The Graham Steell murmur of pulmonary regurgitation, a high-pitched, diastolic, decrescendo blowing murmur along the left sternal border, results from dilation of the pulmonary valve ring and occurs in patients with mitral valve disease and severe pulmonary hypertension. This murmur may be indistinguishable from the more common murmur produced by aortic regurgitation (AR), although it may increase in intensity with inspiration and is accompanied by a loud and often palpable P2. Echocardiography
In most cases, the diagnosis of mitral stenosis is most easily made by echocardiography, which shows left atrial enlargement, thick and calcified mitral valve with narrow and "fish-mouth"-shaped orifice and signs of right ventricular failure in advanced disease. It can also show decreased opening of the mitral valve leaflets, and increased blood flow velocity during diastole. The trans-mitral gradient as measured by Doppler echocardiography is the gold standard in the evaluation of the severity of mitral stenosis. Cardiac chamber catheterization
Another method of measuring the severity of mitral stenosis is the simultaneous left and right heart chamber catheterization. The right heart catheterization (commonly known as Swan-Ganz catheterization) gives the physician the mean pulmonary capillary wedge pressure, which is a reflection of the left atrial pressure. The left heart catheterization, on the other hand, gives the pressure in the left ventricle. By simultaneously taking these pressures, it is possible to determine the gradient between the left atrium and left ventricle during ventricular diastole, which is a marker for the severity of mitral stenosis.
Antibiotics
Antibiotic therapy is empirical, it is given until culture and sensitivity results are obtained. The empirical therapy should be effective against both aerobic and anaerobic bacteria species commonly involved in Ludwigs Angina. Only when culture and sensitivity results return should therapy be tailored to the specific requirements of the patient.Empirical coverage should consist of either a penicillin with a B-lactamase inhibitor such as amoxicillin/ticarcillin with clavulanic acid or a Beta-lactamase resistant antibiotic such as cefoxitin, cefuroxime, imipenem or meropenem. This should be given in combination with a drug effective against anaerobes such as clindamycin or metronidazole. Parenteral antibiotics are suggested until the patient is no longer febrile for at least 48 hours. Oral therapy can then commence to last for 2 weeks, with amoxicillin with clavulanic acid, clindamycin, ciprofloxacin, trimethoprim-sulfamethoxazole, or metronidazole. Incision and drainage
Surgical incision and drainage are the main methods in managing severe and complicated deep neck infections that fail to respond to medical management within 48 hours. It is indicated in cases of:Airway compromise
Septicaemia
Deteriorating condition
Descending infection
Diabetes mellitus
Palpable or radiographic evidence of abscess formation
Bilateral submandibular incisions should be carried out in addition to a midline submental incision. Access to the supramylohyoid spaces can be gained by blunt dissection through the mylohyoid muscle from below. Penrose drains are recommended in both supramylohyoid and inframylohyoid spaces bilaterally. In addition, through and through drains from the submandibular space to the submental space on both sides should be placed as well. The incision and drainage process is completed with the debridement of necrotic tissue and thorough irrigation.