This issue of eMedRef provides information to clinicians on the pathophysiology, diagnosis, and therapeutics of Ludwig's angina

Kamayangi, Olivia

University of Missouri: MOspace

Throat/Mouth  Ludwig's Angina Background  1. Definition  o First described by Wilhelm Fredrick von Ludwig in 1836 as characterized by   Inflammation of cellular tissue around the submandibular gland, neck and floor of mouth  Symmetrical hard sublingual swelling  Induration of the floor of the mouth  Extreme difficulty with deglutition, speech and respiration  o Potentially fatal, rapidly progressing submandibular & sublingual necrotizing cellulitis  2. General information  o Usually originates from 2nd and 3rd mandibular molar infection o Potential therapeutic emergency with risk for life threatening complication of air way obstruction  Pathophysiology  1. Pathology of disease  o Originates from the oropharynx o Spreads by continuity rather than by hematogenous or lymphatic spread  o Extends   Superiorly and posteriorly elevation of the floor of the mouth & tongue  Anteriorly distortion and "bull neck" appearance upper airway obstruction  o Mixed infection of aerobic & anaerobic bacteria including predominately the oral flora   Staph spp, Strep spp and Bacteroides commonly isolated   Atypical organisms eg. G- rods & fungi in immunocompromised host  2. Incidence, prevalence  o Quite rare where health access not generally a problem o Less common in the antibiotic era 3. Risk factors  o Dental caries, recent dental treatment, poor dental hygiene (accounts for 75-90% of cases)  o Systemic diseases (Sickle cell dz, DM, SLE), alcoholism, malnutrition o Immunosuppression (HIV, transplant recipients, chemotherapy); IVDA  o Trauma: mandibular fracture, facial trauma, tongue piercing, frenuloplasty o Submandibular sialoadenitis o No apparent cause (especially in peds ) 4. Mortality  o Currently around 10% ; close to 100% if untreated  o In pre-antibiotic era 60% Diagnostics 1. History  o Tooth pain o Painful neck swelling o Restricted neck movement o Dysphagia o Dysphonia o SOB o Sore throat o Fever, malaise 2. Physical exam  o Carious molar teeth o Tachypnea o Tachycardia o Fever o Erythema o Swelling o Drooling o Dyspnea o Cyanosis o Stridor o Tenderness to palpation of submandibular area o Neck rigidity o Trismus o Tongue displacement indicate imminent airway compromise 3. Diagnostic testing  o Laboratory evaluation   WBC count  ESR  Possible blood culture or other tests to assess severity of illness o Diagnostic imaging   Xray neck and chest   Most important  Contrast enhanced CT of the neck   Dx test of choice o Diagnostic criteria   No validated criteria available in primary care Differential Diagnosis  1. Peritonsillar abscess 2. Parotid space infection 3. Mumps 4. Parapharyngeal or retropharyngeal space infection 5. Paravertebral space infection 6. Suppurative jugular thrombophlebitis Therapeutics  1. Acute treatment  o Requires hospital admission and treatment  o Prompt airway management if compromised   Fiberoptic intubation preferred   Direct laryngoscopy for intubation can precipitate air way collapse   Cricothyrotomy & tracheostomy in emergency for severe cases o IV antibiotics (immunocompetent patients)   Ampicillin/sulbactam 2 g IV q4hr  Penicillin G 2-4 MU IV q4-6hr plus metronidazole 500 mg IV q6hr  Clindamycin 600 mg IV q6hr for PCN allergy o IV antibiotics (immunocompromised host)   Cefotaxime 2 g IV q6hr  Ceftizoxime 3 g IV q8hr  Imipenem 500 mg IV q6hr  Piperacillin-tazobactam 3.375 g q6hr o Dexamethasone 10 mg IV x1, then 4 mg q6hr x48hr  o Nebulized epinephrine 1 ml of 1:1000 diluted to 5 ml with 0.9% NS  2. Further management  o I&D of abscessed carries; decompression of submandibular space  o Removal of carious molars Follow-Up  1. Potential surgical and airway emergency requiring hospital level care and aggressive antibiotic treatment Prognosis  1. Guarded Prevention  1. Oral hygiene  References  1. Marcus BJ, Kaplan J, Collins KA. A case of Ludwig angina. A case report and review of the literature. Am J Forensic Med Path 2008;23(3):255-9. 2. Barakate M, Jensen M, Hemli J, Graham A. Ludwig's angina: Report of a case and review of management issues. Ann Otol Rhinol Laryngol. 2001;110(5):453-6. 3. Abramowicz S, Abramowicz JS, Dolwick MF. Severe life threatening maxillofacial infection in pregnancy presented as Ludwig's angina. Infect Dis Obstet Gynecol. 2006;doi:10.1155/IDOG/2006/51931 4. Yu-Kung C, Chao-Yi L, Hai-Hsuan C. An upper airway emergency: Ludwig Angina. Pediatr Emerg Care. 2007;23(12):892-6.  5. Hartmann RW Jr. Ludwig's Angina. Am Fam Physician 1999;60:109-112. http://www.aafp.org/afp/990700ap/109.html Accessed 2.27.2010. 6. Saifeldeen K, Evans R. Ludwig's angina. Emerg Med J. 2004:21(2):242-3.  7. Furst I, Ersil P, Caminiti M. A rare complication of tooth abscess - Ludwig's angina and mediastinitis. J Can Dent Assoc. 2001;67(6):324-7.  8. Lin HW, O'Neill A, Cunningham MJ. Ludwig's angina in the pediatric population. Clin Pediatr. 2009;48(6):583-7.  9. Weisengreen HH. Ludwig's angina: Historical review and reflections. Ear Nose Throat J. 1986;65:457-61. Contributors  Author: Olivia Kamayangi  Editor: Vince WinklerPrins   

Ludwig's angina

Ludwig’s Angina Page 1 of 4    3.25.10 Ludwig's Angina Background  1. Definition  o First described by Wilhelm Fredrick von Ludwig in 1836 as characterized by   Inflammation of cellular tissue around submandibular gland, neck and floor of mouth  Symmetrical hard sublingual swelling  Induration of floor of mouth  Extreme difficulty w/deglutition, speech and respiration9 o Potentially fatal, rapidly progressing submandibular & sublingual necrotizing cellulitis1 2. General information  o Usually originates from 2nd and 3rd mandibular molar infection o Potential therapeutic emergency w/risk for life threatening complication of air way obstruction2  Pathophysiology  1. Pathology of dz  o Originates from oropharynx o Spreads by continuity rather than by hematogenous or lymphatic spread1,3 o Extends   Superiorly and posteriorly elevation of floor of mouth & tongue  Anteriorly distortion and "bull neck" appearance1upper airway obstruction2,3 o Mixed infection of aerobic & anaerobic bacteria including predominately oral flora3,4  Staph spp, Strep spp and Bacteroides commonly isolated2,5  Atypical organisms eg. G- rods & fungi in immunocompromised host1,2,5 2. Incidence/ prevalence  o Quite rare where health access not generally a problem o Less common in antibiotic era 3. Risk factors  o Dental caries, recent dental Tx, poor dental hygiene (accounts for 75-90% of cases)1,4,5,7 o Systemic dzs1,4 (Sickle cell dz, DM, SLE), alcoholism, malnutrition o Immunosuppression (HIV, transplant recipients, chemotherapy); IVDA1,4,6 o Trauma: mandibular fracture, facial trauma, tongue piercing,1,2,5 frenuloplasty o Submandibular sialoadenitis o No apparent cause (especially in peds4,6) 4. Mortality  o Currently around 10%1; close to 100% if untreated3 o In pre-antibiotic era 60%   Ludwig’s Angina Page 2 of 4    3.25.10 Diagnostics 1. History  o Tooth pain o Painful neck swelling o Restricted neck movement o Dysphagia o Dysphonia o SOB o Sore throat o Fever, malaise 2. Physical exam  o Carious molar teeth o Tachypnea o Tachycardia o Fever o Erythema o Swelling o Drooling o Dyspnea o Cyanosis o Stridor o Tenderness to palpation of submandibular area o Neck rigidity o Trismus o Tongue displacement indicate imminent airway compromise 3. Diagnostic testing  o Laboratory evaluation   WBC count  ESR  Possible blood culture or other tests to assess severity of illness o Diagnostic imaging   Xray neck and chest2  Most important  Contrast enhanced CT7of neck   Dx test of choice o Diagnostic criteria   No validated criteria available in primary care  Differential Diagnosis  1. Peritonsillar abscess 2. Parotid space infection 3. Mumps 4. Parapharyngeal or retropharyngeal space infection 5. Paravertebral space infection 6. Suppurative jugular thrombophlebitis    Ludwig’s Angina Page 3 of 4    3.25.10 Therapeutics  1. Acute Tx  o Requires hospital admission and Tx o Prompt airway mgmt if compromised2  Fiberoptic intubation preferred   Direct laryngoscopy for intubation can precipitate air way collapse   Cricothyrotomy & tracheostomy in emergency for severe cases o IV antibiotics (immunocompetent pts)2-7  Ampicillin/sulbactam 2 g IV q4hr  Penicillin G 2-4 MU IV q4-6hr plus metronidazole 500 mg IV q6hr  Clindamycin 600 mg IV q6hr for PCN allergy o IV antibiotics (immunocompromised host)   Cefotaxime 2 g IV q6hr  Ceftizoxime 3 g IV q8hr  Imipenem 500 mg IV q6hr  Piperacillin-tazobactam 3.375 g q6hr o Dexamethasone 10 mg IV x1, then 4 mg q6hr x48hr6-8 o Nebulized epinephrine 1 ml of 1:1000 diluted to 5 mL w/0.9% NS6 2. Further mgmt  o I&D of abscessed carries; decompression of submandibular space8 o Removal of carious molars  Follow-Up  1. Potential surgical and airway emergency requiring hospital level care and aggressive antibiotic Tx  Prognosis  1. Guarded  Prevention  1. Oral hygiene   References  1. Marcus BJ, Kaplan J, Collins KA. A case of Ludwig angina. A case report and review of the literature. Am J Forensic Med Path 2008;23(3):255-9. 2. Barakate M, Jensen M, Hemli J, Graham A. Ludwig's angina: Report of a case and review of management issues. Ann Otol Rhinol Laryngol. 2001;110(5):453-6. 3. Abramowicz S, Abramowicz JS, Dolwick MF. Severe life threatening maxillofacial infection in pregnancy presented as Ludwig's angina. Infect Dis Obstet Gynecol. 2006;doi:10.1155/IDOG/2006/51931 4. Yu-Kung C, Chao-Yi L, Hai-Hsuan C. An upper airway emergency: Ludwig Angina. Pediatr Emerg Care. 2007;23(12):892-6.  5. Hartmann RW Jr. Ludwig's Angina. Am Fam Physician 1999;60:109-112. http://www.aafp.org/afp/990700ap/109.html Accessed 2.27.2010. 6. Saifeldeen K, Evans R. Ludwig's angina. Emerg Med J. 2004:21(2):242-3.  7. Furst I, Ersil P, Caminiti M. A rare complication of tooth abscess - Ludwig's angina and mediastinitis. J Can Dent Assoc. 2001;67(6):324-7.  Ludwig’s Angina Page 4 of 4    3.25.10 8. Lin HW, O'Neill A, Cunningham MJ. Ludwig's angina in the pediatric population. Clin Pediatr. 2009;48(6):583-7.  9. Weisengreen HH. Ludwig's angina: Historical review and reflections. Ear Nose Throat J. 1986;65:457-61.   Author:  Olivia Kamayangi, MD, Michigan State University-Sparrow Hospital FPRP  Editor:  Vince WinklerPrins, MD, Georgetown University-Providence Hospital Washington DC 

Ludwig's angina

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University of Missouri: MOspace

University of Missouri: MOspace