Case Report: Ludwig's angina - 'The Dangerous Space'

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This unique infection is now rare owing to the antibiotic era. Case: This patient presented to the emergency room with trismus, jaw and neck swelling, mild respiratory distress with tachypnea, hyperthermia, and panic. Clinical examination and radiographic evaluation confirmed the diagnosis of Ludwig's angina. As it is a quickly spreading infection, the patient was taken up for immediate surgical decompression leading to pus drainage, removal of the offending tooth, bacterial culture and sensitivity, and administration of empirical antibiotics. As we had operated promptly, there was no need for emergency airway intervention, and the patient had immediate relief from airway distress. Conclusions: Early accurate diagnosis with conservative surgical decompression, thereby negating the need for airway intervention, was vital to avoiding mortality which is always possible in such an expeditious infection." } { "@context": "http://schema.org", "@type": "BreadcrumbList", "itemListElement": [ { "@type": "ListItem", "position": "1", "item": { "@id": "https://f1000research.com/", "name": "Home" } }, { "@type": "ListItem", "position": "2", "item": { "@id": "https://f1000research.com/browse/articles", "name": "Browse" } }, { "@type": "ListItem", "position": "3", "item": { "@id": "https://f1000research.com/articles/11-1511", "name": "Case Report: Ludwig's angina - 'The Dangerous Space'" } } ] } Home Browse Case Report: Ludwig's angina - 'The Dangerous Space' ALL Metrics - Views Downloads Get PDF Get XML Cite How to cite this article Vasanth S, Chandran S, Pandyan DA et al. Case Report: Ludwig's angina - 'The Dangerous Space' [version 2; peer review: 2 approved, 1 approved with reservations] . F1000Research 2024, 11 :1511 ( https://doi.org/10.12688/f1000research.127242.2 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Close Copy Citation Details Export Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente EXPORT Select a format first Track Share ▬ ✚ Case Report Revised Case Report: Ludwig's angina - 'The Dangerous Space' [version 2; peer review: 2 approved, 1 approved with reservations] Satish Vasanth 1 , Satheesh Chandran 2 , Deepak Abraham Pandyan 2 , [...] Padmashini Gnanam 3 , Sinouvassane Djearamane 4 , Ling Shing Wong 5 , Siddharthan Selvaraj https://orcid.org/0000-0002-7776-3335 6 Satish Vasanth 1 , Satheesh Chandran 2 , [...] Deepak Abraham Pandyan 2 , Padmashini Gnanam 3 , Sinouvassane Djearamane 4 , Ling Shing Wong 5 , Siddharthan Selvaraj https://orcid.org/0000-0002-7776-3335 6 PUBLISHED 27 Jun 2024 Author details Author details 1 Department of Oral And Maxillofacial Surgery, Faculty of Dentistry, AIMST University, Bedong, Kedah, 08100, Malaysia 2 Department of Oral and Maxillofacial Surgery, Madha Dental College and Hospital, Chennai, 600069, India 3 Department of Prosthodontics, Faculty of Dentistry, AIMST University, Bedong, Kedah, 08100, Malaysia 4 Department of Biomedical Science, Faculty of Science, Universiti Tunku Abdul Rahman, Kampar, Perak, 31900, Malaysia 5 Faculty of Health and Life Sciences, INTI International University, Nilai, 71800, Malaysia 6 Department of Community Oral Health and Clinical Prevention, Faculty of Dentistry, University of Malaya, 50603, Kuala Lumpar, Malaysia Satish Vasanth Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Project Administration, Resources, Software, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Satheesh Chandran Roles: Conceptualization, Data Curation, Investigation, Methodology, Project Administration, Visualization, Writing – Review & Editing Deepak Abraham Pandyan Roles: Project Administration, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Padmashini Gnanam Roles: Conceptualization, Project Administration, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Sinouvassane Djearamane Roles: Funding Acquisition, Methodology, Project Administration, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Ling Shing Wong Roles: Funding Acquisition, Methodology, Project Administration, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Siddharthan Selvaraj Roles: Project Administration, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing OPEN PEER REVIEW DETAILS REVIEWER STATUS Abstract Background: Ludwig's angina is a potentially life-threatening disease characterized by diffuse bilateral cellulitis with an odontogenic origin. This unique infection is now rare owing to the antibiotic era. Case: This patient presented to the emergency room with trismus, jaw and neck swelling, mild respiratory distress with tachypnea, hyperthermia, and panic. Clinical examination and radiographic evaluation confirmed the diagnosis of Ludwig's angina. As it is a quickly spreading infection, the patient was taken up for immediate surgical decompression leading to pus drainage, removal of the offending tooth, bacterial culture and sensitivity, and administration of empirical antibiotics. As we had operated promptly, there was no need for emergency airway intervention, and the patient had immediate relief from airway distress. Conclusions: Early accurate diagnosis with conservative surgical decompression, thereby negating the need for airway intervention, was vital to avoiding mortality which is always possible in such an expeditious infection. READ ALL READ LESS Keywords Ludwig's angina, odontogenic space infection, surgical decompression, incision, drainage, case report Corresponding Author(s) Satish Vasanth ( [email protected] ) Sinouvassane Djearamane ( [email protected] ) Ling Shing Wong ( [email protected] ) Close Corresponding authors: Satish Vasanth, Sinouvassane Djearamane, Ling Shing Wong Competing interests: No competing interests were disclosed. Grant information: The author(s) declared that no grants were involved in supporting this work. Copyright: © 2024 Vasanth S et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: Vasanth S, Chandran S, Pandyan DA et al. Case Report: Ludwig's angina - 'The Dangerous Space' [version 2; peer review: 2 approved, 1 approved with reservations] . F1000Research 2024, 11 :1511 ( https://doi.org/10.12688/f1000research.127242.2 ) First published: 13 Dec 2022, 11 :1511 ( https://doi.org/10.12688/f1000research.127242.1 ) Latest published: 27 Jun 2024, 11 :1511 ( https://doi.org/10.12688/f1000research.127242.2 ) Revised Amendments from Version 1 We have added the following contents and listed them below based on the reviewers' recommendations and input: We have included information on the radiographic findings of this case report. Furthermore, we have also included information on the patient's health status while reporting before the treatment procedure. To add upon, we have also elaborated briefly on the treatment procedure done for the patient to make sure it is easily understandable for the readers. We have also added the primary cause for the development of this condition of the patient. We have also justified the context of using the term 'dangerous space' as it can either lead to airway obstruction or, at a later stage, cause dissemination of the infection, which then spreads through several other adjacent spatial planes. The affiliation of the author, Siddharthan Selvaraj, has been updated as he has joined the new institution listed below. “Department of Community Oral Health and Clinical Prevention, Faculty of Dentistry, University of Malaya, 50603 Kuala Lumpur, Malaysia” We have added the following contents and listed them below based on the reviewers' recommendations and input: We have included information on the radiographic findings of this case report. Furthermore, we have also included information on the patient's health status while reporting before the treatment procedure. To add upon, we have also elaborated briefly on the treatment procedure done for the patient to make sure it is easily understandable for the readers. We have also added the primary cause for the development of this condition of the patient. We have also justified the context of using the term 'dangerous space' as it can either lead to airway obstruction or, at a later stage, cause dissemination of the infection, which then spreads through several other adjacent spatial planes. The affiliation of the author, Siddharthan Selvaraj, has been updated as he has joined the new institution listed below. “Department of Community Oral Health and Clinical Prevention, Faculty of Dentistry, University of Malaya, 50603 Kuala Lumpur, Malaysia” See the authors' detailed response to the review by Paramjot Kaur READ REVIEWER RESPONSES Introduction Ludwig's angina, diffuse cellulitis on the floor of the mouth, was first described by a German physician, Wilhelm Frederick von Ludwig, in 1836. 1 The old terminology describes it as “ angina maligna ” in Latin ( angere -to strangle, Morbus strangularis ). 2 Ironically, Ludwig passed away at 75 from the same illness he had earlier described. 3 The most prevalent etiology seems odontogenic in origin. 4 Systemic illnesses such as diabetes mellitus, malnutrition, alcoholism, and AIDS may be risk factors. 5 The incidence has recently dropped from 60% to 10% due to antibiotics and better oral hygiene practices. 2 Although there are no current guidelines for managing acute Ludwig's angina, the mainstay of the treatment includes airway maintenance and following the principles of infection control which we have discussed in this case report. The objective of this case report was to raise awareness and facilitate the detection of similar occurrences, given their rarity. Case report A 40-year-old Indian male patient working as an electrician reported to the department of Oral and Maxillofacial Surgery with a chief complaint of inability to open the mouth, along with pain and swelling in the lower jaw and neck region for the past three days [ Figure 1 ]. Figure 1. Patient with prominent swelling in the submandibular region. No relevant medical history was noted. The patient reported hyperthermia (100° F), pulse rate of 99 beats per minute, respiratory rate of 25 breaths per minute, and oxygen saturation fluctuating between 88 to 90 SPO 2 . On clinical examination, he reported a restricted mouth opening of only 19 mm (about 0.75 in), a tongue deviation [ Figure 2 ], and evident dysphagia and dyspnea. Extra orally, the swelling was indurated, non-fluctuant, with bilateral involvement of the submandibular and sublingual spaces. His dentate status revealed root stumps in relation to 36 and 46 regions, which were tender on percussion. The obliteration of the mucogingival junction was also noted. Radiographic examination with orthopantomogram (OPG) revealed periapical radiolucency concerning 36, 37 and 38 with locules in the submandibular region (more on the right side than the left side), indicating air or pus [ Figure 3 ]. Figure 2. Elevation and posteriorly displaced tongue. Figure 3. Presence of air/pus locules in the right submandibular region. It was diagnosed as Ludwig's angina, and Hilton's incision and drainage were administered promptly. Separate stab incisions were placed with the No. 11 BP blade on the bilateral submandibular and submental regions. The bilateral submandibular spaces were connected to the midline through blunt dissection. The root stumps were extracted with the evacuation of inflammatory exudate. An intra-oral incision was made along the lingual sulcus in relation to 36 and 37, along with two extraoral incisions in the submandibular region combined with superficial dissection; the pus was evacuated [ Figures 4 and 5 ] along with copious povidone-iodine and saline irrigation. Radiographic examination with orthopantomogram (OPG) revealed periapical radiolucency concerning 36, 37 and 38 with locules in the submandibular region (more on the right side than the left side), indicating air or pus. The pus was collected with a sterile swab and sent for culture and antibiotic sensitivity test. The culture sensitivity report revealed the sensitivity to prescribed empirical antibiotics; therefore, the same medicines were continued for a week. Figure 4. Lingual vestibular Incision given, and pus evacuated intraorally. Figure 5. Extra oral incisions. Extra orally corrugated rubber drain tubes were positioned and secured to the skin with silk sutures [ Figure 6 ]. The patient subjectively experienced a reduction in dyspnea. The pus was collected with a sterile swab and sent for culture and antibiotic sensitivity test. The patient was prescribed empirical antibiotics of Tablet amoxicillin and potassium clavulanate 625 mg twice daily, Tablet metronidazole 400 mg thrice daily for five days orally, and the drain tubes were disconnected after five days. Furthermore, maintaining patent airway is the most important consideration, removing the source of infection, antibiotics and Incision and drainage would be course of action. Figure 6. Placement of rubber drains. The culture sensitivity report revealed the sensitivity to prescribed empirical antibiotics; therefore, the same medicines were continued for a week. After one week, the patient's re-evaluation revealed adequate wound healing and an increased mouth opening of 36 mm (about 1.42 in). The infection had nearly resolved with the disappearance of the symptoms. Post operative results showed adequate mouth opening and the infection was resolved [ Figure 7 ]. Figure 7. Post operative results after 1 week. Discussion Ludwig's angina is a plausible life-threatening connective tissue infection of the floor of the mouth and neck, characterized by bilateral brawny supra hyoid swelling over bilateral sublingual and submandibular spaces. It can either lead to airway obstruction or, at a later stage, cause dissemination of the infection, which then spreads through several other adjacent spatial planes. 6 The most cultured organisms include staphylococcus, streptococcus, and Bacteroides species of either aerobic or anaerobic origin. 1 Ludwig's angina is often correlated with the region between the second and third lower molars. Since the apices of these teeth are positioned directly below the mylohyoid ridges, the submandibular space is proximal. If these teeth are infected, the infection will progress and perforate the lingual plate. The infection may rapidly spread into the submandibular, sublingual, and submental tissue spaces. 7 According to the literature, four significant signs indicate the diagnosis of Ludwig's angina: (a) bilateral involvement of more than a single deep-tissue space (b) gangrene with serosanguinous, putrid infiltration but little or no frank pus (c) involvement of connective tissue, fasciae, and muscles but not the glandular structures (d) spread through fascial space continuity rather than by the lymphatic system. 8 If not diagnosed early, complications include thrombophlebitis of the internal jugular vein, mediastinitis, empyema, pericardial effusion, osteomyelitis, aspiration pneumonia, and pleural effusion. 1 Typically, the infection begins at the floor of the mouth and progresses to the submandibular space rapidly, leading to elevation and posterior displacement of the tongue. 2 The physical examination usually reveals aggressive gangrenous cellulitis, including fever, tachycardia, brawny induration and swelling of a tender submandibular space, and an elevated, protruding tongue. Trismus irritates the muscles of mastication. 7 The enlargement of the anterior soft tissues of the neck above the hyoid bone sometimes leads to the characteristic “bull's neck” appearance of affected patients. 8 Some signs of impending airway distress are hoarseness of voice, stridor, respiratory distress, decreased air movement, cyanosis, and a “sniffing” position (upright posture with the neck being put forward with the chin elevated). 8 Patients may lean forward in the tripod posture as respiratory distress intensifies to enhance airway diameter and obtain relief. 1 The risk factors such as age over 65 years old, immunocompromised conditions, diabetes mellitus, and alcoholism are said to increase the mortality and complications in Ludwig's angina. In addition, extended hospital stays, diabetes, and hemodialysis increases the risk of methicillin-resistant Staphylococcus aureus (MRSA) infection. 1 The parameters used to analyze the risk factors leading to life-threatening complications are age, sex, diabetes, type and side of submandibular involvement, anterior visceral space involvement, type of infection, and symptoms like trismus and fever. According to one study, diabetes mellitus is commonly associated with Ludwig's angina. Logistic regression analysis confirmed the other co-morbidities and bilateral submandibular swelling as predictors for mortality in Ludwig's angina. 9 Radiographs of the neck and chest often reveal the degree of soft tissue edema and gas accumulation in the tissues, especially in cases of anaerobic infection. The presence of air in the neck or mediastinum is diagnostic of the intrathoracic extension of the infectious process. 10 According to some authors, ultrasonography may be beneficial in diagnosing early cases of abscess and cellulitis. 5 In addition, computed tomography (CT) and magnetic resonance imaging (MRI) may be proposed to detect airway edema and identify mediastinal fluid collections. CT is accurate in evaluating deep neck and mediastinal collections of pus. By contrast, MRI generates higher resolution images, but imaging time is longer, so CT is the recommended investigation of choice. 1 Although there are no current guidelines for managing acute Ludwig's angina, the mainstay of the treatment includes airway maintenance, where the patency of the airway must be evaluated. The administration of broad-spectrum antibiotics follows evaluation, incision, and drainage removal of the infectious foci, i.e. , mandibular molar, pus culture, and sensitivity test. Literature suggests that the inappropriate use of drugs like antibiotics, steroids & nonsteroidal anti-inflammatory drugs may affect the clinical signs and symptoms of infection and slow the progression of the disease, thereby potentially delaying the precise diagnosis of the condition. 2 However, these medications are still provided to reduce the risk of airway derailment. 4 Despite the use of steroids, most patients in the research (71%) were treated with surgical decompression and drain insertion, demonstrating that steroids are not the primary treatment mechanism. However, it is still debatable whether the usage of steroids necessitates surgical intervention. 4 Corticosteroids are reported to decrease facial edema and airway edema, as well as facilitate antibiotic penetration. The steroid of choice is dexamethasone (IV 10 mg). Furthermore, nebulized epinephrine (1 mL of 1:1,000 diluted to 5 mL in 0.9% normal saline) reduces airway blockage: However, evidence is scarce. Despite contradictory findings, early surgical intervention improves airway conditions. 1 Penicillin is the antibiotic of choice for empirical antibiotic coverage, which targets gram-positive cocci predominantly. Considering the increasing prevalence of penicillin resistant Bacteroides strains, metronidazole is recommended for the anaerobic cover. 4 Clindamycin alone is not advocated, as resistance rates for streptococcal species and MRSA exceed 30%. 1 Surgery is usually accomplished by decompressing the submental, sublingual, and submandibular spaces by external incision and drainage. Significant airway compromise, characterized by stridor and the use of accessory muscles for breathing, necessitates a definitive airway, which can be attained via endotracheal intubation or tracheostomy, depending on the clinical scenario: Mask breathing will be complicated owing to neck swelling; thus, it is essential to pre oxygenate these patients using any suitable methodology. Blind oral or nasotracheal intubation can culminate in airway damage, increasing edema, and severe laryngospasm; hence, this technique is not advised. Additionally, supraglottic airway devices should be discouraged since they cannot be positioned correctly when the edema progresses. Ideally, patients should be treated with nasotracheal intubation while seated utilizing a flexible intubating endoscope and an awake intubation approach, anticipating a surgical airway ( i.e. , cricothyrotomy) if necessary. 1 However, emergency cricothyroidotomy or tracheostomy is preferred in patients in the late stages. 2 In a retrospective study comparing the conservative (antibiotics alone) and surgical decompression with antibiotics, the conclusion was that the latter is superior as there is always a possibility of antibiotics failure. 6 A review of 29 cases over nine years by Greenberg et al. , showed that 21 cases (72%) were managed conservatively, one case required emergency intubation, six cases (24%) were intubated using fiberoptic Naso endoscopy, and one case (3%) required tracheostomy under local anesthesia. 10 In the present case report, the patient was treated conservatively, with the extraction of the mandibular molar, incision and drainage of the involved spaces, and administration of broad-spectrum antibiotics without airway intervention. One week after surgery, adequate mouth opening was achieved with the support of mouth opening exercises. In the present case, air pockets in the neck alerted us to the likelihood of a deadly infection progressing fast 9 , 11 [ Figure 3 ]. We have attempted to eliminate the observer's subjective bias by employing many well-trained observers to document the case independently. In the research about Ludwig's angina, there are voids concerning risk factors such as smoking, drinking, and inadequate antibiotic coverage. Additionally, there are no data on this illness in COVID-19 patients, particularly in this pandemic era. According to our research, there needs to be a precise treatment plan and agreement for Ludwig's angina that could serve as a future reference. The literature on steroids' effects on this illness is still ambiguous; therefore, additional research is required. Conclusions The clinician should be familiar with the presentation of Ludwig's angina since prompt diagnosis and investigation, administration of antibiotic therapy, and possible surgical management is required to prevent the associated morbidity and mortality. Patient perspective I am willing to share my experience if it helps others. It only started as a small swelling in my jaw but later became big and made me uncomfortable as breathing became difficult. I should have come before. But thank God I am better now. Consent Written informed consent for publication of their clinical details and clinical images was obtained from the patient. Data availability Underlying data All data underlying the results are available as part of the article and no additional source data are required. References 1. Bridwell R, Gottlieb M, Koyfman A, et al. : Diagnosis and management of Ludwig's angina: An evidence-based review. Am. J. Emerg. Med. 2021; 41 : 1–5. PubMed Abstract | Publisher Full Text 2. Dowdy RAE, Emam HA, Cornelius BW: Ludwig's Angina: Anesthetic Management. Anesth. Prog. 2019 Summer; 66 (2): 103–110. PubMed Abstract | Publisher Full Text 3. Wasson J, Hopkins C, Bowdler D: Did Ludwig's angina kill Ludwig? J. Laryngol. Otol. 2006; 120 (5): 363–365. PubMed Abstract | Publisher Full Text 4. Tami A, Othman S, Sudhakar A, et al. : Ludwig's angina and steroid use: A narrative review. Am. J. Otolaryngol. 2020; 41 (3): 102411. PubMed Abstract | Publisher Full Text 5. Vallée M, Gaborit B, Meyer J, et al. : Ludwig's angina: A diagnostic and surgical priority. Int. J. Infect. Dis. 2020; 93 : 160–162. PubMed Abstract | Publisher Full Text 6. Edetanlen BE, Saheeb BD: Comparison of Outcomes in Conservative versus Surgical Treatments for Ludwig's Angina. Med. Princ. Pract. 2018; 27 (4): 362–366. Publisher Full Text 7. Barakate MS, Jensen MJ, Hemli JM, et al. : Ludwig's angina: report of a case and review of management issues. Ann. Otol. Rhinol. Laryngol. 2001; 110 (5 Pt 1): 453–456. PubMed Abstract | Publisher Full Text 8. David M, Lemonick MD: Ludwig's Angina: Diagnosis and Treatment. Hosp. Physician. 2002; 38 : 31–37. 9. Snow N, Lucas AE, Grau M, et al. : Purulent mediastinal abscess secondary to Ludwig's angina. Arch. Otolaryngol. 1983; 109 (1): 53–55. PubMed Abstract | Publisher Full Text 10. Boscolo-Rizzo P, Da Mosto MC: Submandibular space infection: a potentially lethal infection. Int. J. Infect. Dis. 2009; 13 (3): 327–333. Publisher Full Text 11. Vasanth S, Gnanam P, Selvaraj S: Ludwig’s Angina- a Forgotten Crisis in the Field of Dentistry? J. Dental Sci. 2022; 7 (3): 000344. Comments on this article Comments (0) Version 2 VERSION 2 PUBLISHED 13 Dec 2022 ADD YOUR COMMENT Comment Author details Author details 1 Department of Oral And Maxillofacial Surgery, Faculty of Dentistry, AIMST University, Bedong, Kedah, 08100, Malaysia 2 Department of Oral and Maxillofacial Surgery, Madha Dental College and Hospital, Chennai, 600069, India 3 Department of Prosthodontics, Faculty of Dentistry, AIMST University, Bedong, Kedah, 08100, Malaysia 4 Department of Biomedical Science, Faculty of Science, Universiti Tunku Abdul Rahman, Kampar, Perak, 31900, Malaysia 5 Faculty of Health and Life Sciences, INTI International University, Nilai, 71800, Malaysia 6 Department of Community Oral Health and Clinical Prevention, Faculty of Dentistry, University of Malaya, 50603, Kuala Lumpar, Malaysia Satish Vasanth Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Project Administration, Resources, Software, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Satheesh Chandran Roles: Conceptualization, Data Curation, Investigation, Methodology, Project Administration, Visualization, Writing – Review & Editing Deepak Abraham Pandyan Roles: Project Administration, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Padmashini Gnanam Roles: Conceptualization, Project Administration, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Sinouvassane Djearamane Roles: Funding Acquisition, Methodology, Project Administration, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Ling Shing Wong Roles: Funding Acquisition, Methodology, Project Administration, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Siddharthan Selvaraj Roles: Project Administration, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Competing interests No competing interests were disclosed. Grant information The author(s) declared that no grants were involved in supporting this work. Article Versions (2) version 2 Revised Published: 27 Jun 2024, 11:1511 https://doi.org/10.12688/f1000research.127242.2 version 1 Published: 13 Dec 2022, 11:1511 https://doi.org/10.12688/f1000research.127242.1 Copyright © 2024 Vasanth S et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Download Export To Sciwheel Bibtex EndNote ProCite Ref. Manager (RIS) Sente metrics Views Downloads F1000Research - - PubMed Central info_outline Data from PMC are received and updated monthly. - - Citations open_in_new 0 open_in_new 0 open_in_new SEE MORE DETAILS CITE how to cite this article Vasanth S, Chandran S, Pandyan DA et al. Case Report: Ludwig's angina - 'The Dangerous Space' [version 2; peer review: 2 approved, 1 approved with reservations] . F1000Research 2024, 11 :1511 ( https://doi.org/10.12688/f1000research.127242.2 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS track receive updates on this article Track an article to receive email alerts on any updates to this article. TRACK THIS ARTICLE Share Open Peer Review Current Reviewer Status: ? Key to Reviewer Statuses VIEW HIDE Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Version 2 VERSION 2 PUBLISHED 27 Jun 2024 Revised Views 0 Cite How to cite this report: Monnazzi MS. Reviewer Report For: Case Report: Ludwig's angina - 'The Dangerous Space' [version 2; peer review: 2 approved, 1 approved with reservations] . F1000Research 2024, 11 :1511 ( https://doi.org/10.5256/f1000research.166856.r321293 ) The direct URL for this report is: https://f1000research.com/articles/11-1511/v2#referee-response-321293 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 17 Sep 2024 Marcelo Silva Monnazzi , São Paulo State University (Unesp) School of Dentistry (Araraquara), Sao Paulo, Brazil Approved VIEWS 0 https://doi.org/10.5256/f1000research.166856.r321293 The cases history and progression could be a little more detailed. But in general I think the article is good. And it is worth indexing. I just think that it is necessary to remove the citations that the ... Continue reading READ ALL The cases history and progression could be a little more detailed. But in general I think the article is good. And it is worth indexing. I just think that it is necessary to remove the citations that the Ludwig angina is a rare infection, because it is not so rare. At least the authors could state that it is rare in their area (if it was the case), because here in Brazil, it is not rare at all. Is the background of the case’s history and progression described in sufficient detail? Partly Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes? Yes Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment? Yes Is the case presented with sufficient detail to be useful for other practitioners? Yes Competing Interests: No competing interests were disclosed. Reviewer Expertise: Oral and maxillofacial surgeon for 24 years. Professor of oral and maxillofacial at the São Paulo state university for at least 17 years. DR. Msc. Phd. I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Monnazzi MS. Reviewer Report For: Case Report: Ludwig's angina - 'The Dangerous Space' [version 2; peer review: 2 approved, 1 approved with reservations] . F1000Research 2024, 11 :1511 ( https://doi.org/10.5256/f1000research.166856.r321293 ) The direct URL for this report is: https://f1000research.com/articles/11-1511/v2#referee-response-321293 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Version 1 VERSION 1 PUBLISHED 13 Dec 2022 Views 0 Cite How to cite this report: Kaur P. Reviewer Report For: Case Report: Ludwig's angina - 'The Dangerous Space' [version 2; peer review: 2 approved, 1 approved with reservations] . F1000Research 2024, 11 :1511 ( https://doi.org/10.5256/f1000research.139725.r272616 ) The direct URL for this report is: https://f1000research.com/articles/11-1511/v1#referee-response-272616 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 10 May 2024 Paramjot Kaur , Baba Jaswant Singh Dental College, Ludhiana, Punjab, India Approved with Reservations VIEWS 0 https://doi.org/10.5256/f1000research.139725.r272616 The authors have failed to reference any established protocols for the management of Ludwig's angina. What course of action should be pursued if the administration of steroids and epinephrine are contraindicated for a case of Ludwig's angina? The authors have ... Continue reading READ ALL The authors have failed to reference any established protocols for the management of Ludwig's angina. What course of action should be pursued if the administration of steroids and epinephrine are contraindicated for a case of Ludwig's angina? The authors have neglected to include citations of recent publications. Is Ludwig's angina the most perilous type of facial and submandibular space infection? Justify the designation of 'dangerous space' in this context. The primary cause for the development of this condition in a 40-year-old male remains unspecified. Which specific diagnostic procedures were employed in the examination of this particular case? No details have been provided regarding the utilization of laboratory tests and radiographic imaging in the assessment. What are the respective roles of the first and second authors in the execution of this research? Was consent obtained from the patient prior to the capture of clinical photographs? The deficiency of comprehensive details in both the case presentation and subsequent deliberations is evident. Is the background of the case’s history and progression described in sufficient detail? Yes Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes? No Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment? Partly Is the case presented with sufficient detail to be useful for other practitioners? Yes Competing Interests: No competing interests were disclosed. Reviewer Expertise: oral and maxillofacial surgery I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Kaur P. Reviewer Report For: Case Report: Ludwig's angina - 'The Dangerous Space' [version 2; peer review: 2 approved, 1 approved with reservations] . F1000Research 2024, 11 :1511 ( https://doi.org/10.5256/f1000research.139725.r272616 ) The direct URL for this report is: https://f1000research.com/articles/11-1511/v1#referee-response-272616 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Author Response 27 Jun 2024 Siddharthan Selvaraj , Department of Dental Public Health, Faculty of Dentistry, AIMST University, Bedong, 08100, Malaysia 27 Jun 2024 Author Response Dear Reviewers, We would like to thank the reviewers for taking their valuable time to provide their insightful queries, we have provided our explanation for the same. Once again thank ... Continue reading Dear Reviewers, We would like to thank the reviewers for taking their valuable time to provide their insightful queries, we have provided our explanation for the same. Once again thank you for your feedback. 1.The authors have failed to reference any established protocols for the management of Ludwig's angina. Answer: Although there are no current guidelines for managing acute Ludwig's angina, the mainstay of the treatment includes airway maintenance and following the principles of infection control which we have already discussed. 2. What course of action should be pursued if the administration of steroids and epinephrine are contraindicated for a case of Ludwig's angina? Answer: Maintaining patent airway is the most important consideration. Removing the source of infection, antibiotics and Incision and drainage would be course of action . 3.The authors have neglected to include citations of recent publications. Is Ludwig's angina the most perilous type of facial and submandibular space infection? Answer: yes, it is highly perilous but in this antibiotic era it has become a rare infection which makes recent publications little difficult. 5.Justify the designation of 'dangerous space' in this context. Answer: It can either lead to airway obstruction or, at a later stage, cause dissemination of the infection, which then spreads through several other adjacent spatial planes. 5.The primary cause for the development of this condition in a 40-year-old male remains unspecified. Answer: yes the patient wasn’t immuno compromised or medically compromised at the time of diagnosis and it still happened 6.Which specific diagnostic procedures were employed in the examination of this particular case? Answer: There is no specific diagnostic test which gives the diagnosis for Ludwigs angina. It’s a combination of clinical examination, symptoms and radiographic examination. The patient reported hyperthermia (100° F), pulse rate of 99 beats per minute, respiratory rate of 25 breaths per minute, and oxygen saturation fluctuating between 88 to 90 SP02. On clinical examination, he reported a restricted mouth opening of only 19 mm (about 0.75 in), a tongue deviation [and evident dysphagia and dyspnea. Extra orally, the swelling was indurated, non-fluctuant, with bilateral involvement of the submandibular and sublingual spaces. His dentate status revealed root stumps in relation to 36 and 46 regions, which were tender on percussion. The obliteration of the mucogingival junction was also noted. Radiographic examination with orthopantomogram (OPG) revealed periapical radiolucency concerning 36,37 and 38 with locules in the submandibular region (more on the right side than the left side), indicating air or pus 7.No details have been provided regarding the utilization of laboratory tests and radiographic imaging in the assessment. Answer: Radiographic examination with orthopantomogram (OPG) revealed periapical radiolucency concerning 36,37 and 38 with locules in the submandibular region (more on the right side than the left side), indicating air or pus. The pus was collected with a sterile swab and sent for culture and antibiotic sensitivity test. The culture sensitivity report revealed the sensitivity to prescribed empirical antibiotics; therefore, the same medicines were continued for a week. 8.What are the respective roles of the first and second authors in the execution of this research? Answer: The first author did the surgical procedure while the second author provided assistance. 9.Was consent obtained from the patient prior to the capture of clinical photographs? Answer: yes. We obtained consent for treatment and for capturing clinical photographs. Dear Reviewers, We would like to thank the reviewers for taking their valuable time to provide their insightful queries, we have provided our explanation for the same. Once again thank you for your feedback. 1.The authors have failed to reference any established protocols for the management of Ludwig's angina. Answer: Although there are no current guidelines for managing acute Ludwig's angina, the mainstay of the treatment includes airway maintenance and following the principles of infection control which we have already discussed. 2. What course of action should be pursued if the administration of steroids and epinephrine are contraindicated for a case of Ludwig's angina? Answer: Maintaining patent airway is the most important consideration. Removing the source of infection, antibiotics and Incision and drainage would be course of action . 3.The authors have neglected to include citations of recent publications. Is Ludwig's angina the most perilous type of facial and submandibular space infection? Answer: yes, it is highly perilous but in this antibiotic era it has become a rare infection which makes recent publications little difficult. 5.Justify the designation of 'dangerous space' in this context. Answer: It can either lead to airway obstruction or, at a later stage, cause dissemination of the infection, which then spreads through several other adjacent spatial planes. 5.The primary cause for the development of this condition in a 40-year-old male remains unspecified. Answer: yes the patient wasn’t immuno compromised or medically compromised at the time of diagnosis and it still happened 6.Which specific diagnostic procedures were employed in the examination of this particular case? Answer: There is no specific diagnostic test which gives the diagnosis for Ludwigs angina. It’s a combination of clinical examination, symptoms and radiographic examination. The patient reported hyperthermia (100° F), pulse rate of 99 beats per minute, respiratory rate of 25 breaths per minute, and oxygen saturation fluctuating between 88 to 90 SP02. On clinical examination, he reported a restricted mouth opening of only 19 mm (about 0.75 in), a tongue deviation [and evident dysphagia and dyspnea. Extra orally, the swelling was indurated, non-fluctuant, with bilateral involvement of the submandibular and sublingual spaces. His dentate status revealed root stumps in relation to 36 and 46 regions, which were tender on percussion. The obliteration of the mucogingival junction was also noted. Radiographic examination with orthopantomogram (OPG) revealed periapical radiolucency concerning 36,37 and 38 with locules in the submandibular region (more on the right side than the left side), indicating air or pus 7.No details have been provided regarding the utilization of laboratory tests and radiographic imaging in the assessment. Answer: Radiographic examination with orthopantomogram (OPG) revealed periapical radiolucency concerning 36,37 and 38 with locules in the submandibular region (more on the right side than the left side), indicating air or pus. The pus was collected with a sterile swab and sent for culture and antibiotic sensitivity test. The culture sensitivity report revealed the sensitivity to prescribed empirical antibiotics; therefore, the same medicines were continued for a week. 8.What are the respective roles of the first and second authors in the execution of this research? Answer: The first author did the surgical procedure while the second author provided assistance. 9.Was consent obtained from the patient prior to the capture of clinical photographs? Answer: yes. We obtained consent for treatment and for capturing clinical photographs. Competing Interests: We declare no competing interest. Close Report a concern Author Response 25 Jun 2024 Siddharthan Selvaraj , Department of Dental Public Health, Faculty of Dentistry, AIMST University, Bedong, 08100, Malaysia 25 Jun 2024 Author Response 1.The authors have failed to reference any established protocols for the management of Ludwig's angina. Answer: Although there are no current guidelines for managing acute Ludwig's angina, the mainstay of ... Continue reading 1.The authors have failed to reference any established protocols for the management of Ludwig's angina. Answer: Although there are no current guidelines for managing acute Ludwig's angina, the mainstay of the treatment includes airway maintenance and following the principles of infection control which we have already discussed. 2.What course of action should be pursued if the administration of steroids and epinephrine are contraindicated for a case of Ludwig's angina? Answer: Maintaining patent airway is the most important consideration. Removing the source of infection, antibiotics and Incision and drainage would be course of action . 3.The authors have neglected to include citations of recent publications. Is Ludwig's angina the most perilous type of facial and submandibular space infection? Answer: yes, it is highly perilous but in this antibiotic era it has become a rare infection which makes recent publications little difficult. 4.Justify the designation of 'dangerous space' in this context. Answer: It can either lead to airway obstruction or, at a later stage, cause dissemination of the infection, which then spreads through several other adjacent spatial planes. 5.The primary cause for the development of this condition in a 40-year-old male remains unspecified. Answer: yes the patient wasn’t immuno compromised or medically compromised at the time of diagnosis and it still happened 6.Which specific diagnostic procedures were employed in the examination of this particular case? Answer: There is no specific diagnostic test which gives the diagnosis for Ludwigs angina. It’s a combination of clinical examination, symptoms and radiographic examination. T he patient reported hyperthermia (100° F), pulse rate of 99 beats per minute, respiratory rate of 25 breaths per minute, and oxygen saturation fluctuating between 88 to 90 SP02. On clinical examination, he reported a restricted mouth opening of only 19 mm (about 0.75 in), a tongue deviation [and evident dysphagia and dyspnea. Extra orally, the swelling was indurated, non-fluctuant, with bilateral involvement of the submandibular and sublingual spaces. His dentate status revealed root stumps in relation to 36 and 46 regions, which were tender on percussion. The obliteration of the mucogingival junction was also noted. Radiographic examination with orthopantomogram (OPG) revealed periapical radiolucency concerning 36,37 and 38 with locules in the submandibular region (more on the right side than the left side), indicating air or pus 7.No details have been provided regarding the utilization of laboratory tests and radiographic imaging in the assessment. Answer: Radiographic examination with orthopantomogram (OPG) revealed periapical radiolucency concerning 36,37 and 38 with locules in the submandibular region (more on the right side than the left side), indicating air or pus. The pus was collected with a sterile swab and sent for culture and antibiotic sensitivity test. The culture sensitivity report revealed the sensitivity to prescribed empirical antibiotics; therefore, the same medicines were continued for a week. 8.What are the respective roles of the first and second authors in the execution of this research? Answer: The first author did the surgical procedure while the second author provided assistance. 9.Was consent obtained from the patient prior to the capture of clinical photographs? Answer: yes. We obtained consent for treatment and for capturing clinical photographs. 1.The authors have failed to reference any established protocols for the management of Ludwig's angina. Answer: Although there are no current guidelines for managing acute Ludwig's angina, the mainstay of the treatment includes airway maintenance and following the principles of infection control which we have already discussed. 2.What course of action should be pursued if the administration of steroids and epinephrine are contraindicated for a case of Ludwig's angina? Answer: Maintaining patent airway is the most important consideration. Removing the source of infection, antibiotics and Incision and drainage would be course of action . 3.The authors have neglected to include citations of recent publications. Is Ludwig's angina the most perilous type of facial and submandibular space infection? Answer: yes, it is highly perilous but in this antibiotic era it has become a rare infection which makes recent publications little difficult. 4.Justify the designation of 'dangerous space' in this context. Answer: It can either lead to airway obstruction or, at a later stage, cause dissemination of the infection, which then spreads through several other adjacent spatial planes. 5.The primary cause for the development of this condition in a 40-year-old male remains unspecified. Answer: yes the patient wasn’t immuno compromised or medically compromised at the time of diagnosis and it still happened 6.Which specific diagnostic procedures were employed in the examination of this particular case? Answer: There is no specific diagnostic test which gives the diagnosis for Ludwigs angina. It’s a combination of clinical examination, symptoms and radiographic examination. T he patient reported hyperthermia (100° F), pulse rate of 99 beats per minute, respiratory rate of 25 breaths per minute, and oxygen saturation fluctuating between 88 to 90 SP02. On clinical examination, he reported a restricted mouth opening of only 19 mm (about 0.75 in), a tongue deviation [and evident dysphagia and dyspnea. Extra orally, the swelling was indurated, non-fluctuant, with bilateral involvement of the submandibular and sublingual spaces. His dentate status revealed root stumps in relation to 36 and 46 regions, which were tender on percussion. The obliteration of the mucogingival junction was also noted. Radiographic examination with orthopantomogram (OPG) revealed periapical radiolucency concerning 36,37 and 38 with locules in the submandibular region (more on the right side than the left side), indicating air or pus 7.No details have been provided regarding the utilization of laboratory tests and radiographic imaging in the assessment. Answer: Radiographic examination with orthopantomogram (OPG) revealed periapical radiolucency concerning 36,37 and 38 with locules in the submandibular region (more on the right side than the left side), indicating air or pus. The pus was collected with a sterile swab and sent for culture and antibiotic sensitivity test. The culture sensitivity report revealed the sensitivity to prescribed empirical antibiotics; therefore, the same medicines were continued for a week. 8.What are the respective roles of the first and second authors in the execution of this research? Answer: The first author did the surgical procedure while the second author provided assistance. 9.Was consent obtained from the patient prior to the capture of clinical photographs? Answer: yes. We obtained consent for treatment and for capturing clinical photographs. Competing Interests: The authors declare no competing interest. Close Report a concern Respond or Comment COMMENTS ON THIS REPORT Author Response 27 Jun 2024 Siddharthan Selvaraj , Department of Dental Public Health, Faculty of Dentistry, AIMST University, Bedong, 08100, Malaysia 27 Jun 2024 Author Response Dear Reviewers, We would like to thank the reviewers for taking their valuable time to provide their insightful queries, we have provided our explanation for the same. Once again thank ... Continue reading Dear Reviewers, We would like to thank the reviewers for taking their valuable time to provide their insightful queries, we have provided our explanation for the same. Once again thank you for your feedback. 1.The authors have failed to reference any established protocols for the management of Ludwig's angina. Answer: Although there are no current guidelines for managing acute Ludwig's angina, the mainstay of the treatment includes airway maintenance and following the principles of infection control which we have already discussed. 2. What course of action should be pursued if the administration of steroids and epinephrine are contraindicated for a case of Ludwig's angina? Answer: Maintaining patent airway is the most important consideration. Removing the source of infection, antibiotics and Incision and drainage would be course of action . 3.The authors have neglected to include citations of recent publications. Is Ludwig's angina the most perilous type of facial and submandibular space infection? Answer: yes, it is highly perilous but in this antibiotic era it has become a rare infection which makes recent publications little difficult. 5.Justify the designation of 'dangerous space' in this context. Answer: It can either lead to airway obstruction or, at a later stage, cause dissemination of the infection, which then spreads through several other adjacent spatial planes. 5.The primary cause for the development of this condition in a 40-year-old male remains unspecified. Answer: yes the patient wasn’t immuno compromised or medically compromised at the time of diagnosis and it still happened 6.Which specific diagnostic procedures were employed in the examination of this particular case? Answer: There is no specific diagnostic test which gives the diagnosis for Ludwigs angina. It’s a combination of clinical examination, symptoms and radiographic examination. The patient reported hyperthermia (100° F), pulse rate of 99 beats per minute, respiratory rate of 25 breaths per minute, and oxygen saturation fluctuating between 88 to 90 SP02. On clinical examination, he reported a restricted mouth opening of only 19 mm (about 0.75 in), a tongue deviation [and evident dysphagia and dyspnea. Extra orally, the swelling was indurated, non-fluctuant, with bilateral involvement of the submandibular and sublingual spaces. His dentate status revealed root stumps in relation to 36 and 46 regions, which were tender on percussion. The obliteration of the mucogingival junction was also noted. Radiographic examination with orthopantomogram (OPG) revealed periapical radiolucency concerning 36,37 and 38 with locules in the submandibular region (more on the right side than the left side), indicating air or pus 7.No details have been provided regarding the utilization of laboratory tests and radiographic imaging in the assessment. Answer: Radiographic examination with orthopantomogram (OPG) revealed periapical radiolucency concerning 36,37 and 38 with locules in the submandibular region (more on the right side than the left side), indicating air or pus. The pus was collected with a sterile swab and sent for culture and antibiotic sensitivity test. The culture sensitivity report revealed the sensitivity to prescribed empirical antibiotics; therefore, the same medicines were continued for a week. 8.What are the respective roles of the first and second authors in the execution of this research? Answer: The first author did the surgical procedure while the second author provided assistance. 9.Was consent obtained from the patient prior to the capture of clinical photographs? Answer: yes. We obtained consent for treatment and for capturing clinical photographs. Dear Reviewers, We would like to thank the reviewers for taking their valuable time to provide their insightful queries, we have provided our explanation for the same. Once again thank you for your feedback. 1.The authors have failed to reference any established protocols for the management of Ludwig's angina. Answer: Although there are no current guidelines for managing acute Ludwig's angina, the mainstay of the treatment includes airway maintenance and following the principles of infection control which we have already discussed. 2. What course of action should be pursued if the administration of steroids and epinephrine are contraindicated for a case of Ludwig's angina? Answer: Maintaining patent airway is the most important consideration. Removing the source of infection, antibiotics and Incision and drainage would be course of action . 3.The authors have neglected to include citations of recent publications. Is Ludwig's angina the most perilous type of facial and submandibular space infection? Answer: yes, it is highly perilous but in this antibiotic era it has become a rare infection which makes recent publications little difficult. 5.Justify the designation of 'dangerous space' in this context. Answer: It can either lead to airway obstruction or, at a later stage, cause dissemination of the infection, which then spreads through several other adjacent spatial planes. 5.The primary cause for the development of this condition in a 40-year-old male remains unspecified. Answer: yes the patient wasn’t immuno compromised or medically compromised at the time of diagnosis and it still happened 6.Which specific diagnostic procedures were employed in the examination of this particular case? Answer: There is no specific diagnostic test which gives the diagnosis for Ludwigs angina. It’s a combination of clinical examination, symptoms and radiographic examination. The patient reported hyperthermia (100° F), pulse rate of 99 beats per minute, respiratory rate of 25 breaths per minute, and oxygen saturation fluctuating between 88 to 90 SP02. On clinical examination, he reported a restricted mouth opening of only 19 mm (about 0.75 in), a tongue deviation [and evident dysphagia and dyspnea. Extra orally, the swelling was indurated, non-fluctuant, with bilateral involvement of the submandibular and sublingual spaces. His dentate status revealed root stumps in relation to 36 and 46 regions, which were tender on percussion. The obliteration of the mucogingival junction was also noted. Radiographic examination with orthopantomogram (OPG) revealed periapical radiolucency concerning 36,37 and 38 with locules in the submandibular region (more on the right side than the left side), indicating air or pus 7.No details have been provided regarding the utilization of laboratory tests and radiographic imaging in the assessment. Answer: Radiographic examination with orthopantomogram (OPG) revealed periapical radiolucency concerning 36,37 and 38 with locules in the submandibular region (more on the right side than the left side), indicating air or pus. The pus was collected with a sterile swab and sent for culture and antibiotic sensitivity test. The culture sensitivity report revealed the sensitivity to prescribed empirical antibiotics; therefore, the same medicines were continued for a week. 8.What are the respective roles of the first and second authors in the execution of this research? Answer: The first author did the surgical procedure while the second author provided assistance. 9.Was consent obtained from the patient prior to the capture of clinical photographs? Answer: yes. We obtained consent for treatment and for capturing clinical photographs. Competing Interests: We declare no competing interest. Close Report a concern Author Response 25 Jun 2024 Siddharthan Selvaraj , Department of Dental Public Health, Faculty of Dentistry, AIMST University, Bedong, 08100, Malaysia 25 Jun 2024 Author Response 1.The authors have failed to reference any established protocols for the management of Ludwig's angina. Answer: Although there are no current guidelines for managing acute Ludwig's angina, the mainstay of ... Continue reading 1.The authors have failed to reference any established protocols for the management of Ludwig's angina. Answer: Although there are no current guidelines for managing acute Ludwig's angina, the mainstay of the treatment includes airway maintenance and following the principles of infection control which we have already discussed. 2.What course of action should be pursued if the administration of steroids and epinephrine are contraindicated for a case of Ludwig's angina? Answer: Maintaining patent airway is the most important consideration. Removing the source of infection, antibiotics and Incision and drainage would be course of action . 3.The authors have neglected to include citations of recent publications. Is Ludwig's angina the most perilous type of facial and submandibular space infection? Answer: yes, it is highly perilous but in this antibiotic era it has become a rare infection which makes recent publications little difficult. 4.Justify the designation of 'dangerous space' in this context. Answer: It can either lead to airway obstruction or, at a later stage, cause dissemination of the infection, which then spreads through several other adjacent spatial planes. 5.The primary cause for the development of this condition in a 40-year-old male remains unspecified. Answer: yes the patient wasn’t immuno compromised or medically compromised at the time of diagnosis and it still happened 6.Which specific diagnostic procedures were employed in the examination of this particular case? Answer: There is no specific diagnostic test which gives the diagnosis for Ludwigs angina. It’s a combination of clinical examination, symptoms and radiographic examination. T he patient reported hyperthermia (100° F), pulse rate of 99 beats per minute, respiratory rate of 25 breaths per minute, and oxygen saturation fluctuating between 88 to 90 SP02. On clinical examination, he reported a restricted mouth opening of only 19 mm (about 0.75 in), a tongue deviation [and evident dysphagia and dyspnea. Extra orally, the swelling was indurated, non-fluctuant, with bilateral involvement of the submandibular and sublingual spaces. His dentate status revealed root stumps in relation to 36 and 46 regions, which were tender on percussion. The obliteration of the mucogingival junction was also noted. Radiographic examination with orthopantomogram (OPG) revealed periapical radiolucency concerning 36,37 and 38 with locules in the submandibular region (more on the right side than the left side), indicating air or pus 7.No details have been provided regarding the utilization of laboratory tests and radiographic imaging in the assessment. Answer: Radiographic examination with orthopantomogram (OPG) revealed periapical radiolucency concerning 36,37 and 38 with locules in the submandibular region (more on the right side than the left side), indicating air or pus. The pus was collected with a sterile swab and sent for culture and antibiotic sensitivity test. The culture sensitivity report revealed the sensitivity to prescribed empirical antibiotics; therefore, the same medicines were continued for a week. 8.What are the respective roles of the first and second authors in the execution of this research? Answer: The first author did the surgical procedure while the second author provided assistance. 9.Was consent obtained from the patient prior to the capture of clinical photographs? Answer: yes. We obtained consent for treatment and for capturing clinical photographs. 1.The authors have failed to reference any established protocols for the management of Ludwig's angina. Answer: Although there are no current guidelines for managing acute Ludwig's angina, the mainstay of the treatment includes airway maintenance and following the principles of infection control which we have already discussed. 2.What course of action should be pursued if the administration of steroids and epinephrine are contraindicated for a case of Ludwig's angina? Answer: Maintaining patent airway is the most important consideration. Removing the source of infection, antibiotics and Incision and drainage would be course of action . 3.The authors have neglected to include citations of recent publications. Is Ludwig's angina the most perilous type of facial and submandibular space infection? Answer: yes, it is highly perilous but in this antibiotic era it has become a rare infection which makes recent publications little difficult. 4.Justify the designation of 'dangerous space' in this context. Answer: It can either lead to airway obstruction or, at a later stage, cause dissemination of the infection, which then spreads through several other adjacent spatial planes. 5.The primary cause for the development of this condition in a 40-year-old male remains unspecified. Answer: yes the patient wasn’t immuno compromised or medically compromised at the time of diagnosis and it still happened 6.Which specific diagnostic procedures were employed in the examination of this particular case? Answer: There is no specific diagnostic test which gives the diagnosis for Ludwigs angina. It’s a combination of clinical examination, symptoms and radiographic examination. T he patient reported hyperthermia (100° F), pulse rate of 99 beats per minute, respiratory rate of 25 breaths per minute, and oxygen saturation fluctuating between 88 to 90 SP02. On clinical examination, he reported a restricted mouth opening of only 19 mm (about 0.75 in), a tongue deviation [and evident dysphagia and dyspnea. Extra orally, the swelling was indurated, non-fluctuant, with bilateral involvement of the submandibular and sublingual spaces. His dentate status revealed root stumps in relation to 36 and 46 regions, which were tender on percussion. The obliteration of the mucogingival junction was also noted. Radiographic examination with orthopantomogram (OPG) revealed periapical radiolucency concerning 36,37 and 38 with locules in the submandibular region (more on the right side than the left side), indicating air or pus 7.No details have been provided regarding the utilization of laboratory tests and radiographic imaging in the assessment. Answer: Radiographic examination with orthopantomogram (OPG) revealed periapical radiolucency concerning 36,37 and 38 with locules in the submandibular region (more on the right side than the left side), indicating air or pus. The pus was collected with a sterile swab and sent for culture and antibiotic sensitivity test. The culture sensitivity report revealed the sensitivity to prescribed empirical antibiotics; therefore, the same medicines were continued for a week. 8.What are the respective roles of the first and second authors in the execution of this research? Answer: The first author did the surgical procedure while the second author provided assistance. 9.Was consent obtained from the patient prior to the capture of clinical photographs? Answer: yes. We obtained consent for treatment and for capturing clinical photographs. Competing Interests: The authors declare no competing interest. Close Report a concern COMMENT ON THIS REPORT Views 0 Cite How to cite this report: Tabnjh A. Reviewer Report For: Case Report: Ludwig's angina - 'The Dangerous Space' [version 2; peer review: 2 approved, 1 approved with reservations] . F1000Research 2024, 11 :1511 ( https://doi.org/10.5256/f1000research.139725.r158065 ) The direct URL for this report is: https://f1000research.com/articles/11-1511/v1#referee-response-158065 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 22 Dec 2022 Abedelmalek Tabnjh , Department of Applied Dental Sciences, Jordan University of Science and Technology, Ar-Ramtha, Jordan Approved VIEWS 0 https://doi.org/10.5256/f1000research.139725.r158065 This paper is a well prepared case report. In the introduction the authors were covered the Ludwig's angina's definition, history, etiology, risk factors and the objective of the report. Then, they described patient's details, symptoms, diagnostic procedure, and treatment. The ... Continue reading READ ALL This paper is a well prepared case report. In the introduction the authors were covered the Ludwig's angina's definition, history, etiology, risk factors and the objective of the report. Then, they described patient's details, symptoms, diagnostic procedure, and treatment. The discussion section covered all aspects of the topic very well with good details. Just one point for improving: It will be better if the authors added if the patient had any risk factors or not. Yes they mention that he didn't have any medical history, but what about other risk factors such as alcoholism and malnutrition? Over all this is a good case report. Is the background of the case’s history and progression described in sufficient detail? Yes Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes? Yes Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment? Yes Is the case presented with sufficient detail to be useful for other practitioners? Yes Competing Interests: No competing interests were disclosed. Reviewer Expertise: Oral Epidemiology, Biostatistics, Oral Hygiene, and Dental Materials. I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Tabnjh A. Reviewer Report For: Case Report: Ludwig's angina - 'The Dangerous Space' [version 2; peer review: 2 approved, 1 approved with reservations] . F1000Research 2024, 11 :1511 ( https://doi.org/10.5256/f1000research.139725.r158065 ) The direct URL for this report is: https://f1000research.com/articles/11-1511/v1#referee-response-158065 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Comments on this article Comments (0) Version 2 VERSION 2 PUBLISHED 13 Dec 2022 ADD YOUR COMMENT Comment keyboard_arrow_left keyboard_arrow_right Open Peer Review Reviewer Status info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Reviewer Reports Invited Reviewers 1 2 3 Version 2 (revision) 27 Jun 24 read Version 1 13 Dec 22 read read Abedelmalek Tabnjh , Jordan University of Science and Technology, Ar-Ramtha, Jordan Paramjot Kaur , Baba Jaswant Singh Dental College, Ludhiana, India Marcelo Silva Monnazzi , São Paulo State University (Unesp) School of Dentistry (Araraquara), Sao Paulo, Brazil Comments on this article All Comments (0) Add a comment Sign up for content alerts Sign Up You are now signed up to receive this alert Browse by related subjects keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2024 Monnazzi M. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 17 Sep 2024 | for Version 2 Marcelo Silva Monnazzi , São Paulo State University (Unesp) School of Dentistry (Araraquara), Sao Paulo, Brazil 0 Views copyright © 2024 Monnazzi M. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions The cases history and progression could be a little more detailed. But in general I think the article is good. And it is worth indexing. I just think that it is necessary to remove the citations that the Ludwig angina is a rare infection, because it is not so rare. At least the authors could state that it is rare in their area (if it was the case), because here in Brazil, it is not rare at all. Is the background of the case’s history and progression described in sufficient detail? Partly Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes? Yes Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment? Yes Is the case presented with sufficient detail to be useful for other practitioners? Yes Competing Interests No competing interests were disclosed. Reviewer Expertise Oral and maxillofacial surgeon for 24 years. Professor of oral and maxillofacial at the São Paulo state university for at least 17 years. DR. Msc. Phd. I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. reply Respond to this report Responses (0) Monnazzi MS. Peer Review Report For: Case Report: Ludwig's angina - 'The Dangerous Space' [version 2; peer review: 2 approved, 1 approved with reservations] . F1000Research 2024, 11 :1511 ( https://doi.org/10.5256/f1000research.166856.r321293) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/11-1511/v2#referee-response-321293 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2024 Kaur P. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 10 May 2024 | for Version 1 Paramjot Kaur , Baba Jaswant Singh Dental College, Ludhiana, Punjab, India 0 Views copyright © 2024 Kaur P. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (2) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions The authors have failed to reference any established protocols for the management of Ludwig's angina. What course of action should be pursued if the administration of steroids and epinephrine are contraindicated for a case of Ludwig's angina? The authors have neglected to include citations of recent publications. Is Ludwig's angina the most perilous type of facial and submandibular space infection? Justify the designation of 'dangerous space' in this context. The primary cause for the development of this condition in a 40-year-old male remains unspecified. Which specific diagnostic procedures were employed in the examination of this particular case? No details have been provided regarding the utilization of laboratory tests and radiographic imaging in the assessment. What are the respective roles of the first and second authors in the execution of this research? Was consent obtained from the patient prior to the capture of clinical photographs? The deficiency of comprehensive details in both the case presentation and subsequent deliberations is evident. Is the background of the case’s history and progression described in sufficient detail? Yes Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes? No Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment? Partly Is the case presented with sufficient detail to be useful for other practitioners? Yes Competing Interests No competing interests were disclosed. Reviewer Expertise oral and maxillofacial surgery I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (2) Author Response 27 Jun 2024 Siddharthan Selvaraj, Department of Dental Public Health, Faculty of Dentistry, AIMST University, Bedong, 08100, Malaysia Dear Reviewers, We would like to thank the reviewers for taking their valuable time to provide their insightful queries, we have provided our explanation for the same. Once again thank you for your feedback. 1.The authors have failed to reference any established protocols for the management of Ludwig's angina. Answer: Although there are no current guidelines for managing acute Ludwig's angina, the mainstay of the treatment includes airway maintenance and following the principles of infection control which we have already discussed. 2. What course of action should be pursued if the administration of steroids and epinephrine are contraindicated for a case of Ludwig's angina? Answer: Maintaining patent airway is the most important consideration. Removing the source of infection, antibiotics and Incision and drainage would be course of action . 3.The authors have neglected to include citations of recent publications. Is Ludwig's angina the most perilous type of facial and submandibular space infection? Answer: yes, it is highly perilous but in this antibiotic era it has become a rare infection which makes recent publications little difficult. 5.Justify the designation of 'dangerous space' in this context. Answer: It can either lead to airway obstruction or, at a later stage, cause dissemination of the infection, which then spreads through several other adjacent spatial planes. 5.The primary cause for the development of this condition in a 40-year-old male remains unspecified. Answer: yes the patient wasn’t immuno compromised or medically compromised at the time of diagnosis and it still happened 6.Which specific diagnostic procedures were employed in the examination of this particular case? Answer: There is no specific diagnostic test which gives the diagnosis for Ludwigs angina. It’s a combination of clinical examination, symptoms and radiographic examination. The patient reported hyperthermia (100° F), pulse rate of 99 beats per minute, respiratory rate of 25 breaths per minute, and oxygen saturation fluctuating between 88 to 90 SP02. On clinical examination, he reported a restricted mouth opening of only 19 mm (about 0.75 in), a tongue deviation [and evident dysphagia and dyspnea. Extra orally, the swelling was indurated, non-fluctuant, with bilateral involvement of the submandibular and sublingual spaces. His dentate status revealed root stumps in relation to 36 and 46 regions, which were tender on percussion. The obliteration of the mucogingival junction was also noted. Radiographic examination with orthopantomogram (OPG) revealed periapical radiolucency concerning 36,37 and 38 with locules in the submandibular region (more on the right side than the left side), indicating air or pus 7.No details have been provided regarding the utilization of laboratory tests and radiographic imaging in the assessment. Answer: Radiographic examination with orthopantomogram (OPG) revealed periapical radiolucency concerning 36,37 and 38 with locules in the submandibular region (more on the right side than the left side), indicating air or pus. The pus was collected with a sterile swab and sent for culture and antibiotic sensitivity test. The culture sensitivity report revealed the sensitivity to prescribed empirical antibiotics; therefore, the same medicines were continued for a week. 8.What are the respective roles of the first and second authors in the execution of this research? Answer: The first author did the surgical procedure while the second author provided assistance. 9.Was consent obtained from the patient prior to the capture of clinical photographs? Answer: yes. We obtained consent for treatment and for capturing clinical photographs. View more View less Competing Interests We declare no competing interest. reply Respond Report a concern Author Response 25 Jun 2024 Siddharthan Selvaraj, Department of Dental Public Health, Faculty of Dentistry, AIMST University, Bedong, 08100, Malaysia 1.The authors have failed to reference any established protocols for the management of Ludwig's angina. Answer: Although there are no current guidelines for managing acute Ludwig's angina, the mainstay of the treatment includes airway maintenance and following the principles of infection control which we have already discussed. 2.What course of action should be pursued if the administration of steroids and epinephrine are contraindicated for a case of Ludwig's angina? Answer: Maintaining patent airway is the most important consideration. Removing the source of infection, antibiotics and Incision and drainage would be course of action . 3.The authors have neglected to include citations of recent publications. Is Ludwig's angina the most perilous type of facial and submandibular space infection? Answer: yes, it is highly perilous but in this antibiotic era it has become a rare infection which makes recent publications little difficult. 4.Justify the designation of 'dangerous space' in this context. Answer: It can either lead to airway obstruction or, at a later stage, cause dissemination of the infection, which then spreads through several other adjacent spatial planes. 5.The primary cause for the development of this condition in a 40-year-old male remains unspecified. Answer: yes the patient wasn’t immuno compromised or medically compromised at the time of diagnosis and it still happened 6.Which specific diagnostic procedures were employed in the examination of this particular case? Answer: There is no specific diagnostic test which gives the diagnosis for Ludwigs angina. It’s a combination of clinical examination, symptoms and radiographic examination. T he patient reported hyperthermia (100° F), pulse rate of 99 beats per minute, respiratory rate of 25 breaths per minute, and oxygen saturation fluctuating between 88 to 90 SP02. On clinical examination, he reported a restricted mouth opening of only 19 mm (about 0.75 in), a tongue deviation [and evident dysphagia and dyspnea. Extra orally, the swelling was indurated, non-fluctuant, with bilateral involvement of the submandibular and sublingual spaces. His dentate status revealed root stumps in relation to 36 and 46 regions, which were tender on percussion. The obliteration of the mucogingival junction was also noted. Radiographic examination with orthopantomogram (OPG) revealed periapical radiolucency concerning 36,37 and 38 with locules in the submandibular region (more on the right side than the left side), indicating air or pus 7.No details have been provided regarding the utilization of laboratory tests and radiographic imaging in the assessment. Answer: Radiographic examination with orthopantomogram (OPG) revealed periapical radiolucency concerning 36,37 and 38 with locules in the submandibular region (more on the right side than the left side), indicating air or pus. The pus was collected with a sterile swab and sent for culture and antibiotic sensitivity test. The culture sensitivity report revealed the sensitivity to prescribed empirical antibiotics; therefore, the same medicines were continued for a week. 8.What are the respective roles of the first and second authors in the execution of this research? Answer: The first author did the surgical procedure while the second author provided assistance. 9.Was consent obtained from the patient prior to the capture of clinical photographs? Answer: yes. We obtained consent for treatment and for capturing clinical photographs. View more View less Competing Interests The authors declare no competing interest. reply Respond Report a concern Kaur P. Peer Review Report For: Case Report: Ludwig's angina - 'The Dangerous Space' [version 2; peer review: 2 approved, 1 approved with reservations] . F1000Research 2024, 11 :1511 ( https://doi.org/10.5256/f1000research.139725.r272616) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/11-1511/v1#referee-response-272616 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2022 Tabnjh A. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 22 Dec 2022 | for Version 1 Abedelmalek Tabnjh , Department of Applied Dental Sciences, Jordan University of Science and Technology, Ar-Ramtha, Jordan 0 Views copyright © 2022 Tabnjh A. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions This paper is a well prepared case report. In the introduction the authors were covered the Ludwig's angina's definition, history, etiology, risk factors and the objective of the report. Then, they described patient's details, symptoms, diagnostic procedure, and treatment. The discussion section covered all aspects of the topic very well with good details. Just one point for improving: It will be better if the authors added if the patient had any risk factors or not. Yes they mention that he didn't have any medical history, but what about other risk factors such as alcoholism and malnutrition? Over all this is a good case report. Is the background of the case’s history and progression described in sufficient detail? Yes Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes? Yes Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment? Yes Is the case presented with sufficient detail to be useful for other practitioners? Yes Competing Interests No competing interests were disclosed. Reviewer Expertise Oral Epidemiology, Biostatistics, Oral Hygiene, and Dental Materials. I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. reply Respond to this report Responses (0) Tabnjh A. Peer Review Report For: Case Report: Ludwig's angina - 'The Dangerous Space' [version 2; peer review: 2 approved, 1 approved with reservations] . F1000Research 2024, 11 :1511 ( https://doi.org/10.5256/f1000research.139725.r158065) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. 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