- Email: [email protected]
Use of soft tissue radiographs for assessing impending airway obstruction in head and neck infections: Report of cases
J Oral Maxillofac Surg 44: 398-401,1986
Use of Soft Tissue Radiographs for Assessing Impending Airway Obstruction in Head and Neck Infections: Report of Cases LEON A. ASSAEL, DMD,* AND LAURIER L. McCRAVY, DMDt
Airway obstruction as a consequence of odontogenic infection is a rare but devastating complication. I - 4 In evaluating the patient at risk for such obstruction, surgeons have generally looked for elevation of the floor of the mouth or swelling of the parenchyma of the tongue. While examination of this type is effective for one type of airway obstruction, it fails to consider several other potential mechanisms. Endotrachael edema, epiglottic edema, and pharyngeal wall abscess may all produce airway obstruction in the patient- with an odontogenic infection.v' and, a patient -may proceed rapidly to respiratory insufficiency with any of these conditions. Because it is often not possible to recognize such difficulties merely by clinical observation, the use of soft tissue radiographs can be helpful in ascertaining sites of potential airway obstruction, and thereby lead to early management of the problem. For patients with odontogenic infections involving the submandibular, sublingual, or lateral pharyngeal space, lateral and postero-anterior soft tissue radiographs are obtained routinely at our institution. In three recent cases, the radiographic findings proved to be helpful in the airway management of the patients.
liquids since the previous day. His history revealed a toothache of four days' duration. Three days prior to admission, pulpectomy on the lower left first molar had been performed by his family dentist. A regimen of oral penicillin, 500 mg every six hours, had then been started. Because of pain and swelling, the patient's oral intake had been minimal in the previous 24 hours. Physical examination on admission revealed a temperature of 38°C, blood pressure of 106/60 mm Hg, and pulse of 94 beatsl minute. A carious lower left first molar was observed, with gingival inflammation and marked mobility. The submandibular space was slightly edematous. Recent laboratory values were significant for a glucose level of 155 mg/dl, a hemoglobin level of 14.5 mg/dl, and a leukocyte count of II ,500/mm.3 There was a history of oliguria. The patient was admitted for rehydration, surgical management of the infection, and intravenous antibiotic therapy. He was taken to the Oral Surgery Clinic for intraoral incision and drainage and extraction of the offending tooth. Under block anesthesia with 2% lidocaine, an intraoral incision and drainage of the left sublingual and submandibular spaces were performed, yielding a small amount of thin, foul-smelling pus. The lower molar was extracted. Soft tissue radiographs obtained on the day of admission showed tracheal deviation and almost total obstruction of the trachea (Figs. I, 2). Epiglottic edema and tissue emphysema in the anterior neck were also observed. The mild airway obstruction that developed following the incision and drainage was relieved by oxygen administered via nasal mask. Because the soft tissue radiographs had determined the impending airway obstruction to be in the trachea, the patient was immediately prepared for tracheostomy. During preparation for the procedure, severe airway obstruction developed. The patient was supported briefly with positive pressure ventilation while tracheostomy under local anesthesia was quickly done. After the induction of general anesthesia, direct laryngoscopy confirmed the results of the soft tissue radiographs. Severe endotracheal edema in the cricothyroid region had completely obliterated the airway. In addition, there was some epiglottic and low lateral pharyngeal edema. The tongue was not significantly elevated, and the floor of the mouth was soft. There was no changes in the retropharyngeal wall. Extraoral incision and drainage were done to drain the submandibular and lateral pharyngeal spaces. Gram stain revealed mixed bacterial flora. Neisseria species, alpha streptococcus, Staphylococcus epidermidis, and Bacteroides melanlno-
Report of Cases
Case 1 A 53-year-old man was admitted to the Oral and Maxillofacial Service because of difficulty in swallowing
* Director, Department of Oral Surgery, Mount Sinai Services, City Hospital Center at Elmhurst; Director, Residency Training Programin Oral and Maxillofacial Surgery, Mount Sinai MedicalCenter, New York, New York. t Resident in Oral and Maxillofacial Surgery, Mount Sinai MedicalCenter, New York, New York. Address correspondence and reprint requests to Dr. Assael: Mount Sinai School of Medicine of the City University of New York, Department of Dentistry, Fifth Avenue and 100th Street, New York. NY 10029.
398
399
ASSAEL AND McCRAVY
FIGURE I (left). Posteroanterior soft tissue film of the neck showing severe tracheal deviation and obstruction (arrow). FIGURE 2 (right). Lateral view of the neck showing brawny edema. gas, and tracheal obstruction (arroll' ).
genicus were cultured from the pus. Initially, the patient received ampicillin, c1indamycin, and gentamicin. He rapidly improved in the 48 hours following incision and drainage. Drainage continued through the surgical sites for ten days, and the patient later had an uneventful recovery.
Case 2 A 60-year-old man presented to the Outpatient Oral Surgery Clinic at City Hospital Center at Elmhurst because of loose lower teeth. Clinical examination revealed grossly mobile mandibular incisors secondary to periodontal disease. The patient's medical history was significant for two myocardial infarctions in the past seven years, with current angina and hypertension. He was receiving hydrochlorothiazide, 50 mg daily, and nifedipine, 20 mg three times daily. After consultation with his physician, the teeth were uneventfully extracted under 2% lidocaine block anesthesia. Approximately three days after extraction, the patient returned to the clinic complairiing of the inability to eat or take medications because of difficulty in swallowing. Physical examination revealed brawny edema bilaterally in the submandibular, submental, and sublingual regions, with elevation of the tongue. There was no dyspnea. The patient's temperature was 38°C, blood pressure 115/80 mm Hg, pulse 85 beats/minute, and R 20. He was admitted for intravenous antibiotic therapy and incision and drainage. A regimen of 2,000,000 U of intravenous penicillin G every four hours was begun, and soft tissue radiographs were obtained. The radiographs were remarkable for a grossly enlarged epiglottis, and submandibular and submental emphysema. The retropharyngeal space
did not appear to be involved (Fig. 3). Shortly after the radiographs were taken, dyspnea was observed. Examination of the soft tissue radiographs revealed severe epiglottic edema. It was believed that endotracheal intubation would be difficult and could damage the infected epiglottis. Tracheostomy and incision and drainage were performed. Laryngoscopy revealed pronounced epiglottic edema. Drainage was accomplished by an incision in the submental and submandibular area, and dissection posteriorly and superiorly through the mylohyoid muscle. Copious foul-smelling pus was obtained. Gram stain revealed mixed bacterial flora. Culture produced alpha streptococcus, Hemophilus parainfluenzae, Enterobacter species, and Bacteriodes species. All were sensitive to penicillin. The patient tolerated the surgery well, and two days later he was afebrile. His further recovery was uneventful.
Case 3 A 13-month-old male infant was brought to the hospital by his mother because of a hard, tender swelling under the chin. The mother had first noticed the swelling 18 hours prior to admission. At that time, she stated that he had no fever and had full ability to swallow food. However, the swelling progressed, and the child began to have difficulty swallowing his saliva. Vital signs on admission were as follows: temperature, 38°C; pulse, 104 beats/ minute; and R, 30. Clinical examination revealed a bilateral firm, nonfluctuant swelling in the submandibular, submental and sublingual spaces, with noticeable elevation of the tongue. The primary mandibular incisors were erupted and free of caries. The salivary flow appeared clear and copious, with no evidence of obstruction.
400
AIRWAY OBSTRUCTION IN HEAD AND NECK INFECTION
FIGURE 3 (left). Lateral soft tis sue film showing marked epiglottic edema (arroll').
FIGURE 4 (right) . Lateral soft tissue film showing marked elevation of the tongue.
There was no evidence of dental infection or trauma either extraorally or intraorally. Results of the remainder of the physical examination were unremarkable . The child appeared to have a clear airway and was breathing without difficulty. No suprasternal retractions were evident. Admission laboratory values were sodium, 134 mmol/l; potassium, 5.6 mmol!l; chlorides"; 105 mmolJ1; blood urea nitrogen, 23 rng/dl; glucose, 103 mgldl; leukocyte count, 18,500!mm 3 ; RBS, 5.12; and hematocrit, 37.0%. Soft tissue films showed marked elevation of the tongue, obstructing most of the upper airway (Fig . 4). The patient was taken to the operating room for incision and drainage and possible tracheostomy. Because the impending airway obstruction was high, intubation was preferred over tracheostomy. This was accomplished via awake intubation. A 4-cm incision was then made in the submental and submandibular area and the submental, submandibular, and sublingual spaces were entered by blunt dissection. No purulence was found in the sublingual space; however, necrotic debris was present. Pus was evacuated from the submental and submandibular spaces. The area was drained with multiple Penrose drains. Gram stain revealed few gram-negative rods, a few gram-positive cocci in pairs and groups, and moderate numbers of leukocytes. Ampicillin and oxacillin, 220 mg every six hours, were administered. The cultured organism was Escherichia coli. The patient continued to improve and was discharged approximately nine days later with the infection resolved . No cause of the infection could be established.
Discussion
Airway obstruction may occur by enlargement of the lingual, parapharyngeal, or retropharyngeal spaces.v It may also be a consequence of epiglottic, endotracheal, or lower airway obstruction. Respiratory obstruction can occur rapidly or even abruptly, requiring that maintenance of the airway
be the prime concern of the surgeon. 1.7.8 Soft tissue radiographs have proved valuable in the management of airway obstruction associated with serious infections of the head and neck. Knowledge of the site of respiratory obstruction is essential if the airway is to be restored rapidly, effectively, and without complications. For example, airway obstruction limited solely to the upper airway, as in patient 3 (Fig. 4), may be managed by the initial placement of an oropharyngeal or nasopharyngeal airway, and subsequent endotracheal intubation: However, airway obstruction due to endotracheal edema is managed best by tracheostomy, as is obstruction due to epiglottic edema. Laryngoscopy prior to intubation would be difficult due to the displacement of the epiglottis, and attempted endotracheal intubation would also be difficult and might result in traumatic injury to the epiglottis and/or trachea. While some of the features of respiratory obstruction can be established by clinical examination, soft tissue radiographs do provide important additional information. Because of trismus from masticator space involvement or elevation of the tongue due to sublingual space involvement, direct visualization of the pharynx is difficult. Indirect laryngoscopy to visualize the epiglottis and endotracheal tissues can be even more problematic. The identification of areas of edema prior to clinical signs of airway obstruction is beneficial so that if obstruction occurs, the proper method for restoring adequate respiration can be used. For this reason, soft tissue radiographs have become an important part of our admission examination of patients with serious infections of the head and neck.
401
TAKEUCHI ET AL.
Summary
Three patients with airway obstruction subsequent to head and neck infection are presented, and the usefulness of soft tissue radiographs of the region in determining the location of the problem is discussed.
3. 4. 5. 6.
References 7. I. Schwartz H, Bauer R: Ludwig's angina: use of fiberoptic
laryngoscopy to avoid tracheostomy. J Oral Surg 32:608, 1974 2. Burke JR: Angina Ludovici, a translation together with a
8.
biography of Wilhelm Frederic K. von Ludwig. Bull Hist Med 7: 1115, 1939 Sinha SN: Acute epiglottis with Ludwig's angina. Eye, Ear, Nose, Throat Monthly 59:1973 Topazian R, Goldberg M: Management of Infection of the Oral and Maxillofacial Region. Philade1pha, WB Saunders, 1981, pp 211-217 Steinhauser P: Ludwig's angina: report of case in a 12 year old boy. J Oral Surg 25:251, 1967. Strauss H, Tilghman OM: Ludwig's angina, empyema, pulmonary infiltration and pericarditis secondary to extraction of a tooth. J Oral Surg 38:223, 1980 Meyers B. Lawson W. Hirschmann SZ: Ludwig's angina, case report, with review of bacteriology and current therapy. Am J Med 53:258, 1972 Chow A, Roser S: Orofacial odontogenic infections. Ann Intern Med 88:392, 1978
J Oral Maxillofac Surg 44: 401-403.1986
Life-threatening Sublingual Hematoma in a Severely Hemophilic Patient with Factor VIII Inhibitor M, TAKEUCHI, DDS, M. SHIKIMORI, DDS, AND T, KANEDA, DDS, PHD
Factor VIII inhibitor develops in about 15% of hemophilic patients who receive repeated courses of replacement therapy.t-? This inhibitor may render them unresponsive to conventional infusion with Factor VIII concentrates, and they cannot receive concentrates of Factor VIII without subsequent elevation of the titer of inhibitor. Activated prothrombin complex concentrates (APCCs) have recently been used for hemostasis in such patients.t-s Successful treatment of severe hemorrhage in hemophiliacs with Factor VIII inhibitor with APCC has not been described in the oral surgery literature. The present report describes the management of a patient with this condition in whom a marked hematoma of the sublingual region developed. Report of Case A 42-year-old hemophiliac with a Factor VIII activity level of less than 1% had received frequent replacement therapy for multiple bleeding episodes. During the pre-
Received from the Department of Oral Surgery, School of Medicine, Nagoya University, Japan. Address correspondence and reprint requests to Dr. Takeuchi: Department of Oral Surgery, Nagoya University School ofMedicine, 65 Tsuruma-cho, Showa-ku, Nagoya-shi, Japan.
ceding two years, he had been given 530,000 units of Factor VIII concentrate because of retroperitoneal bleeding and blood loss from the gastrointestinal tract. On November 7, 1981, he injured the sublingual region while eating; he received replacement therapy consisting of 2,000 units of concentrated Factor VIII preparation several times at a nearby hospital. However, the sublingual hematoma gradually enlarged. The patient was admitted to Nagoya University Hospital two days later because the swelling had expanded to involve the submandibular region. The inhibitor titer at that time was 64 Bethesda units.> An initial dose of 2,4000 units of Autoplex (40 U/kg) transiently produced a hemostatic effect, but the hematoma continued to enlarge, causing orthopnea. Administration of an additional 6,000 units (100 U1kg) was begun concurrently with transnasal insertion of an airway to ensure the patency of the respiratory tract. However, the bleeding progressed, occupying the oral cavity and causing respiratory insufficiency, resulting in shock (Figs. I, 2). Because of the extensive hematoma, both direct glottic exposure and tracheotomy were impossible. Therefore, a nasotracheal tube was threaded over the fiberoptic laryngoscope into the trachea. The administration of 1800 units of Autoplex was followed by 24oo-unit doses at six-hour intervals for three days, and then 1800unit doses at six-hour intervals for three additional days. The hematoma had diminished remarkably by the third day, and the nasotracheal tube was removed. The patient was discharged 34 days later. The results of the hemostatic studies performed before and 15 minutes after the administration of Autoplex (100
Use of Soft Tissue Radiographs for Assessing Impending Airway Obstruction in Head and Neck Infections: Report of Cases LEON A. ASSAEL, DMD,* AND LAURIER L. McCRAVY, DMDt
Airway obstruction as a consequence of odontogenic infection is a rare but devastating complication. I - 4 In evaluating the patient at risk for such obstruction, surgeons have generally looked for elevation of the floor of the mouth or swelling of the parenchyma of the tongue. While examination of this type is effective for one type of airway obstruction, it fails to consider several other potential mechanisms. Endotrachael edema, epiglottic edema, and pharyngeal wall abscess may all produce airway obstruction in the patient- with an odontogenic infection.v' and, a patient -may proceed rapidly to respiratory insufficiency with any of these conditions. Because it is often not possible to recognize such difficulties merely by clinical observation, the use of soft tissue radiographs can be helpful in ascertaining sites of potential airway obstruction, and thereby lead to early management of the problem. For patients with odontogenic infections involving the submandibular, sublingual, or lateral pharyngeal space, lateral and postero-anterior soft tissue radiographs are obtained routinely at our institution. In three recent cases, the radiographic findings proved to be helpful in the airway management of the patients.
liquids since the previous day. His history revealed a toothache of four days' duration. Three days prior to admission, pulpectomy on the lower left first molar had been performed by his family dentist. A regimen of oral penicillin, 500 mg every six hours, had then been started. Because of pain and swelling, the patient's oral intake had been minimal in the previous 24 hours. Physical examination on admission revealed a temperature of 38°C, blood pressure of 106/60 mm Hg, and pulse of 94 beatsl minute. A carious lower left first molar was observed, with gingival inflammation and marked mobility. The submandibular space was slightly edematous. Recent laboratory values were significant for a glucose level of 155 mg/dl, a hemoglobin level of 14.5 mg/dl, and a leukocyte count of II ,500/mm.3 There was a history of oliguria. The patient was admitted for rehydration, surgical management of the infection, and intravenous antibiotic therapy. He was taken to the Oral Surgery Clinic for intraoral incision and drainage and extraction of the offending tooth. Under block anesthesia with 2% lidocaine, an intraoral incision and drainage of the left sublingual and submandibular spaces were performed, yielding a small amount of thin, foul-smelling pus. The lower molar was extracted. Soft tissue radiographs obtained on the day of admission showed tracheal deviation and almost total obstruction of the trachea (Figs. I, 2). Epiglottic edema and tissue emphysema in the anterior neck were also observed. The mild airway obstruction that developed following the incision and drainage was relieved by oxygen administered via nasal mask. Because the soft tissue radiographs had determined the impending airway obstruction to be in the trachea, the patient was immediately prepared for tracheostomy. During preparation for the procedure, severe airway obstruction developed. The patient was supported briefly with positive pressure ventilation while tracheostomy under local anesthesia was quickly done. After the induction of general anesthesia, direct laryngoscopy confirmed the results of the soft tissue radiographs. Severe endotracheal edema in the cricothyroid region had completely obliterated the airway. In addition, there was some epiglottic and low lateral pharyngeal edema. The tongue was not significantly elevated, and the floor of the mouth was soft. There was no changes in the retropharyngeal wall. Extraoral incision and drainage were done to drain the submandibular and lateral pharyngeal spaces. Gram stain revealed mixed bacterial flora. Neisseria species, alpha streptococcus, Staphylococcus epidermidis, and Bacteroides melanlno-
Report of Cases
Case 1 A 53-year-old man was admitted to the Oral and Maxillofacial Service because of difficulty in swallowing
* Director, Department of Oral Surgery, Mount Sinai Services, City Hospital Center at Elmhurst; Director, Residency Training Programin Oral and Maxillofacial Surgery, Mount Sinai MedicalCenter, New York, New York. t Resident in Oral and Maxillofacial Surgery, Mount Sinai MedicalCenter, New York, New York. Address correspondence and reprint requests to Dr. Assael: Mount Sinai School of Medicine of the City University of New York, Department of Dentistry, Fifth Avenue and 100th Street, New York. NY 10029.
398
399
ASSAEL AND McCRAVY
FIGURE I (left). Posteroanterior soft tissue film of the neck showing severe tracheal deviation and obstruction (arrow). FIGURE 2 (right). Lateral view of the neck showing brawny edema. gas, and tracheal obstruction (arroll' ).
genicus were cultured from the pus. Initially, the patient received ampicillin, c1indamycin, and gentamicin. He rapidly improved in the 48 hours following incision and drainage. Drainage continued through the surgical sites for ten days, and the patient later had an uneventful recovery.
Case 2 A 60-year-old man presented to the Outpatient Oral Surgery Clinic at City Hospital Center at Elmhurst because of loose lower teeth. Clinical examination revealed grossly mobile mandibular incisors secondary to periodontal disease. The patient's medical history was significant for two myocardial infarctions in the past seven years, with current angina and hypertension. He was receiving hydrochlorothiazide, 50 mg daily, and nifedipine, 20 mg three times daily. After consultation with his physician, the teeth were uneventfully extracted under 2% lidocaine block anesthesia. Approximately three days after extraction, the patient returned to the clinic complairiing of the inability to eat or take medications because of difficulty in swallowing. Physical examination revealed brawny edema bilaterally in the submandibular, submental, and sublingual regions, with elevation of the tongue. There was no dyspnea. The patient's temperature was 38°C, blood pressure 115/80 mm Hg, pulse 85 beats/minute, and R 20. He was admitted for intravenous antibiotic therapy and incision and drainage. A regimen of 2,000,000 U of intravenous penicillin G every four hours was begun, and soft tissue radiographs were obtained. The radiographs were remarkable for a grossly enlarged epiglottis, and submandibular and submental emphysema. The retropharyngeal space
did not appear to be involved (Fig. 3). Shortly after the radiographs were taken, dyspnea was observed. Examination of the soft tissue radiographs revealed severe epiglottic edema. It was believed that endotracheal intubation would be difficult and could damage the infected epiglottis. Tracheostomy and incision and drainage were performed. Laryngoscopy revealed pronounced epiglottic edema. Drainage was accomplished by an incision in the submental and submandibular area, and dissection posteriorly and superiorly through the mylohyoid muscle. Copious foul-smelling pus was obtained. Gram stain revealed mixed bacterial flora. Culture produced alpha streptococcus, Hemophilus parainfluenzae, Enterobacter species, and Bacteriodes species. All were sensitive to penicillin. The patient tolerated the surgery well, and two days later he was afebrile. His further recovery was uneventful.
Case 3 A 13-month-old male infant was brought to the hospital by his mother because of a hard, tender swelling under the chin. The mother had first noticed the swelling 18 hours prior to admission. At that time, she stated that he had no fever and had full ability to swallow food. However, the swelling progressed, and the child began to have difficulty swallowing his saliva. Vital signs on admission were as follows: temperature, 38°C; pulse, 104 beats/ minute; and R, 30. Clinical examination revealed a bilateral firm, nonfluctuant swelling in the submandibular, submental and sublingual spaces, with noticeable elevation of the tongue. The primary mandibular incisors were erupted and free of caries. The salivary flow appeared clear and copious, with no evidence of obstruction.
400
AIRWAY OBSTRUCTION IN HEAD AND NECK INFECTION
FIGURE 3 (left). Lateral soft tis sue film showing marked epiglottic edema (arroll').
FIGURE 4 (right) . Lateral soft tissue film showing marked elevation of the tongue.
There was no evidence of dental infection or trauma either extraorally or intraorally. Results of the remainder of the physical examination were unremarkable . The child appeared to have a clear airway and was breathing without difficulty. No suprasternal retractions were evident. Admission laboratory values were sodium, 134 mmol/l; potassium, 5.6 mmol!l; chlorides"; 105 mmolJ1; blood urea nitrogen, 23 rng/dl; glucose, 103 mgldl; leukocyte count, 18,500!mm 3 ; RBS, 5.12; and hematocrit, 37.0%. Soft tissue films showed marked elevation of the tongue, obstructing most of the upper airway (Fig . 4). The patient was taken to the operating room for incision and drainage and possible tracheostomy. Because the impending airway obstruction was high, intubation was preferred over tracheostomy. This was accomplished via awake intubation. A 4-cm incision was then made in the submental and submandibular area and the submental, submandibular, and sublingual spaces were entered by blunt dissection. No purulence was found in the sublingual space; however, necrotic debris was present. Pus was evacuated from the submental and submandibular spaces. The area was drained with multiple Penrose drains. Gram stain revealed few gram-negative rods, a few gram-positive cocci in pairs and groups, and moderate numbers of leukocytes. Ampicillin and oxacillin, 220 mg every six hours, were administered. The cultured organism was Escherichia coli. The patient continued to improve and was discharged approximately nine days later with the infection resolved . No cause of the infection could be established.
Discussion
Airway obstruction may occur by enlargement of the lingual, parapharyngeal, or retropharyngeal spaces.v It may also be a consequence of epiglottic, endotracheal, or lower airway obstruction. Respiratory obstruction can occur rapidly or even abruptly, requiring that maintenance of the airway
be the prime concern of the surgeon. 1.7.8 Soft tissue radiographs have proved valuable in the management of airway obstruction associated with serious infections of the head and neck. Knowledge of the site of respiratory obstruction is essential if the airway is to be restored rapidly, effectively, and without complications. For example, airway obstruction limited solely to the upper airway, as in patient 3 (Fig. 4), may be managed by the initial placement of an oropharyngeal or nasopharyngeal airway, and subsequent endotracheal intubation: However, airway obstruction due to endotracheal edema is managed best by tracheostomy, as is obstruction due to epiglottic edema. Laryngoscopy prior to intubation would be difficult due to the displacement of the epiglottis, and attempted endotracheal intubation would also be difficult and might result in traumatic injury to the epiglottis and/or trachea. While some of the features of respiratory obstruction can be established by clinical examination, soft tissue radiographs do provide important additional information. Because of trismus from masticator space involvement or elevation of the tongue due to sublingual space involvement, direct visualization of the pharynx is difficult. Indirect laryngoscopy to visualize the epiglottis and endotracheal tissues can be even more problematic. The identification of areas of edema prior to clinical signs of airway obstruction is beneficial so that if obstruction occurs, the proper method for restoring adequate respiration can be used. For this reason, soft tissue radiographs have become an important part of our admission examination of patients with serious infections of the head and neck.
401
TAKEUCHI ET AL.
Summary
Three patients with airway obstruction subsequent to head and neck infection are presented, and the usefulness of soft tissue radiographs of the region in determining the location of the problem is discussed.
3. 4. 5. 6.
References 7. I. Schwartz H, Bauer R: Ludwig's angina: use of fiberoptic
laryngoscopy to avoid tracheostomy. J Oral Surg 32:608, 1974 2. Burke JR: Angina Ludovici, a translation together with a
8.
biography of Wilhelm Frederic K. von Ludwig. Bull Hist Med 7: 1115, 1939 Sinha SN: Acute epiglottis with Ludwig's angina. Eye, Ear, Nose, Throat Monthly 59:1973 Topazian R, Goldberg M: Management of Infection of the Oral and Maxillofacial Region. Philade1pha, WB Saunders, 1981, pp 211-217 Steinhauser P: Ludwig's angina: report of case in a 12 year old boy. J Oral Surg 25:251, 1967. Strauss H, Tilghman OM: Ludwig's angina, empyema, pulmonary infiltration and pericarditis secondary to extraction of a tooth. J Oral Surg 38:223, 1980 Meyers B. Lawson W. Hirschmann SZ: Ludwig's angina, case report, with review of bacteriology and current therapy. Am J Med 53:258, 1972 Chow A, Roser S: Orofacial odontogenic infections. Ann Intern Med 88:392, 1978
J Oral Maxillofac Surg 44: 401-403.1986
Life-threatening Sublingual Hematoma in a Severely Hemophilic Patient with Factor VIII Inhibitor M, TAKEUCHI, DDS, M. SHIKIMORI, DDS, AND T, KANEDA, DDS, PHD
Factor VIII inhibitor develops in about 15% of hemophilic patients who receive repeated courses of replacement therapy.t-? This inhibitor may render them unresponsive to conventional infusion with Factor VIII concentrates, and they cannot receive concentrates of Factor VIII without subsequent elevation of the titer of inhibitor. Activated prothrombin complex concentrates (APCCs) have recently been used for hemostasis in such patients.t-s Successful treatment of severe hemorrhage in hemophiliacs with Factor VIII inhibitor with APCC has not been described in the oral surgery literature. The present report describes the management of a patient with this condition in whom a marked hematoma of the sublingual region developed. Report of Case A 42-year-old hemophiliac with a Factor VIII activity level of less than 1% had received frequent replacement therapy for multiple bleeding episodes. During the pre-
Received from the Department of Oral Surgery, School of Medicine, Nagoya University, Japan. Address correspondence and reprint requests to Dr. Takeuchi: Department of Oral Surgery, Nagoya University School ofMedicine, 65 Tsuruma-cho, Showa-ku, Nagoya-shi, Japan.
ceding two years, he had been given 530,000 units of Factor VIII concentrate because of retroperitoneal bleeding and blood loss from the gastrointestinal tract. On November 7, 1981, he injured the sublingual region while eating; he received replacement therapy consisting of 2,000 units of concentrated Factor VIII preparation several times at a nearby hospital. However, the sublingual hematoma gradually enlarged. The patient was admitted to Nagoya University Hospital two days later because the swelling had expanded to involve the submandibular region. The inhibitor titer at that time was 64 Bethesda units.> An initial dose of 2,4000 units of Autoplex (40 U/kg) transiently produced a hemostatic effect, but the hematoma continued to enlarge, causing orthopnea. Administration of an additional 6,000 units (100 U1kg) was begun concurrently with transnasal insertion of an airway to ensure the patency of the respiratory tract. However, the bleeding progressed, occupying the oral cavity and causing respiratory insufficiency, resulting in shock (Figs. I, 2). Because of the extensive hematoma, both direct glottic exposure and tracheotomy were impossible. Therefore, a nasotracheal tube was threaded over the fiberoptic laryngoscope into the trachea. The administration of 1800 units of Autoplex was followed by 24oo-unit doses at six-hour intervals for three days, and then 1800unit doses at six-hour intervals for three additional days. The hematoma had diminished remarkably by the third day, and the nasotracheal tube was removed. The patient was discharged 34 days later. The results of the hemostatic studies performed before and 15 minutes after the administration of Autoplex (100