Difference between revisions of "Ludwig's angina"

Line 35: Line 35:
 
**Must cover typical oral flora
 
**Must cover typical oral flora
 
**Usually 3rd generation cehpalosporin + (clindamycin or metronidazole)
 
**Usually 3rd generation cehpalosporin + (clindamycin or metronidazole)
 +
**Immunocompetent vs. immunocompromised (IV abx for 2-3 wks, with fever and leukocytosis corrected)
 +
***Immunocompetent
 +
****Amp-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 (preferred for pcn allergy)
 +
***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
 
*Awake intubation
 
*Awake intubation
 +
*Surgical extraction of tooth if it is the source of infection
 +
*Surgery unlikely to locate abscess or drainable pus - abscesses develop after the first 24-36 hrs
 +
*If formal I&D or aspiration needed, it should be performed under general anesthesia with a tracheostomy in place
  
 
==Disposition==
 
==Disposition==

Revision as of 21:45, 25 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
  1. Begins in floor of mouth
  2. Aggressive "woody" or brawny cellulitis in submandibular space
  3. No lymphatic involvement
  4. Generally no abscess formation
  5. Bilateral infection
  • CT face with contrast
    • Only obtain if diagnosis is question
    • Pt may lose airway in scanner if lies flat

Treatment

  • Airway management
  • Emergent ENT consult for I&D
  • Abx
    • Must cover typical oral flora
    • Usually 3rd generation cehpalosporin + (clindamycin or metronidazole)
    • Immunocompetent vs. immunocompromised (IV abx for 2-3 wks, with fever and leukocytosis corrected)
      • Immunocompetent
        • Amp-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 (preferred for pcn allergy)
      • 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
  • Awake intubation
  • Surgical extraction of tooth if it is the source of infection
  • Surgery unlikely to locate abscess or drainable pus - abscesses develop after the first 24-36 hrs
  • If formal I&D or aspiration needed, it should be performed under general anesthesia with a tracheostomy in place

Disposition

  • Admit, usually ICU for airway monitoring

See Also

  1. PTA
  2. Retropharyngeal Abscess
  3. Pharyngitis

Source

  • Tintinalli
  • ER Atlas
  • Rosen's
  • Uptodate