Ludwig's angina

Ludwig's

Classification and external resources

Swelling in the submandibular area in a patient with Ludwig's angina.

ICD-10

K12.2

ICD-9

528.3

DiseasesDB

29336

MedlinePlus

001047

MeSH

D008158

Ludwig's angina, otherwise known as angina ludovici, is a serious, potentially life-threatening cellulitis[1][dead link], or connective tissue infection, of the floor of the mouth, usually occurring in adults with concomitant dental infections and if left untreated, may obstruct the airways, necessitating tracheotomy. It is named after the German physician, Wilhelm Friedrich von Ludwig who first described this condition in 1836.[2][3] Other names include "angina Maligna" and "Morbus Strangularis". Ludwig's angina should not be confused with angina pectoris, which is also otherwise commonly known as "angina". The word "angina" comes from the Greek word ankhon, meaning "strangling", so in this case, Ludwig's angina refers to the feeling of strangling, not the feeling of chest pain, though there may be chest pain in Ludwig's angina if the infection spreads into the retrosternal space. The life threatening nature of this condition generally necessitates surgical management with involvement of critical care physicians such as those found in an intensive care unit[4] .

Causes

Dental infections account for approximately eighty percent of cases of Ludwig's angina.[5] Mixed infections, due to both aerobes and anaerobes, are of the cellulitis associated with Ludwig's angina. Typically, these include alpha-hemolytic streptococci, staphylococci and bacteroides groups.[5] The route of infection in most cases is from infected lower molars or from pericoronitis, which is an infection of the gums surrounding the partially erupted lower (usually third) molars. Although the widespread involvement seen in Ludwig's usually develops in immunocompromised persons, it can also develop in otherwise healthy individuals. Thus, it is very important to obtain dental consultation for lower-third molars at the first sign of any pain, bleeding from the gums, sensitivity to heat/cold or swelling at the angle of the jaw. Ludwig's angina is also associated with piercings of the lingual frenulum.[6][7][8]

Symptoms and signs

True Ludwig's Angina is a cellulitic facial infection. The signs are bilateral (meaning both sides) lower facial swelling around the lower jaw and upper neck. This is because the infection has spread to involve the Submandibular, Sublingual and Submental spaces of the face. Swelling of the Submandibular space, while externally is concerning the true danger lies in the fact that the swelling has also spread inwardly - compromising, or in effect narrowing the airway. Dysphagia (difficulty swallowing), Odynophagia (pain during swallowing) are symptoms that are typically seen and demand immediate attention. The Sublingual and Submental spaces are anterior (beneath the middle and chin areas of the lower jaw) to the Submandibular space. Swelling in these areas can often push the floor of the mouth, including the tongue upwards and backwards - further compromising the airway.

Localisation of infection to the sublingual space is accompanied by swelling of structures in the floor of the mouth as well as the tongue being pushed upwards and backwards.[5] Spread of infection to submaxillary space is usually accompanied by signs of cellulitis rather than those of an abscess. Submental and submandibular regions are swollen and tender. Additional symptoms include malaise, fever, dysphagia (difficulty swallowing), odynophagia (pain during swallowing)[5] and, in severe cases, stridor or difficulty breathing. There may also be varying degrees of trismus. Swelling of the submandibular and/or sublingual space is imminent.

Treatment
Treatment involves appropriate antibiotic medications, monitoring and protection of the airway in severe cases, and, where appropriate, urgent maxillo-facial surgery and/or dentalconsultation to incise and drain the collections.The antibiotic of choice is from Penicillin group. Incision and drainage of the abscess may be either intraoral or external. An intraoral incision and drainage procedure is indicated if the infection is localized to the sublingual space. External incision and drainage is performed if infection involves the submaxillary space.[5]

A nasotracheal tube is sometimes warranted for ventilation if the tissues of the mouth make insertion of an oral airway difficult or impossible. In cases where the patency of the airway is compromised, skilled airway management is mandatory. This entails management of the airway according to the American Society of Anesthesiologists' Difficult Airway Algorithm and necessitates fiberoptic intubation.

Alveolar osteitis

Alveolar osteitis. Note exposed bone as marked by the arrow.

Alveolar osteitis or, colloquially, a dry socket, is a complication of wound healing following extraction of a tooth. The term alveolarrefers to the alveolus, which is the part of the jawbone that surrounds the teeth; osteitis means simply "bone inflammation". It is known as "dry socket" as after the clot is lost, the socket has a dry appearance because of exposed bone. The blood clot helps in stopping the bleeding and lays framework for new tissues to develop there but in case of dry socket, the clot is dislodged and the bone is exposed. This bare bone is exposed to bacteria in the saliva and the food which the patient consumes and the bone becomes infected and painful.

Signs and symptoms

Alveolar osteitis usually occurs 35 days after tooth extraction and causes severe throbbing and radiating pain which is difficult to localize. Alveolar osteitis is characterized bydetritus, grayish slough, severe pain and foul odor.[1][2][3] The foul odor, in particular, is a result of the disintegration of the blood clot by putrefaction rather than by orderly resorption. If a probe is gently passed in the tooth extraction socket, then bare bone is encountered which is very sensitive.
[1]

Cause

Alveolar osteitis, "dry socket" type. Note exposed bone, as marked by arrow.

Multiple types of alveolar osteitis can result from disturbances in the healing process. The type that is commonly referred to as "dry socket" is one in which the disturbance is from the time a blood clot forms immediately after tooth extraction to the initiation of healing in the 45 day period after extraction occurs. The healing tissue that is supposed to replace the blood clot, known asgranulation tissue, may fail to grow or be disrupted after beginning to grow, leading to the well known symptoms of alveolar osteitis.[1] Wound healing is a complex process and can be positively and negatively affected by many factors. [4] Alveolar osteitis is the most common healing disturbance of extraction sockets.[1] Suppurative osteitis results when the disturbance of extraction socket wound healing occurs later, during the third stage of healing from day 14 to 16 after extraction, and is a manifestation of the disruption of connective tissue development. This form usually results from an infection and exhibits a purulent discharge (pus) from the extraction socket.[1] Disruption of the extraction socket during an even later stage of healing might result in necrotizing osteitis in which encapsulated shards of bone (bony sequestrae) will be noted alongside inflammatory cells.[1]

Prevention
True alveolar osteitis, as opposed to simple postoperative pain, occurs in only about 13% of extractions.[5] No one knows for certain how or why dry sockets develop followingdental extraction but certain factors are associated with increased risk. One of these factors is the complexity of the extraction. Smoking may be a contributing factor, possibly due to the decreased amount of oxygen available in the healing tissues. It is advisable to avoid smoking for at least 48 hours following tooth extraction to reduce the risk of developing dry socket. Women are generally at higher risk than men of developing alveolar osteitis, because estrogen slows down healing. Dentists recommend that their female patients have extractions performed during the last week of their menstrual cycle, when estrogen levels are lowest, to minimize chances of developing alveolar osteitis.[6]

Treatment
The pain from alveolar osteitis usually lasts for 2472 hours. There is no real treatment for alveolar osteitis; it is a selflimiting condition that will improve and disappear with time, but certain interventions can significantly decrease pain during an episode of alveolar osteitis. These interventions usually consist of a gentle rinsing of the inflamed socket followed by the direct placement within the socket of some type of sedative dressing, which soothes the inflamed bone for a period of time and

promotes tissue growth. This is usually done without anesthesia.[7] The active ingredients in these sedative dressings usually include substances like, zinc oxide, eugenol, and oil of cloves. It is usually necessary to have this done for two or three consecutive days, although occasionally it can take longer. Because true alveolar osteitis pain is so intense, additional analgesics are sometimes prescribed.