emDOCs Podcast: Episode 33 – Ludwig’s Angina

Today on the emDOCs cast with Brit Long, MD (@long_brit) and Rachel Bridwell, MD (@rebridwell), we cover the challenge of Ludwig’s Angina


Ludwig’s Angina

Epidemiology:

    • Risk Factors: Poor dental hygiene, recent dental infection, immunosuppression, IVDU, DM, chronic EtOH abuse, recent tongue piercing.
    • Odontogenic infection accounts for 70% of Ludwig’s Angina.1
      • Most commonly periapical abscesses of mandibular molars (esp. 2ndand 3rd) in adults.
      • URI more commonly causes Ludwig’s Angina in children.1
    • IgG hypogammaglobulinemia possible risk factor for severe complication.2
    • Named for Karl Friedrich Wilhelm von Ludwig in 1836, who first described the fatal and rapidly progressive infection of the mouth floor.

 

Anatomy and Pathophysiology:

    • Mylohyoid subdivides submandibular space:
      • Sublingual space
      • Submaxillary (submylohyoid) space
    • Infection extends posteriorly and superiorly, elevating tongue against hypopharynx.
    • Untreated, extension inferiorly to retropharyngeal space and into superior mediastinum.3
    • Polymicrobial oral flora, but most common bacterial culprits:4
      • Enterococcus
      • E. coli
      • Fusobacterium
      • Streptococcus spp.
      • S. aureus
      • Klebsiella pneumonia
      • Actinomyces spp.

 

Clinical Presentation:

    • Initially oral infection, progressing to trismus, tongue protrusion, inability to handle secretions, odynophagia, tripoding, respiratory distress. Patients may demonstrate signs of systemic toxicity with fever, tachycardia, and hypotension.

 

Evaluation:

    • Assess ABCs and begin resuscitation.
    • Patient may be leaning forward to optimize diameter of the airway.
    • Perform a complete physical examination.
      • ENT: Decreased intercisal mouth opening distance, indurated mouth floor, brawny neck with submandibular and submental edema, sublingual and submental lymphadenopathy, superior displacement of tongue.
      • Integumentary: Erythema with inferior tracking denotes spreading infection.
    •  Laboratory evaluation:
      • CBC, BMP, VBG with lactate.
    •  Imaging: Consider CT head/neck to assess anatomic reaches of infection if clinical situation permits. Highly accurate, but ensure the patient can tolerate lying flat prior to going to CT.

 

Treatment:

    • ABCs—Sit upright.
    • Early airway management is paramount.
      • Intubation often unsuccessful, with a majority of cases requiring surgical airways.4-5
    • Source control of infection—Typically to OR for needle aspiration versus surgical decompression.
    • Early antibiotics—Coverage for beta-lactamase producing aerobic or anaerobic GPC, GNR +/- MRSA
      • PCN G + metronidazole, clindamycin, or unasyn.6
    • Steroids
      • 10 mg dexamethasoneà4 mg q6hrs x 48 hrs
        • Thought to chemically decompress for airway protection and increase antibiotic penetration.6
    • Nebulized epinephrine
    • Resuscitation and pain control

 

Disposition:

    • Consult ENT, OMFS, and anesthesia for airway assistance .and surgical decompression of infection, extraction of infected teeth.
      • Awake fiberoptic vs surgical airway
    • Admit to ICU.
    • May progress to cervical necrotizing fasciitis or descending necrotizing mediastinitis through carotid sheath or retropharyngeal space.2
    • Consider negative pressure wound therapy.7

 

Pearls:

    • Mortality in treated Ludwig’s Angina is approximately 8%.7
    • Airway compromise is the leading cause of death.8

 

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