Ludwig's angina

Background

• Bilateral infection of submental, submandibular, and sublingual spaces
• Cellulitis without clear fluctuance/abscess
• 85% of cases arise from an odontogenic source, usually mandibular molars
  • Strep, staphylococcus, bacteroides
• Patients usually 20-60yr; male predominance
• Intubation may be very difficult
  • Consider awake endoscopic NP or OP intubation
  • Anesthesia or ENT back-up if possible

Clinical Features

• Dysphagia
• Odynophagia
• Trismus
• Edema of upper midline neck and floor of mouth
• Late signs
  • Stridor, drooling, cyanosis

Diagnosis

• Classical definition
  • Infection of sublingual AND submylohyoid/submaxillary spaces

1. Begins in floor of mouth
2. Aggressive "woody" or brawny cellulitis in submandibular space
3. No lymphatic involvement
4. Generally no abscess formation
5. Bilateral infection

• CT face with contrast
  • Only obtain if diagnosis is question
  • Pt may lose airway in scanner if lies flat

Treatment

• Airway management
• Emergent ENT consult for I&D
• Abx
  • Must cover typical oral flora
  • Usually 3rd generation cehpalosporin + (clindamycin or metronidazole)
  • Immunocompetent vs. immunocompromised (IV abx for 2-3 wks, with fever and leukocytosis corrected)
    • Immunocompetent
      • Amp-sulbactam 3 g IV q6 hrs
      • Penicillin G 2-4 MU IV q6 hrs + metronidazole 500 mg IV q6 hrs
      • Clindamycin 600 mg IV q6 hrs (preferred for pcn allergy)
    • Immunocompromised
      • Cefepime 2 g IV q12 hrs + metronidazole 500 mg IV q6 hrs
      • Meropenem 1 g IV q8 hrs
      • Piperacillin-tazobactam 4.5 g IV q6 hrs
    • Add vancomycin 15-20 mg/kg q8 hrs (max 2 g per dose) if concern for MRSA risk factors
• Awake intubation
• Surgical extraction of tooth if it is the source of infection
• Surgery unlikely to locate abscess or drainable pus - abscesses develop after the first 24-36 hrs
• If formal I&D or aspiration needed, it should be performed under general anesthesia with a tracheostomy in place

Disposition

• Admit, usually ICU for airway monitoring

See Also

1. PTA
2. Retropharyngeal Abscess
3. Pharyngitis

Source

• Tintinalli
• ER Atlas
• Rosen's
• Uptodate