The document describes a male patient's visit to the emergency department with spontaneous bleeding from the sublingual region. His medical history includes recurrent untreated toothaches. On examination, he had swelling of the neck and submandibular region. Imaging showed an abscess extending from the sublingual space to the parapharyngeal space. He was diagnosed with Ludwig's angina and treated with antibiotics, electrolyte management, and extraction of infected teeth.
The document describes a male patient's visit to the emergency department with spontaneous bleeding from the sublingual region. His medical history includes recurrent untreated toothaches. On examination, he had swelling of the neck and submandibular region. Imaging showed an abscess extending from the sublingual space to the parapharyngeal space. He was diagnosed with Ludwig's angina and treated with antibiotics, electrolyte management, and extraction of infected teeth.
The document describes a male patient's visit to the emergency department with spontaneous bleeding from the sublingual region. His medical history includes recurrent untreated toothaches. On examination, he had swelling of the neck and submandibular region. Imaging showed an abscess extending from the sublingual space to the parapharyngeal space. He was diagnosed with Ludwig's angina and treated with antibiotics, electrolyte management, and extraction of infected teeth.
The document describes a male patient's visit to the emergency department with spontaneous bleeding from the sublingual region. His medical history includes recurrent untreated toothaches. On examination, he had swelling of the neck and submandibular region. Imaging showed an abscess extending from the sublingual space to the parapharyngeal space. He was diagnosed with Ludwig's angina and treated with antibiotics, electrolyte management, and extraction of infected teeth.
Chief Complaint: Spontaneous bleeding from sublingual region since 3 hours prior to admission Medical History
1 day 4 days - Fever - Hard to open - Swollen on right mouth gum extended to - Hot potato voice left neck
Admission day 2 day - Spontaneous bleeding from - Worsening of the sublingual swollen neck, pain - Brought to nearest clinic VAS 5 Referred to CMGH due to lack of facility Medical History
No difficulty of breathing. Only able to swallow porridge since 1 day, no cough & choking while eating. No other ENT complaint.
History of recurrent untreated tootache.
History of amoxicillin allergy. History of DM, Hypertension were denied. Physical Examination
General condition: There were no dyspnea, stridor, nor
Moderately ill retraction
Vital sign: • BP: 140/70mmHg • RR: 24x/min • T: 37 C • HR: 120x/min • O2 Sat: 98% on room air ENT Examination ENT Examination Right & Left: EAR Right & Left: Trismus (+) 3 cm,
NOSE
THROAT active bleeding (-), Wide ear canal, no Wide nasal cavity, minimal clotting discharge, no inferior turbinate formation in cerumen, intact eutrophy, no septum sublingual tympanic membrane deviation (+),elevated tongue (+) pharyngeal arch was symmetric and not hyperemic, uvula in the middle, other structure were hard to evaluate
6 ENT Examination
Colli Region: • Visible edema from submental to submandible region of neck 15x5x3cm, angle of mandible not palpated, hyperemic, hard consistency, fluctuation (-), tenderness (+). • Aspiration: blood (+), pus (-) Flexible Laryngoscope
Wide nasal cavity, discharge (-),
euthrophic inferior turbinate, deviated septum (-), post nasal drip (-), oedema epiglottis and arythenoid, vocal & ventricular fold movement were symmetric in static & dynamic phase, glottic rim was open, standing secretion in bilateral pyriform sinus, post cricoid and vallecula, penetration (+), aspiration (-) Hb : 16.1 gr/dL CRP : 253.4 Ht : 46.6 % Procalcitonin : 0.34 Platelet : 335.000 Neutrofil count : 14.06 ↑ WBC : 17.390 ↑ Limfosit count : 1.63 Glucose : 286 ↑ NLCR : 8.63 ↑ Sodium : 129 ↓ HBsAg : non reactive Potassium : 3.9 Anti HCV : non reactive Laboratory Chloride : 94.6 ↓ Examination SGOT : 15 SGPT : 18 CMER Ur : 19.6 SARS CoV2 (January 17th Cr : 0.60 IgM antibody: NR PT : 10.9 (11.3) IgG antibody: NR 2021) APTT : 29.6 (32.6) RT-PCR: Negative Keton : 3.1 ↑
Blood Gas Analysis
pH 7.335 ↓ / pCO2 22.90 ↓ / pO2 108.70 ↑ / HCO3 12.30 ↓ / Total CO2 13.00 ↓ / BE -10.80 ↓ / O2 sat 97.90 / Stand HCO3 16.1 ↓ / Stand BE -13.7 ↓ Thorax X-Ray CMER (January 17th 2021)
- No radiological abnormality of heart and lung - Soft tissue swelling on bilateral colli region visualized Cervical Soft Tissue X-Ray CMER (Jan 17th, 2021)
- Soft tissue swelling on bilateral
colli region, from submandible extending to 6th cervical vertebrae level - No narrowing of upper airway visualized Working Diagnosis WORKING DIAGNOSIS Ludwig’s Angina with Parapharyngeal infiltrate (K12.2) Periodontitis (K05.6) Hyperglicemia (R73.9)
Electrolyte Imbalance (E87.8)
Management Report to Arie Cahyono, MD, ORL-HNS: • Liquid diet per NGT
• Agreed for hospitalization • Consult to Internal Medicine Department
for evaluation & management of • Trendelenburg position hyperglycemia, tolerance for IV • Neck MSCT Scan with contrast Methylprednisolone 1x125mg (once) • IV Ceftriaxone 1x2g • Consult to Oral Surgery Department for • IV Metronidazole 3x500mg evaluation & management of source of
• IV Ranitidin 2x50mg infection
• Paracetamol 3x1000mg / NGT
Internal Medicine Department Assessment WORKING DIAGNOSIS Assesment Planning • Ludwig’s Angina due to periodontitis 48, 35 • Daily blood glucose curve observation, • Diabetic ketosis dd/ acute reactive Hba1c hyperglycemia • IVFD NaCl 0.9% 500ml/8 hrs • Hyponatremia with hypoosmolarity • Diet DM 1700kcal/day • Insulin drip 0.5 iu/hr • SC Novorapid 3x5 iu • Methylprednisolone dosage according to ENT Department Oral Surgery Department Assessment WORKING DIAGNOSIS Assesment Planning • Ludwig’s Angina due to periodontitis 48, 35 • Observation of general condition and • Hyperglycemia suspicious of Diabetes vital signs Mellitus • Planned for source of infection control • Electrolyte Imbalance 48, 35 teeth extraction (join with ENT Department) • Minosep gargle 2x10ml • Other management according to ENT & Internal Medicine Department Neck CT Scan with contrast CMER January 17th, 2021
- Abscess in bilateral sublingual region, with extention to bilateral sublingual space mainly on left side, parapharyngeal space, adjacent to bilateral digastric muscle, with sublingual to left perirtonsiller region inflammation which mildly narrowed the oropharyngeal lumen - Multiple enlarged lymph node in bilateral colli region, the biggest in level II left colli region, short axis was 1.6 cm Larynx Pharynx Division Follow Up (Jan 18th, 2020)
S: A: Pain on the swollen neck (VAS 3), hard to open mouth - Sublingual abscess extended to parapharyngeal space due to periodontitis 48, 35 O: - Diabetic ketosis dd/ acute reactive hyperglycemia Conscious, dyspneu(-), retraction(-), stridor (-) - Hyponatremia with hypoosmolarity BP: 140/100, HR: 137, RR: 24, T: 36,5, O2 sat: 98% on nasal canule 3 lpm P: - Sublingual aspiration pus found Trismus (+) + 3cm - IV Ceftriaxone 1x2000 mg Submandible & submental: - IV Metronidazole 3x500mg Oedema, hyperemic, tenderness, fluctuative (-), elevated - IV Ranitidine 2x50 mg tongue (+) - Paracetamol 3x1000 mg / NGT - DKA protocol management - Minosep gargle 2x10ml Sublingual Aspiration (Jan 18th, 2020)
• Aspiration + 5ml of pus sent for culture &
antibiotics sensitivity • Culture & antibiotics sensitivity result not finished yet Larynx Pharynx Division Follow Up (Jan 19th, 2020) S: A: Pain on the swollen neck (VAS 3), hard to open - Sublingual abscess extended to parapharyngeal space due to mouth periodontitis 48, 35 - Diabetic ketosis dd/ acute reactive hyperglycemia O: - Hyponatremia with hypoosmolarity Conscious, dyspneu(-), retraction(-), stridor (-) BP: 140/100, HR: 137, RR: 24, T: 36,5, O2 sat: 98% P: on nasal canule 3 lpm - Planned for abscess incision & exploration Trismus (+) + 3cm - Consult to internal medicine & anesthesiology for surgery Submandible & submental: tolerance Oedema, hyperemic, tenderness, fluctuative (-) - IV Meropenem 3x1000 mg - IV Ranitidin 2x50 mg - Paracetamol 3x1000 mg / NGT - DKA protocol management - Minosep gargle 2x10ml Preoperative Assessment WORKING DIAGNOSIS Internal Medicine Dept. Anesthesiology Dept. - Diabetic ketoacidosis on protocol • Informed consent - Ludwig’s Angina due to periodontitis • Planned for GA - Hyponatremia resolved • Post op: Back up ICU • Fasting 6 hours prior to surgery • Cardiology : moderate tolerance • Diabetic Ketoacidosis management according • Pulmonology: mild tolerance to Internal Medicine Department (Blood • Hematology: mild tolerance Glucose target < 200) • Endocrine: moderate tolerance • PINERE: Non Covid
Report to Arie Cahyono, MD, ORL-HNS surgical intervention
postponed until DKA is resolved Larynx Pharynx Division Follow Up (Jan 20th, 2020)
S: A: Adequate contact, pain on swollen neck (VAS 3) - Sublingual abscess extended to parapharyngeal space due to periodontitis 48, 35 O: Conscious, dyspneu(-), retraction(-), stridor (-) - Diabetic ketosis (improved) BP: 120/80, HR: 92, RR: 20, T: 36,5, O2 sat: 98% on - Hyponatremia resolved nasal canule 3 lpm P: Trismus (+) + 3cm - Planned for abscess incision & exploration today Submandible & submental: Oedema, hyperemic, tenderness, fluctuative in -- IV Meropenem 3x1000 mg submental region - IV Ranitidin 2x50 mg - Paracetamol 3x1000 mg / NGT - DKA protocol management - Minosep gargle 2x10ml Abscess Incision & Exploration (Jan 20th, 2020)
- Nasal intubation using FOB
- Extraction of teeth 38, 35, 48 - Incision in left submandible, blunt dissection was done pus (-) - Incision in submental + 20cc bloody pus was found sent for culture - Left peritonsillar aspiration pus (-) - Bilateral sublingual aspiration parallel to 2nd premolar pus (-) - Irrigation using H2O2, Saline, Povidone Iodine - Penrose drains were inserted in left submandible & submental Larynx Pharynx Division Follow Up (Jan 21st, 2020)
S: A: Adequate contact, pain after surgery (VAS 2) - Post exploration of sublingual et submental abcess with parapharyngeal infiltrate day-1 due to O: periodontitis 35, 38, 48 Conscious, dyspneu(-), retraction(-), stridor (-) BP: 122/89, HR: 81, RR: 18, T: 36,5, O2 sat: - Diabetic ketoacidosis (improved) 100% on nasal canule 3 lpm - Hyponatremia resolved
Trismus (-) P: Submandible & submental: Wound care penrose drain (+), pus (-), active bleeding (-) IV Meropenem 3x1000 mg iv IV Tranexamic acid 3x500 mg IV Ranitidin 2x50 mg IV Paracetamol 3x1000 mg THANK YOU
