Ludwig’s Angina
Ludwig’s angina is a bilateral cellulitis involving the submandibular, submental, or sublingual spaces. It presents as edema and cellulitis with an intact skin. It is named after Karl Friedrich Wilhelm Von Ludwig who was the first to describe it in 1836. The most serious complications that makes the condition rapidly fatal is airway obstruction due to the progressive swelling of the soft tissues of the floor of the mouth as well as the elevation and posterior displacement of the tongue. The three characteristics of Ludwig’s angina can be remembered as the three F’s – Feared, Fatal and rarely fluctuant. Ludwig’s angina is mainly a clinical diagnosis hence investigations do not assist in the immediate management of the patient. Securing the airway and administering broad-spectrum antibiotics should be done before taking the patient for any tests.
Before the advent of antibiotics and refined surgical techniques the mortality rate was 50% but with medical advancement it has dropped to 8%. Since odontogenic infections are the leading cause, patients should be educated on the importance of maintaining good oral hygiene and visiting the dentist regularly.
- Sources of infection for Ludwig’s angina
- 75% from infection of the 2nd and 3rd lower mandibular molars ( The roots of the teeth are located inferior to the attachment of the mylohyoid muscle allowing infection to spread to the submandibular space.)
- Infected fractures of the mandible
- Peritonsillar abscess
- Foreign bodies
- Sialadenitis (of the submandibular and sublingual glands)
- Neck trauma
- Otitis media
- Traumatic intubation
- Oral piercings
- Risk factors
- Dental related: poor oral hygiene, dental caries, recent dental treatment
- Immunosuppression (uncontrolled diabetes, HIV)
- Alcohol use
- Malnutrition
- Elderly (65 years and above)
- Pathogens Poly-microbial involvement with the following being the most common:
- Staphylococcus
- Streptococcus
- Peptostreptococcus
- Fusobacterium
- Bacteriodes
- Actinomyces
- Morganella morganii
- Gemella morbillorum
- Signs and symptoms
- Board like oedema of the upper neck
- Oedema of the floor of the mouth
- Elevation and oedema of the tongue
- Degrees of airway obstruction (hoarseness, repeated cough and nasal flaring are danger signs)
- Dysphagia
- Drooling
- Neck pain
- Dysphonia
- Dysarthria
- Trismus (advanced disease)
- Danger signs of airway obstruction
- Hoarseness of voice
- Repeated coughing
- Flaring of alae nasi
- Tachypnea
- Dyspnea
- Tripod positioning
- Late signs include stridor and cyanosis
- Differentials
- Angioneurotic edema
- Cellulitis
- Peritonsillar abscess
- Sublingual hematoma
- Lingual carcinoma
- Lymphadenitis
- Salivary gland abscess
- Areas that may be secondarily involved
- Posterior-superior spread to the masticator spaces
- Posterior spread to the larynx leading to laryngeal oedema
- Posterior spread to the prevertebral fascia and ****inferiorly towards the posterior mediastinum to cause mediastinitis
- Inferior spread along the investing fascia
- Spread to the pre-tracheal fascia then inferiorly to the superior mediastinum causing mediastinitis
- Contiguous spread to the retropharyngeal and parapharyngeal spaces
- Hematogenous spread causing cerbral abscesses and infective endocarditis
- Laboratory tests (mostly done to check for concomittant illness)
- Blood cultures to check for hematogenous spread
- Exudate culture
- Complete blood count
- Random blood sugar
- Peripheral blood film
- C reactive protein
- Imaging tests
- Neck CT scan with IV contrast: done to assess severity and check for suppurative complications
- Chest X-ray/CT scan: to check for chest involvement
- Treatment
- Emergency admission to a hospital with tracheostomy facilities and ICU/HDU
- Aggressive airway management (early tracheostomy under local anaesthesia or awake fiberoptic nasotracheal intubation)
- Broad spectrum IV antibiotics
- Fluid and electrolyte balance management
- External incision (straw-colored fluid weeping, no true abscess fluid)
- Remove the cause e.g. dental extraction
- Complications of Ludwig’s angina
- Airway obstruction
- Descending necrotizing mediastinitis
- Osteomyelitis
- Cerebral abscesses (due to hematogenous spread)
- Disseminated intravascular coagulation
- Neck cellulitis
- Meningitis
- Infective endocarditis
- Renal failure
- Aspiration pneumonia
- Sepsis particularly in the immunocompromised
Image showing how the infection causes swelling.
Image showing how the infection causes swelling.
Relevant anatomy.
Bull neck characteristic of Ludwig’s angina
Bull neck characteristic of Ludwig’s angina
Ludwig’s angina following a mandibular fracture
Ludwig’s angina following a mandibular fracture
Childhood Ludwig’s angina. Note the tongue elevation and submandibular swelling.
Childhood Ludwig’s angina. Note the tongue elevation and submandibular swelling.
Sagittal head and neck CT scan showing submandibular swelling
Sagittal head and neck CT scan showing submandibular swelling
| Medical history | Antibiotic regimen |
|---|---|
| Immunocompetent | Ampicillin-sulbactam 3g IV every 6 hours OR Ceftriaxone 2g IV every 12 hours with Metronidazole 500mg every 8 hours OR Clindamycin 600mg IV every 6 hours to 8 hours with levofloxacin 750mg every 24 hours |
| Immunocompromised | Cefepime 2g IV every 8 hours with Metronidazole 500mg every 8 hours OR Ipipenem 1g IV every 6 to 8 hours OR Meropenem 2g IV every 8 hours OR Piperacillin-tazobactam 4.5g IV every 6 hours |
| MRSA coverage | Added to the above regimen: Vancomycin 20mg/kg IV OR Linezolid 600mg IV every 12 hours |
Cervicofacial Necrotizing Fasciitis (CNF)
CNF is an aggressive polymicrobial infection involving the subcutaneous tissue and fascia of the face and neck. There is local ischemia (due to vascular thrombosis) which leads to necrosis and ulceration of the skin and soft tissue. Myonecrosis can occur from superinfection with anaerobes and other gram-negative organisms.
- Causes of CNF
- Carious teeth with periapical infection
- Trauma (untreated fractures of the mandible)
- Peri-tonsilar abscesses
- infected salivary glands
- Foreign bodies
- Varicella Zoster Virus infection
- Neck surgery
- Risk factors
- Immunocompromise (Uncontrolled diabetes, HIV)
- IV drug use
- Pathogens
- Group A-Beta Hemolytic streptococci
- Staphylococci
- Gram negative rods
- Anaerobes
- Signs and symptoms
- Rapid severe necrosis of the skin, fascia, and soft tissues
- Foul smelling neck discharge
- Crepitus
- Pitting neck oedema with peau d’ orange appearance
- Signs of sepsis (fever, hypotension, tachycardia)
- Signs of respiratory distress
- Investigations
- CT scan of the neck
- Subcutaneous emphysema
- Necrotic soft-tissue
- Culture and sensitivity
- Complete blood count: leukocytosis with left shift, low hemoglobin
- ESR: elevated
- CRP: elevated
- U/E/C: high creatinine, hyponatremia
- RBS: may have hypoglycemia
- CXR: if there is suspected mediastinitis
- CT scan of the neck
- Treatment
- Admit to the ICU
- Airway management (may include tracheostomy)
- Daily aggressive surgical debridement and irrigation with viable tissue margins
- Broad spectrum IV antibiotics
- Hyperbaric oxygen (HBO) and IVIG may be used
- Manage gluid and electrolytes
- Control Diabetes
- Definitive cover with skin grafts and flap covers
