Ludwig

1
Ludwigs Angina

• Ernest E. Wang MD, FACEP
• Evanston Northwestern Healthcare
• Northwestern University Medical School

2
Ludwigs 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 (lt 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)
• Ludwigs Angina (n38, 37)
• Odontogenic (n25, 67)
• Tracheostomy (n4)
• Medical management (n13)
• Medical and surgical management (n25)

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 (n4)
• Reinfection (n3)
• Asphyxiation (n1)
• Descending mediastinitis (n1)
• Spread to other spaces (n1)
• Death (n2)

Larawin et al. Head and neck space infections.
Otolaryngol Head Neck Surg. 2006, 135(6)899-993.
14
Ludwigs 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 Dec135(6)889-93.
• Marple BF. Ludwig angina a review of current
  airway management. Arch Otolaryngol Head Neck
  Surg. 1999125596-599.
• Busch RF. Ludwig angina early aggressive
  therapy. Arch Otolaryngol Head Neck Surg. 1999
  Nov125(11)1283-4.
• Maimon MS, Janjuh AS, and Goldman RD. Images in
  emergency medicine. Ludwigs Angina in a 4 Month
  Old Infant. Ann Emerg Med, 2006 May47(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.