Ludwig's angina: Difference between revisions
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==Treatment== | ==Treatment== | ||
===Airway Managment=== | |||
*Airway management | *Airway management | ||
*Emergent ENT consult for I&D | *Preference for an awake [[Intubation]] | ||
*Emergent ENT consult for operative I&D and extraction of dentition if source is dental abscess | |||
**Must cover typical oral flora | ===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<ref>Costain N, Marrie T. Ludwig’s Angina. American Journal of Medicine. Feb 2011. 124(2): 115-117</ref> | |||
===Immunocompetent Host=== | |||
'''Antibiotics Options:'''<ref>Barton E, Blair A. Ludwig’s Angina. J Emerg Med. 2008. 34(2): 163-169.</ref> | |||
#[[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== | ==Disposition== | ||
Revision as of 13:55, 26 August 2014
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