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 periapical abscesses of mandibular molars
• Source of infection often polymicrobial, most commonly Strep, Staphylococcus, and Bacteroides species
• Patients usually 20-60yr; male predominance
• Often there is no lymphatic involvement and no abscess formation but infection rapidly spreads bilaterally

Clinical Features

Swelling in the submandibular area in a person with Ludwig's angina.

Significant submandibular swelling and discoloration typical in Ludwig's Angina

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
• Tongue protrusion
• Trismus
• Dysphonia
• Cyanosis
• Acute laryngospasm

Complications

• Carotid sheath infection
• IJ thrombophlebitis (Lemierre's Disease)
• Mediastinitis
• Empyema
• Pericardial effusion
• Pleural effusion
• Mandibular osteomyelitis
• 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
• Coxsackie virus
  • 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
• Vincent's angina
• Acute necrotizing ulcerative gingivitis

Evaluation

• Clinical diagnosis, based on history and physical exam.
• 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 or transfer to OR for definitive care
  • Be aware of possibility of respiratory distress/airway compromise with laying flat for CT scan
• CBC
• Chem
• Lactate
• Blood Cultures

Management

• Emergent ENT or OMFS consult for operative I&D and extraction of dentition if source is dental abscess

Airway Management

• Intubation may be very difficult due to trismus and posterior pharyngeal extension
• Preference for an awake fiberoptic intubation (ideally in OR if time allows) with setup immediately available 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 million units IV q6 hrs + Metronidazole 500 mg IV q6 hrs OR
• Clindamycin 600 mg IV q6 hrs (option for those allergic to penicillin)

Pediatric Immunocompetent

• Ampicillin/Sulbactam 50mg/kg IV q6hrs (max 3g/dose) OR
• Penicillin G 50,000 units/kg IV q6hrs (max 4 million units) + Metronidazole 7.5mg/kg IV q6hrs (max 500mg) OR
• Clindamycin 10-13mg/kg IV q8hrs (max 900mg/dose)

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

Pediatric Immunocompromised

• Cefepime 50mg/kg IV q8hrs (max 2g) + Metronidazole 7.5mg/kg IV q6hrs (max 500mg) OR
• Meropenem 20mg/kg IV q8hrs (max 1g) OR
• Piperacillin/Tazobactam 80-100mg/kg IV q6-8hrs (max 4.5g)
• Add Vancomycin 15mg/kg IV q6hrs if concern for MRSA

Disposition

• Admit, usually ICU for airway monitoring

See Also

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