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A 40 year old female is complaining of attacks of lacrimation and watery nasal discharge accompanied by sneezing. She had a severe attack one spring morning that was accompanied by respiratory difficulty and she was admitted to hospital. She received the proper treatment and her condition improved. On examination she had bilateral nasal obstruction by bluish pedunculated masses that were covered by a clear mucous discharge. QUESTIONS: 1. DIAGNOSIS AND REASONS 2.EXPLAIN THE UNDERLINED MANIFESTAIONS 3.WHAT ARE FURTHER EXAMINATION AND INVESTIGATIONS 4.TRETMENT TIME :7 MIN

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A 30 year old male had an attack of left severe earache and left loss of hearing together with deviation of the angle of the mouth to the right side and failure to close the left eye. 3 days later, a swelling vesicular in nature appeared in the left external auditory meatus. The condition subsided 10 months later. QUESTIONS: 1. DIAGNOSIS AND REASONS 2.EXPLAIN THE UNDERLINED MANIFESTAIONS 3.WHAT ARE FURTHER EXAMINATION AND INVESTIGATIONS 4.TRETMENT TIME :7 MIN


LUDWIG’S ANGINA It is infection of the submandibular space which lies between mucous membrane of the floor of fouth and tongue on one side and superficial layer of deep cervical fascia extending between the hyoid bone and mandible on the other It is divided into two compartments by the mylohyoid muscle: Sublingual compartment (above the mylohyoid) Submaxillary and submental compartment (below the mylohyoid).

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AETIOLOGY: DENTAL INFECTIONS: Account for 80% cases. Roots of premolars often lie above the attachment of mylohyoid and cause sublingual space infection while roots of the molar teeth extend up to or below the mylohyoid line and primary cause submaxillary space infection. SUBMANDIBULAR sialadenitis, injuries of oral mucosa and fractures of the mandible account for other cases.

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Bacteriology: Mixed infections involving both aerobes and anaerobes are common. Alpha haemolytic streptococci, staphylococci, and bacteroides groups are common… Rarely H.influenze, Esch.coli and Pseudomonas are seen.

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Clinical features: Odynophagia with varying degrees of trismus Floor of mouth are swollen and tongue seems to be pushed up and back. When infections spreads to submaxillary space, submental and submandibular regions become swollen and tender, and impart woody-hard feel. There is cellulitis of the tissues rather than frank abscess Tongue is progressively pushed upwords and backwards threatening the airway. Laryngeal oedema may appear.

Fig- submandibular swelling : 

Fig- submandibular swelling


TREATMENT Systemic antibiotics. Incision and drainage of abscess. Tracheostomy , if airway is endangered.


COMPLICATIONS Spread of infection to parapharyngeal and retropharyngeal spaces and then to the mediastinum. Airway obstruction due to laryngeal oedema, or swelling and pushing back of the tongue. Septicaemia Aspiration pneumonia.


CASE DISCUSSION Case 1A 14-month-old girl was admitted to the hospital because of swelling below the chin that had increased during the previous two days. Fever developed on the day of admission, and she had reduced fluid intake and urine output.

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On physical examination, a tender, indurated, warm swelling that spread laterally was seen in the submental area. An excoriated oval lesion was present on the chin. The child was uncomfortable and preferred to keep her mouth open. She had no respiratory distress or cyanosis. Her temperature (taken rectally) was 38.8°C (101.8°F); respiratory rate was 34 breaths per minute; and heart rate was 166 beats per minute. The oxygen saturation, in room air, was 95 percent. Neck radiographs revealed marked submandibular soft tissue prominence that was characteristic of Ludwig's angina. No abscess was seen on ultrasonogram.

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THANK YOU FUTURE DOCTORS IN 7TH C The white blood cell count was elevated,. Blood culture was sterile. The illness resolved following initial treatment with intravenous oxacillin followed by oral dicloxacillin.

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Final Comment Ludwig's angina can be fatal. Failure to diagnose deep neck infections promptly may be caused by a clinical picture that is altered by previous antibiotic use. With early diagnosis, aggressive intravenous antibiotic therapy and management in an intensive care unit, the process should resolve without complications


SUBMUCOUS FIBROSIS It is a chronic insidious process characterised by juxta epithelial deposition of fibrous tissue in the oral cavity and sometimes in the pharynx. The condition was first described in India by Joshi in 1953.

Showing clinical picture (blanching and fibrosis) in oral submucous fibrosis : 

Showing clinical picture (blanching and fibrosis) in oral submucous fibrosis

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PATHOLOGY Basic change is fibroelastotic transformation of connective tissues in lamina propria associated with epithelial atrophy, sometimes preceded by vesicle formation . When fibrosis is marked, there is progressive trismus and difficulty to protrude the tongue.

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CLINICAL FEATURE AGE AND SEX: 20-40 Soreness of mouth with constant burning sensation ; worsened during meals particularly of pungent spicy type Repeated vesicular eruption on the palate and pillars. Difficulty to open the mouth fully Difficulty to protrude the tongue

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FINDING :- changes of submucous fibrosis are most marked over Soft palate Faucial pillars and buccal mucosa In iniitial stages, there is patchy redness of mucous membrane with formation of vesicles which rupture to form superficial ulcers. In later stages, when fibrosis develops in the submucosal layers, there is blanching of mucosa with loss of suppleness. Fibrosis and scarring has also been demonstrated in the underlying muscle leading to further restrictive mobility of soft palate, tongue and jaw. Trismus is progressive.

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Tretment Medical Topical injection of steroids into the affected area is more effective than their systemic use as it also has the advantage of fewer side effects. It may be combined with hylase Avoid irritant factors Treat existent anaemia or vit deficiencies

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Surgical attempts to force open the mouth or cutting bands under anaesthesia to relieve trismus have resulted in more fibrosis and disability. Recently, lasers have been used to cut the fibrous bands.



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