Airway

Ludwig's Angina

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Ludwig's Angina, Ludwig Angina, Cellulitis of Floor of Mouth, Submandibular Space Infection

  • Pathophysiology
  1. Dental Infection spreads to bilateral submandibular space with rapid progression
  2. Infection displaces the Tongue posteriorly, resulting in airway compromise
  3. Infection is typically polymicrobial
    1. Streptococcus Pyogenes and Streptococcus viridans
    2. Anaerobic Bacteria (e.g. Fusobacteria)
    3. Immunocompromised patients are a risk of Staphylococcus aureus and Gram Negative Bacteria
  • Causes
  1. Dental Infection (Odontogenic Infection)
    1. Typically involves a mandibular tooth with periapical infection
  2. Mandibular Fracture Complication
  3. Tongue or frenulum piercing
  • Symptoms
  1. Choking sensation (Ludwig's Angina)
  2. Dental Infection or lesion
  3. Facial pain, swelling, redness
  • Signs
  1. Fever
  2. Cellulitis of lower face and neck
  3. Stridor
  4. Trismus
  5. Firm, indurated floor of mouth
    1. Not Ludwig's Angina if this space is soft
  • Management
  1. Emergent orofacial surgery or otolaryngology Consultation
    1. Surgical debridement if abscess seen on imaging
    2. Surgical debridement reduces airway compromise risk by 10 fold
      1. Edetanlen (2018) Med Princ Pract 27(4):362-6 +PMID:29886486 [PubMed]
  2. Airway management
    1. Intubation is typically required to secure the airway
    2. Consider intravenous Dexamethasone to reduce airway impingement
    3. Consider nebulized Epinephrine
  3. Antibiotics: Immunocompetent (2-3 agent protocol)
    1. Metronidazole 500 mg IV every 6 hours AND
    2. Penicillin G 3 MUIV q6 hours
      1. If severe, replace Penicillin with Zosyn or Meropenem
      2. Piperacillin-Tazobactam (Zosyn) 4.5 g IV every 6 hours OR
      3. Meropenem 1 g IV q8 hours
    3. Add Vancomycin 1 g IV every 6 hours if Staphylococcus aureus infection (presumed MRSA)
      1. Indicated if Gram Stain with Gram Positive Cocci in clusters
  4. Antibiotics: Immunocompromised
    1. Piperacillin-Tazobactam (Zosyn) 4.5 g IV every 6 hours (or Meropenem 1 g IV q8 hours) AND
    2. Vancomycin 1 g IV every 6 hours
  5. Antibiotics: Less Severe Infections
    1. Amoxicillin-Clavulanate 875-125 mg orally twice daily every 12 hours
  6. Antibiotics: Penicillin Allergy
    1. Clindamycin 600 mg IV every 6-8 hours
  • Complications
  1. Airway obstruction
  2. Mediastinal spread via the parapharyngeal space
  • References
  1. (2019) Sanford Guide, accessed 11/23/2019
  2. Costain (2010) Am J Med 124(2): 115-7 +PMID:20961522 [PubMed]
    1. https://www.amjmed.com/article/S0002-9343(10)00742-4/fulltext