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Endgames Spot Diagnosis

A rapidly enlarging neck swelling

BMJ 2020; 371 doi: https://doi.org/10.1136/bmj.m3395 (Published 22 October 2020) Cite this as: BMJ 2020;371:m3395

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Re: A rapidly enlarging neck swelling

Dear Editor

We were interested in the article by Baily and Renwick (BMJ 2020;371:m3395). [1] We would like to discuss two related matters.

The authors discuss the management of Ludwig’s Angina of dental origin. Clearly the immediate treatment will comprise airway management, fluid resuscitation, and antibiotic therapy. Sometimes, more often in our experience than not, surgical drainage of the swelling is needed. However, we wish to stress the importance of extracting the offending tooth or teeth that are causing the infection.

They report that the incidence of Ludwig’s Angina has decreased since the 1940s: would that were so. The incidence of severe cervicofacial infections is increasing, not decreasing.[2,3,4] In our unit we have had ten fatalities in twenty-four years as a result of cervicofacial infections. One common factor in almost all our patients with such severe infections is that they have been treated previously for dental infection with antibiotics, but without extraction of the infected teeth. Given the difficulty many patients have in obtaining dental treatment, this is understandable. It is essential however that extractions are undertaken when teeth have been infected.

The Covid-19 pandemic has reduced dental availability, with even emergency appointments difficult to obtain, and has also had the unwanted effect of raising anxiety in patients and possibly leading them to delay seeking treatment. Antibiotic treatment alone is insufficient treatment for dental infections.

References
1. A rapidly enlarging neck swelling. Br Med J 2020;371:m3395.
2. Jevon P, Abdelrahman A, Pigadas N. Management of odontogenic infections and sepsis: an update. British Dental Journal 2020; 229:363–370.
3. Cervicofacial infection of dental origin presenting to maxillofacial surgery units in the United Kingdom: a national audit. Carter LM, Layton S. Br Dent J; 2009;206:73-8.
4. Potentially fatal oro-facial infections: five cautionary tales. Cousin GC. JR Coll Surg Edinb 2002;47:585-586.

Competing interests: No competing interests

29 October 2020
Gary C Cousin
Consultant Oral and Maxillofacial Surgeon
Imran Yousaf
East Lancashire NHS Trust
Royal Blackburn Teaching Hospital, Haslingden Road, Blackburn BB2 3LR, UK.