Ludwig’s Angina Ernest E. Wang MD, FACEP Evanston Northwestern Healthcare Northwestern University Medical School

Ludwig’s Angina Extension of localized periapical infection Anterior mandibular  Sublingual Posterior mandibular (molar)  Submandibular Fascial planes

Historical cues Recent dental extraction or work Dental caries Fever Swelling of mouth, face, neck Compromised host Co-morbidities (diabetes)

Physical exam Toxicity Brawny bilateral boardlike edema Submandibular, submental, sublingual Trismus Tongue elevation No fluctuance

Figure 66-32 A, Ludwig angina may initially appear benign Figure 66-32 A, Ludwig angina may initially appear benign. B, In Ludwig angina, rapid progression may compromise the airway in a few hours. Figure 66-32 A, Ludwig angina may initially appear benign. B, In Ludwig angina, rapid progression may compromise the airway in a few hours. Roberts and Hedges, p. 1339

Etiology Streptococcus Staphylococcus Mixed aerobic/anaerobic infection B. Fragilis ß-lactamase resistance (<= 40%)

Diagnosis Clinical CT scan

4-month-old with fever, irritability, and decreased oral intake x 24 hours. Swelling x 10 hrs (Maimon et al, Ann Emerg Med, 2006) A 4-month-old girl presented to emergency department with fever of 40°C, irritability, and decrease in oral intake during the previous 24 hours. Ten hours before the girl’s presentation, her mother noticed swelling of her right submandibular area that rapidly progressed to the submental area. On physical examination, the child had a pulse rate of 178 beats/min, respiratory rate of 60 breaths/min, temperature of 38.7°C, and oxygen saturation of 98% in room air. The patient was stridorous while crying but had no respiratory distress at rest. A symmetric generalized fullness was noted in the submental area, with no erythema (Figure 1). Intraoral examination revealed a firm, tender swelling of the floor of the mouth, which was displacing the child’s tongue superiorly and posteriorly toward her palate and posterior pharyngeal wall (Figure 2). Diagnosis Ludwig’s angina. Intravenous clindamycin and hydrocortisone were started with marked clinical improvement in the first 24 hours. Computed tomographic scan of the neck demonstrated diffuse inflammation extending from the floor of the mouth to the thyroid gland. Ludwig’s angina is a rare life-threatening infection in children, although patients as young as 12 days old were reported to have this condition.1 and 2 This is a rapidly progressing cellulitis involving the submaxillary, sublingual, and submandibular spaces and characterized by firm induration of the floor of the mouth and elevation of the tongue.3, 4 and 5 In more than half of cases, the cause is polymicrobial infection, with predominance of Streptococcus species. Mortality is a result of upper airway obstruction.3, 4 and 5 Management includes airway protection, intravenous antibiotics, and intravenous steroids to decrease the edema. Surgical debridement should be considered if clinical improvement is not seen after 24 hours of treatment.4 and 5

Treatment Airway control - EARLY Surgical consultation mandatory ICU Fiberoptic Deterioration may be rapid Cricothyrotomy or tracheostomy may be necessary Surgical consultation mandatory Oral maxillofacial surgeon or ENT Definitive surgical drainage and debridement ICU Airway - deterioration may be rapid, control aggressively The most important therapeutic treatment is surgical debridement

Antibiotics Extended spectrum penicillins Ampicillin/Sulbactam (Unasyn) Ticarcillin/Clauvulate (Timentin) Piperacillin/Tazobactam (Zosyn) Clindamycin + Cipro (PCN allergy) Flagyl (B. Fragilis) Adjunctive therapy to surgical management

Steroids Reduce edema “Used routinely when airway compromise suspected” (Larawin et al.) Dexamethasone 10-20 mg IV Then 4-6 mg Q6 for 8 doses (Busch) Marple BF. Ludwig angina: a review of current airway management. Arch Otolaryngol Head Neck Surg. 1999;125:596-599. Busch RF. Ludwig angina: early aggressive therapy. Arch Otolaryngol Head Neck Surg. 1999 Nov;125(11):1283-4. Upon admission to the emergency department, patients are given an immediate dose of 10 to 20 mg of dexamethasone, followed by 4 to 6 mg every 6 hours for a maximum of 8 doses. Antibiotic therapy consists of ampicillin-sulbactam, 3.0 g administered intravenously every 6 hours, in addition to clindamycin, 600 mg administered intravenously every 6 hours. For patients who are allergic to penicillin, ciprofloxacin, 400 mg administered intravenously every 12 hours, is used instead of ampicillin-sulbactam in addition to the clindamycin therapy. Within 24 to 48 hours, patients are taken to the operating room, where decompression of the sublingual and submandibular spaces is accomplished through the submental space. A through-and-through Penrose drain is placed in the midline adjacent to the lingual aspect of the mandible between and anterior to the submandibular duct orifices. This drain is removed in the clinic 1 week later. At the time of surgical decompression, any offending teeth are removed and any additional involved spaces are drained.

Deep Neck Space Infections 103 patients (1993 - 2005) Ludwig’s Angina (n=38, 37%) Odontogenic (n=25, 67%) Tracheostomy (n=4) Medical management (n=13) Medical and surgical management (n=25) Varqa Larawin MMeda, James Naipao MMeda and Siba P. Dubey MSa, b, Corresponding Author Contact Information, E-mail The Corresponding Author aDepartment of Ear, Nose, and Throat; Port Moresby General Hospital, Papua New Guinea bSchool of Medicine and Health Sciences; University of Papua New Guinea, Papua New Guinea Objective The purpose of this study was to evaluate the incidence, causes, management, and complications of the different head and neck space infections in a Melanesian population. Study design and setting We conducted a retrospective study in a tertiary referral and teaching hospital. Results Of the total 103 patients with deep neck space infections (DNSI), odontogenic causes and suppurative lymphadenitis were responsible in 62 (60%) patients. A wide range of DNSI was encountered in our series. Ludwig’s angina was the most commonly encountered infection seen in 38 (37%) patients, whereas prevertebral abscess was only seen in 1 (1%) patient. A combination of surgical drainage and medical treatment was the main mode of treatment. Nine (8.7%) patients with DNSI with upper airway obstruction underwent tracheostomy; 9 (8.7%) patients with DNSI succumbed to their infection. Conclusion DNSI needs early detection and aggressive management in order to evade dreaded complications. Larawin et al. Head and neck space infections. Otolaryngol Head Neck Surg. 2006, 135(6):899-993.

Deep Neck Space Infections Complications Upper airway obstruction (n=4) Reinfection (n=3) Asphyxiation (n=1) Descending mediastinitis (n=1) Spread to other spaces (n=1) Death (n=2) Larawin et al. Head and neck space infections. Otolaryngol Head Neck Surg. 2006, 135(6):899-993.

Ludwig’s Angina - Summary Serious deep space infection Potentially fatal Aggressive manage airway as indicated Surgical consultation Antibiotics and steroids ICU

References Larawin V, Naipao J, Dubey SP. Head and neck space infections. Otolaryngol Head Neck Surg. 2006 Dec;135(6):889-93. Marple BF. Ludwig angina: a review of current airway management. Arch Otolaryngol Head Neck Surg. 1999;125:596-599. Busch RF. Ludwig angina: early aggressive therapy. Arch Otolaryngol Head Neck Surg. 1999 Nov;125(11):1283-4. Maimon MS, Janjuh AS, and Goldman RD. Images in emergency medicine. Ludwig’s Angina in a 4 Month Old Infant. Ann Emerg Med, 2006 May;47(5):503, 507. Amsterdam J. Chapter 65: Oral Medicine. In Marx J, Hockberger R, Walls R: Rosen's Emergency Medicine, Concepts and Clinical Practice, 5th ed. St. Louis, Mosby, 2002, 892-908 pp. Benko, K. Chapter 66: Emergency Dental Procedures. In Roberts J, Hedges J: Clinical Procedures in Emergency Medicine, 4th ed. 4th ed, Philadelphia, Saunders, 2004, 1317-1340 pp.