Ludwig's Angina 3

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Scope of this discussiony y y y y y y

Ludwig s Angina definition. Anatomy of facial spaces involved. Clinical Presentation. Etiology Diagnosis Clinical & Radiological. Bacteriology. Emergency management Medical & Surgical . Complications.

Definition:y Rapidly spreading floor of mouth cellulitis with y firmly indurated cellulitis that originates intraorally y and involves submandibular and sublingual spaces y bilaterally, but without abscess or lymphadenopathy.

Named after Karl Wilhelm von Ludwig.

Background Ludwig's angina, named after the German physician who

described the condition for the first time in 1948 A rapidly progressive gangrenous cellulitis originating in

submandibular space. Inflammatory distention of the facial planes of the neck can

lead to respiratory tract obstruction and death. It extends by continuity rather than lymphatic spread. Mortality rate exceeds 50% during the preantibiotic era,

attributed to overwhelming sepsis, in antibiotic era the mortality & morbidity % reduced below 5%. Untreated, the mortality is close to 100 %, both from the acute

sepsis and from airway obstruction. In the early 1900s the deadly role of mechanical respiratory

obstruction was realized.

Facial Spaces Involved:a) b) c) Submandibular space. Sublingual space. Submental space.

Facial Spaces Involved:

Etiology:y a)

> 90% odontogenic in origin The most frequent cause of the disease is periapical or periodontal infection of mandibular teeth, especially of those whose apices are found beneath the mylohyoid muscle. Peritonsillar absecess Parapharyngeal abscesses Oral lacerations Mandibular fractures Submandibular sialadenitis

y b) y c) y d) y e) y f)

Pathogens:Polymicrobial comprising aerobes & anaerobes.

Common organisms identified include a) Streptococcus, y b) Staphylococcus Aureus,& y c) Bacteroides species. Other isolated gram-negative bacteria a) Klebsiella species, b) Hemophilus influenzae c) Proteus species & d) P aeruginosa.


History:Recent dental extraction or work y 2) Dental caries y 3) Fever y 4) Swelling of mouth, face, neck y 5) Compromised host y 6) Co-morbidities (diabetes, hypertension, chronic glumerulonephritis, SLE, aplastic anemia, neutropenia, immunodeficiency HIV, alcohol abuse.) y 7) Pregnant lady with bad oral & periodontal health status.y 1)

Presentation:y Neck swelling y Tooth pain y Protruding or elevated tongue y Fever y Dysphagia

Trismus y Difficulty breathing y Asphyxia y Odynophagia.

linical Findings:a) c) e) g) i) fever, b) tachycardia, d) Stridor, f) respiratory distress, h) decreased air movement . k) tachypnea, fetid breath, hoarseness, cyanosis, leucocytosis.

Although abscess formation is not always associated with Ludwig s angina, some cases will eventually evolve into an abscess.

Physical Examination:y Palpation of the submental and bilateral submandibular

spaces reveals firm, nonpitting induration of the suprahyoid neck bilaterally. Inspection of oral cavity is limited because of trismus, but a firm, raised floor of the mouth may be evident. Toxicity, Trismus, Tongue elevation, No fluctuance .

Intraoral Examination:y a) y b) y c) y d) y e) y f) y g)

Caries Swellings of oral vestibule Periodontal disease Tooth mobility Pericoronitis Swellings Position of uvula

RADIOLOGICAL DIAGNOSIS:CT CONTRAST:Contrast-enhanced CT can help determine the extent of the infection, especially in the presence of an abscess. Clinical examination has a low sensitivity (55%) for predicting drainable collections of pus in deep neck infections, but when combined with CT findings, the accuracy is 89%, sensitivity is 95%, and specificity is 80% for identifying a drainable collection.

CT scan showing , edema, inflammation & air in soft tissue. adjacent to Right & Left mandible.

y Plain radiographs of the neck may show soft-tissue swelling,

the presence of gas, and the extent of airway narrowing.

Dental Panoramic Radiograph OPG

Differential Diagnosis:Differential diagnosis of Ludwig s angina includes:1) 2) 3) 4) Angioneurotic edema, Lingual carcinoma, Sublingual hematoma, & Peritonsillar abscess.


Treatment:Primary goal:y Preserve the oropharyngeal airway.

Secondary goal:y Antibiotic agent or incision and drainage.

Airway maintenance:The need for immediate artificial airway:y a) y b) y c) y d) y e) y f)

Stridor Cyanosis Retractions difficulty managing secretions. Rapid progression of edema Comorbid health problems, DM

Airway assessmenty Ludwig's Angina causes obstruction of oropharynx and

potentially supraglotic areay Mallampatti score - crowding in Oropharynx y Nasopharyngoscopy only way of assessing supra- glotic

obstruction .

Mallampatti Score:

Airway MaintenanceAirway maintenance may be difficult:y Endotraclear intubation: Supraglottic edema Nuchal rigidity Trismus y Nasal intubation: Requires careful awake Flexible endoscope Patient in an upright position. y Last resort: Cricothyroidotomy Tracheotomy.

Airway Management:y 1) Airway management is the most important aspect of immediate care. y 2) Risk of rapid airway compromise, all patients with Ludwig s angina should be admitted to the ICU. y 3) Death is usually the result of hypoxia or asphyxia, not overwhelming sepsis. y 4) Fiber optic intubation. y 5) When fiber optic intubation is not possible tracheotomy using local anesthesia recommended y 6) Tracheotomy using local anesthesia has been considered the gold standard of airway management in patients with deep-neck infections. However, cellulitis of the neck with involvement of the tracheostomy site makes the procedure difficult. y 7) A recent study on patients with Ludwig s angina showed that tracheal intubation with a flexible bronchoscope using topical anesthesia provided good airway management.

Antibiotic agentEarly aggressive antibiotic therapy: Initial antibiotic therapy is targeted at gram-positive organisms and oral cavity anaerobes. Empiric therapy with IV penicillin G, or metro-nidazole is recommended before culture and sensitivity results are available.8 Some experts recommend the addition of gentamicin. In penicillin-allergic patients, use clindamycin.y IV dexamethasone, given for 48 h, has been beneficial in reducing edema.

Use of Steroidsy a) IV dexamethasone (eg, Dalalone, Decadron, Dexasone), given for 48 hours, can decrease edema and cellulitis and thus help maintain the integrity of the airway and enhance antibiotic penetration.

Used routinely when airway compromise suspected (Larawin et al.) b) Dexamethasone 10-20 mg IV Then 4-6 mg Q6 for 8 doses (Busch) If an abscess is present, the definitive treatment would be incision and drainage and, if applicable, removal of the abscessed tooth or teeth.

Surgical intervention:y Decompression Sublingual and Submandibular & Submental spaces. y Incision and drainagey 1)

Therapy includes early surgical removal of the source of infection (which is often grossly carious dentition) via extraction, aggressive, and vigorous incision and drainage procedures with appropriate placement of drains, along with intense and prolonged antibiotic therapy and maintenance of a patient airway

y 2)

Surgical drainage is indicated in the presence of clinical a) fluctuance or crepitus, b) radiologic evidence of fluid collection or air in the soft tissues. c) a relative indication is the lack of clinical improvement within 24 hours of initiation of antibiotic therapy

y Ludwig s angina.

a) Diagrammatic illustration showing the spread of purulent infection in five fascial spaces of the mandible. y b) Clinical photograph of extensive extraoral swelling in submental and submandibular spaces y Ludwig s Angina


y y y y

a)Clinical intraoral photograph showing severe edema of the floor of the mouth and elevation of the tongue, due to suppuration of sublingual spaces (risk of asphyxiation). b)Intraoral incision, parallel to the ducts of the submandibular glands.

Incisional Planes:

y y y y

a)Incision for drainage of inflammation. b)The incisions must be bilateral, extraoral, parallel, and medial to the inferior border of the mandible, at the premolar and molar region.

y Placement of rubber drains at the sites of incision

y Postoperative clinical photograph 1 month after treatment of infection

Complications:y y y y

Deep neck infection. Mediastinitis. Pericarditis. Sepsis.

y Pneumonia. y Empyema. y Asphyxia. y Pneumothorax .

Ludwig's Angina & Pregnancyy PREDISPOSING FACTORS:y 1)

Pregnancy is accompanied by many physiological changes which place the mother at a higher risk of infection or of doing worse once infected.

2) Immune response greatly diminished resulting in potential faster progression of an infection. 3) Decreased neutrophil ,chemotaxis, cell mediated immunity, and natural killer cell activity


50% pregnant women complain of dyspnea by 19 weeks gestation , results in lower oxygen reserve which could increase fetal hypoxia during periods of hypoventilation. Pregnancy gingivitis :- pregnancy associated hormonal changes begin to affect a woman's gingival tissues plaque accumulates resulting in a constant, low-grade intraoral infection Dietary habits:- women tend to maintain frequent meals and snacks, which cause further plaque accumulation, as well as an increase in decay or rapid progression of previously present decay can lead to odontogenic infections. Pt unwilling to give high risk consents for treating minor orodental infection which turns later in facial space infection in due course of pregnancy.

y y 5)

y 6)

y 7)

Ludwig's & Pregnancyy COMPLICATIONS:y 1)

Risks of maternal and fetal morbidity include both septicemia and asphyxia

y 2)

An infection in itself can infect the placenta, uterus, and possibly the fetus, causing fetal septicemia Poor oxygenation is compromising to the fetus.

y 3)

4) Maternal infective process sometimes resulting in preterm labor, preterm premature rupture membranes, and low birth weight.

Management :y PREVENTION:-

Regular visits to dental clinics during antenatal appointments. y 2) Health care providers should not neglect even minimal complaints of dental pain, timely identification of infection during the early stages of pregnancy & proper elimination of potential problems with extremely aseptic technique is prime importance. y 3) An appropriate time for dental care from a medical standpoint is the second trimester and pregnant women usually experience the greatest sense of well being during this time.y 1)

Management Cont


y Surgical management of Ludwig's Angina infection in

pregnant lady is same but following points should be considered. Formal consultation to the Departments of Obstetrics and Gynecology (Ob/Gyn) and Anesthesiology. y Ob/Gyn continued follow up on the patient by frequent monitoring of the fetal heart rate 2) Healthcare provider must consider the risks that the condition and the possible treatments may cause the mother, her unborn child & perinatal effects of the treatment to new born.y 1)

y 3)

Prolonged intubation and certain intravenous medications can also harm the fetus. During a life threatening infectious situation ,the risk of maternal and fetal morbidity may overshadow potential teratogenic side effects.

yEmergency Management of

Ludwig's Angina at yPrimary Health Care Level

This is a picture showing grade II or progressing grade III Ludwig's angina. In this case the patient is maintaining his airway. In such case what is the role of primary attending physician a). Assessment b). Check airway & SPO2 c). Start high dose antibiotics d). IV steroids e). Arrange for early transfer to higher health care center

This is a severe form of ludwig s angina. In such cases :a). Maintain airway by using oropharyngeal airway b). Decompression of indurated facial spaces should be done by incision under local anesthesia c). Urgent transfer to higher center escorted by a doctor

Conclusion:y The very name angina, meaning spasmodic suffocative pain when not treated. y Tracheotomy may eliminate the decision-making burden, but y Early aggressive antimicrobial therapy has reduced the need for airway intervention. y The treatment plan for each patient should be individualized. y The condition of the patient and comorbid health problems, physician experience, available resources, and manpower are all crucial factors in this decision-making process.

IMPORTANT NOTE:y Ludwig s angina usually resolves without

complications, but the condition can be fatal. Prompt diagnosis, appropriate airway management, aggressive IV antibiotic therapy, and close monitoring in the ICU promote good outcomes in most patients.