Pus in the neck[md]Ludwig's angina

You may see these acute suppurative infections in a patient's neck:

(1) Suppuration in a lymph node, especially a deep cervical one, is common in children, and is much like suppuration in any other lymph node.

(2) Suppuration arising from an infected tooth (Ludwig's angina) occurs in children and adults. It is a severe bilateral brawny cellulitis of the sublingual and submandibular regions, and may extend as far as the patient's clavicles. It usually starts as a dental abscess in his mandible, which makes him febrile and very ill. If Ludwig's angina is neglected, it may obstruct his respiration by causing oedema of his glottis, and by pushing his tongue up against the roof of his mouth. Anaerobes and spirochaetes may be responsible. He can also die from septicaemia. He needs intensive antibiotic treatment urgently, and drainage to decompress the tissues at the floor of his mouth.

Fig 5-8 LUDWIG'S ANGINA. A, note the massive swelling of the patient's chin. B, his swollen tissues have compressed his tongue against his palate. The infection may spread to cause oedema of his glottis. Partly after ''Hamilton Bailey's Emergency Surgery', edited by HAF Dudley HAF, Figs. 153 and 154, John Wright, with kind permission.

LUDWIG'S ANGINA For the general method, see Section 5.2. This is an acute emergency: admit the patient, and give him high doses of antibiotics (2.7). He needs a megaunit of penicillin 4 to 6- hourly, metronidazole and chloramphenicol (2.9).

If his breathing is not significantly obstructed, you may be wiser to wait for 24 hours for the antibiotics to act and the oedema to subside a little, before you drain his lesion.

If it is significantly obstructed, you may be forced to do a tracheostomy (unusual, 52.2). This is difficult, because the tissues of his neck are firm and oedematous.

ANAESTHESIA. (1) Ketamine is acceptable, unless his airway is almost totally obstructed. (2) Don't give him an inhalation anaesthetic. He probably needs the help of his voluntary muscles to maintian his airway, and you will be unable to pass a tracheal tube. (3) You may occasionally have to use local infiltration anaesthesia, but it will be painful and distressing.

INCISION. Make a generous incision below the angle of his mandible, over the point of maximum tenderness, taking care to avoid his facial artery and in the line of a skin crease if possible. The abscess will be surrounded by inflammatory oedema. Cut through his skin and deep fascia, and explore it by Hilton's method (5-3). You may need to do some careful blunt dissection to release a little pus at the centre of the abscess. Leave the wound open, or partly close it and insert a drain. Later, remove the offending tooth (if this is the cause, 26.3).