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