Ludwig’s Angina: Pearls, Pitfalls, and Highlights

Author: Richard Slama, MD (EM Resident Physician, Naval Medical Center Portsmouth) // Editors: Jennifer Robertson, MD and Alex Koyfman, MD (@EMHighAK)

Introduction

Ludwig’s angina was originally described in 1836 by Wilhelm Friedrich Von Ludwig. ludwigIt is defined as a bilateral infection of the submandibular, submental, and sublingual spaces that can lead to rapid airway failure. Ludwig’s angina is a diagnosis that can be easily missed or confused with more benign conditions. Thus, emergency physicians should keep a high level of suspicion for this potentially fatal disease.

Anatomy/Physiology

The submandibular space is divided into the sublingual, supramylohyoid and inframylohyoid portions by the mylohyoid muscles (figure 1). The submental space is the area between the two anterior bellies of the digastric muscles (Figure 2). Up to 85% of cases will arise from an infection in one of the molar teeth (1). Since the roots of the teeth are below the mylohyoid muscle, the infection starts in the inframylohyoid portion of the submandibular space. The submandibular space is in direct communication with the sublingual space in the posterior aspect, which leads to easy spread of the infection (note the red circle in Figure 1). The end result is edema and posterior displacement of the tongue and possibly epiglottis, leading to potential airway compromise (2).

Figure 1
Figure 1
Figure 2
Figure 2

Important Clinical Questions

1. Is my patient’s airway in danger?
2. If my patient requires an airway what is the best approach to establish one?
3. If my patient looks well, should I just monitor him/her after giving antibiotics and steroids?
4. Is this really even Ludwig’s angina?

1. The Dangerous Airway
Patients with Ludwig’s angina have the potential for rapid airway decompensation. This is especially important to remember, even if they look well without a significant amount of swelling. Patients can develop unilateral to bilateral swelling rapidly, even within 30 to 45 minutes of presentation. Once the cellulitis gets into any of the neck spaces there are really no barriers to stop its spread.

The first lesson is to be prepared for an emergent airway in any patient who may have Ludwig’s angina. Move the airway cart and the cricothyrotomy kit to the bedside.
If the patient has low oxygen saturation levels, provide supplemental oxygen. If he or she continues to worsen, then establish a surgical airway without hesitation (3). The reason for this is that all of the structures at the level of the glottis tend to be so edematous that a tube can never be passed, no matter how good your view is. If the patient is stable, then prophylactic intubation can be considered. This brings us to pearl #2.

2. How Do I Establish an Airway?
Patients with Lugwig’s angina may initially appear stable, but they have the potential for rapid decompensation. Although not a hard and fast rule, many patients should be intubated to protect their airways as swelling can take a week or more to resolve (1). Below are some tips to handle these potentially difficult airways.

Do
1. Assess your own skill level and decide if you can reasonably intubate the patient.
2. Be comfortable with performing awake nasotracheal intubation.
3. Mentally prepare yourself for a cricothyrotomy
4. Consult early and send the patient to the operating room (OR) if needed

Do NOT
1. Use supraglottic devices or blind intubation techniques as these can make everything worse by irritating the glottic area.
2. Try to look with a laryngoscope. This will probably hurt the patient and worsen swelling.
3. Attempt orotracheal intubation, unless you are in a controlled environment with the appropriate safety nets.
4. Wait until your patient is crashing to consult the appropriate services (maxillofacial surgery, otolaryngology (ENT) and anesthesia).
5. Try to do the intubation unless you are experienced and willing to perform a rescue surgical airway.
6. Let the patient leave the emergency department (ED) without a definitive airway or at least plans to obtain one.

Because Ludwig’s angina is rare, there has only been expert opinion and case reports about how these airways should be managed. Awake nasotracheal intubation is preferred because of obstruction of the oropharynx by the tongue (although there have been successful oral intubations) (4).

Induction and paralysis should be considered on a case by case basis. If induction is performed, ketamine is a good option as it is less likely to decrease respiratory drive and allow patients to maintain their own airways. Glycopyrrolate pre-treatment should be considered as edema can cause pooling of secretions. Finally, if you are performing an awake nasotracheal intubation, you should consider pretreating the nasopharynx with topical lidocaine and phenylephrine.

3. Antibiotics, Steroids, and Observation?
In any patient who has suspected Ludwig’s angina, antibiotics should be started as soon as possible. The choice of antibiotic therapy should target hemolytic streptococcus as well as anaerobic bacteria (5).  Of note, any patient who is at risk for methicillin resistant staphylococcus aureus or is septic upon arrival should have additional antibiotic coverage on top of the following regimens (6).
• Immunocompetent Patients
o Unasyn (3 g IV Q6) or
o Penicillin G (2 to 4 MU IV Q4-6) + Flagyl (500 mg IV Q6-8) or
o Clindamycin (600 mg IV Q6-8)
• Immunocompromised Patients
o Cefepime (2 g IV Q12) + metronidazole (500 mg IV Q6-8) or
o Imipenem (500 mg IV Q6) or
o Meropenem (1 g IV Q8) or
o Zosyn (4.5 g IV Q6)

While steroids may be beneficial in other upper respiratory conditions such as angioedema, asthma, and epiglottitis, there has been no evidence to prove that steroids have any role in the treatment of this disease.

In terms of disposition, the priority is airway stabilization. If a patient is stable in the ED, then prophylactically intubate and send him/her to the ICU for monitoring or the OR for drainage. The rapidity at which these infections spread and the duration of swelling should be taken very seriously.

4. Is it really Ludwig’s?
Chances are that most of what you will see in the Department is not going to be Ludwig’s angina. There are many conditions that look similar to this condition including periodontal abscess, periapical abscess, pericoronal abscess, canine space abscess, parapharyngeal space abscess, angioedema, and many more. There was a recently published review of odontogenic infections in Emergency Medicine Australia that gives a great description of many of these conditions and their relevance to emergency physicians (7).

Summary

Ludwig’s is a potentially deadly infection of the bilateral submandibular, sublingual, and submental spaces. Anytime you suspect a patient might have this condition, you should manage the airway early. If your patient is unstable, do not hesitate to establish a surgical airway. If a patient is stable, then intubate prophylactically, preferably via awake nasotracheal intubation. Any attempts at orotracheal intubation, supraglottic airways, or blind intubation may worsen your patient’s airway. Administer antibiotics as soon as possible. There are many causes of jaw and submandibular swelling, but always consider that your patient could have, or could be developing, Ludwig’s angina. Finally, always make sure that you have back-up available when you need it. These are not airways that you want to be doing by yourself unless that is the only option left.

In conclusion, Ludwig’s angina should always be a diagnosis in the back of your mind. It is a deadly condition for which emergency physicians are fully capable of executing life-saving measures if we are vigilant enough to catch it. However it is also a condition that can get us into trouble quickly if treatment or a multidisciplinary approach is not undertaken aggressively.

References // Further Reading:

1. Tintinalli J. Tintinalli’s Emergency Medicine. 7th ed. Chapel Hill: McGraw Hill; 2911:1586-1587.
2. Boscolo-Rizzo P, Da Mosto MC. Submandibular space infection: a potentially lethal infection. Int. J. Infect. Dis. 2009;13(3):327-33. doi:10.1016/j.ijid.2008.07.007.
3. Barton ED, Bair AE. Ludwig’s angina. J. Emerg. Med. 2008;34(2):163-9. doi:10.1016/j.jemermed.2007.08.053.
4. Ovassapian A, Tuncbilek M, Weitzel EK, Joshi CW. Airway management in adult patients with deep neck infections: a case series and review of the literature. Anesth. Analg. 2005;100(2):585-9. doi:10.1213/01.ANE.0000141526.32741.CF.
5. John Marx MD , Robert Hockberger MD RWM. Rosens Emergency Medicine. 8th ed. Saunders; 2013.
6. Chow A. Submandibular space infections (Ludwig’s angina). Uptodate 2014. Available at: http://www-uptodate-com.ezproxy3.lhl.uab.edu/contents/submandibular-space-infections-ludwigs-angina?source=search_result&search=ludwigs+angina&selectedTitle=1~8.
7. DeAngelis AF, Barrowman R a, Harrod R, Nastri AL. Review article: Maxillofacial emergencies: oral pain and odontogenic infections. Emerg. Med. Australas. 2014;26(4):336-42. doi:10.1111/1742-6723.12266.
8. Melanson T. Bavarian Illuminati. 2014. Available at: http://www.bavarian-illuminati.info/2010/01/the-influence-of-the-illuminati-and-freemasonry-on-german-student-orders-and-vice-versa/.
9. Wesley Norman P. Anterior Triangle of the Neck In Detail. Available at: http://www.wesnorman.com/lesson5.htm.
10. Hartmann RW. Ludwig ’ s Angina in Children Illustrative Cases. AAFP 1999;60(1):109-112.
11. http://www.ncbi.nlm.nih.gov/pubmed/23601483
12. http://www.ncbi.nlm.nih.gov/pubmed/23433016
13. http://www.ncbi.nlm.nih.gov/pubmed/21031047
14. http://www.ncbi.nlm.nih.gov/pubmed/19945607
15. http://www.ncbi.nlm.nih.gov/pubmed/21760800

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