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Winning Abstracts from the 2009 Medical Student Abstract Competition: Is All Angina Really Chest Pain?

Authors: Shashank Shekhar Sinha; matched at the University of Pennsylvania’s Internal Medicine residency program, Nathan Sandbo, MD; Instructor of Medicine, Section of Pulmonary/Critical Care, Department of Medicine, Vineet Arora, MD, FACP; Assistant Professor of Medicine, Assistant Dean for Scholarship and Discovery, Pritzker School of Medicine; Associate Program Director, Internal Medicine Residency Program

Case Presentation
A 50-year-old woman with hypertension, tobacco abuse, and a family history of early coronary artery disease presented with 10110 substernal chest pain over one day, without dyspnea, nausea or vomiting. She was afebrile, tachycardic, and hypotensive, with mild tachypnea but normoxia. Her EKG showed sinus tachycardia and ST depression in the inferolateralleads, raising concern for myocardial ischemia.

Her physical exam was significant for tongue elevation and bilateral fullness of the submandibular space, without overlying erythema or crepitus. Cardiac and pulmonary exams were unremarkable. Laboratory studies showed a leukocytosis with bandemia and normal cardiac enzymes. Head and neck CT demonstrated extensive subcutaneous emphysema in the parapharyngeal spaces bilaterally, tracking posteriorly to the retropharyngeal space, and inferiorly into the superior mediastinum.

Notably, three days prior to presentation, the patient noticed right mandibular tooth pain without antecedent trauma or dental procedures, with subsequent progressive neck swelling, trismus, and dysphagia.

A diagnosis of Ludwig's angina was made and she was empirically started on broad-spectnnn antibiotics. Nasotracheal intubation was performed given the risk of airway compromise and she was taken to the operating room for incision and drainage of the deep neck abscess. Intraoperative findings included a periapical abscess adjacent to the right mandibular second molar, which was extracted.

Not all angina refers to chest pain. Ludwig's angina is a rapidly progressive cellulitis of the submandibular and sublingual spaces. Its name derives from the etymological root of angina, Latin angere, "to strangle," referring to the choking sensation experienced by affected patients. The condition is odontogenic in 90% of cases, arising trom the second and third mandibular molar teeth in 75%-85%, of cases. The infection spreads via the fascial planes, first expanding the submandibular space, followed by the parapharyngeal space (via the buccopharyngeal gap) and subsequently the retropharyngeal space and superior mediastinum. Causative organisms represent typical oral flora: streptococci, staphylococci, and anaerobes. Predisposing factors include dental caries, recent dental treatment, and systemic immunocompromise. Exam findings include symmetric swelling, induration, and tenderness of the neck ("bull neck"), occasionally with palpable crepitus. The tongue can significantly enlarge, distending posteriorly into the hypopharynx, potentially leading to airway obstruction. Trismus, mouth pain, drooling and dysphagia may also be present. Management includes empiric beta-Iactam based antibiotics or c1indamycin in penicillin-allergic patients. Airway compromise is of paramount concern. Endotracheal tube placement with flexible fiberoptic visualization should be performed before the onset of stridor, cyanosis, and asphyxia (most common cause of death). Definitive treatment requires intraoperative surgical drainage of the abscess, along with extraction of any infected teeth. These management strategies have decreased the mortality rate from over 50 percent in the preantibiotic era to o to 4 percent currently.

Back to September 2009 Issue of IMpact

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