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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

Ludwig’s Angina

Ernest E. Wang MD, FACEP

Evanston Northwestern Healthcare

Northwestern University Medical School

ludwig s angina2
Ludwig’s Angina
  • Extension of localized periapical infection
    • Anterior mandibular  Sublingual
    • Posterior mandibular (molar)  Submandibular
  • Fascial planes
historical cues
Historical cues
  • Recent dental extraction or work
  • Dental caries
  • Fever
  • Swelling of mouth, face, neck
  • Compromised host
  • Co-morbidities (diabetes)
physical exam
Physical exam
  • Toxicity
  • Brawny bilateral boardlike edema
  • Submandibular, submental, sublingual
  • Trismus
  • Tongue elevation
  • No fluctuance
slide5
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
Etiology
  • Streptococcus
  • Staphylococcus
  • Mixed aerobic/anaerobic infection
    • B. Fragilis
  • ß-lactamase resistance (<= 40%)
diagnosis
Diagnosis
  • Clinical
  • CT scan
slide8
4-month-old with fever, irritability, and decreased oral intake x 24 hours. Swelling x 10 hrs (Maimon et al, Ann Emerg Med, 2006)
treatment
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
antibiotics
Antibiotics
  • Extended spectrum penicillins
    • Ampicillin/Sulbactam (Unasyn)
    • Ticarcillin/Clauvulate (Timentin)
    • Piperacillin/Tazobactam (Zosyn)
  • Clindamycin + Cipro (PCN allergy)
  • Flagyl (B. Fragilis)
steroids
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)
deep neck space infections
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.

deep neck space infections13
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
Ludwig’s Angina - Summary
  • Serious deep space infection
  • Potentially fatal
  • Aggressive manage airway as indicated
  • Surgical consultation
  • Antibiotics and steroids
  • ICU
references
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.