Ludwig's angina: Difference between revisions

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== Background ==
==Background==
*Bilateral infection of submental, submandibular, and sublingual spaces
*Bilateral infection of submental, submandibular, and sublingual spaces
*Cellulitis without clear fluctuance/abscess
*[[Cellulitis]] without clear fluctuance/[[abscess]] should heighten suspicion
*85% of cases arise from an odontogenic source, usually mandibular molars  
*85% of cases arise from an odontogenic source, usually mandibular molars
**Strep, staphylococcus, bacteroides
*Source of infection are polymicrobial most commonly [[Strep]] [[Staphylococcus]] and Bacteroides species
*Patients usually 20-60yr; male predominance  
*Patients usually 20-60yr; male predominance <ref>Buckley M, O’Connor K.  Ludwig’s angina in a 76-year-old man.  Emerg Med J. 2009;26:679-680</ref>
*Intubation may be very difficult
*Often there is no lymphatic involvement and no [[abscess]] formation but infection rapidly spreads bilaterally
**Consider awake endoscopic NP or OP intubation
**Anesthesia or ENT back-up if possible


== Clinical Features ==
==Clinical Features==
*Dysphagia
===Early Signs===
*[[Dysphagia]]
*Odynophagia
*Odynophagia
*Trismus
*Trismus
*Edema of upper midline neck and floor of mouth
*Edema of upper midline neck and floor of mouth
*Late signs
**Raised tongue
**Stridor, drooling, cyanosis
*"Woody" or brawny texture to floor of mouth with visible swelling and erythema


== Diagnosis ==
===Late signs===
*Classical definition
*[[Stridor]]
**Infection of sublingual AND submylohyoid/submaxillary spaces
*Drooling
#Begins in floor of mouth
*Trismus
#Aggressive "woody" or braqny cellulitis in submandibular space
*Dysphonia
#No lymphatic involvement
*Cyanosis
#Generally no abscess formation
*Acute Laryngospasm
#Bilateral infection
 
*CT face with contrast
===Complications===
**Only obtain if diagnosis is question
*Carotid sheath infection
**Pt may lose airway in scanner if lies flat
*IJ thrombophlebitis ([[Lemierre's Disease]])
*Mediastinitis
*Empyema
*Pericardial effusion
*Pleural effusion
*Mandibular Osteomyelitis
*Subphrenic abscess
*Aspiration pneumonia
*Cavernous sinus thrombosis
*Brain abscess
 
==Differential Diagnosis==
{{Acute sore throat DDX}}


==Treatment==
==Evaluation==
*Clinical diagnosis, based on history and physical exam.
 
===Workup===
*CT face with contrast will help delineate area of infection
**Only necessary to obtain imaging if diagnosis is in question - imaging should not delay emergent airway management.
**Be aware of possibility of respiratory distress/compromise with laying flat for CT scan.
*CBC
*Metabolic Panel
*Blood Cultures
*Lactate
 
==Management==
===Airway Management===
*Airway management
*Airway management
*Emergent ENT consult for I&D
*Preference for an awake [[Intubation]]
*Abx
*Emergent ENT consult for operative I&D and extraction of dentition if source is dental abscess
**Must cover typical oral flora
*Intubation may be very difficult due to trismus and posterior pharyngeal extension
**Usually 3rd generation cehpalosporin + (clindamycin or metronidazole)
**Consider awake fiberoptic with Anesthesia or ENT back-up with setup for [[Cricothyrotomy]]
*Awake intubation
 
===Antibiotics===
{{Ludwig's Antibiotics}}


==Disposition==
==Disposition==
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==See Also==
==See Also==
#[[PTA]]
*[[Peritonsillar Abscess (PTA)]]
#[[Retropharyngeal Abscess]]  
*[[Retropharyngeal abscess]]  
#[[Pharyngitis]]
*[[Sore throat]]
 
==Video==
{{#widget:YouTube|id=qVn3jagukiw}}


==Source==
==References==
*Tintinalli
<references/>
*ER Atlas
*Rosen's


[[Category:Peds]]
[[Category:ENT]]
[[Category:ENT]]

Revision as of 22:36, 28 November 2017

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 no lymphatic involvement and no abscess formation but infection rapidly spreads bilaterally

Clinical Features

Early Signs

  • Dysphagia
  • Odynophagia
  • Trismus
  • Edema of upper midline neck and floor of mouth
    • Raised tongue
  • "Woody" or brawny texture to floor of mouth with visible swelling and erythema

Late signs

  • Stridor
  • Drooling
  • Trismus
  • Dysphonia
  • Cyanosis
  • Acute Laryngospasm

Complications

  • Carotid sheath infection
  • IJ thrombophlebitis (Lemierre's Disease)
  • Mediastinitis
  • Empyema
  • Pericardial effusion
  • Pleural effusion
  • Mandibular Osteomyelitis
  • Subphrenic abscess
  • Aspiration pneumonia
  • Cavernous sinus thrombosis
  • Brain abscess

Differential Diagnosis

Acute Sore Throat

Bacterial infections

Viral infections

Noninfectious

Other

Evaluation

  • Clinical diagnosis, based on history and physical exam.

Workup

  • CT face with contrast will help delineate area of infection
    • Only necessary to obtain imaging if diagnosis is in question - imaging should not delay emergent airway management.
    • Be aware of possibility of respiratory distress/compromise with laying flat for CT scan.
  • CBC
  • Metabolic Panel
  • Blood Cultures
  • Lactate

Management

Airway Management

  • 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[3]

Immunocompetent Host[4]

Immunocompromised[5]

Disposition

  • Admit, usually ICU for airway monitoring

See Also

Video

{{#widget:YouTube|id=qVn3jagukiw}}

References

  1. Buckley M, O’Connor K. Ludwig’s angina in a 76-year-old man. Emerg Med J. 2009;26:679-680
  2. Melio, Frantz, and Laurel Berge. “Upper Respiratory Tract Infection.” In Rosen’s Emergency Medicine., 8th ed. Vol. 1, n.d.
  3. Costain N, Marrie T. Ludwig’s Angina. American Journal of Medicine. Feb 2011. 124(2): 115-117
  4. Barton E, Blair A. Ludwig’s Angina. J Emerg Med. 2008. 34(2): 163-169.
  5. Spitalnic SJ, Sucov A. Ludwig's angina: case report and review. J Emerg Med. 1995;13:499-503