Airway
Ludwig's Angina
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Ludwig's Angina
, Ludwig Angina, Cellulitis of Floor of Mouth, Submandibular Space Infection
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
Causes
Dental Infection
(
Odontogenic Infection
)
Typically involves a mandibular tooth with periapical infection
Mandibular
Fracture Complication
Tongue
or frenulum piercing
Symptoms
Choking
sensation (Ludwig's Angina)
Dental Infection
or lesion
Facial pain, swelling, redness
Signs
Fever
Cellulitis
of lower face and neck
Stridor
Trismus
Firm, indurated floor of mouth
Not Ludwig's Angina if this space is soft
Management
Emergent orofacial surgery or otolaryngology
Consultation
Surgical debridement if abscess seen on imaging
Surgical debridement reduces airway compromise risk by 10 fold
Edetanlen (2018) Med Princ Pract 27(4):362-6 +PMID:29886486 [PubMed]
Airway management
Intubation is typically required to secure the airway
Consider intravenous
Dexamethasone
to reduce airway impingement
Consider nebulized
Epinephrine
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
Amoxicillin
-Clavulanate 875-125 mg orally twice daily every 12 hours
Antibiotics:
Penicillin Allergy
Clindamycin
600 mg IV every 6-8 hours
Complications
Airway obstruction
Mediastinal spread via the parapharyngeal space
References
(2019) Sanford Guide, accessed 11/23/2019
Costain (2010) Am J Med 124(2): 115-7 +PMID:20961522 [PubMed]
https://www.amjmed.com/article/S0002-9343(10)00742-4/fulltext
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