Ludwig's angina: Difference between revisions
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== Background | ==Background== | ||
*Bilateral infection of submandibular and sublingual spaces | *Bilateral infection of submental, submandibular, and sublingual spaces | ||
*85% of cases arise from an odontogenic source, usually mandibular molars | *[[Cellulitis]] without clear fluctuance/[[abscess]] should heighten suspicion | ||
* | *85% of cases arise from an odontogenic source, usually mandibular molars | ||
*Patients usually 20-60yr | *Source of infection are polymicrobial most commonly [[Strep]] [[Staphylococcus]] and Bacteroides species | ||
* | *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> | ||
*Often there is no lymphatic involvement and no [[abscess]] formation but infection rapidly spreads bilaterally | |||
== 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 | ||
* | **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 DDX}} | |||
== | ==Evaluation== | ||
*Emergent ENT consult for I&D | *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=== | |||
{{Ludwig's Antibiotics}} | |||
==Disposition== | ==Disposition== | ||
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==See Also== | ==See Also== | ||
*[[Peritonsillar Abscess (PTA)]] | |||
*[[Retropharyngeal abscess]] | |||
*[[Sore throat]] | |||
==Video== | |||
{{#widget:YouTube|id=qVn3jagukiw}} | |||
== | ==References== | ||
<references/> | |||
[[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
- Streptococcal pharyngitis (Strep Throat)
- Neisseria gonorrhoeae
- Diphtheria (C. diptheriae)
- Bacterial Tracheitis
Viral infections
- Infectious mononucleosis (EBV)
- Patients with peritonsillar abscess have a 20% incidence of mononucleosis [2]
- Laryngitis
- Acute Bronchitis
- Rhinovirus
- Coronavirus
- Adenovirus
- Herpesvirus
- Influenza virus
- Coxsackie virus
- HIV (Acute Retroviral Syndrome)
Noninfectious
Other
- Deep neck space infection
- Peritonsillar Abscess (PTA)
- Epiglottitis
- Kawasaki disease
- Penetrating injury
- Caustic ingestion
- Lemierre's syndrome
- Peritonsillar cellulitis
- Lymphoma
- Internal carotid artery aneurysm
- Oral Thrush
- Parotitis
- Post-tonsillectomy hemorrhage
- Vincent's angina
- Acute necrotizing ulcerative gingivitis
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]
- Ampicillin/Sulbactam 3g (50mg/kg) IV q6 hrs OR
- Penicillin G 2-4 million units IV q6 hrs + Metronidazole 500 mg IV q6 hrs OR
- Clindamycin 600 mg IV q6 hrs (option for those allergic to penicillin)
Immunocompromised[5]
- Cefepime 2 g IV q12 hrs + Metronidazole 500 mg IV q6 hrs OR
- Meropenem 1 g IV q8 hrs OR
- Imipenem/Cilastatin 500mg (20mg/kg) IV q6 hours
- Piperacillin-tazobactam 4.5g (80mg/kg) IV q6 hours
- Add Vancomycin 15-20 mg/kg IV q8 hrs (max 2 g per dose) if concern for MRSA risk factors
Disposition
- Admit, usually ICU for airway monitoring
See Also
Video
{{#widget:YouTube|id=qVn3jagukiw}}
References
- ↑ Buckley M, O’Connor K. Ludwig’s angina in a 76-year-old man. Emerg Med J. 2009;26:679-680
- ↑ Melio, Frantz, and Laurel Berge. “Upper Respiratory Tract Infection.” In Rosen’s Emergency Medicine., 8th ed. Vol. 1, n.d.
- ↑ Costain N, Marrie T. Ludwig’s Angina. American Journal of Medicine. Feb 2011. 124(2): 115-117
- ↑ Barton E, Blair A. Ludwig’s Angina. J Emerg Med. 2008. 34(2): 163-169.
- ↑ Spitalnic SJ, Sucov A. Ludwig's angina: case report and review. J Emerg Med. 1995;13:499-503