Ludwig's angina: Difference between revisions
| (5 intermediate revisions by 2 users not shown) | |||
| Line 2: | Line 2: | ||
*Bilateral infection of submental, submandibular, and sublingual spaces | *Bilateral infection of submental, submandibular, and sublingual spaces | ||
*[[Cellulitis]] without clear fluctuance/[[abscess]] should heighten suspicion | *[[Cellulitis]] without clear fluctuance/[[abscess]] should heighten suspicion | ||
*85% of cases arise from an odontogenic source, usually periapical | *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 | *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> | *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 | *Often there is no lymphatic involvement and no [[abscess]] formation but infection rapidly spreads bilaterally | ||
==Clinical Features== | ==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=== | ===Early Signs=== | ||
*[[Dysphagia]] | *[[Dysphagia]] | ||
| Line 21: | Line 23: | ||
*Tongue protrusion | *Tongue protrusion | ||
*Trismus | *Trismus | ||
*Dysphonia | *[[Dysphonia]] | ||
*Cyanosis | *Cyanosis | ||
*Acute | *Acute laryngospasm | ||
===Complications=== | ===Complications=== | ||
*Carotid sheath infection | *Carotid sheath infection | ||
*IJ thrombophlebitis ([[Lemierre's Disease]]) | *IJ thrombophlebitis ([[Lemierre's Disease]]) | ||
*Mediastinitis | *[[Mediastinitis]] | ||
*Empyema | *[[Empyema]] | ||
*Pericardial effusion | *[[Pericardial effusion]] | ||
*Pleural effusion | *[[Pleural effusion]] | ||
*Mandibular | *Mandibular [[osteomyelitis]] | ||
*Subphrenic abscess | *Subphrenic [[abscess]] | ||
*Aspiration pneumonia | *[[aspiration pneumonia and pneumonitis|Aspiration pneumonia]] | ||
*Cavernous sinus thrombosis | *[[Cavernous sinus thrombosis]] | ||
*Brain abscess | *[[Brain abscess]] | ||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
| Line 43: | Line 45: | ||
==Evaluation== | ==Evaluation== | ||
*Clinical diagnosis, based on history and physical exam. | *Clinical diagnosis, based on history and physical exam. | ||
*CT face with contrast will help delineate area of infection | *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 | **Only necessary to obtain imaging if diagnosis is in question - imaging should not delay emergent airway management or transfer to OR for definitive care | ||
| Line 50: | Line 50: | ||
*CBC | *CBC | ||
*Chem | *Chem | ||
*Lactate | *[[Lactate]] | ||
*Blood Cultures | *Blood Cultures | ||
| Line 56: | Line 56: | ||
*Emergent ENT or OMFS consult for operative I&D and extraction of dentition if source is dental abscess | *Emergent ENT or OMFS consult for operative I&D and extraction of dentition if source is dental abscess | ||
===Airway Management=== | ===Airway Management=== | ||
*Intubation may be very difficult due to trismus and posterior pharyngeal extension | *[[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]] | *Preference for an awake fiberoptic [[intubation]] (ideally in OR if time allows) with setup immediately available for [[cricothyrotomy]] | ||
===Antibiotics=== | ===Antibiotics=== | ||
| Line 76: | Line 76: | ||
[[Category:ENT]] | [[Category:ENT]] | ||
[[category:ID]] | |||
Revision as of 16:32, 25 March 2021
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 abscesses of mandibular molars
- Source of infection often 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
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
- Streptococcal pharyngitis (Strep Throat)
- Neisseria gonorrhoeae
- Diphtheria (C. diptheriae)
- Bacterial Tracheitis
Viral infections
- Infectious mononucleosis (EBV)
- Patients with peritonsillar abscess have a 20% incidence of mononucleosis [2]
- Laryngitis
- Acute Bronchitis
- Rhinovirus
- Coronavirus
- Adenovirus
- Herpesvirus
- Influenza virus
- Coxsackie virus
- HIV (Acute Retroviral Syndrome)
Noninfectious
Other
- Deep neck space infection
- Peritonsillar Abscess (PTA)
- Epiglottitis
- Kawasaki disease
- Penetrating injury
- Caustic ingestion
- Lemierre's syndrome
- Peritonsillar cellulitis
- Lymphoma
- Internal carotid artery aneurysm
- Oral Thrush
- Parotitis
- Post-tonsillectomy hemorrhage
- Vincent's angina
- Acute necrotizing ulcerative gingivitis
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
- 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]
- Ampicillin/Sulbactam 3g (50mg/kg) IV q6 hrs OR
- Penicillin G 2-4 million units IV q6 hrs + Metronidazole 500 mg IV q6 hrs OR
- Clindamycin 600 mg IV q6 hrs (option for those allergic to penicillin)
Immunocompromised[5]
- Cefepime 2 g IV q12 hrs + Metronidazole 500 mg IV q6 hrs OR
- Meropenem 1 g IV q8 hrs OR
- Imipenem/Cilastatin 500mg (20mg/kg) IV q6 hours
- Piperacillin-tazobactam 4.5g (80mg/kg) IV q6 hours
- Add Vancomycin 15-20 mg/kg IV q8 hrs (max 2 g per dose) if concern for MRSA risk factors
Disposition
- Admit, usually ICU for airway monitoring
See Also
Video
{{#widget:YouTube|id=qVn3jagukiw}}
References
- ↑ Buckley M, O’Connor K. Ludwig’s angina in a 76-year-old man. Emerg Med J. 2009;26:679-680
- ↑ Melio, Frantz, and Laurel Berge. “Upper Respiratory Tract Infection.” In Rosen’s Emergency Medicine., 8th ed. Vol. 1, n.d.
- ↑ Costain N, Marrie T. Ludwig’s Angina. American Journal of Medicine. Feb 2011. 124(2): 115-117
- ↑ Barton E, Blair A. Ludwig’s Angina. J Emerg Med. 2008. 34(2): 163-169.
- ↑ Spitalnic SJ, Sucov A. Ludwig's angina: case report and review. J Emerg Med. 1995;13:499-503