Ludwig's angina
Revision as of 14:13, 26 August 2014 by Ostermayer (talk | contribs)
Background
- Bilateral infection of submental, submandibular, and sublingual spaces
- Cellulitis without clear fluctuance/abscess should heighten suspicion
- 85% of cases arise from an odontogenic source, usually mandibular molars
- Source of infection are polymicrobial most commonly Strep Staphylococcus and Bacteroides species
- Patients usually 20-60yr; male predominance [1]
- Often there is noo lymphatic involvement and no abscess formation but infection rapidly spreads bilateraly
Clinical Features
Early Signs
- Dysphagia
- Odynophagia
- Trismus
- Edema of upper midline neck and floor of mouth
- "Woody" or brawny texture to floor of mouth with visible swelling and errythema
Late signs
- Stridor, drooling, cyanosis
Diagnosis
Classical definition
- Infection of sublingual AND submylohyoid/submaxillary spaces
Imaging Studies
- CT face with contrast will help delineate area of inifection
- Only necessary to obtain imaging if diagnosis is question. Imaging should not delay emergent airway managment and as patient lays flat in CT scanner there is a high risk for respiratory failure.
Treatment
Airway Managment
- Airway management
- Preference for an awake Intubation
- Emergent ENT consult for operative I&D and extraction of dentition if source is dental abscess
- Intubation may be very difficult due to trismus and posterior pharyngeal extension
- Consider awake fiberoptic with Anesthesia or ENT back-up with setup for Cricothyrotomy
Antibiotics
- Must cover typical polymicrobial oral flora and tailored based on patient's immune status
- Most commonly a 3rd generation cehpalosporin + (clindamycin or metronidazole)
- If the patient is immuncompromised, the antibiotics need to also cover MRSA and gram-negative rods[2]
Immunocompetent Host
Antibiotics Options:[3]
- Ampicillin/Sulbactam 3 g IV q6 hrs
- Penicillin G 2-4 MU IV q6 hrs + metronidazole 500 mg IV q6 hrs
- Clindamycin 600 mg IV q6 hrs (option for those allergic to penicillin)
Immunocompromised
Antibiotics Options:[3]
- Cefepime 2 g IV q12 hrs + Metronidazole 500 mg IV q6 hrs
- Meropenem 1 g IV q8 hrs
- Piperacillin-tazobactam 4.5 g IV q6 hrs
- Add Vancomycin 15-20 mg/kg q8 hrs (max 2 g per dose) if concern for MRSA risk factors
Disposition
- Admit, usually ICU for airway monitoring