Difference between revisions of "Ludwig's angina"

(Late signs)
(Clinical Features)
 
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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 should heighten suspicion
+
*[[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 [[periapical abscess]]es of mandibular molars
*Source of infection are 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 noo lymphatic involvement and no abscess formation but infection rapidly spreads bilateraly
+
*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]]
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*[[Stridor]]
 
*[[Stridor]]
 
*Drooling
 
*Drooling
 +
*Tongue protrusion
 
*Trismus
 
*Trismus
*Dysphonia
+
*[[Dysphonia]]
 
*Cyanosis
 
*Cyanosis
 +
*Acute laryngospasm
  
== Diagnosis ==
+
===Complications===
===Classical definition===
+
*Carotid sheath infection
*Infection of sublingual AND submylohyoid/submaxillary spaces
+
*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]]
  
===Imaging Studies===
+
==Differential Diagnosis==
*CT face with contrast will help delineate area of inifection
+
{{Acute sore throat DDX}}
**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==
+
==Evaluation==
===Airway Managment===
+
*Clinical diagnosis, based on history and physical exam.
*Airway management
+
*CT face with contrast will help delineate area of infection
*Preference for an awake [[Intubation]]
+
**Only necessary to obtain imaging if diagnosis is in question - imaging should not delay emergent airway management or transfer to OR for definitive care
*Emergent ENT consult for operative I&D and extraction of dentition if source is dental abscess
+
**Be aware of possibility of respiratory distress/airway compromise with laying flat for CT scan
*Intubation may be very difficult due to trismus and posterior pharyngeal extension
+
*CBC
**Consider awake fiberoptic with Anesthesia or ENT back-up with setup for [[Cricothyrotomy]]
+
*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===
 
===Antibiotics===
 
{{Ludwig's Antibiotics}}
 
{{Ludwig's Antibiotics}}
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==See Also==
 
==See Also==
#[[PTA]]
+
*[[Peritonsillar Abscess (PTA)]]
#[[Retropharyngeal Abscess]]  
+
*[[Retropharyngeal abscess]]  
#[[Pharyngitis]]
+
*[[Sore throat]]
  
==Source==
+
==Video==
 +
{{#widget:YouTube|id=qVn3jagukiw}}
 +
 
 +
==References==
 
<references/>
 
<references/>
[[Category:Peds]]
+
 
 
[[Category:ENT]]
 
[[Category:ENT]]
 +
[[category:ID]]

Latest 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

Swelling in the submandibular area in a person with Ludwig's angina.
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

Differential Diagnosis

Acute Sore Throat

Bacterial infections

Viral infections

Noninfectious

Other

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]

Immunocompromised[5]

Disposition

  • Admit, usually ICU for airway monitoring

See Also

Video

References

  1. Buckley M, O’Connor K. Ludwig’s angina in a 76-year-old man. Emerg Med J. 2009;26:679-680
  2. Melio, Frantz, and Laurel Berge. “Upper Respiratory Tract Infection.” In Rosen’s Emergency Medicine., 8th ed. Vol. 1, n.d.
  3. Costain N, Marrie T. Ludwig’s Angina. American Journal of Medicine. Feb 2011. 124(2): 115-117
  4. Barton E, Blair A. Ludwig’s Angina. J Emerg Med. 2008. 34(2): 163-169.
  5. Spitalnic SJ, Sucov A. Ludwig's angina: case report and review. J Emerg Med. 1995;13:499-503