OVERVIEW
Ludwig angina: rapidly progressive gangrenous bilateral cellulitis of the submandibular space with risk of life-threatening airway compromise
PATHOPHYSIOLOGY
Submandibular space
- subdivided by the mylohyoid muscle into the sublingual space superiorly and submaxillary space inferiorly
- Once an infection is present, it may spread freely through tissue planes because of communicating spaces and results in the bilateral nature of Ludwig’s angina
- Infection can also spread to pharyngomaxillary and retropharyngeal spaces
Typically polymicrobial flora with causative organisms including GPCs, GNBs and anaerobes such as
- Streptococcus pyogenes
- Staphylococcus aureus
- Prevotella melaninogenicus
- Fusobacterium spp.
Risk factors
- Diabetes mellitus
- Chronic alcohol abuse
- intravenous drug abuse
- HIV/ AIDS
- Malnutrition
- Poor oral hygiene
- Recent dental procedures
70% of Ludwig’s angina is odontogenic in origin
CLINICAL FEATURES
- Mouth and throat pain
- Trismus (limited mouth opening)
- Hot potato voice
- Inability to swallow saliva and stridor suggest imminent airway compromise
- Fever, tachycardia, and progression to septic shock
- Bull neck appearance
- Tripod position and respiratory distress
- Tongue appears displaced superiorly and anteriorly, and inability to protrude the tongue
- Tenderness over the neck and throat
- Submandibular “woody” induration, crepitus or tenderness
Complications
- airway compromise
- mediastinitis
- septic shock
INVESTIGATIONS
CT neck and face
- airway patency
- extent of soft-tissue swelling
- Underlying dental disease
- Local skin thickening
- Increased attenuation of subcutaneous fat
- Muscle enlargement
- Loss of fat planes within the submandibular space
- soft tissue emphysema
- focal fluid collections (abscess)
- rapidly progressive cellulitis of the floor of the mouth
MANAGEMENT
Resuscitation
- Attend to ABCs
- sit upright
- often the airway can be conservatively managed
- awake fiberoptic intubation or awake tracheostomy may be required
- nebulised adrenaline may be helpful as a temporising measure
- treat septic shock if present
Early administration of antibiotics
- Metronidazole 500mg IV every 12 hours AND Benzylpenicillin 1.2g IV every 6 hours
- For patients with non-immediate hypersensitivity to penicillin: Cephazolin 1g IV every 8 hours
- For patients with immediate hypersensitivity to penicillin: clindamycin 450 mg IV every 8 hours OR lincomycin 600 mg IV every 8 hours
Steroids
- Dexamethasone 8-12 mg IV initially then give in dose’s of 4-8mg every 6 hours for the first 48 hours
- It’s postulated that dexamethasone provides initial chemical decompression by decreasing oedema and cellulitis, thus allowing improved penetration of antibiotics in the area
Source control
- needle aspiration
- surgical decompression of the sublingual, submental and submandibular spaces if: airway compromise, focal collections, necrotizing infection, poor response to antibiotics
Supportive care and monitoring
- close airway observation on a specialised airway unit if definitive airway deemed unnecessary
Disposition
- Early notification of ENT, anaesthetics and the operating theatres to facilitate definitive airway management if needed
- Early referral to the maxillofacial surgical team for surgical decompression
- Admitted to ICU, for further supportive and post operative care
PROGNOSIS
- high mortality untreated
- mortality ~8% with appropriate therapy
References and Links
LITFL
- Eponymictionary – Wilhelm Frederick von Ludwig (1790 – 1865).
- Eponymictionary – Ludwig Angina.
- Clinical Case – The True Angina.
Journal Articles
- Buckley, M. & O’Connor, K. (2009). Ludwig’s angina in a 76-year-old man. Emergency Medicine Journal. 26(9), 679-680. PMID: 19700596
- Costain, N. & Marrie, T. (2011). Ludwig’s Angina. The American Journal of Medicine. 124, (2) 115-117. PMID: 20961522
- Duprey, K. & Rose, J. (2010). Ludwig’s Angina. International Journal of Emergency Medicine. 3, 201-202. PMID: 21031047
- Reynolds, S. & Chow, A. (2009). Severe soft tissue infections of the head and neck: A primer for the critical care physicians. Lung. 187, 271-279. PMID: 19653038
- Saifeldeen K, Evans R. Ludwig’s angina. Emerg Med J. 2004 Mar;21(2):242-3. PMC1726306.
- Wolfe, M. Davis, J. & Parks, S. (2011). Is surgical airway necessary for airway management in deep neck infections and Ludwig’s angina? Journal of Critical Care. 26, 11-14. PMID: 20537506
Critical Care
Compendium
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