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Home | Medical Specialty | Infectious Disease | Ludwig angina

Ludwig angina

by Dr Chris Nickson, last update April 23, 2019

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

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About Dr Chris Nickson

An oslerphile emergency physician and intensivist suffering from a bad case of knowledge dipsosis. Key areas of interest include: the ED-ICU interface, toxicology, simulation and the free open-access meducation (FOAM) revolution. @Twitter | INTENSIVE| SMACC

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