Ludwig's angina
Background
- Bilateral infection of submental, submandibular, and sublingual spaces
- Cellulitis without clear fluctuance/abscess
- 85% of cases arise from an odontogenic source, usually mandibular molars
- Strep, staphylococcus, bacteroides
- Patients usually 20-60yr; male predominance
- Intubation may be very difficult
- Consider awake endoscopic NP or OP intubation
- Anesthesia or ENT back-up if possible
Clinical Features
- Dysphagia
- Odynophagia
- Trismus
- Edema of upper midline neck and floor of mouth
- Late signs
- Stridor, drooling, cyanosis
Diagnosis
- Classical definition
- Infection of sublingual AND submylohyoid/submaxillary spaces
- Begins in floor of mouth
- Aggressive "woody" or brawny cellulitis in submandibular space
- No lymphatic involvement
- Generally no abscess formation
- Bilateral infection
- CT face with contrast
- Only obtain if diagnosis is question
- Pt may lose airway in scanner if lies flat
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
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[1]
Immunocompetent Host
Antibiotics Options:[2]
- 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
- 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
See Also
Source
- Tintinalli
- ER Atlas
- Rosen's
- Uptodate