Ludwig's Angina: Management and Outcomes Study Conducted at Kitwe Teaching Hospital: A

5-Year Single-Center Retrospective Study.

Chisenga M. Zulu

Reg: No: 22900160

A research proposal submitted in the Department of ……………………………..School of

……………………………in partial fulfillment of the requirements for the award of the degree

Master of Public Health at Copperbelt University.

Year
1 DECLARATION
This report is my original work and has not been presented in any institution leading to the award

of a degree or any other award.

Sign……………………………………… Date……………………………………

Student’s Name

Chisenga Mambwe Zulu

I confirm that this proposal was written by the above-named student and has been submitted

with our approval as supervisor.

Name:

Sign …………………………………… Date ……………………………………………

ii
 TABLE OF CONTENTS

DECLARATION...........................................................................................................................II

ABSTRACT...................................................................................................................................V

INTRODUCTION.........................................................................................................................4

3.1 BACKGROUND INFORMATION..........................................................................................4

3.2 STATEMENT OF THE PROBLEM........................................................................................5

3.3 SIGNIFICANCE OF THE STUDY..........................................................................................5

3.4 RESEARCH QUESTIONS....................................................................................................5

3.5 HYPOTHESIS OF THE STUDY............................................................................................6

3.6 OBJECTIVES OF THE STUDY.............................................................................................6

1.6.2. SPECIFIC OBJECTIVES OF THE STUDY.........................................................................6

LITERATURE REVIEW..............................................................................................................7

4.1 CONCEPTUAL FRAMEWORK............................................................................................7

4.1.1 Dependent variable.......................................................................................................8

4.1.2 Ludwig’s Angina...........................................................................................................8

4.1.3 Independent variables..................................................................................................9

4.1.4 Cause of infection (i.e., trauma, laceration, odontogenic-etc.)..................................9

4.1.5 Existence of risk factors.............................................................................................10

4.1.6 Administration of treatment.......................................................................................10

MATERIALS AND METHODS.................................................................................................14

5.1 STUDY SITE.....................................................................................................................14

5.2 STUDY DESIGN................................................................................................................14

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 5.3 STUDY VARIABLES..........................................................................................................14

5.4 STUDY POPULATION.......................................................................................................15

5.5 INCLUSION CRITERIA.....................................................................................................15

5.5.1 Exclusion Criteria......................................................................................................15

5.5.2 Sample Size determination.........................................................................................15

5.6 DATA COLLECTION.........................................................................................................15

5.7 DATA MANAGEMENT AND ANALYSIS..............................................................................16

5.8 LIMITATION OF THE STUDY...........................................................................................16

5.9 ETHICAL CONSIDERATIONS...........................................................................................16

WORK PLAN..............................................................................................................................17

BUDGET......................................................................................................................................17

REFERENCES............................................................................................................................18

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2 ABSTRACT

Although Ludwig’s Angina (LA) is relatively uncommon but it can be a life-threatening

infection. It was discovered in 1836 by a German physician, Friedrich Von Ludwig who

described LA as a dangerous infectious disease that affecting the cellulitis of the floor of the

mouth and the neck that involves the submandibular, sublingual and submental fascial

compartments and is characterized by its potential to rapidly spread to the adjacent structures

(Winters, 2003). LA is predominant between 20 and 40 years with males largely infected

(McMorran et al., 2017). There are various predisposing conditions that expose patients to this

condition, i.e., recent dental medication, dental decay, poor dentition, poor immune system,

chronic disease and organ transplantation (Candamourty et al., 2012).

This research intends to investigate the etiology and the factors impacting the prognosis and

management of Ludwig’s Angina, A case study carried out at Kitwe Teaching Hospital, Zambia

with emphasis on the management, treatment and outcome of this gangrenous condition.

Key words: Life threatening, odontogenic, Ludwig’s angina, poly microbia

iii
 CHAPTER ONE

3 INTRODUCTION

3.1 Background information

The introduction of antibiotics in 1940’s resulted into improved and advanced surgical

approaches as well as enhanced dental and oral hygiene. The rate at which Ludwig’s Angina

affected people exceeded 50% at that time before the introduction of the antibiotics but it has

now reduced drastically, (Saifeldeen & Evans, 2004; Lai & Pancer, 2012). Currently, the fatality

rate of Ludwig’s Angina ranges between 5%-10%, (Balakrishnan and Thenmozhi, 2014; Lanctot,

1996) and it’s now not an emergency that requires surgery.

The most significant concern with Ludwig’s angina is maintaining the patency of the airways

and a tracheostomy may be considered in some cases in order to prevent airway obstruction

(Rakes, B. S. et al., 2020). For example, in reviewing incidences of the deep-space-neck

infections the rate was 4% (Srirompotong & Art-Smart, 2003). The decrease of its fatality rate

was as a result of both curative and preventive health care however, the latter has led to limited

experience amongst the health care specialists in dealing with Ludwig’s Angina (Saifeldeen &

Evans, 2004). Because of its (LA) ability to spread rapidly, without proper and adequate

treatment coupled by the limited experience the health care practitioners have, Ludwig’s Angina

can spread very fast and become fatal to the patients on the off chance that there is lack of timely

prognosis.

4
3.2 Statement of the problem

Ludwig’s Angina is a fatal infection and has the ability to spread pretty fast to other

compartments of the floor of the mouth as well as infectious. As a matter of fact, there has been

increased medical advances to prevent its infectious state, but the fact remains health care

practitioners have limited experience towards Ludwig’s Angina prognosis and management.

Based on the clinical studies and observations at Kitwe Teaching Hospital, Zambia, the

management and prognosis of patients presenting Ludwig’s Angina remain poorly managed and

it has become fatal especially in immune-compromised individuals.

3.3 Significance of the study

The results of this study will help clinicians as well as health care practitioners optimize patient

care and outcomes as it will provide clinicians with the best options for managing their patients

that are presented with Ludwig’s Angina characteristics.

3.4 Research Questions

The following will be the research questions that the study will undertake

1. What is the epidemiology of Ludwig’s angina in adults at Kitwe Teaching Hospital?

2. What are the commonest risk factors of Ludwig’s angina in adults at Kitwe Teaching

Hospital?

3. What are the diagnostic and therapeutic modalities used in the management of Ludwig’s

angina in adults at Kitwe Teaching Hospital?

4. What are the outcomes of patients presented with Ludwig’s angina in adults at Kitwe

Teaching Hospital?

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3.5 Hypothesis of the study

1. Ludwig’s etiology is briskly progressive and leads to blockage of airways

2. Common risk factors associated with Ludwig’s Angina include; diabetes, alcoholism,

dental caries, immunocompromised and malnutrition status.

3. Therapeutic and diagnosis of Ludwig’s Angina include airway management, surgical

intervention and antibiotic therapy

3.6 Objectives of the study

1.6.1. General objectives of the study

To analyze clinical characteristics, management and outcomes of Ludwig’s angina at Kitwe

Teaching Hospital, Kitwe, Zambia.

1.6.2. Specific objectives of the study

1. To determine the epidemiology of Ludwig’s angina in Kitwe.

2. To determine the common risk factors of Ludwig’s angina in children and adults in

Kitwe.

3. To evaluate the diagnosis and treatment of Ludwig’s angina at Kitwe Teaching Hospital

4. To determine the outcomes of patients with Ludwig’s angina at Kitwe Teaching Hospital.

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 CHAPTER TWO

4 LITERATURE REVIEW
4.1 Conceptual Framework
The conceptual framework presents concepts on Ludwig’s Angina that highlights the dependent

as well as the independent variables that affect the severity of the malady. In this case, the

dependent variable is represented by how severe Ludwig’s Angina is whereas three independent

variables are represented as; lack of timely prognosis, dental caries and immunocompromised

state. Dental caries independent variable is a common causative agent of Ludwig’s Angina

whereas immunocompromised variable escalates the susceptivity to infection. Lack of timely

prognosis leads to seriousness of the disease. An understanding of the relation between the

variables aids healthcare practitioners in the diagnosis, prevention and management of the

disease.

Immunocompromised
state

Presence of dental Delay in seeking

caries medical attention

The severity of
Ludwig's angina

Fig.1. Conceptual Framework

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4.1.1 Dependent variable
The dependent variable for the research was identified to be the severity of Ludwig's angina, and

its discussed as follows:

4.1.2 Ludwig’s Angina

Various studies have been advanced to study of the prognosis and management of Ludwig’s

Angina, for example; a retrospective study by (An et al., 2021) showed that the presence of

systemic complications such as sepsis, pneumonia, and acute respiratory distress syndrome was

associated with more severe cases of Ludwig's angina. Another study done by (Rakes et al.,

2020) reported that the duration of symptoms before hospital admission was also a significant

predictor of disease severity. Moreover, a study done by (Dowdy et al., 2019) identified several

risk factors for severe Ludwig's angina, including diabetes, alcoholism, malnutrition, and

immunosuppression. The authors suggested that early recognition of these risk factors and

prompt intervention could potentially reduce the severity of the disease.

(Kawataki et al., 2021) reported that imaging modalities such as computed tomography (CT) and

magnetic resonance imaging (MRI) can provide valuable information on the extent and severity

of Ludwig's angina. The authors noted that these imaging techniques could help in the early

diagnosis and overall management of Ludwig’s Angina. Therefore, the severity of the disease is

caused by; systematic conditions, time of diagnosis, imaging findings as well as other underlying

factors.

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4.1.3 Independent variables
The researcher identified three independent variables below:

4.1.4 Cause of infection (i.e., trauma, laceration, odontogenic-etc.)

The major cause of infection is a vital independent variable in the advancement of Ludwig’s

Angina. Odontogenic infections present the commonest risk factor of Ludwig’s Angina then

trauma, laceration as well as other less risk causes. Various studies have identified the infectious

causes of Ludwig’s Angina. For instance, retrospective research done by (An et al., 2021) which

involved 156 patients suffering from Ludwig’s Angina discovered that odontogenic infections

amounted to 88% of most cases. Whereas, trauma as well as other factors amounted to 11.5% of

the cases. Likewise, another study done by (Dowdy et al., 2019) identified that dental caries were

the major factors causing Ludwig’s Angina that accounted for 67% of the cases.

Other researchers have identified the existing relationship between development of Ludwig’s

Angina and odontogenic infections. (Rakes et al., 2020) discovered that patients suffering from

Ludwig’s Angina likely suffered from dental infections in comparison to control patients.

Moreover, another research done by (An et al., 2021) discovered that lower molars that’s the

second and the third molar were mostly affected by odontogenic infections that lead to Ludwig’s

Angina.

To summarize, majorly, the cause of Ludwig’s Angina infection is a vital variable, odontogenic

infections being the major common cause.

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4.1.5 Existence of risk factors
Several research identifies that the existence of risk factors increases the chances of contracting

Ludwig’s Angina. A study conducted in 2019 identifies that dental infections, recent dental

medication as well as alcoholism presented the major risk factors causing Ludwig’s Angina

(Dowdy et al., 2019). Moreover, the socioeconomic status of patients was also identified as a risk

factor in contracting Ludwig’s Angina according to the study done in 2018 (Alqutami et al.,

2018). Therefore, the existence of risk factors significantly enhances the development of

Ludwig’s Angina. Thus, early prognosis and management of such risk factors helps in preventing

the contraction of Ludwig’s Angina.

4.1.6 Administration of treatment

The type of treatment administered represents a dependent variable and has been explored by

several researcher. In retrospective research done in 2019, researchers examined the prognosis

and management of patients suffering from Ludwig’s Angina. Those studies discovered that

primary medication approaches included surgical treatment and antibiotic therapy. Nevertheless,

the study highlighted the prevalences of early prognosis as well as prompt medication to avert

complications and reduction of invasive interventions.

In a standardized analysis as well as meta-review of studies done in 2000-2019, researchers

examined the efficiency of various medications for Ludwig’s Angina. It was determined that

surgical treatment, specifically effluent of Ludwig’s Angina infection, was the most effective

treatment for the condition. The authors also suggested that early recognition and treatment were

crucial in reducing the need for aggressive interventions.

Overall, these studies suggest that early recognition and prompt treatment with a combination of

antibiotics and surgical intervention, specifically drainage of the infection, are crucial for

successful management of Ludwig's angina. Worldwide etiologies according to an article by

10
Botha and Postma (2015) are divided into odontogenic and non-odontogenic groups.

Internationally diabetics mellitus (DM) is a comorbidity which has been well documented while

in Southern Africa only a few of such research have been conducted. This lack of information

and research could contribute to disease burden Botha et al (2015)

The management of patients with LA consists of a multidisciplinary approach depending on the

presentation and other accompanying comorbidities (Boamah, M. O. et al, 2019). While the

overall treatment of LA consists of airway maintenance, surgical drainage and broad-spectrum

parenteral antibiotics, airway management is unarguably the most important aspect of the

immediate care in the presence of airway compromise Ugboko, (2005). Prompt airway

management is important as patients are at high risk of developing airway obstruction which is

the most common cause of death in LA (Pak, S. et al, 2017). Identification of the causative

agents, institution of antibiotic therapy to control infection and surgical drainage is also of

optimum importance (An J et al., 2021) and Miah, M. R., & Ali, A. S. (2020).

Evaluation of patients after prompt resuscitation involves both laboratory and radiological

workups. A computed tomography scan is usually indicated and may show swelling of the soft

tissues with multiple abscesses in the sublingual and submandibular space (Kawataki, M. et al,

2021). Bilateral cervical lymphadenopathies can also be visualized on CT scan according to a

case report by (Pak, S. et al., 2017). (Boamah, M. O. et al., 2019) suggested that a timely

diagnosis of LA can be made by a combination of a clinical history, physical examination

findings, CT scan and Gram stain of the fluid aspirated from the site. Early contrast-enhanced CT

scan is recommended in the diagnosis of LA as physical examination alone has a sensitivity as

low as 55% (Miller et al, 1999). This results in timely initiation of appropriate treatment before

any serious complications. Streptococcus viridans and anaerobes like Fusobacterium nucleatum,

11
Pepto streptococcus species, and Actinomyces species are the most common pathogens identified

on culture (Boamah, M. O. et al, 2019)

Airway management should be one of the first steps in LA management and difficulty intubation

was reported to be the commonest cause of morbidity as far back as the 1990s (Dowdy, R. et al,

2019 and Boamah, M. O. et al, 2019). While flexible fiber optic nasal intubation is most widely

used, there is a need to make arrangements for emergency tracheostomy as the first airway

intervention (An J et al., 2022). Trasmus and tongue elevation make traditional direct

laryngoscopy challenging especially as an emergency intervention. (Okoje et al., 2018) reported

that handling LA cases as surgical emergencies with early recognition and attention to the airway

increases survival rate. Botha et al, 2015, found that most patients (65.6%) that required surgical

management of the airways were those who already had airways compromised on presentation.

(Boamah, M. O. et al, 2019), explains that the subsequent application of antibiotics in the

treatment of Ludwig’s Angina like penicillin G, Clindamycin or metronidazole before the lab

results are out determines the patient’s outcomes (Boamah, M. O. et al., 2019).

A research study done by (Okoje et al., 2018) at the University College Hospital-Ibadan indicates

that intravenous use of antibiotics with fluids, analgesics, multivitamins and application of

steroids in the treatment of Ludwig’s Angina improves the patient’s outcome. 2g starting dose

then 1g 12 hourly of Ceftriaxone and 500mg 8 hourly of metronidazole was used and maintained

throughout the duration of treatment of their patients. The steroid of choice was Dexamethasone

maintained for the first 48 hours administered s 8mg starting dose then 4mg 8 hourly for 48

hours.

In addition to airway management and antibiotic coverage, adequate supportive therapy with

fluid resuscitation, pain management and nutritional support are the foundation of the modern

12
management of LA according to (Okoje et al., 2018). (Okoje et al., 2018) also suggested that

thorough surgical drainage of the involved spaces is of prime importance. (Ugboko et al., 2005),

found that out of 16 patients being managed for LA at a Suburban Nigerian Tertiary Hospital, 14

underwent surgical decompression using interrupted submandibular and submental skin incisions

with blunt dissection of the fascial planes. Corrugated rubber drains were subsequently inserted

for 24 to 72 hours to allow complete drainage of the discharge from the incision sites. (Ugboko

et al., 2005) added that drainage was necessary to further relieve airway compromise.

Ludwig angina is a life-threatening condition with a high rate of mortality and morbidity if not

promptly managed. A study by (Botha et al., 2015) revealed that acute airway compromise and

infection-related complications accounted for 11.8% of deaths. This was attributed to late

presentation when infection had progressed, consequently compromising their surgical

intervention and/or postoperative course. With prompt management, the length of hospital stay

mostly ranges from zero to seven days (53.84%) but can extend to weeks or a month with the

commonest complication being necrotizing fasciitis in 33.3% and severe sepsis in 16.7% of

patients as revealed by (Okoje et al., 2018). Other complications found included aspiration

pneumonia, diabetic ketoacidosis, airway obstruction and tracheoesophageal fistula accounting

for 8.3% of cases each. They also found a mortality rate of 16.7% of the patients seen at the

facility. This was similar to the findings by (Botha et al., 2015) who found 11.8% mortality rate

and necrotizing fasciitis and descending mediastinitis as complications accounting for 7.53% and

8.60% of cases respectively.

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 CHAPTER THREE

5 MATERIALS AND METHODS

This chapter introduces the methodological details used in this study

5.1 Study site

This will be a hospital based retrospective cross-sectional 5-year single center study at Kitwe

Teaching Hospital in Kitwe, Zambia. The study site was chosen because little study has been

done at Kitwe Teaching Hospital, Zambia, on patients with Ludwig’s Angina, and thus most

health care practitioners in this hospital lack enough knowledge and experience in respect to

Ludwig’s Angina infection.

5.2 Study design

This will be a hospital based retrospective cross-sectional 5-year single center study at Kitwe

Teaching Hospital in Kitwe, Zambia. A non-probability, convenient sampling method will be

used to collect data from hospital records of patients who presented and were managed for

Ludwig’s angina between January 1st, 2017 and December 31st, 2022. A data abstraction tool

will be used to collect all relevant medical records from the hospital.

5.3 Study variables

The study variables will include age, sex, ethnicity, race, education, dental history, past medical

and surgical history, drug history, diagnosis (laboratory and radiology), treatment (supportive,

medical and surgical) and outcomes (length of hospital stay, complete recovery, length of follow

up as outpatient, readmission, morbidity and mortality). This will be categorized into two; that’s

independent and dependent variables.

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5.4 Study population
The study population will comprise of all adults who presented to Kitwe Teaching Hospital with

Ludwig’s angina. This will be categorized based on the age and sex respectively.

5.5 Inclusion Criteria

1. All in-patients who were managed for Ludwig’s angina at Kitwe Teaching Hospital

2. Patients were managed for Ludwig’s angina between January 2017 and December 2022

3. Patients treated at Kitwe Teaching Hospital.

5.5.1 Exclusion Criteria

1. Out-patients managed for Ludwig’s angina at Kitwe Teaching Hospital.

2. Patients managed for Ludwig’s angina outside the study period

3. Patients treated at other facilities.

5.5.2 Sample Size determination

Cases of Ludwig’s angina that presented to and were managed by the Dental and General

Surgery departments at Kitwe Teaching Hospital, Kitwe, Zambia between January 1st, 2017 and

December 31st, 2022 will comprise the sample size of this study. Cases will be selected using a

non-probability, convenient sampling method.

5.6 Data collection

A data abstraction tool will be designed and used to collect all relevant medical records from the

hospital. This tool will be a pre-designed form used to collect data that includes aspects date of

admission, sociodemographic information, risk factors, comorbid conditions, past

medical/surgical history, diagnosis (laboratory and radiology), treatment (supportive, medical

and surgical) and outcomes (length of hospital stay, complete recovery, length of follow up as

outpatient, re-admission, morbidity and mortality).

15
 5.7 Data management and analysis
The data collected using the data collection tool will be imported into the Statistical Package for

Social Sciences (SPSS). The Pearson’s Chi-square Test will be used to determine associations

between categorical variables in the study.

5.8 Limitation of the study

Since this study will use secondary data, some medical records may have incomplete and

missing information about some observations. Additionally, the study will be conducted at only

one facility. This may not reflect the full picture of the management and outcomes of Ludwig’s

angina in Zambia.

5.9 Ethical considerations

Ethical clearance for the study will be obtained from the Tropical Diseases Research Center

(TDRC) Ethics Review Committee in Ndola. Further clearance will be obtained from the

National Health Research Authority (NHRA) and approval from Kitwe Teaching Hospital to

commence the study. All medical records reviewed and data collected will be kept anonymous

and confidentiality shall be maintained at all stages of the study.

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 6 WORK PLAN

Item April May June July August September October November

Proposal writing

Ethical approval

Data collection

Data analysis

Final report

Submission

7 BUDGET
ITEM COST (K)

Ethical Clearance 1,500

Data Collection 500

Miscellaneous 500

TOTAL 2,500

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comparative study of the efficacy of intravenous benzylpenicillin and intravenous Augmentin in

the empirical management of Ludwig's angina. Annals of African Medicine, 18(2),

65. https://doi.org/10.4103/aam.aam_22_18

Botha, A., Jacobs, F., & Postma, C. (2015). Retrospective analysis of etiology and comorbid

diseases associated with Ludwig's angina. Annals of Maxillofacial Surgery, 5(2),

168. https://doi.org/10.4103/2231-0746.175758

Dowdy, R. A., Emam, H. A., & Cornelius, B. W. (2019). Ludwig's angina: Anesthetic

management. Anesthesia Progress, 66(2), 103-110. https://doi.org/10.2344/anpr-66-01-13

Muthupandian, V., Kannan, R., Thenmozhi Priya, B., & Alagar, K. (2016). A retrospective

study on histoid Hansen’s disease - An insight into aetiopathogenesis and disease

pattern. Journal of Evolution of Medical and Dental Sciences, 5(98), 7209

7212. https://doi.org/10.14260/jemds/2016/1630

Saifeldeen, K. (2004). Ludwig's angina. Emergency Medicine Journal, 21(2), 242

243. https://doi.org/10.1136/emj.2003.012336

Srirompotong, S., & Art-smart, T. (2003). Ludwig's angina: A clinical review. European

Archives of Oto-Rhino-Laryngology, 260(7), 401-403. https://doi.org/10.1007/s00405-003-

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Vincent Ugboko, Kizito Ndukwe, Fadekemi Oginni. Ludwig’s Angina: An Analysis of
Sixteen Cases in a Suburban Nigerian Tertiary Facility. African Journal of oral Health
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Saudi Surgical Journal. 2016, Volume: 4, Issue Number: 2, Page: 77-83

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