Ludwig's angina

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
• 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
• Acute Laryngospasm

Complications

• Carotid sheath infection
• IJ thrombophlebitis
• Mediastinitis
• Empyema
• Pericardial effusion
• Pleural effusion
• Mandibular OM
• Subphrenic abscess
• Aspiration pneumonia
• Cavernous sinus thrombosis
• Brain abscess

Differential Diagnosis

Acute Sore Throat

Bacterial infections

• Streptococcal pharyngitis (Strep Throat)
• Neisseria gonorrhoeae
• Diphtheria (C. diptheriae)
• Bacterial Tracheitis

Viral infections

• Infectious mononucleosis (EBV)
  • Patients with peritonsillar abscess have a 20% incidence of mononucleosis
• Laryngitis
• Acute Bronchitis
• Rhinovirus
• Coronavirus
• Adenovirus
• Herpesvirus
• Influenza virus
• Coxsackievirus
  • Herpangina
  • Hand-foot-and-mouth disease
• HIV (Acute Retroviral Syndrome)

Noninfectious

• Stevens-Johnson Syndrome
• Pemphigus
• Angioedema

Other

• Deep neck space infection
  • Retropharyngeal abscess
  • Ludwig's angina
  • Parapharyngeal space infection
• Peritonsillar Abscess (PTA)
• Epiglottitis
• Kawasaki disease
• Penetrating injury
• Caustic ingestion
• Lemierre's syndrome
• Peritonsillar cellulitis
• Lymphoma
• Internal carotid artery aneurysm
• Oral Thrush
• Parotitis
• Post-tonsillectomy hemorrhage

Evaluation

• 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

Management

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

Immunocompetent Host

• Ampicillin/Sulbactam 3g (50mg/kg) IV q6 hrs OR
• Penicillin G 2-4 MU IV q6 hrs + Metronidazole 500 mg IV q6 hrs OR
• Clindamycin 600 mg IV q6 hrs (option for those allergic to penicillin)

Immunocompromised

• 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 q8 hrs (max 2 g per dose) if concern for MRSA risk factors

Disposition

• Admit, usually ICU for airway monitoring

See Also

• Peritonsillar Abscess (PTA)
• Retropharyngeal abscess
• Sore throat

References

Authors

Ross Donaldson, Michael O'Brien, MD