How Do You Diagnose Ludwigs Angina
Your doctor will give you a physical examination to check your neck, jaw, lymph nodes, the inside of your mouth, your chest, and lungs. In most cases, this physical exam shows enough symptoms to diagnose Ludwigâs angina.
âIf your doctor canât make the diagnosis, they may order blood and salivary cultures to check for bacteria. They may also order a computed tomography or magnetic resonance imaging scan using contrast dye. These procedures scan your mouth, neck, and jaw to look for swelling, gas, pus, or inflammation.
How Do These Patients Present
Most commonly these patients present with sore throat followed by odynophagia . Painful neck swelling, tooth pain, dysphagia, dyspnea, fever, and malaise are the most common complaints. Neck swelling and a protruding or elevated tongue are seen in the vast majority. Stridor, trismus, cyanosis, and tongue displacement suggest an impending airway crisis. Edema and induration of the anterior neck, often with cellulitis, may be present in advanced cases. Early signs and symptoms of obstruction may be subtle. Airway compromise is always synonymous with the term Ludwigs angina, and it is the leading cause of death. Therefore, airway management is the primary therapeutic concern
What Causes Ludwigs Angina
Bacteria from dental infections or poor oral hygiene are the cause of this skin infection. You can develop Ludwigâs angina if you get a cavity or tooth abscess â often in your second and third molars â or you get periodontitis or gingivitis.
Streptococcal and staphylococcal bacteria are the most common types of bacteria that lead to Ludwigâs angina, especially Streptococcus viridans, Staphylococcus epidermis, and Staphylococcus aureus.
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Ludwigs Angina: A Rapid Review
In the Rapid Review series, we briefly review the key points of a clinical review paper. The topic this time: Ludwigs angina.
Cite this article as:
This is a guest post by Punithan Thiagalingam, an MD student at the University of Toronto. He has a background in biochemistry and development of novel cancer biotechnology platforms. His areas of interest include EBM, FOAMed, emergency medicine, and working to rectify health disparities impacting marginalized patient populations.
Other Things To Consider
Adequate nutrition and hydration support is essential in any patient following surgery, particularly young children. In this case, pain and swelling in the neck region would usually cause difficulties in eating or swallowing, hence reducing patient’s food and fluid intake. Patients must therefore be well-nourished and hydrated to promote wound healing and to fight off infection.
Extubation, which is the removal of endotracheal tube to liberate the patient from mechanical ventilation, should only be done when the patient’s airway is proved to be patent, allowing adequate breathing. This is indicated by a decrease in swelling and patient’s capability of breathing adequately around an uncuffed endotracheal tube with the lumen blocked.
During the hospital stay, patient’s condition will be closely monitored by:
- carrying out cultures and sensitivity tests to decide if any changes need to be made to patient’s antibiotic course
- observing for signs of further infection or sepsis including fevers, hypotension, and tachycardia
- monitoring patient’s white blood cell count – a decrease implies effective and sufficient drainage
- repeating CT scans to prove patient’s restored health status or if infection extends, the anatomical areas that are affected.
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A Brief Note On Airway Management
Neck anatomy can be very distorted, resulting in difficulty for both intubation and rescue techniques such as supraglottic airways and cricothyrotomy. Definitive management is best done in the OR where a tracheotomy can be done if required consult ENT and anesthesia early.
If a surgeon or anesthesiologist is not available, an awake fibreoptic intubation can be a good choice. During intubation pay careful attention to avoid airway trauma that will worsen airway edema and/or cause laryngospasm. A supraglottic airway is a poor choice as it can get displaced as swelling progresses.
What Is Ludwigs Angina
Figure 1. Ludwigs Angina typically originates from dental infections of 2nd mandibular molar
Ludwigs angina is a diffuse, rapidly expanding infection of the submandibular space . The submandibular space is subdivided by the mylohyoid muscle into the sublingual space superiorly and the submaxillary space inferiorly. These areas communicate freely without the aid of lymphatics, therefore once an infection is present, it can disseminate quickly . To complicate things further, the spaces of the neck also communicate freely with one another making it easy for infection to spread over a wide area. This gives the potential for submandibular infections to involve the pharyngomaxillary and retropharyngeal spaces with minimal resistance .
Most cases of Ludwigs angina are due to dental infections, with the second mandibular molar being the most common site . Other causes include: sialadenitis, injury to the floor of the mouth , peritonsillar abscess, lymphadenitis, infected mandibular fractures, infected abscess of the chin, and oral lacerations .
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Can You Prevent Ludwigs Angina
âIn most cases, you can help prevent this rare but serious skin infection.
One of the first preventive measures should be good oral hygiene. Make sure you brush and floss your teeth each day and see a dentist for regular cleanings. During your appointment, your dentist will check for signs of tooth decay, infection, or plaque buildup.
You should try to avoid tongue piercings and other mouth piercings that could let bacteria invade the jawbone and soft tissues. And if you have any dental pain, gum bleeding, or loose teeth, make an appointment with your dentist as soon as possible.
Along with regular dental checkups, get regular doctor checkups and keep your doctor informed about any dental infections you had. They may order blood cultures and blood tests to check for signs of lingering infection.
With good care and a healthy diet, you can reduce your risk of getting Ludwigâs angina.
Enhancing Healthcare Team Outcomes
Ludwig’s angina is a rapidly progressive cellulitis that can quickly cause airway obstruction. It requires immediate intervention and close monitoring to prevent death from asphyxiation. It can also result in mediastinitis, necrotizing cellulitis of the neck, and aspiration pneumonia. The safest way to deal with these patients is a coordinated interprofessional approach involving the provider, nurse, and, if needed, a consultant such as an otolaryngologist or anesthesiologist. This will provide the best outcome and highest patient safety.
Contributed by Wikimedia Commons, Anand H Kulkarni, Et al., https://creativecommons.org/licenses/by/2.0/
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How Do You Treat Ludwigs Angina
Ludwigs angina is an emergency and you should call 911 or get to the nearest emergency room as quickly as possible.
You will be admitted to the hospital for close monitoring, imaging tests, like a CT scan, and you will receive intravenous antibiotics.
The doctors will monitor the swelling and your airways to make sure your breathing isnt compromised. If you cant breathe well enough on your own, you may have to have a flexible tube put down your throat to pump oxygen in. If your mouth or throat is too swollen, they may put the tube in through your nose or neck .
You will need IV antibiotics for 2 to 3 weeks. Once you can breathe on your own, you will probably be sent home with a special catheter inserted so you can continue to get the antibiotics at home. Its important that you complete the entire round of antibiotics as directed by a doctoror else the infection could recur.
Symptoms Of Ludwigs Angina
The symptoms include swelling of the tongue, neck pain, and breathing problems.
Ludwigs angina often follows a tooth infection or other infection or injury in the mouth. The symptoms include:
- pain or tenderness in the floor of your mouth, which is underneath your tongue
- difficulty swallowing
You need immediate medical attention if you have a blocked airway. You should go to the emergency room or call 911 if this occurs.
Ludwigs angina is a bacterial infection. The bacteria Streptococcus and Staphylococcus are common causes. It often follows a mouth injury or infection, such as a tooth abscess. The following may also contribute to developing Ludwigs angina:
- poor dental hygiene
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What Are The Treatment Options
Ludwigâs angina is a serious infection that can spread rapidly. It needs immediate treatment to get the infection under control and ensure your airway remains open.
The first treatment is to make sure you can breathe properly. If your breathing is partially restricted, you may receive a breathing tube through your mouth or nose. If your breathing is severely restricted, you will receive a tracheotomy surgical procedure to insert a breathing tube into your windpipe.
Ludwigâs angina causes a lot of fluid buildup in the neck and jaw area, so itâs important to drain this fluid so you can get relief. Doctors make an incision to drain the fluid and help you breathe easier.
You will also receive intravenous antibiotics that help treat bacteria in the mouth. Once your infection clears, your doctor may give you a prescription for oral antibiotics to ensure the symptoms donât return.
It Is Just An Abscess Isnt It Why The Concern
In order to understand this condition a review of anatomy is key. Many subcutaneous abscesses we in the Emergency Department are fluctuant with purulent discharge. Why doesnt this occur in Ludwigs? The superficial layer of the deep cervical fascia is an essential structure in understanding deep space infections of the neck. The SLDCF generally forms the outer margin of odontogenic deep space neck infections. The tenacity of this fascia prevents the egress of pus toward the skin until neck infections are quite late. The result is that because of the barrier of the SLDCF, infections will expand to the point of descending toward the mediastinum, ascending to the lateral pharynx and masticator spaces, or will expand to the point of causing airway obstruction. Understanding the SLDCF is essential to understanding the pathway of infection. Clinically, this means you may see significant cellulitis, occasionally with serosanguinous fluid, but no frank pus. The sagittal image in the figure below highlights this fascia in red:
Image used under fair use from Quizlet.com
The submandibular space is limited by the oral mucosa of the floor and below by the superficial layer of the deep cervical fascia this extends from the mandible to the hyoid bone. Myolohyoid muscles divide the space into the sublingual and submaxiallary spaces.
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What Bugs Need To Be Covered
Infections are polymicrobial including gram positive, gram negative, and anaerobic bacteria. In immunocompetent hosts recommended antibiotics regimens include:
- Ceftriaxone 2g IV q12h + metronidazole 500mg IV q8h
- Clindamycin 600mg IV q6-8h + levofloxacin 750mg IV q24h
Additional coverage should be considered for immunocompromised patients and those with risk factors for MRSA .
Significance Of The Study
Ludwigs angina is usually fatal if not managed successfully in the early stage in resource-challenged centers. Controversies abound concerning early surgical intervention in individuals presenting early with this life-threatening condition. Therefore, this study sought to determine the outcome of surgical intervention in early stages of this condition in a resource-challenged center.
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How Do Patients Typically Present
Patients present with submandibular swelling and induration, and may also have generalized weakness, fever, malaise, and chills. The outer neck can be erythematous and edematous, and there may be sublingual, submental, and/or cervical lymphadenopathy.
Trismus and meningismus are late signs and are associated with parapharyngeal and retropharyngeal expansion, respectively. Other late signs include drooling, dysphagia, dysphonia, and respiratory distress.
What Are The Complications
With immediate treatment, you can expect a good recovery with minimal to no lasting effects. However, there are numerous complications of having Ludwigâs angina if itâs left untreated.
You may develop serious or life-threatening complications such as:
- Blood clot in the neck
- Aneurysm bulge in the carotid artery
- Chest inflammation
These complications could even lead to premature death because the infection spreads so quickly and can block airflow. Immediate treatment for Ludwigâs angina is the best course of action.
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Where Do The Infections Originate
Review of cultures have demonstrated odontogenic infection in approximately 60-85% of those with this presentation.
Image used under fair use from Julie Gains
These are frequently polymicrobial with most related to the second or third mandibular molar teeth. Other sources include peritonsillar or parapharyngeal abscesses, mandibular fracture, oral lacerations/piercing, or submandibular sialodentitis. Predisposing factors include: dental carries, recent dental treatment, systemic illnesses such as diabetes mellitus, malnutrition, alcoholism, compromised immune system such as AIDS, and organ transplantation and trauma up to 50% have no identifiable site of origin. Although as many as 50 to 100 bacterial species may be present on the oral or nasopharyngeal mucosal surface, the typical deep neck space infection includes, on average, five or six bacterial types. As 2/3 of these infections will involve a beta-lactamase producing organism, the most efficacious antimicrobial agents include amoxicillin/clavulanate, ticarcillin/clavulanate, cefoxitin, carbapenem, or clindamycin.
Ludwig’s Angina In Children
RICHARD W. HARTMANN, JR., M.D., Halifax Medical Center, Daytona Beach, Florida
Am Fam Physician. 1999 Jul 1 60:109-112.
Ludwig’s angina is a potentially life-threatening, rapidly expanding, diffuse inflammation of the submandibular and sublingual spaces that occurs most often in young adults with dental infections. However, this disorder can develop in children, in whom it can cause serious airway compromise. Symptoms include severe neck pain and swelling, fever, malaise and dysphagia. Stridor suggests an impending airway crisis. Causative bacteria include many gram-negative and anaerobic organisms, streptococci and staphylococci. Initial treatment consists of high doses of penicillin G given intravenously, sometimes in combination with other drugs. Patients usually recover without complications.
Ludwig’s angina was described initially by Wilhelm Frederick von Ludwig in 1836. Five patients had marked swelling of the neck that progressed to involve the tissues covering the muscles between the larynx and the floor of the mouth. Ludwig described indurated edema of the submandibular and sublingual areas with minimal throat inflammation but without lymph node involvement or suppuration. At that time, the condition was almost always fatal.1,2
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Who Gets It
Although Wilhelm Fredrick von Ludwig did die shortly after the onset of neck inflammation, sources indicate it is unlikely he had the infection he named.
Patients at high risk for Ludwigs angina include those with local sources of infection, such as piercings or dental infections, and those who have a systemic predisposition to infection, such as diabetes, malnutrition, or IV drug use.