The use of Neutrophil – Lymphocyte Ratio (NLR) as a potential biomarker to predict the prognosis of Ludwig's angina patients

Ruli Sakarozi; Dwi Hari Susilo; Marjono Dwi Wibowo

doi:10.15562/bmj.v11i3.3612

The use of Neutrophil – Lymphocyte Ratio (NLR) as a potential biomarker to predict the prognosis of Ludwig's angina patients

Ruli Sakarozi ,

Dwi Hari Susilo ,

Marjono Dwi Wibowo ,

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DOI: https://doi.org/10.15562/bmj.v11i3.3612 |
Published: 2022-11-13

Abstract

Background: Ludwig's angina is an infection of the submandibular cavity in the form of cellulitis that is rapidly progressive and potentially life-threatening. Neutrophils and lymphocytes play an important role in this infection process. Neutrophil-lymphocyte Ratio (NLR) is a simple biomarker to evaluate systemic inflammation. We aimed to determine the association between NLR and various prognostic parameters in patients with Ludwig's Angina.

Methods: A retrospective cohort study was conducted using medical records of Ludwig's Angina patients treated at Dr. Soetomo General Hospital, Surabaya, Indonesia, between January 2018 – December 2021. The NLR cut-off value was calculated using the receiver operating characteristics (ROC) curve. The association between NLR with severity, length of stay (LoS), and mortality were analyzed using SPSS version 23 for Windows.

Results: We recruited a total of 96 patients. NLR values are divided categorically into low NLR and high NLR using a cut-off value of 16.86. There were 49 patients (51%) with low NLR and 47 (49%) with high NLR. There was a significant relationship between NLR with severity, LoS, and mortality in Ludwig’s angina patients (p=0.032, p=0.002, and p=0.026, respectively). According to a survival study, the high NLR group's survival rate was significantly lower than the low NLR group's (p=0.009).

Conclusion: There was a significant relationship between NLR severity grading, survival, and the length of stay in patients with Ludwig's Angina.

References

Moreland LW, Corey J, McKenzie R. Ludwig’s angina. Report of a case and review of the literature. Arch Intern Med. 1988;148(2):461–466.
Candamourty R, Venkatachalam S, Babu MR, Kumar GS. Ludwig's Angina - An emergency: A case report with literature review. J Nat Sci Biol Med. 2012;3(2):206-208.
Grodinsky M. Ludwig’s angina: an anatomical and clinical study with review of the literature. Surgery. 1939;5(5):678–696.
Rijal S, Romdhoni AC. Bacteria Pattern, Results of Antibiotic Sensitivity Test, and Complications of Deep Neck Abscess Patients in Dr. Soetomo General Hospital. Biomol Heal Sci J. 2018;1(2):124–130.
Re Cecconi D, Fornara R. Ludwig’s angina: a case report with a 5-year follow-up. G Ital Endod. 2018;32(2):70–75.
Martins EC, Silveira L da F, Viegas K, Beck AD, Fioravantti Júnior G, Cremonese RV, et al. Neutrophil-lymphocyte ratio in the early diagnosis of sepsis in an intensive care unit: a case-control study. Rev Bras Ter intensiva. 2019;31(1):64–70.
Lowsby R, Gomes C, Jarman I, Lisboa P, Nee PA, Vardhan M, et al. Neutrophil to lymphocyte count ratio as an early indicator of bloodstream infection in the emergency department. Emerg Med J. 2015;32(7):531– 534.
Saputra HM, Hakim L. The Prognostic Role of Neutrophil-to-Lymphocyte Ratio (NLR) in Testicular Germ Cell Tumor (GCT). Folia Medica Indones. 2022;58(1):39–45.
Sainuddin S, Hague R, Howson K, Clark S. New admission scoring criteria for patients with odontogenic infections: a pilot study. Br J Oral Maxillofac Surg. 2017;55(1):86–89.
Bansal A, Miskoff J, Lis RJ. Otolaryngologic critical care. Crit Care Clin. 2003;19(1):55–72.
Bridwell R, Gottlieb M, Koyfman A, Long B. Diagnosis and management of Ludwig’s angina: An evidence-based review. Am J Emerg Med. 2021;41:1–5.
Tu A, Gilbert JD, Byard RW. Ludwig angina and sudden death. Forensic Sci Med Pathol. 2021;17(3):506–509.
Kimura A, Miyamoto S, Yamashita T. Clinical predictors of descending necrotizing mediastinitis after deep neck infections. Laryngoscope. 2020;130(11):E567–72.
Baglam T, Binnetoglu A, Yumusakhuylu AC, Gerin F, Demir B, Sari M. Predictive value of the neutrophil-to-lymphocyte ratio in patients with deep neck space infection secondary to acute bacterial tonsillitis. Int J Pediatr Otorhinolaryngol. 2015;79(9):1421–1424.
de Jager CPC, van Wijk PTL, Mathoera RB, de Jongh-Leuvenink J, van der Poll T, Wever PC. Lymphocytopenia and neutrophil-lymphocyte count ratio predict bacteremia better than conventional infection markers in an emergency care unit. Crit Care. 2010;14(5):R192.
Liu X, Shen Y, Wang H, Ge Q, Fei A, Pan S. Prognostic Significance of Neutrophil-to-Lymphocyte Ratio in Patients with Sepsis: A Prospective Observational Study. Mediators Inflamm. 2016;2016:8191254.
Zahorec R. Ratio of neutrophil to lymphocyte counts--rapid and simple parameter of systemic inflammation and stress in critically ill. Bratisl Lek Listy. 2001;102(1):5–14.
Gürol G, Çiftci İH, Terizi HA, Atasoy AR, Ozbek A, Köroğlu M. Are there standardized cut-off values for neutrophil-lymphocyte ratios in bacteremia or sepsis? J Microbiol Biotechnol. 2015;25(4):521–525.
Dogruel F, Gonen ZB, Gunay-Canpolat D, Zararsiz G, Alkan A. The neutrophil-to-lymphocyte ratio as a marker of recovery status in patients with severe dental infection. Med Oral Patol Oral Cir Bucal. 2017;22(4):e440–5.
Velissaris D, Pantzaris ND, Bountouris P, Gogos C. Correlation between neutrophil-to-lymphocyte ratio and severity scores in septic patients upon hospital admission. A series of 50 patients. Rom J Intern Med. 2018;56(3):153–157.
Wardhana AA, Lesmana T. Neutrophil Lymphocyte Ratio (NLR) as a predictive factor radiological response of Neoadjuvant Chemotherapy (NAC) in Locally Advanced Rectal Cancer (LARC). Bali Med J. 2021;10(2):717-723.
Tanojo N, Damayanti, Utomo B, Ervianti E, Murtiastutik D, Prakoeswa CRS, et al. Diagnostic Value of Neutrophil-to-Lymphocyte Ratio, Lymphocyte-to-Monocyte Ratio, and Platelet-to-Lymphocyte Ratio in the Diagnosis of Erythema Nodosum Leprosum: A Retrospective Study. Trop Med Infect Dis. 2022;7(3):39.
Akilli NB, Yortanli M, Mutlu H, Günaydin YK, Koylu R, Akca HS, et al. Prognostic importance of neutrophil-lymphocyte ratio in critically ill patients: Short- and long-term outcomes. Am J Emerg Med. 2014;32(12):1476–1480.
Hwang SY, Shin TG, Jo IJ, Jeon K, Suh GY, Lee TR, et al. Neutrophil-to-lymphocyte ratio as a prognostic marker in critically-ill septic patients. Am J Emerg Med. 2017;35(2):234–239.
Riché F, Gayat E, Barthélémy R, Le Dorze M, Matéo J, Payen D. Reversal of neutrophil-to-lymphocyte count ratio in early versus late death from septic shock. Crit Care. 2015;19:439.
Prabawa IPY, Bhargah A, Liwang F, Tandio DA, Tandio AL, Lestari AAW, et al. Pretreatment Neutrophil-to-Lymphocyte ratio (NLR) and Platelet-to-Lymphocyte Ratio (PLR) as a Predictive Value of Hematological Markers in Cervical Cancer. Asian Pac J Cancer Prev. 2019;20(3):863-868.

[1] Moreland LW, Corey J, McKenzie R. Ludwig’s angina. Report of a case and review of the literature. Arch Intern Med. 1988;148(2):461–466.

[2] Candamourty R, Venkatachalam S, Babu MR, Kumar GS. Ludwig's Angina - An emergency: A case report with literature review. J Nat Sci Biol Med. 2012;3(2):206-208.

[3] Grodinsky M. Ludwig’s angina: an anatomical and clinical study with review of the literature. Surgery. 1939;5(5):678–696.

[4] Rijal S, Romdhoni AC. Bacteria Pattern, Results of Antibiotic Sensitivity Test, and Complications of Deep Neck Abscess Patients in Dr. Soetomo General Hospital. Biomol Heal Sci J. 2018;1(2):124–130.

[5] Re Cecconi D, Fornara R. Ludwig’s angina: a case report with a 5-year follow-up. G Ital Endod. 2018;32(2):70–75.

[6] Martins EC, Silveira L da F, Viegas K, Beck AD, Fioravantti Júnior G, Cremonese RV, et al. Neutrophil-lymphocyte ratio in the early diagnosis of sepsis in an intensive care unit: a case-control study. Rev Bras Ter intensiva. 2019;31(1):64–70.

[7] Lowsby R, Gomes C, Jarman I, Lisboa P, Nee PA, Vardhan M, et al. Neutrophil to lymphocyte count ratio as an early indicator of bloodstream infection in the emergency department. Emerg Med J. 2015;32(7):531– 534.

[8] Saputra HM, Hakim L. The Prognostic Role of Neutrophil-to-Lymphocyte Ratio (NLR) in Testicular Germ Cell Tumor (GCT). Folia Medica Indones. 2022;58(1):39–45.

[9] Sainuddin S, Hague R, Howson K, Clark S. New admission scoring criteria for patients with odontogenic infections: a pilot study. Br J Oral Maxillofac Surg. 2017;55(1):86–89.

[10] Bansal A, Miskoff J, Lis RJ. Otolaryngologic critical care. Crit Care Clin. 2003;19(1):55–72.

[11] Bridwell R, Gottlieb M, Koyfman A, Long B. Diagnosis and management of Ludwig’s angina: An evidence-based review. Am J Emerg Med. 2021;41:1–5.

[12] Tu A, Gilbert JD, Byard RW. Ludwig angina and sudden death. Forensic Sci Med Pathol. 2021;17(3):506–509.

[13] Kimura A, Miyamoto S, Yamashita T. Clinical predictors of descending necrotizing mediastinitis after deep neck infections. Laryngoscope. 2020;130(11):E567–72.

[14] Baglam T, Binnetoglu A, Yumusakhuylu AC, Gerin F, Demir B, Sari M. Predictive value of the neutrophil-to-lymphocyte ratio in patients with deep neck space infection secondary to acute bacterial tonsillitis. Int J Pediatr Otorhinolaryngol. 2015;79(9):1421–1424.

[15] de Jager CPC, van Wijk PTL, Mathoera RB, de Jongh-Leuvenink J, van der Poll T, Wever PC. Lymphocytopenia and neutrophil-lymphocyte count ratio predict bacteremia better than conventional infection markers in an emergency care unit. Crit Care. 2010;14(5):R192.

[16] Liu X, Shen Y, Wang H, Ge Q, Fei A, Pan S. Prognostic Significance of Neutrophil-to-Lymphocyte Ratio in Patients with Sepsis: A Prospective Observational Study. Mediators Inflamm. 2016;2016:8191254.

[17] Zahorec R. Ratio of neutrophil to lymphocyte counts--rapid and simple parameter of systemic inflammation and stress in critically ill. Bratisl Lek Listy. 2001;102(1):5–14.

[18] Gürol G, Çiftci İH, Terizi HA, Atasoy AR, Ozbek A, Köroğlu M. Are there standardized cut-off values for neutrophil-lymphocyte ratios in bacteremia or sepsis? J Microbiol Biotechnol. 2015;25(4):521–525.

[19] Dogruel F, Gonen ZB, Gunay-Canpolat D, Zararsiz G, Alkan A. The neutrophil-to-lymphocyte ratio as a marker of recovery status in patients with severe dental infection. Med Oral Patol Oral Cir Bucal. 2017;22(4):e440–5.

[20] Velissaris D, Pantzaris ND, Bountouris P, Gogos C. Correlation between neutrophil-to-lymphocyte ratio and severity scores in septic patients upon hospital admission. A series of 50 patients. Rom J Intern Med. 2018;56(3):153–157.

[21] Wardhana AA, Lesmana T. Neutrophil Lymphocyte Ratio (NLR) as a predictive factor radiological response of Neoadjuvant Chemotherapy (NAC) in Locally Advanced Rectal Cancer (LARC). Bali Med J. 2021;10(2):717-723.

[22] Tanojo N, Damayanti, Utomo B, Ervianti E, Murtiastutik D, Prakoeswa CRS, et al. Diagnostic Value of Neutrophil-to-Lymphocyte Ratio, Lymphocyte-to-Monocyte Ratio, and Platelet-to-Lymphocyte Ratio in the Diagnosis of Erythema Nodosum Leprosum: A Retrospective Study. Trop Med Infect Dis. 2022;7(3):39.

[23] Akilli NB, Yortanli M, Mutlu H, Günaydin YK, Koylu R, Akca HS, et al. Prognostic importance of neutrophil-lymphocyte ratio in critically ill patients: Short- and long-term outcomes. Am J Emerg Med. 2014;32(12):1476–1480.

[24] Hwang SY, Shin TG, Jo IJ, Jeon K, Suh GY, Lee TR, et al. Neutrophil-to-lymphocyte ratio as a prognostic marker in critically-ill septic patients. Am J Emerg Med. 2017;35(2):234–239.

[25] Riché F, Gayat E, Barthélémy R, Le Dorze M, Matéo J, Payen D. Reversal of neutrophil-to-lymphocyte count ratio in early versus late death from septic shock. Crit Care. 2015;19:439.

[26] Prabawa IPY, Bhargah A, Liwang F, Tandio DA, Tandio AL, Lestari AAW, et al. Pretreatment Neutrophil-to-Lymphocyte ratio (NLR) and Platelet-to-Lymphocyte Ratio (PLR) as a Predictive Value of Hematological Markers in Cervical Cancer. Asian Pac J Cancer Prev. 2019;20(3):863-868.

The use of Neutrophil – Lymphocyte Ratio (NLR) as a potential biomarker to predict the prognosis of Ludwig's angina patients

Abstract

References

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