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  • Ludwig S Angina: Ernest E. Wang MD, FACEP

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    Ludwig's angina is a serious deep space infection of the neck that can potentially be fatal if not treated aggressively. It involves the spread of a localized dental infection along fascial planes from the mouth to the sublingual or submandibular spaces. Physical exam reveals toxic appearance, brawny swelling of the submandibular area, and difficulty opening the mouth. Treatment requires securing the airway early, surgical consultation for drainage and debridement, broad-spectrum IV antibiotics including coverage for B. fragilis, and steroids to reduce swelling. Patients require intensive care monitoring due to risk of airway obstruction, spread of infection, and death.

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    Ludwig's angina is a serious deep space infection of the neck that can potentially be fatal if not treated aggressively. It involves the spread of a localized dental infection along fascial planes from the mouth to the sublingual or submandibular spaces. Physical exam reveals toxic appearance, brawny swelling of the submandibular area, and difficulty opening the mouth. Treatment requires securing the airway early, surgical consultation for drainage and debridement, broad-spectrum IV antibiotics including coverage for B. fragilis, and steroids to reduce swelling. Patients require intensive care monitoring due to risk of airway obstruction, spread of infection, and death.

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    19 vues15 pages

    Ludwig S Angina: Ernest E. Wang MD, FACEP

    Transféré par

    neeru_27
    Ludwig's angina is a serious deep space infection of the neck that can potentially be fatal if not treated aggressively. It involves the spread of a localized dental infection along fascial planes from the mouth to the sublingual or submandibular spaces. Physical exam reveals toxic appearance, brawny swelling of the submandibular area, and difficulty opening the mouth. Treatment requires securing the airway early, surgical consultation for drainage and debridement, broad-spectrum IV antibiotics including coverage for B. fragilis, and steroids to reduce swelling. Patients require intensive care monitoring due to risk of airway obstruction, spread of infection, and death.

    Droits d'auteur :

    Attribution Non-Commercial (BY-NC)
    Téléchargez comme PPT, PDF, TXT ou lisez en ligne sur Scribd
    Signaler comme contenu inapproprié
    sur 15

    Ludwigs Angina

    Ernest E. Wang MD, FACEP


    Evanston Northwestern Healthcare Northwestern University Medical School

    Ludwigs Angina
    Extension of localized periapical infection
    Anterior mandibular Sublingual Posterior mandibular (molar) Submandibular

    Fascial planes

    Historical cues
    Recent dental extraction or work Dental caries Fever Swelling of mouth, face, neck Compromised host Co-morbidities (diabetes)

    Physical exam
    Toxicity Brawny bilateral boardlike edema Submandibular, submental, sublingual Trismus Tongue elevation No fluctuance

    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

    Etiology
    Streptococcus Staphylococcus Mixed aerobic/anaerobic infection
    B. Fragilis

    -lactamase resistance (<= 40%)

    Diagnosis
    Clinical CT scan

    4-month-old with fever, irritability, and decreased oral intake x 24 hours. Swelling x 10 hrs
    (Maimon et al, Ann Emerg Med, 2006)

    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

    Antibiotics
    Extended spectrum penicillins
    Ampicillin/Sulbactam (Unasyn) Ticarcillin/Clauvulate (Timentin) Piperacillin/Tazobactam (Zosyn)

    Clindamycin + Cipro (PCN allergy) Flagyl (B. Fragilis)

    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)

    Deep Neck Space Infections


    103 patients (1993 - 2005) Ludwigs Angina (n=38, 37%) Odontogenic (n=25, 67%) Tracheostomy (n=4) Medical management (n=13) Medical and surgical management (n=25)

    Larawin et al. Head and neck space infections. Otolaryngol Head Neck Surg. 2006, 135(6):899-993.

    Deep Neck Space Infections


    Complications
    Upper airway obstruction (n=4) Reinfection (n=3) Asphyxiation (n=1) Descending mediastinitis (n=1) Spread to other spaces (n=1) Death (n=2)

    Larawin et al. Head and neck space infections. Otolaryngol Head Neck Surg. 2006, 135(6):899-993.

    Ludwigs Angina Summary


    Serious deep space infection Potentially fatal Aggressive manage airway as indicated Surgical consultation Antibiotics and steroids ICU

    References
    Larawin V, Naipao J, Dubey SP. Head and neck space infections. Otolaryngol Head Neck Surg. 2006 Dec;135(6):889-93. Marple BF. Ludwig angina: a review of current airway management. Arch Otolaryngol Head Neck Surg. 1999;125:596-599. Busch RF. Ludwig angina: early aggressive therapy. Arch Otolaryngol Head Neck Surg. 1999 Nov;125(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 May;47(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, 892908 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, 13171340 pp.

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