-- Dr. Hardik VoraPG OMFS

MRADC

LUDWIG’S ANGINA

Regional anatomy

Ludwig’s angina

Etiology

Clinical presentation

Microflora

Investigations

Treatment

Airway management

Definitive treatment

CONTENTS

REGIONAL ANATOMY

First described in 1836 by Wilhelm Frederick von Ludwig as

a cellulitis of fast evolution involving the region of the

submandibular gland which is disseminated through

anatomic contiguity without tendency towards abscess

formation

3 Fs

It was to be feared

Rarely became fluctuant

Often was fatal

LUDWIG’S ANGINA (LATIN TERM ANGERE = “TO STRANGLE”)

Grodinsky stated in a 1939 paper that Ludwig’s angina was

a unique deep neck abscess characterized by

occurrence bilaterally in more than one space,

production of gangrenous serosanguineous infiltration with or

without pus,

involvement of connective tissue and muscle but not glandular

structures,

Spread by continuity, not via lymphatics

Airway compromise has been recognised as the leading cause of death

Mortality rate – 50% in preantibiotic era

8% currently

LUDWIG’S ANGINA

Dental caries, recent dental treatment, poor dental hygiene (accounts for 75-90% of cases)

Trauma: mandibular fracture, facial trauma, tongue

piercing, frenuloplasty

Infections of oral malignancy

Submandibular sialadenitis

Systemic compromise such as AIDS, glomerulonephritis,

diabetes mellitus, aplastic anemia, transplant recipients,

chemotherapy; IVDA (Soares et al. and Tavares et al.)

ETIOLOGY

CLINICAL FEATURES

Bilateral wood like

swelling

Double chin

appearance

Elevation and protrusion of

tongue

Airway obstruction

Bilateral ‘wood like’ swelling in the submandibular,

sublingual and submental spaces

Double chin appearance

Skin is tense and tends to pit and blanch on pressure

Rapidly spreading edema

Edema and congestion of floor of the mouth

Elevation and protrusion of tongue

Elevation of the tongue is associated with dysphagia,

odynophagia, dysphonia and cyanosis

CLINICAL FEATURES

Dyspnea in supine position impending laryngeal edema

Dysphagia and drooling of saliva

Septicemia

High grade fever

Malaise

Body aches

Leukocytosis

CLINICAL FEATURES

Thumb sign on epiglottis indicating

laryngeal edema

Staphylococcus aureus in the pre-antibiotic era

Change in the microbial flora – aerobic streptococcal species

and nonstreptococcal anaerobes

The bacteria that commonly cause deep neck infections

represent the normal oral flora that becomes pathogenic when

normal host defenses are ineffective

MICROBIOLOGY

Oral Maxillofacial Surg Clin N Am 20 (2008) 353–365

Common organisms

• Streptococcus viridans

• Streptococcus millerigroup species

• B-hemolytic streptococci

• Neisseria species

• Peptostreptococcus

• Coagulase-negative staphylococci

• Bacteroides

Should be considered but are uncommon

• Bartonella henselae

• Mycobacterium tuberculosis

Anaerobic bacteria

• Prevotella and Porphyromonas species

• Actinomyces species

• Bacteroides species

• Propionobacterium

• Hemophilus

• Eikenella

MICROBIOLOGY

Oral Maxillofacial Surg Clin N Am 20 (2008) 353–365

In diabetic patients, the microbial nature of DSNI shows a higher infection rate

of Klebsiella pneumoniae when compared with those who do not have diabetes

mellitus

Laboratory tests – hemogram, blood glucose, etc.

Panoramic x-ray – to identify possible odontogenic sources

Cervical, profile and posterior-anterior radiographs – to

observe the volume increasing in the soft tissues and any

deviation of the trachea

Ultra sound has been recommended to differentiate

between cellulitis, abscess and adenopathy in head and

neck infection

USG has a sensitivity of 95% and specificity of 75%

INVESTIGATIONS

INVESTIGATIONS

Measure the distance from the

anterior aspect of the vertebral

body to the air column of the

posterior pharyngeal wall.

At the level of C-2, 7mm

At the level of C-6,

22 mm in adults and

14mm in children .

Jain et al. Deep-neck space infections – a diagnostic dilemma! Indian J.

Otolaryngol. Head Neck Surg. 350 (October–December 2008) 60:349–352

CT scan is most widely used modality

Readily available, can localize abscesses in the head and neck

Not as effective as ultrasound in determining abscess from cellulitis

Cellulitis appears as soft-tissue swelling, increased density of surrounding fat, enhancement of involved muscles and obliteration of fat planes

Abscess low density area with a peripheral enhancement

CT has been reported to have sensitivity of 91% and specifi city of 60%

CT

Ultrasonography is very sensitive in detecting fluid

collection

Quick, widely available, relatively inexpensive, painless

Involves no radiation

An effective diagnostic tool to confirm abscess

formation in the superficial facial spaces and is highly

predictable in detecting the stage of infection

ULTRASOUND

S. Pallagatti et al. / European Journal of Radiology 81 (2012) 1821–1827

Sufficient airway management

Early and aggressive antibiotic therapy

Incision and drainage for any who fail medical management or form localized abscesses

Adequate nutrition and hydration support

TREATMENT GOALS

Chou Y Lee Y, Chao H: An upper airway obstruction emergency: Ludwig’s angina, Pediatr

Emerg Care 23:892-896, 2007.

Airway management in Ludwig’s angina can be

challenging

No consensus regarding the airway management in the

available literature

Suggested methods include tracheostomy, conventional

laryngoscopy and intubation (after administration of

muscle relaxant), awake blind nasal intubation and

awake fibreoptic intubation.

AIRWAY MANAGEMENT

Tracheostomy using local anaesthesia was considered as

the gold standard in the past

Risk of the spread of infection to the mediastinum,

aspiration of pus, rupture of the innominate artery,

spread of infection to the thorax, airway loss and

tracheal stenosis

Blind nasal intubation (BNI) is questionable because of

infrequent success on first pass and increased trauma

with repeated attempts might necessitate emergency

cricothyrotomy

AIRWAY MANAGEMENT

The first successful fibreoptic nasotracheal intubation in a

patient was first reported in the year 1974 (Schwartz et al)

Fibreoptic intubation is a sophisticated and less invasive

method of securing airway in patients with deep neck

infection

AIRWAY MANAGEMENT

Airway Advantages Disadvantages

Close clinical

observation

• No mechanical

intervention

• Unrecognized impending

airway loss

• Risk of oversedation with

loss of airway

• Extension of infection and

edema leading to

asphyxiation

Endotracheal

intubation

• Speed with which airway

control is achieved

• Nonsurgical procedure

• Potential for failed

intubation,

• Inability to bypass upper

airway obstruction

• Requirement for

mechanical ventilation

• Subglottic stenosis

• ET displacement

Tracheostomy • Allows for bypass of upper

airway obstruction

• Very secure airway

• Less need for sedation

and mechanical

ventilation

• Earlier transfer out of CCU

• Surgical procedure with

inherent risks

• Pneumothorax

• Bleeding, subglottic

stenosis, tracheoinnominate

or tracheoesophageal

fistula, unsightly scar

Journal of Critical Care (2011) 26, 11–14

Intravenous access, fluid resuscitation, and administration

of IV antibiotics

Antibiotic therapy should be administered empirically and

tailored to culture and sensitivity results

Antibiotic therapy should be administered empirically and

tailored to culture and sensitivity results

Other regimens –

Penicillins with β-lactamase inhibitor,

Second, third, or fourth generation Cephalosporins and

Metranidazole

MEDICAL MANAGEMENT

Ampicillin/Sulbactam and clindamycin – effective for

anaerobic infections

Pipercillin/Tazobactam has shown efficacy in treating

polymicrobial infections as a single agent

Comorbid medical conditions require thorough workup

and monitoring because they can be exacerbated by the

infection, and can also lead to more severe infections

Addition of gentamicin to the empirical therapy should be strongly considered for diabetic patients

Control of blood sugar below 200 mg/dL is imperative for

good control of infection

MEDICAL MANAGEMENT

Principles (Topazian & Goldberg)

Incise in healthy skin and mucosa when possible, not at

the site of maximum fluctuance, because these wounds

tend to heal with an unsightly scar;

Place the incision in a natural skin fold;

Place the incision in a dependent position;

Dissect bluntly;

Place a drain; and

Remove drains when drainage becomes minimal

SURGICAL TREATMENT

Bilateral submandibular incisions as well as a midline submental incision

Incision approximately 3 to 4 cm below the angle of the mandible and below the inferior extent of swelling roughly parallel to the inferior border of mandible

INCISION & DRAINAGE

Ludwig’s angina is a life-threatening infection

Early diagnosis and immediate treatment is the key for successful

management

Antibiotic therapy should be administered empirically and

tailored to culture and sensitivity results

Prompt and early surgical intervention is required to provide a

higher control of the patient’s health.

CONCLUSION

Topazian RG, Goldberg MH, Hupp JR. Oral and Maxillofacial Infections. 4th ed. Philadelphia, Pa: W. B. Saunders; 2002.

Bagheri SC, Bell RB, Khan HA. Current Therapy in Oral and Maxillofacial Surgery - Saunders; 1 edition;2011

Osborn et al. Deep space neck infection. Oral Maxillofacial Surg Clin N Am 20 (2008) 353–365

Bahl, et al.: Microflora in odontogenic infections. Contemporary Clinical Dentistry | Jul-Sep 2014 | Vol 5 | Issue 3

S. Pallagatti et al. / European Journal of Radiology 81 (2012) 1821–1827

Jain et al. Deep-neck space infections – a diagnostic dilemma! Indian J. Otolaryngol. Head Neck Surg. (October–December 2008) 60:349–352

M.M. Wolfe et al. Surgical airway in deep neck infections and ludwig angina. Journal of Critical Care (2011) 26, 11–14

Potter, Herford, and Ellis. Tracheotomy Versus Endotracheal Intubation for Airway Management in Deep Neck Space Infections.J Oral Maxillofac Surg 60:349-354, 2002

REFERENCES