Ludwig angina

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

Risk factors

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

INVESTIGATIONS

CT neck and face

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

LITFL

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