Airway

Ludwig's Angina

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Ludwig's Angina, Ludwig Angina, Cellulitis of Floor of Mouth, Submandibular Space Infection

  • See Also
  1. Difficult Airway Assessment
  • Pathophysiology
  1. Dental Infection spreads to bilateral submandibular space with rapid progression
  2. Infection displaces the Tongue posteriorly, resulting in airway compromise
  3. Infection is typically polymicrobial
    1. Streptococcus Pyogenes and Streptococcus viridans
    2. Anaerobic Bacteria (e.g. Fusobacteria)
    3. Immunocompromised patients are a risk of Staphylococcus aureus and Gram Negative Bacteria
  • Causes
  1. Dental Infection (Odontogenic Infection)
    1. Typically involves a mandibular tooth with periapical infection
  2. Mandibular Fracture Complication
  3. Tongue or frenulum piercing
  • Symptoms
  1. Choking Sensation (Ludwig's Angina)
  2. Dental Infection or lesion
  3. Facial pain, swelling, redness
  • Signs
  1. Fever
  2. Cellulitis of lower face and neck
  3. Stridor
  4. Trismus
  5. Firm, indurated floor of mouth
    1. Not Ludwig's Angina if this space is soft
  • Imaging
  1. CT Soft Tissue Neck with IV Contrast
    1. Definitive study
    2. Initial management is often based on bedside clinical diagnosis before imaging
    3. As with all imaging, patient must be stable to perform (no signs of impending airway compromise)
      1. Patient must be able to lie supine for CT without worsening dynamic airway compromise
      2. Obtain definitive airway (e.g. Endotracheal Intubation) as needed before imaging
  • Management
  1. Emergent orofacial surgery or otolaryngology Consultation
    1. Surgical Debridement if abscess seen on imaging
    2. Surgical Debridement reduces airway compromise risk by 10 fold
      1. Edetanlen (2018) Med Princ Pract 27(4):362-6 +PMID:29886486 [PubMed]
  2. Airway management
    1. Airway management is typically challenging
      1. See Difficult Airway Assessment
      2. Submandibular and deep space swelling distort anatomy
      3. Trismus reduces mouth opening
    2. Intubation is typically required to secure the airway
    3. In stable patients, consider emergent Consultation with otolaryngology and Anesthesia (for double set-up in OR)
    4. Consider Fiberoptic Nasal Intubation (awake or under Ketamine sedation)
    5. Be prepared for emergent Cricothyrotomy (double set-up) in case of failed airway
  3. Measures to reduce airway edema
    1. Nebulized Epinephrine
    2. Corticosteroids (effect may be delayed up to 6 hours)
      1. Dexamethasone 0.6 mg/kg (up to 10 mg) IV or
      2. Methylprednisolone (Solumedrol) 2.3 mg/kg IV
  4. Antibiotics: Immunocompetent (2-3 agent protocol)
    1. Metronidazole 500 mg IV every 6 hours AND
    2. Penicillin G 3 MUIV q6 hours
      1. If severe, replace Penicillin with Zosyn or Meropenem
      2. Piperacillin-Tazobactam (Zosyn) 4.5 g IV every 6 hours OR
      3. Meropenem 1 g IV q8 hours
    3. Add Vancomycin 1 g IV every 6 hours if Staphylococcus aureus infection (presumed MRSA)
      1. Indicated if Gram Stain with Gram Positive Cocci in clusters
  5. Antibiotics: Immunocompromised
    1. Piperacillin-Tazobactam (Zosyn) 4.5 g IV every 6 hours (or Meropenem 1 g IV q8 hours) AND
    2. Vancomycin 1 g IV every 6 hours
  6. Antibiotics: Less Severe Infections
    1. No allergy to Penicillin
      1. Ampicillin/Sulbactam (Unasyn) OR
      2. Amoxicillin-Clavulanate 875-125 mg orally twice daily every 12 hours
    2. Penicillin Allergy
      1. Clindamycin 600 mg IV every 6-8 hours
  • Complications
  1. Airway obstruction
  2. Mediastinal spread via the parapharyngeal space
  • References
  1. (2019) Sanford Guide, accessed 11/23/2019
  2. Swaminathan and Shoenberger in Swadron (2023) EM:Rap 23(3): 1-2
  3. Costain (2010) Am J Med 124(2): 115-7 +PMID:20961522 [PubMed]
    1. https://www.amjmed.com/article/S0002-9343(10)00742-4/fulltext