Ludwig's angina

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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

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

Authors

Michael Holtz