Join the EMGuideWire Crew from CMC EM Residency Program as they discuss Ludwig's Angina and the management Priorities!!!

BACKGROUND

• Angina = “Strangling”
• Bilateral infection of submental, submandibular, and sublingual spaces
• 70-85% of cases arise from odontogenic source
  • Periapical abscesses of mandibular molars
  • Piercings (frenulum)
  • URI more common cause in children

• Source of infection often polymicrobial
  • Most commonly viridans; also Staphylococcus and Bacteroides species
• Patients usually 20-60 years-old; more common in males1
• Mortality in treated Ludwig’s Angina = 8%7
• ***Airway compromise = leading cause of death8

Who Is At Risk?

• Diabetes mellitus
• Chronic alcohol abuse
• IVDA
• HIV/AIDS
• Malnutrition
• Poor oral hygiene
• Smokers

Anatomy & Pathophysiology

• Mylohyoid subdivides submandibular space:
  • Sublingual space
  • Submaxillary (submylohyoid) space
• Infection extends posteriorly and superiorly, elevating tongue against hypopharynx
• If left untreated, can extend inferiorly to retropharyngeal space and into superior mediastinum3

Clinical Signs & Symptoms

• Dysphagia
• Odynophagia
• Trismus
• Edema of upper midline neck and floor of mouth
  • Raised tongue
• "Woody" or brawny texture to floor of mouth with visible swelling and erythema

Late Findings

• Drooling
• Tongue protrusion
• Trismus
• Dysphonia
• Cyanosis
• Acute laryngospasm
• Stridor
• Patients may demonstrate signs of systemic toxicity → fever, tachycardia, and hypotension

How Do I Make the Diagnosis?

• Clinically!
• Consider CT head/neck
  • Can help evaluate extent of infection if clinical situation persists
• CBC
• Chemistry
• Lactate
• Blood Cultures

Management

• Emergent ENT/OMFS consult for I&D in OR and extraction of dentition if source is dental abscess
• Airway Management
  • Intubation will be VERY difficult due to trismus and posterior pharyngeal extension
  • Ideal situation = awake fiberoptic intubation in OR
• ALWAYS have a surgical airway ready as your back up plan
• Blind insertion devices (e.g. intubating LMA) are NOT recommended

Management - Antibiotics

• Must cover typical polymicrobial oral flora
• Immunocompetent
  • 3rd-generation Cephalosporin + (Clindamycin or Metronidazole)
  • Ampicillin/Sulbactam
  • Penicillin G + Metronidazole
  • Clindamycin (allergic to penicillin)
• Immunocompromised → *Need MRSA and GNR coverage!3
  • Cefepime + Metronidazole
  • Meropenem
  • Piperacillin-tazobactam
  • Add Vancomycin if concern for MRSA risk factors

• Steroids
  • Dexamethasone 10 mg IV
    • Thought to chemically decompress for airway protection and increase antibiotic penetration6
  • Nebulized epinephrine
  • Resuscitation and pain control

Complications

• Intracranial infections (e.g. CST, brain abscess)
• IJ thrombophlebitis (Lemirre’s Syndrome)
• Mediastinitis
• Mandibular osteomyelitis
• Empyema

Pearls

Three characteristics of Ludwig’s angina can be remembered as the 3 Fs:

• Feared
• Often Fatal
• Rarely Fluctuant
• ABCs—Sit upright
• Early notification of ENT/OMFS and anesthesia to facilitate definitive airway management
• Arrange for the patient to be admitted to ICU

Priorities!!!

• Secure the airway EARLY!
  • Prepare and be ready for a difficult airway — expect that the patient will require a surgical airway
• Prevent the development of septic shock and multi-organ failure — give antibiotics early

References

1. Lin HW, O’Neil A, Cunningham MJ. Ludwig’s Angina in the Pediatric Population. Clin Pediatr (Phila) 2009;48:583-7.
2. Baez-Pravia, Orville V. et al. “Should We Consider IgG Hypogammaglobulinemia a Risk Factor for Severe Complications of Ludwig Angina?: A Case Report and Review of the Literature.” Medicine. 2017;96(47):e8708.
3. Pandey M, Kaur M, Sanwal M, Jain A, Sinha SK. Ludwig’s Angina in children anesthesiologist’s nightmare: Case series and review of literature. J Anaesthesiol Clin Pharmacol. 2017 Jul-Sep;33(3):406-409.
4. Botha A, Jacobs F, Postma C. Retrospective analysis of etiology and comorbid diseases associated with Ludwig’s Angina Ann Maxillofac Surg. 2015 Jul-Dec;5(2):168-73.
5. Parhiscar A, Har-El G. Deep neck abscess: a retrospective review of 210 cases. Ann Otol Rhinol Laryngol 110: 1051, 2001.
6. Saifeldeen K, R Evans. Ludwig’s Angina. Emerg Med J 2004; 21: 242-243
7. Nanda N, Zalzal HG, Borah Gl. Negative-Pressure Wound Therapy for Ludwig’s Angina: A Case Series.Plast Reconstr Surg Glob Open2017 Nov 7;5(11):e1561.
8. Pak S, Cha D, Meyer C, Dee C, Fershko A.Ludwig’s Angina. Cureus. 2017 Aug 21;9(8):e1588.