II. Pathophysiology
- Dental Infection spreads to bilateral submandibular space with rapid progression
- Infection displaces the Tongue posteriorly, resulting in airway compromise
- Infection is typically polymicrobial
- Streptococcus Pyogenes and Streptococcus viridans
- Anaerobic Bacteria (e.g. Fusobacteria)
- Immunocompromised patients are a risk of Staphylococcus aureus and Gram Negative Bacteria
III. Causes
-
Dental Infection (Odontogenic Infection)
- Typically involves a mandibular tooth with periapical infection
- Mandibular Fracture Complication
- Tongue or frenulum piercing
IV. Symptoms
- Choking Sensation (Ludwig's Angina)
- Dental Infection or lesion
- Facial pain, swelling, redness
V. Signs
- Fever
- Cellulitis of lower face and neck
- Stridor
- Trismus
- Firm, indurated floor of mouth
- Not Ludwig's Angina if this space is soft
VI. Imaging
- CT Soft Tissue Neck with IV Contrast
- Definitive study
- Initial management is often based on bedside clinical diagnosis before imaging
- As with all imaging, patient must be stable to perform (no signs of impending airway compromise)
- Patient must be able to lie supine for CT without worsening dynamic airway compromise
- Obtain definitive airway (e.g. Endotracheal Intubation) as needed before imaging
VII. Management
- Emergent orofacial surgery or otolaryngology Consultation
- Surgical Debridement if abscess seen on imaging
- Surgical Debridement reduces airway compromise risk by 10 fold
- Airway management
- Airway management is typically challenging
- See Difficult Airway Assessment
- Submandibular and deep space swelling distort anatomy
- Trismus reduces mouth opening
- Intubation is typically required to secure the airway
- In stable patients, consider emergent Consultation with otolaryngology and Anesthesia (for double set-up in OR)
- Consider Fiberoptic Nasal Intubation (awake or under Ketamine sedation)
- Be prepared for emergent Cricothyrotomy (double set-up) in case of failed airway
- Airway management is typically challenging
- Measures to reduce airway edema
- Nebulized Epinephrine
- Corticosteroids (effect may be delayed up to 6 hours)
- Dexamethasone 0.6 mg/kg (up to 10 mg) IV or
- Methylprednisolone (Solumedrol) 2.3 mg/kg IV
- Antibiotics: Immunocompetent (2-3 agent protocol)
- Metronidazole 500 mg IV every 6 hours AND
- Penicillin G 3 MUIV q6 hours
- If severe, replace Penicillin with Zosyn or Meropenem
- Piperacillin-Tazobactam (Zosyn) 4.5 g IV every 6 hours OR
- Meropenem 1 g IV q8 hours
- Add Vancomycin 1 g IV every 6 hours if Staphylococcus aureus infection (presumed MRSA)
- Indicated if Gram Stain with Gram Positive Cocci in clusters
- Antibiotics: Immunocompromised
- Piperacillin-Tazobactam (Zosyn) 4.5 g IV every 6 hours (or Meropenem 1 g IV q8 hours) AND
- Vancomycin 1 g IV every 6 hours
- Antibiotics: Less Severe Infections
- No allergy to Penicillin
- Ampicillin/Sulbactam (Unasyn) OR
- Amoxicillin-Clavulanate 875-125 mg orally twice daily every 12 hours
- Penicillin Allergy
- Clindamycin 600 mg IV every 6-8 hours
- No allergy to Penicillin
VIII. Complications
- Airway obstruction
- Mediastinal spread via the parapharyngeal space
IX. References
- (2019) Sanford Guide, accessed 11/23/2019
- Swaminathan and Shoenberger in Swadron (2023) EM:Rap 23(3): 1-2
- Costain (2010) Am J Med 124(2): 115-7 +PMID:20961522 [PubMed]