Ludwig's Angina

This man came to the A&E with complaint of pain in the floor of the mouth, difficulty and painful swallowing as well as loss of voice. He had history of tooth extraction three days prior to the day of admission.

On examination, there was a tender induration over the floor of the mouth; his voice was muffled; febrile with stable vital signs. Tonsils were injected.

Working diagnosis: Ludwig's angina





Lateral neck x-ray taken of this patient shows a soft tissue enlargement over the submandibular space with gas formation.


Ludwig's angina
- is actually a progressive cellulitis of the connective tissues of the floor of the mouth and neck that begins in the submandibular space
- dental disease is the most common cause
- an infected or recently extracted lower molar is noted in most affected patients

Anatomic Basis of the Pathophysiology of Infection Spread


Note: The above two diagrams are linked from the American Academy of Family Physician's webpage on Ludwig's Angina. Click here to access: http://www.aafp.org/afp/990700ap/109.html)

In order to appreciate the potential of this infection to spread from the floor of the mouth to the neck and mediastinal structures, a brief review of the involved anatomy is helpful (Figure 8).

The submandibular space comprises part of the space above the hyoid bone.
The total space is divided into the sublingual space superiorly and submaxillary space inferiorly. The sublingual space is located between the geniohyoid and mylohyoid muscles.

The submaxillary space is located between the mylohyoid muscle and the superficial fascia and skin.

Odontogenic infections break through the relatively thin cortex of the mandible below the mylohyoid ridge.

Due to the nature of the spread, the combination of tense edema and brawny induration of the neck above the hyoid may be present and is described as a “bull neck.” See the article here to see the appearance of a "bull neck" picture (http://www.aafp.org/afp/990700ap/109.html)

Causes
Other causes of Ludwig's angina (besides spread of dentoalveolar infection) include:
1/ fractured mandible
2/ foreign body or laceration in the floor of the mouth
3/ tongue piercing resulting in infection
4/ secondary infections of an oral malignancy
5/ otitis media
6/ spread of infections around the oral region: submandibular sialoadenitis, peritonsillar abscess

Ludwig's angina is most commonly a polymicrobial disease of mixed aerobic-anaerobic bacteria of oral origin.

The most frequently isolated organisms are streptococci, staphylococci, and Bacteroides species. Other organisms include H. influenzae, Pseudomonas aeruginosa, Klebsiella species, and Candida albicans.

Clinical Features

Infection of the sublingual and submaxillary spaces leads to edema and soft tissue displacement, which may result in airway obstruction.

The most common symptoms in patients with Ludwig's angina include
- dysphagia
- odynophagia
- neck swelling
- dysphonia
- “hot potato” voice
- drooling
- tongue swelling
- pain in the floor of the mouth
- restricted neck movement, and
- sore throat.

Surprisingly, generally there is no cervical lymphadenopathy.

Click here for another great article from Hospital Physician on Ludwig's angina (in pdf).
(URL: http://turner-white.com/pdf/hp_jul02_angina.pdf)

Management
The main problem with Ludwig's angina is because of the rapid enlargement of the swelling. edema and displacement of soft tissue resulting in upper airway obstruction.

Airway management in such cases may become complicated. We were fortunate that this patient was still comfortable in his breathing, although he has "lost" his voice.

Emergent antibiotic regimens include high-dose penicillin with metronidazole, or cefoxitin. Alternately, clindamycin, ticarcillin-clavulanate, piperacillin, azobactam, or ampicillin-sulbactam may be used.

The value of corticosteroids in the setting of Ludwig's angina is unclear.

Surgical incision plus drainage was the therapy of choice in the preantibiotic era.

With the exception of dental extractions, surgery is reserved for patients who do not respond to medical therapy and those with crepitus and purulent collections,

Mortality caused by Ludwig's angina is less than 10% with early aggressive antibiotic therapy and adequate protection of the airway.

Infection can easily spread into other deep spaces of the neck and into the thoracic cavity and cause empyema, mediastinitis, mediastinal abscess, and pericarditis.

Reference:
Chapter 17 Upper Respiratory Tract Infections from Marx: Rosen's Emergency Medicine: Concepts and Clinical Practice, 6th ed.