Ludwig's angina: Difference between revisions
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Revision as of 11:09, 10 August 2015
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
- Raised tongue
- "Woody" or brawny texture to floor of mouth with visible swelling and erythema
Late signs
- Stridor
- Drooling
- Trismus
- Dysphonia
- Cyanosis
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[3]
- 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[4]
- 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
Source
- ↑ Buckley M, O’Connor K. Ludwig’s angina in a 76-year-old man. Emerg Med J. 2009;26:679-680
- ↑ 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