Ludwig's angina: Difference between revisions
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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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*Trismus
*Trismus
*Edema of upper midline neck and floor of mouth
*Edema of upper midline neck and floor of mouth
*"Woody" or brawny texture to floor of mouth with visible swelling and errythema
**Raised tongue
*"Woody" or brawny texture to floor of mouth with visible swelling and erythema
 
===Late signs===
===Late signs===
*[[Stridor]], drooling, cyanosis
*[[Stridor]]
*Drooling
*Tongue protrusion
*Trismus
*[[Dysphonia]]
*Cyanosis
*Acute laryngospasm
 
===Complications===
*Carotid sheath infection
*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]]
 
==Differential Diagnosis==
{{Acute sore throat DDX}}


== Diagnosis ==
==Evaluation==
===Classical definition===
*Clinical diagnosis, based on history and physical exam.
*Infection of sublingual AND submylohyoid/submaxillary spaces
*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


===Imaging Studies===
==Management==
*CT face with contrast will help delineate area of inifection
*Emergent ENT or OMFS consult for operative I&D and extraction of dentition if source is dental abscess
**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.
===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]]


==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===
===Antibiotics===
*Must cover typical polymicrobial oral flora and tailored based on patient's immune status
{{Ludwig's Antibiotics}}
*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<ref>Costain N, Marrie T. Ludwig’s Angina. American Journal of Medicine. Feb 2011. 124(2):  115-117</ref>
{{Antibiotics Ludwigs Immunocompetent}}
 
{{Antibiotics Ludwigs Immunocompromised}}


==Disposition==
==Disposition==
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==See Also==
==See Also==
#[[PTA]]
*[[Peritonsillar Abscess (PTA)]]
#[[Retropharyngeal Abscess]]  
*[[Retropharyngeal abscess]]  
#[[Pharyngitis]]
*[[Sore throat]]


==Source==
==References==
<references/>
<references/>
[[Category:Peds]]
 
[[Category:ENT]]
[[Category:ENT]]
[[category:ID]]

Latest revision as of 20:01, 17 April 2024

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

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
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