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Ludwig ’ s Angina

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.

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Ludwig ’ s Angina

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

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

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

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

  5. 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

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

  7. Diagnosis • Clinical • CT scan

  8. 4-month-old with fever, irritability, and decreased oral intake x 24 hours. Swelling x 10 hrs (Maimon et al, Ann Emerg Med, 2006)

  9. Treatment • Airway control - EARLY • 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

  10. Antibiotics • Extended spectrum penicillins • Ampicillin/Sulbactam (Unasyn) • Ticarcillin/Clauvulate (Timentin) • Piperacillin/Tazobactam (Zosyn) • Clindamycin + Cipro (PCN allergy) • Flagyl (B. Fragilis)

  11. 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)

  12. 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) Larawin et al. Head and neck space infections. Otolaryngol Head Neck Surg. 2006, 135(6):899-993.

  13. 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.

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

  15. 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.

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