Ludwig's angina

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Ludwig's angina
Other namesAngina Ludovici
Ludwig angina.jpg
Swelling in the submandibular area in a person with Ludwig's angina.
Specialty Otorhinolaryngology, oral and maxillofacial surgery   OOjs UI icon edit-ltr-progressive.svg
Symptoms Fever, pain, a raised tongue, trouble swallowing, neck swelling [1]
Complications Airway compromise [1]
Usual onsetRapid [1]
Risk factors Dental infection [1]
Diagnostic method Based on symptoms and examination, CT scan [1]
Treatment Antibiotics, corticosteroids, endotracheal intubation, tracheostomy [1]

Ludwig's angina (Latin : Angina ludovici) is a type of severe cellulitis involving the floor of the mouth [2] and is often caused by bacterial sources. [1] Early in the infection, the floor of the mouth raises due to swelling, leading to difficulty swallowing saliva. As a result, patients may present with drooling and difficulty speaking. [3] As the condition worsens, the airway may be compromised and hardening of the spaces on both sides of the tongue may develop. [4] Overall, this condition has a rapid onset over a few hours.

Contents

The majority of cases follow a dental infection. [3] Other causes include a parapharyngeal abscess, mandibular fracture, cut or piercing inside the mouth, or submandibular salivary stones. [5] The infection spreads through the connective tissue of the floor of the mouth and is normally caused by infectious and invasive organisms such as Streptococcus, Staphylococcus, and Bacteroides. [6]

Prevention is by appropriate dental care including management of dental infections. Initial treatment is generally with broad-spectrum antibiotics and corticosteroids. [1] In more advanced cases endotracheal intubation or tracheostomy may be required. [1]

With the advent of antibiotics in 1940s, improved oral and dental hygiene, and more aggressive surgical approaches for treatment, the risk of death due to Ludwig's angina has significantly reduced. It is named after a German physician, Wilhelm Frederick von Ludwig, who first described this condition in 1836. [7]

Signs and symptoms

Ludwig's angina is a form of severe, widespread cellulitis of the floor of the mouth, usually with bilateral involvement. Infection is usually primarily within the submandibular space, and the sublingual and submental spaces can also be involved. It presents with an acute onset and spreads very rapidly, therefore early diagnosis and immediate treatment planning is vital and lifesaving. [8] The external signs may include bilateral lower facial swelling around the jaw and upper neck. Signs inside the mouth may include elevation of the floor of mouth due to sublingual space involvement and posterior displacement of the tongue, creating the potential for a compromised airway. [8] Additional symptoms may include painful neck swelling, drooling, tooth pain, dysphagia, shortness of breath, fever, and general malaise. [9] Stridor, trismus, and cyanosis may also be seen when an impending airway crisis is nearing. [9]

Causes

The most prevalent cause of Ludwig's angina is dental related, [10] accounting for approximately 75–90% of cases. [10] [11] [12] [13] Infections of the lower second and third molars are usually implicated due to their roots extending below the mylohyoid muscle. [10] [14] Periapical abscesses of these teeth also result in lingual cortical penetration, leading to submandibular infection. [10]

Other causes such as oral ulcerations, infections secondary to oral malignancy, mandible fractures, sialolithiasis-related submandibular gland infections, [10] and penetrating injuries of the mouth floor [15] have also been documented as potential causes of Ludwig's angina. Patients with systemic illness, such as diabetes mellitus, malnutrition, compromised immune system, and organ transplantation are also commonly predisposed to Ludwig's angina. [13] A review reporting the incidence of illnesses associated with Ludwig angina found that 18% of cases involved diabetes mellitus, 9% involved acquired immune deficiency syndrome, and another 5% were human immunodeficiency virus (HIV) positive. [16]

Diagnosis

Infections originating in the roots of teeth can be identified with a dental X-ray. [17] [18] A CT scan of the neck with contrast material is used to identify deep neck space infections. [19] If there is suspicion of the infection of the chest cavity, a chest scan is sometimes done. [18]

Angioneurotic oedema, [20] lingual carcinoma and sublingual hematoma formation following anticoagulation should be ruled out as possible diagnoses. [19]

Microbiology

There are a few methods that can be used for determining the microbiology of Ludwig's angina. Traditionally, a culture sample is collected although it has some limitations, primarily being the time-consuming and sometimes unreliable results if the culture is not processed correctly. [21] Ludwig's angina is most often found to be polymicrobial and anaerobic. [2] [22] Some of the commonly found microbes are Viridans streptococci, Staphylococci, Peptostreptococci, Prevotella , Porphyromonas and Fusobacterium . [2] [22]

Treatment

For each patient, the treatment plan should be consider the patient's stage of infection, airway control, and comorbidities. Other things to consider include physician experience, available resources, and personnel are critical factors in formulation of a treatment plan. [23] There are four principles that guide the treatment of Ludwig's angina: [24] Sufficient airway management, early and aggressive antibiotic therapy, incision and drainage for any who fail medical management or form localized abscesses, and adequate nutrition and hydration support.

Airway management

Placement of an endotracheal tube to aid breathing Endotracheal Tube.png
Placement of an endotracheal tube to aid breathing

Airway management has been found to be the most important factor in treating patients with Ludwig's angina, [25] i.e. it is the "primary therapeutic concern". [26] Airway compromise is known to be the leading cause of death from Ludwig's angina. [5]

Antibiotics

Incision and drainage

Other things to consider

Nutritional support

Adequate nutrition and hydration support is essential in any patient following surgery, particularly young children. [24] 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. [29]

Post-operative care

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. [29]

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. [29]

[24]

Etymology

The term "angina", is derived from the Latin word angere, which means "choke"; and the Greek word ankhone, which means "strangle". Placing it into context, Ludwig's angina refers to the feeling of strangling and choking, secondary to obstruction of the airway, which is the most serious potential complication of this condition. [22]

See also

Related Research Articles

<span class="mw-page-title-main">Tracheal intubation</span> Placement of a tube into the trachea

Tracheal intubation, usually simply referred to as intubation, is the placement of a flexible plastic tube into the trachea (windpipe) to maintain an open airway or to serve as a conduit through which to administer certain drugs. It is frequently performed in critically injured, ill, or anesthetized patients to facilitate ventilation of the lungs, including mechanical ventilation, and to prevent the possibility of asphyxiation or airway obstruction.

<span class="mw-page-title-main">Pharyngitis</span> Inflammation of the back of the throat

Pharyngitis is inflammation of the back of the throat, known as the pharynx. It typically results in a sore throat and fever. Other symptoms may include a runny nose, cough, headache, difficulty swallowing, swollen lymph nodes, and a hoarse voice. Symptoms usually last 3–5 days, but can be longer depending on cause. Complications can include sinusitis and acute otitis media. Pharyngitis is a type of upper respiratory tract infection.

<span class="mw-page-title-main">Tracheotomy</span> Temporary surgical incision to create an airway into the trachea

Tracheotomy, or tracheostomy, is a surgical airway management procedure which consists of making an incision (cut) on the anterior aspect (front) of the neck and opening a direct airway through an incision in the trachea (windpipe). The resulting stoma (hole) can serve independently as an airway or as a site for a tracheal tube or tracheostomy tube to be inserted; this tube allows a person to breathe without the use of the nose or mouth.

A tracheal tube is a catheter that is inserted into the trachea for the primary purpose of establishing and maintaining a patent airway and to ensure the adequate exchange of oxygen and carbon dioxide.

<span class="mw-page-title-main">Airway management</span> Medical procedure ensuring an unobstructed airway

Airway management includes a set of maneuvers and medical procedures performed to prevent and relieve airway obstruction. This ensures an open pathway for gas exchange between a patient's lungs and the atmosphere. This is accomplished by either clearing a previously obstructed airway; or by preventing airway obstruction in cases such as anaphylaxis, the obtunded patient, or medical sedation. Airway obstruction can be caused by the tongue, foreign objects, the tissues of the airway itself, and bodily fluids such as blood and gastric contents (aspiration).

<span class="mw-page-title-main">Peritonsillar abscess</span> Pus behind the tonsil due to an infection

Peritonsillar abscess (PTA), also known as quinsy, is an accumulation of pus due to an infection behind the tonsil. Symptoms include fever, throat pain, trouble opening the mouth, and a change to the voice. Pain is usually worse on one side. Complications may include blockage of the airway or aspiration pneumonitis.

<span class="mw-page-title-main">Epiglottitis</span> Inflammation of the epiglottis

Epiglottitis is the inflammation of the epiglottis—the flap at the base of the tongue that prevents food entering the trachea (windpipe). Symptoms are usually rapid in onset and include trouble swallowing which can result in drooling, changes to the voice, fever, and an increased breathing rate. As the epiglottis is in the upper airway, swelling can interfere with breathing. People may lean forward in an effort to open the airway. As the condition worsens, stridor and bluish skin may occur.

Stridor is a high-pitched extra-thoracic breath sound resulting from turbulent air flow in the larynx or lower in the bronchial tree. It is different from a stertor which is a noise originating in the pharynx.

<span class="mw-page-title-main">Pericoronitis</span> Inflammation of the soft tissues surrounding the crown of a partially erupted tooth

Pericoronitis is inflammation of the soft tissues surrounding the crown of a partially erupted tooth, including the gingiva (gums) and the dental follicle. The soft tissue covering a partially erupted tooth is known as an operculum, an area which can be difficult to access with normal oral hygiene methods. The hyponym operculitis technically refers to inflammation of the operculum alone.

A dental emergency is an issue involving the teeth and supporting tissues that are of high importance to be treated by the relevant professional. Dental emergencies do not always involve pain, although this is a common signal that something needs to be looked at. Pain can originate from the tooth, surrounding tissues or can have the sensation of originating in the teeth but be caused by an independent source. Depending on the type of pain experienced an experienced clinician can determine the likely cause and can treat the issue as each tissue type gives different messages in a dental emergency.

<span class="mw-page-title-main">Anterior jugular vein</span>

The anterior jugular vein is a vein in the neck.

<span class="mw-page-title-main">Sialadenitis</span> Medical condition

Sialadenitis (sialoadenitis) is inflammation of salivary glands, usually the major ones, the most common being the parotid gland, followed by submandibular and sublingual glands. It should not be confused with sialadenosis (sialosis) which is a non-inflammatory enlargement of the major salivary glands.

<span class="mw-page-title-main">Dental abscess</span> Medical condition

A dental abscess is a localized collection of pus associated with a tooth. The most common type of dental abscess is a periapical abscess, and the second most common is a periodontal abscess. In a periapical abscess, usually the origin is a bacterial infection that has accumulated in the soft, often dead, pulp of the tooth. This can be caused by tooth decay, broken teeth or extensive periodontal disease. A failed root canal treatment may also create a similar abscess.

<span class="mw-page-title-main">Retropharyngeal abscess</span> Medical condition

Retropharyngeal abscess (RPA) is an abscess located in the tissues in the back of the throat behind the posterior pharyngeal wall. Because RPAs typically occur in deep tissue, they are difficult to diagnose by physical examination alone. RPA is a relatively uncommon illness, and therefore may not receive early diagnosis in children presenting with stiff neck, malaise, difficulty swallowing, or other symptoms listed below. Early diagnosis is key, while a delay in diagnosis and treatment may lead to death. Parapharyngeal space communicates with retropharyngeal space and an infection of retropharyngeal space can pass down behind the esophagus into the mediastinum. RPAs can also occur in adults of any age.

Mouth infections, also known as oral infections, are a group of infections that occur around the oral cavity. They include dental infection, dental abscess, and Ludwig's angina. Mouth infections typically originate from dental caries at the root of molars and premolars that spread to adjacent structures. In otherwise healthy patients, removing the offending tooth to allow drainage will usually resolve the infection. In cases that spread to adjacent structures or in immunocompromised patients, surgical drainage and systemic antibiotics may be required in addition to tooth extraction. Since bacteria that normally reside in the oral cavity cause mouth infections, proper dental hygiene can prevent most cases of infection. As such, mouth infections are more common in populations with poor access to dental care or populations with health-related behaviors that damage one's teeth and oral mucosa. This is a common problem, representing nearly 36% of all encounters within the emergency department related to dental conditions.

<span class="mw-page-title-main">Facial trauma</span> Medical condition

Facial trauma, also called maxillofacial trauma, is any physical trauma to the face. Facial trauma can involve soft tissue injuries such as burns, lacerations and bruises, or fractures of the facial bones such as nasal fractures and fractures of the jaw, as well as trauma such as eye injuries. Symptoms are specific to the type of injury; for example, fractures may involve pain, swelling, loss of function, or changes in the shape of facial structures.

<span class="mw-page-title-main">Sublingual space</span>

The sublingual space is a fascial space of the head and neck. It is a potential space located below the mouth and above the mylohyoid muscle, and is part of the suprahyoid group of fascial spaces.

<span class="mw-page-title-main">Submental space</span>

The submental space is a fascial space of the head and neck. It is a potential space located between the mylohyoid muscle superiorly, the platysma muscle inferiorly, under the chin in the midline. The space coincides with the anatomic region termed the submental triangle, part of the anterior triangle of the neck.

<span class="mw-page-title-main">Surgical airway management</span>

Surgical airway management is the medical procedure ensuring an open airway between a patient’s lungs and the outside world. Surgical methods for airway management rely on making a surgical incision below the glottis in order to achieve direct access to the lower respiratory tract, bypassing the upper respiratory tract. Surgical airway management is often performed as a last resort in cases where orotracheal and nasotracheal intubation are impossible or contraindicated. Surgical airway management is also used when a person will need a mechanical ventilator for a longer period. The surgical creation of a permanent opening in the larynx is referred to as laryngostomy. Surgical airway management is a primary consideration in anaesthesia, emergency medicine and intensive care medicine.

<span class="mw-page-title-main">Advanced airway management</span>

Advanced airway management is the subset of airway management that involves advanced training, skill, and invasiveness. It encompasses various techniques performed to create an open or patent airway – a clear path between a patient's lungs and the outside world.

References

  1. 1 2 3 4 5 6 7 8 9 Gottlieb, M; Long, B; Koyfman, A (May 2018). "Clinical Mimics: An Emergency Medicine-Focused Review of Streptococcal Pharyngitis Mimics". The Journal of Emergency Medicine. 54 (5): 619–629. doi: 10.1016/j.jemermed.2018.01.031 . PMID   29523424.
  2. 1 2 3 Candamourty R, Venkatachalam S, Babu MR, Kumar GS (July 2012). "Ludwig's Angina - An emergency: A case report with literature review". Journal of Natural Science, Biology, and Medicine. 3 (2): 206–8. doi: 10.4103/0976-9668.101932 . PMC   3510922 . PMID   23225990.
  3. 1 2 Coulthard P, Horner K, Sloan P, Theaker ED (2013-05-17). Master dentistry (3rd ed.). Edinburgh: Elsevier. ISBN   978-0-7020-4600-1. OCLC   786161764.
  4. ↑ Kremer MJ, Blair T (December 2006). "Ludwig angina: forewarned is forearmed". AANA Journal. 74 (6): 445–51. PMID   17236391.
  5. 1 2 3 4 5 6 Saifeldeen K, Evans R (March 2004). "Ludwig's angina". Emergency Medicine Journal. 21 (2): 242–3. doi:10.1136/emj.2003.012336. PMC   1726306 . PMID   14988363.
  6. ↑ The atlas of emergency medicine. Kevin J. Knoop, Lawrence B Stack, Alan B Storrow, R. Jason Thurman (Fifth ed.). New York. 2021. ISBN   978-1-260-13495-7. OCLC   1145903874.{{cite book}}: CS1 maint: location missing publisher (link) CS1 maint: others (link)
  7. ↑ Murphy SC (October 1996). "The person behind the eponym: Wilhelm Frederick von Ludwig (1790-1865)". Journal of Oral Pathology & Medicine. 25 (9): 513–5. doi:10.1111/j.1600-0714.1996.tb00307.x. PMID   8959561.
  8. 1 2 Candamourty, Ramesh; Venkatachalam, Suresh; Babu, M. R. Ramesh; Kumar, G. Suresh (2012). "Ludwig's Angina – An emergency: A case report with literature review". Journal of Natural Science, Biology, and Medicine. 3 (2): 206–208. doi: 10.4103/0976-9668.101932 . ISSN   0976-9668. PMC   3510922 . PMID   23225990.
  9. 1 2 Saifeldeen, K.; Evans, R. (2004-03-01). "Ludwig's angina". Emergency Medicine Journal. 21 (2): 242–243. doi:10.1136/emj.2003.012336. ISSN   1472-0205. PMC   1726306 . PMID   14988363.
  10. 1 2 3 4 5 Current therapy in oral and maxillofacial surgery. Bagheri, Shahrokh C., Bell, R. Bryan., Khan, Husain Ali. Philadelphia: Elsevier Saunders. 2012. ISBN   9781416025276. OCLC   757994410.{{cite book}}: CS1 maint: others (link)
  11. ↑ Moreland, L. W.; Corey, J.; McKenzie, R. (February 1988). "Ludwig's angina. Report of a case and review of the literature". Archives of Internal Medicine. 148 (2): 461–466. doi:10.1001/archinte.1988.00380020205027. ISSN   0003-9926. PMID   3277567.
  12. ↑ Sethi, D. S.; Stanley, R. E. (February 1994). "Deep neck abscesses--changing trends". The Journal of Laryngology and Otology. 108 (2): 138–143. doi:10.1017/S0022215100126106. ISSN   0022-2151. PMID   8163915. S2CID   45325553.
  13. 1 2 Chou, Yu-Kung; Lee, Chao-Yi; Chao, Hai-Hsuan (December 2007). "An upper airway obstruction emergency: Ludwig angina". Pediatric Emergency Care. 23 (12): 892–896. doi:10.1097/pec.0b013e31815c9d4a. ISSN   1535-1815. PMID   18091599. S2CID   2891390.
  14. ↑ Prince, Jim McMorran, Damian Crowther, Stew McMorran, Steve Youngmin, Ian Wacogne, Jon Pleat, Clive. "Ludwig's angina - General Practice Notebook". gpnotebook.co.uk. Retrieved 2018-02-17.{{cite web}}: CS1 maint: multiple names: authors list (link)
  15. ↑ "Peterson's Principles of Oral and Maxillofacial Surgery 2nd Ed 2004". Scribd. Retrieved 2018-02-17.
  16. ↑ Moreland, Larry W. (1988-02-01). "Ludwig's Angina". Archives of Internal Medicine. 148 (2): 461–6. doi:10.1001/archinte.1988.00380020205027. ISSN   0003-9926. PMID   3277567.
  17. ↑ Spitalnic SJ, Sucov A (July 1995). "Ludwig's angina: case report and review". The Journal of Emergency Medicine. 13 (4): 499–503. doi:10.1016/0736-4679(95)80007-7. PMID   7594369.
  18. 1 2 Bagheri SC (2014). Clinical Review of Oral and Maxillofacial Surgery: A Case-Based Approach (Second ed.). St. Louis: Mosby Elsevier. pp. 95–118. ISBN   978-0-323-17127-4.
  19. 1 2 Crespo AN, Chone CT, Fonseca AS, Montenegro MC, Pereira R, Milani JA (November 2004). "Clinical versus computed tomography evaluation in the diagnosis and management of deep neck infection". Sao Paulo Medical Journal. 122 (6): 259–63. doi: 10.1590/S1516-31802004000600006 . PMID   15692720.
  20. ↑ Ohn, May H.; Wadhwa, Roopma (2021), "Angioneurotic Edema", StatPearls, Treasure Island (FL): StatPearls Publishing, PMID   32809446 , retrieved 2021-11-15
  21. ↑ Siqueira JF, Rôças IN (April 2013). "Microbiology and treatment of acute apical abscesses". Clinical Microbiology Reviews. 26 (2): 255–73. doi:10.1128/CMR.00082-12. PMC   3623375 . PMID   23554416.
  22. 1 2 3 Costain N, Marrie TJ (February 2011). "Ludwig's Angina". The American Journal of Medicine. 124 (2): 115–7. doi: 10.1016/j.amjmed.2010.08.004 . PMID   20961522.
  23. ↑ Shockley WW (May 1999). "Ludwig angina: a review of current airway management". Archives of Otolaryngology–Head & Neck Surgery. 125 (5): 600. doi:10.1001/archotol.125.5.600. PMID   10326825.
  24. 1 2 3 Chou YK, Lee CY, Chao HH (December 2007). "An upper airway obstruction emergency: Ludwig angina". Pediatric Emergency Care. 23 (12): 892–6. doi:10.1097/pec.0b013e31815c9d4a. PMID   18091599. S2CID   2891390.
  25. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 Bagheri SC, Bell RB, Khan HA (2011). Current Therapy in Oral and Maxillofacial Surgery. Philadelphia: Elsevier. pp. 1092–1098. ISBN   978-1-4160-2527-6.
  26. ↑ Moreland LW, Corey J, McKenzie R (February 1988). "Ludwig's angina. Report of a case and review of the literature". Archives of Internal Medicine. 148 (2): 461–6. doi:10.1001/archinte.1988.00380020205027. PMID   3277567.
  27. ↑ Kurien M, Mathew J, Job A, Zachariah N (June 1997). "Ludwig's angina". Clinical Otolaryngology and Allied Sciences. 22 (3): 263–5. doi:10.1046/j.1365-2273.1997.00014.x. PMID   9222634.
  28. ↑ Parhiscar A, Har-El G (November 2001). "Deep neck abscess: a retrospective review of 210 cases". The Annals of Otology, Rhinology, and Laryngology. 110 (11): 1051–4. doi:10.1177/000348940111001111. PMID   11713917. S2CID   40027551.
  29. 1 2 3 Bagheri SC, Bell RB, Khan HA (2012). Current Therapy in Oral and Maxillofacial Surgery. Philadelphia: Elsevier Saunders. ISBN   978-1-4160-2527-6. OCLC   757994410.
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