?

Airway obstruction is assessed clinically by history and physical examination. Oxygen saturation, respiratory rate, stridor, tracheal tug, intercostal indrawing, and use of accessory muscles are assessed and changes are noted. Lateral x-ray (Figure 28–2) and CT scan of the head and neck can quantify the degree of obstruction. Skilled providers may also be able to assess airway obstruction with ultrasound. Nasopharyngoscopy is particularly useful in that it allows for a dynamic assessment of the obstruction. However, due to the risk of sudden deterioration in this patient with severe stridor, a clear airway management plan should be articulated with the team prior to proceeding with nasopharyngoscopy.

What Are the Indications for Establishing a Definitive Airway in Patients with Deep Neck Infections?