Ludwig's angina

Ludwig's angina





- is actually
a progressive cellulitis of the connective tissues of the floor of the
mouth and neck that begins in the submandibular space
- dental disease is the most common cause
- an infected or recently extracted lower molar is noted in most affected patients


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Anatomic Basis of the Pathophysiology of Infection Spread


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Lateral neck x-ray taken of a patient shows a soft tissue enlargement over the submandibular space with gas formation.



Causes

Other causes of Ludwig's angina (besides spread of dentoalveolar infection) include:
1/ fractured mandible
2/ foreign body or laceration in the floor of the mouth
3/ tongue piercing resulting in infection
4/ secondary infections of an oral malignancy
5/ otitis media
6/ spread of infections around the oral region: submandibular sialoadenitis, peritonsillar abscess

Ludwig's angina is most commonly a polymicrobial disease of mixed aerobic-anaerobic bacteria of oral origin.

The
most frequently isolated organisms are streptococci, staphylococci, and
Bacteroides species. Other organisms include H. influenzae, Pseudomonas
aeruginosa, Klebsiella species, and Candida albicans.

Clinical Features

Infection
of the sublingual and submaxillary spaces leads to edema and soft
tissue displacement, which may result in airway obstruction.

The most common symptoms in patients with Ludwig's angina include
- dysphagia
- odynophagia
- neck swelling
- dysphonia
- “hot potato” voice
- drooling
- tongue swelling
- pain in the floor of the mouth
- restricted neck movement, and
- sore throat.

Surprisingly, generally there is no cervical lymphadenopathy.




Management


The main
problem with Ludwig's angina is because of the rapid enlargement of the
swelling. edema and displacement of soft tissue resulting in upper airway obstruction.

Airway
management in such cases may become complicated. We were fortunate that
this patient was still comfortable in his breathing, although he has
"lost" his voice.

Emergent antibiotic regimens include high-dose
penicillin with metronidazole, or cefoxitin. Alternately, clindamycin,
ticarcillin-clavulanate, piperacillin, azobactam, or
ampicillin-sulbactam may be used.



Surgical incision plus drainage was the therapy of choice in the preantibiotic era.

With
the exception of dental extractions, surgery is reserved for patients
who do not respond to medical therapy and those with crepitus and
purulent collections,

Mortality caused by Ludwig's angina is less
than 10% with early aggressive antibiotic therapy and adequate
protection of the airway.

Infection can easily spread into other
deep spaces of the neck and into the thoracic cavity and cause empyema,
mediastinitis, mediastinal abscess, and pericarditis.

Reference:

Chapter 17 Upper Respiratory Tract Infections from Marx: Rosen's Emergency Medicine: Concepts and Clinical Practice, 6th ed.




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