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 noo lymphatic involvement and no abscess formation but infection rapidly spreads bilateraly
**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
*"Woody" or brawny texture to floor of mouth with visible swelling and errythema
**Stridor, drooling, cyanosis
===Late signs===
*[[Stridor]], drooling, cyanosis


== Diagnosis ==
== Diagnosis ==
*Classical definition
===Classical definition===
**Infection of sublingual AND submylohyoid/submaxillary spaces
*Infection of sublingual AND submylohyoid/submaxillary spaces
#Begins in floor of mouth
 
#Aggressive "woody" or brawny cellulitis in submandibular space
===Imaging Studies===
#No lymphatic involvement
*CT face with contrast will help delineate area of inifection
#Generally no abscess formation
**Only necessary to obtain imaging if diagnosis is question.  Imaging should not delay emergent airway managment and as patient lays flat in CT scanner there is a high risk for respiratory failure.
#Bilateral infection
*CT face with contrast  
**Only obtain if diagnosis is question
**Pt may lose airway in scanner if lies flat


==Treatment==
==Treatment==
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*Preference for an awake [[Intubation]]
*Preference for an awake [[Intubation]]
*Emergent ENT consult for operative I&D and extraction of dentition if source is dental abscess
*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===
===Antibiotics===
**Must cover typical polymicrobial oral flora and tailored based on patient's immune status
*Must cover typical polymicrobial oral flora and tailored based on patient's immune status
**Most commonly a 3rd generation cehpalosporin + (clindamycin or metronidazole)
*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>
*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===
===Immunocompetent Host===
'''Antibiotics Options:'''<ref>Barton E, Blair A.  Ludwig’s Angina.  J Emerg Med. 2008. 34(2): 163-169.</ref>
'''Antibiotics Options:'''<ref name="abx">Barton E, Blair A.  Ludwig’s Angina.  J Emerg Med. 2008. 34(2): 163-169.</ref>
#[[Ampicillin/Sulbactam]] 3 g IV q6 hrs
#[[Ampicillin/Sulbactam]] 3 g IV q6 hrs
#[[Penicillin G]] 2-4 MU IV q6 hrs + metronidazole 500 mg 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)
#[[Clindamycin]] 600 mg IV q6 hrs (option for those allergic to penicillin)
===Immunocompromised===
===Immunocompromised===
'''Antibiotics Options:'''<ref name="abx"></ref>
#[[Cefepime]] 2 g IV q12 hrs + [[Metronidazole]] 500 mg IV q6 hrs
#[[Cefepime]] 2 g IV q12 hrs + [[Metronidazole]] 500 mg IV q6 hrs
#[[Meropenem]] 1 g IV q8 hrs
#[[Meropenem]] 1 g IV q8 hrs
#[[Piperacillin-tazobactam 4.5 g IV q6 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
#Add [[Vancomycin]] 15-20 mg/kg q8 hrs (max 2 g per dose) if concern for MRSA risk factors


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==Source==
==Source==
*Tintinalli
<references/>
*ER Atlas
*Rosen's
*Uptodate
 
[[Category:Peds]]
[[Category:Peds]]
[[Category:ENT]]
[[Category:ENT]]

Revision as of 14:13, 26 August 2014

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 noo lymphatic involvement and no abscess formation but infection rapidly spreads bilateraly

Clinical Features

Early Signs

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

Late signs

Diagnosis

Classical definition

  • Infection of sublingual AND submylohyoid/submaxillary spaces

Imaging Studies

  • CT face with contrast will help delineate area of inifection
    • Only necessary to obtain imaging if diagnosis is question. Imaging should not delay emergent airway managment and as patient lays flat in CT scanner there is a high risk for respiratory failure.

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
  • 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[2]

Immunocompetent Host

Antibiotics Options:[3]

  1. Ampicillin/Sulbactam 3 g IV q6 hrs
  2. Penicillin G 2-4 MU IV q6 hrs + metronidazole 500 mg IV q6 hrs
  3. Clindamycin 600 mg IV q6 hrs (option for those allergic to penicillin)

Immunocompromised

Antibiotics Options:[3]

  1. Cefepime 2 g IV q12 hrs + Metronidazole 500 mg IV q6 hrs
  2. Meropenem 1 g IV q8 hrs
  3. Piperacillin-tazobactam 4.5 g IV q6 hrs
  4. 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

  1. PTA
  2. Retropharyngeal Abscess
  3. Pharyngitis

Source

  1. ↑ Buckley M, O’Connor K. Ludwig’s angina in a 76-year-old man. Emerg Med J. 2009;26:679-680
  2. ↑ Costain N, Marrie T. Ludwig’s Angina. American Journal of Medicine. Feb 2011. 124(2): 115-117
  3. ↑ 3.0 3.1 Barton E, Blair A. Ludwig’s Angina. J Emerg Med. 2008. 34(2): 163-169.
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