What is Ludwig’s Angina?
Ludwig’s angina is a deep neck space infection involving the floor of the mouth.
It is a life-threatening soft tissue cellulitis that affects the floor of the mouth and neck. These are three compartments of the floor of the mouth, the sublingual, submental and submandibular. The infection progresses rapidly and leads to possible airway obstruction.
The most common etiology is a dental infection in the lower molars, mainly second and third, which represent more than 90% of cases. Any recent infection or injury to the area can predispose the patient to developing Ludwig’s angina.
Predisposing factors include diabetes, oral malignancy, dental caries, alcoholism, malnutrition, and immunocompromised status.
Because it is important?
The infection can spread quickly, causing enlargement and elevation of the tongue and ultimately airway obstruction.
It also causes edema of other airway structures, including the epiglottis, true and false vocal cords, and aryepiglottic folds. Airway edema can progress very quickly.
Who suffers from it?
Although Wilhelm Fredrick von Ludwig died shortly after the onset of neck inflammation, sources indicate that it is unlikely that he had the infection he named.
Patients at high risk for Ludwig’s angina include those with local sources of infection, such as perforations or dental infections, and those who have a systemic predisposition to infection, such as diabetes, malnutrition, or intravenous drug use.
How do patients typically present?
Patients present with submandibular swelling and induration, and may also have generalized weakness, fever, malaise, and chills. The external part of the neck may be erythematous and edematous, and there may be sublingual, submental, and/or cervical lymphadenopathy.
Lockjaw and meningism are late signs and are associated with parapharyngeal and retropharyngeal expansion, respectively. Other late signs include drooling, dysphagia, dysphonia, and respiratory distress.
What is the initial management?
- Evaluation and management of the airway.
- Broad spectrum antibiotics.
- Dexamethasone (to reduce edema and improve antibiotic penetration).
- Surgical debridement of any necrotic tissue and drainage of any abscess.
- Swabs from the affected area are low-yield and likely to have multiple contaminants.
- There is limited evidence for nebulized epinephrine.
A quick (important) note on airway management :
The anatomy of the neck may be greatly distorted, making both intubation and rescue techniques such as supraglottic airways and cricothyrotomy difficult.
Definitive treatment is best performed in the operating room , where a tracheostomy can be performed if necessary; consult ENT and anesthesia early.
If a surgeon or anesthesiologist is not available, an awake fiberoptic intubation may be a good option. During intubation, pay special attention to avoid airway trauma that worsens airway edema and/or causes laryngospasm. A supraglottic airway is a poor choice as it can become displaced as the inflammation progresses.
Choice images?
Ludwig’s angina is a clinical diagnosis and does not require imaging .
A contrast-enhanced CT scan of the neck may be performed in stable patients who can tolerate the supine position to evaluate the location and extent of involvement and help determine the need for surgical intervention.
The POCUS may also be useful. It will show hypoechoic lesions on the face and neck. The diameter of the subglottic airway can also be estimated by ultrasound.
What errors need to be covered?
Infections are polymicrobial, including gram-positive, gram-negative, and anaerobic bacteria.
In immunocompetent hosts, recommended antibiotic regimens include:
Ceftriaxone 2 g IV every 12 hours + metronidazole 500 mg IV every 8 hours
Clindamycin 600 mg IV every 6-8 hours + levofloxacin 750 mg IV every 24 hours
Additional coverage should be considered for immunocompromised patients and those with MRSA risk factors (diabetes, intravenous drug use, hemodialysis, recent hospitalizations, and long-term care residents).
Driving
Patients should be admitted to the ICU and undergo serial airway evaluations along with monitoring for complications, including descending mediastinitis and necrotizing fasciitis.
Conclusion Ludwig’s angina is a life-threatening condition that all emergency physicians should be aware of. It is important for clinicians to be aware of current evidence regarding the diagnosis, management, and final disposition of these patients. |
Reference: Bridwell R, Gottlieb M, Koyfman A, Long B. Diagnosis and management of Ludwig’s angina: an evidence-based review. I am J Emerg Med. March 2021; 41:1-5. doi: 10.1016/j.ajem.2020.12.030 . Epub 2020 December 23. PMID: 33383265
