Ludwig's angina: Difference between revisions
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*Cyanosis | *Cyanosis | ||
== Diagnosis == | ==Differential Diagnosis== | ||
=== | |||
*CT face with contrast will help delineate area of | ==Diagnosis== | ||
**Only necessary to obtain imaging if diagnosis is question | *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 | ===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]] | |||
*[[Retropharyngeal Abscess]] | |||
*[[Pharyngitis]] | |||
== | ==References== | ||
<references/> | <references/> | ||
[[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]
- 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
References
- ↑ 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