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
Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health, a Clinical Adjunct Associate Professor at Monash University, and the Chair of the Australian and New Zealand Intensive Care Society (ANZICS) Education Committee. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.
After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.
He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE. He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of LITFL.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.
His one great achievement is being the father of two amazing children.
On Twitter, he is @precordialthump.
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