Difference between revisions of "Ludwig's angina"

m (Mholtz moved page Ludwig's Angina to Ludwig's angina)
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*Cyanosis
 
*Cyanosis
  
== Diagnosis ==
+
==Differential Diagnosis==
===Classical definition===
 
*Infection of sublingual AND submylohyoid/submaxillary spaces
 
  
===Imaging Studies===
+
 
*CT face with contrast will help delineate area of inifection
+
==Diagnosis==
**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.
+
*Clinical diagnosis, based on history and physical exam.
 +
 
 +
===Workup===
 +
*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.
 +
**Be aware of possibility of respiratory distress/compromise with laying flat for CT scan.
 +
*CBC
 +
*Metabolic Panel
 +
*Blood Cultures
 +
*Lactate
  
 
==Treatment==
 
==Treatment==
===Airway Managment===
+
===Airway Management===
 
*Airway management
 
*Airway management
 
*Preference for an awake [[Intubation]]
 
*Preference for an awake [[Intubation]]
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*Intubation may be very difficult due to trismus and posterior pharyngeal extension
 
*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]]
 
**Consider awake fiberoptic with Anesthesia or ENT back-up with setup for [[Cricothyrotomy]]
 +
 
===Antibiotics===
 
===Antibiotics===
 
{{Ludwig's Antibiotics}}
 
{{Ludwig's Antibiotics}}
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==See Also==
 
==See Also==
#[[PTA]]
+
*[[PTA]]
#[[Retropharyngeal Abscess]]  
+
*[[Retropharyngeal Abscess]]  
#[[Pharyngitis]]
+
*[[Pharyngitis]]
  
==Source==
+
==References==
 
<references/>
 
<references/>
[[Category:Peds]]
+
 
 
[[Category:ENT]]
 
[[Category:ENT]]

Revision as of 11:14, 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

Differential Diagnosis

Diagnosis

  • Clinical diagnosis, based on history and physical exam.

Workup

  • 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.
    • Be aware of possibility of respiratory distress/compromise with laying flat for CT scan.
  • CBC
  • Metabolic Panel
  • Blood Cultures
  • Lactate

Treatment

Airway Management

  • 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]

Immunocompromised[4]

Disposition

  • Admit, usually ICU for airway monitoring

See Also

References

  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. Barton E, Blair A. Ludwig’s Angina. J Emerg Med. 2008. 34(2): 163-169.
  4. Spitalnic SJ, Sucov A. Ludwig's angina: case report and review. J Emerg Med. 1995;13:499-503