View source for Ludwig's angina

==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 [[periapical abscess]]es of mandibular molars
*Source of infection often 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==
[[File:Ludwig angina.jpg|thumb|Swelling in the submandibular area in a person with Ludwig's angina.]]
[[File:Ludwigs_submandibular.jpeg|thumb|Significant submandibular swelling and discoloration typical in Ludwig's Angina]]
===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
*Tongue protrusion
*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 and pneumonitis|Aspiration pneumonia]]
*[[Cavernous sinus thrombosis]]
*[[Brain abscess]]

==Differential Diagnosis==
{{Acute sore throat DDX}}

==Evaluation==
*Clinical diagnosis, based on history and physical exam.
*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 or transfer to OR for definitive care
**Be aware of possibility of respiratory distress/airway compromise with laying flat for CT scan
*CBC
*Chem
*[[Lactate]]
*Blood Cultures

==Management==
*Emergent ENT or OMFS consult for operative I&D and extraction of dentition if source is dental abscess
===Airway Management===
*[[Intubation]] may be very difficult due to trismus and posterior pharyngeal extension
*Preference for an awake fiberoptic [[intubation]] (ideally in OR if time allows) with setup immediately available for [[cricothyrotomy]]

===Antibiotics===
{{Ludwig's Antibiotics}}

==Disposition==
*Admit, usually ICU for airway monitoring

==See Also==
*[[Peritonsillar Abscess (PTA)]]
*[[Retropharyngeal abscess]] 
*[[Sore throat]]

==References==
<references/>

[[Category:ENT]]
[[category:ID]]