An investigation into the etiology and the factors impacting on the

prognosis and management of Ludwig’s Angina, A case study carried out

at Kitwe teaching Hospital.

Management and Outcomes of Ludwig’s Angina at Kitwe Teaching

Hospital: A 5-Year Single Center Retrospective Study - Proposal

Chisenga M. Zulu

Copperbelt University

Directorate of Distance Education and Open Learning

MRM 700: Research Methods in Epidemiology

Dr. Donald Chungu

12th April, 2022.

Table of Contents
ABSTRACT................................................................................................................................................3
INTRODUCTION......................................................................................................................................5
LITERATURE REVIEW...........................................................................................................................8
METHODOLOGY...................................................................................................................................11
ACTION PLAN........................................................................................................................................12
ETHICAL CONSIDERATION................................................................................................................14
LIMITATIONS..........................................................................................................................................14
BUDGET..................................................................................................................................................14
REFERENCES........................................................................................................................................15
APPENDICES.........................................................................................................................................17
ABSTRACT
Background

Ludwig’s angina (LA) is a life-threatening and rapidly expanding 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. Usually, patients with Ludwig’s angina have been reported to
generally present with history and clinical features of a prior dental infection.

Aims and Objectives

The aim of this study is to analyze clinical characteristics, management and outcomes
of Ludwig’s angina at Kitwe Teaching Hospital, Kitwe, Zambia

Materials and Methods

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, 2016 and December 31st,
2021. A data abstraction tool will be used to collect all relevant medical records from the
hospital

Results

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

Conclusion

Ludwig’s angina still remains highly prevalent especially in individuals with low
socioeconomic status, dental patients and patients with a compromised immune
system. Unfortunately, the management and outcomes of these patients still remain
poor mainly due to late presentation and inadequate antibiotic therapy.
KEYWORDS

Ludwig's angina, airway obstruction, compartments, antibiotics, Kitwe Teaching

Hospital, polymicrobial
INTRODUCTION
Background
Ludwig’s angina (LA), also known as “Angina Ludovici'', “Angina Maligna'' and “Morbus
Strangularis'', is a life-threatening and rapidly expanding cellulitis of the floor of the
mouth and the neck (Srirompotong, S. & Art-smart, T. 2003 and Dowdy, R. et al, 2019).
It involves the submandibular, sublingual and submental fascial compartments and is
characterized by its potential to rapidly spread to the adjacent structures (An J et al,
2021 and Pak, S. et al, 2017). There is usually induration of the floor and suprahyoid
region with associated elevation of the tongue which begins to cause airway obstruction
(Srirompotong, S. & Art-smart, T. 2003). Ludwig’s angina was originally described in
1836 by a German physician Wilhelm Friedrich von Ludwig, whom it was named after
(An J et al, 2021 and Rama, O. B, et al, 2016).

Odontogenic and other dental infections due to both aerobic and anaerobic bacteria are
the most common cause of LA (Dowdy, R. et al, 2019 and An J et al, 2021) and
patients with Ludwig’s angina have been reported to generally present with history and
clinical features of a prior dental infection (Rakes, B. S. et al, 2020). Although infection
of the lower molars, particularly the second and third molar, is the hallmark of true
Ludwig’s angina and accounts for over 90% of the causes, it is also used to describe
any floor of the mouth infection complicating into involvement of the sublingual and
submandibular compartments (An J et al, 2021). Other causes, accounting for less than
10% of causes are injury or laceration of the flow of the mouth, oral piercing, fractures of
the mandible, osteomyelitis, traumatic intubation, otitis media, submandibular
sialadenitis, injury of the tongue, thyroglossal cyst infection and peritonsillar abscess
(An J et al, 2021). Common risk factors of developing Ludwig’s angina include recent
dental treatment, dental caries, and alcoholism, chronic conditions such as diabetes
mellitus, intravenous drug use, malnutrition and immunosuppression such as in
HIV/AIDS, malignancy and organ transplant. Additionally, a lower socioeconomic status
is an important risk factor for developing LA (Dowdy, R. et al, 2019).
Typically, LA starts from the floor of the mouth, particularly the second and third
mandibular molars and rapidly spreads to the mandibular space and causes elevation
and posterior displacement of the tongue (Dowdy, R. et al, 2019 and An J et al, 2021)..
It is also reported that the infection spreads lingually instead of buccally because the
lingual aspect of the tooth socket is known to be thinner than the buccal aspect. The
causative agent is usually said to be polymicrobial involving common organisms such
as Staphylococcus, Streptococcus, Fusobacterium, Peptostreptococcus, Bacteroides
and Actinomyces (An J et al, 2021).

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). Common clinical features include fever,
dysphonia, drooling, dysphagia, malaise, bilateral cervical swelling, elevation, posterior
displacement and restricted neck movements (Dowdy, R. et al, 2019 and Kawataki, M.
et al, 2021). Patients also present with sore throat, swelling of the tongue, pain in the
floor of the mouth and stridor (Dowdy, R. et al, 2019).

Problem Statement
Based on clinical observations, the outcomes of patients presenting with Ludwig’s
angina remains poor in our settings, especially in immunocompromised individuals.

Significance
The results of our study will help clinicians optimize patient care and outcomes as it will
provide clinicians with the best options for managing their patients.

Research Questions
Our research questions for this study are as follows

1. What is the epidemiology of Ludwig’s angina in Kitwe?

2. What are the commonest risk factors of Ludwig’s angina in patients presenting at
Kitwe Teaching Hospital?

3. What are the diagnostic and therapeutic modalities used in the management of
Ludwig’s angina patients at Kitwe Teaching Hospital?
 4. What are the outcomes of patients presenting with Ludwig’s angina at Kitwe
Teaching Hospital?

Research Objectives
The general objective of this study is to analyze clinical characteristics, management
and outcomes of Ludwig’s angina at Kitwe Teaching Hospital, Kitwe, Zambia. In
addition, the following are the specific objectives of this study.

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

2. To determine the common risk factors of Ludwig’s angina in our setting.

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.
LITERATURE REVIEW
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,
u). 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,
Peptostreptococcus 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 fiberoptic
nasal intubation is most widely used, there is a need to make arrangements for
emergency tracheostomy as the first airway intevention (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.
According to Boamah, M. O. et al, 2019, the empirical choice and subsequent
administration of antibiotics like Penicillin G, metronidazole, or clindamycin even before
culture and sensitivity results is usually crucial for patient outcome Boamah, M. O. et al,
2019). Okoje et al (2018) in their analysis of cases seen at the University College
Hospital, Ibadan suggested that the use of intravenous antibiotics with analgesics,
fluids, multivitamins and steroids improves patient 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 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 tracheo-oesophageal 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.
METHODOLOGY
Study Design
This will be a hospital based retrospective cross-sectional 5-year single center study at
Kitwe Teaching Hospital in Kitwe, Zambia.

Study Population and Variables

Our study population will comprise of all children and adults who presented to Kitwe
Teaching Hospital with Ludwig’s angina. 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)

Sample Size and Sampling

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, 2016 and December 31st, 2021 will comprise the sample size of this study.
Cases will be selected using a non-probability, convenient sampling method.

Study Subject
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 2016 and
December 2021.

3. Patients treated at Kitwe Teaching Hospital.

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.

Data Collection
A data abstraction tool (Appendix 1) 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)

Data 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.

ACTION PLAN
April May June July Augus Septemb Octob Novemb
t er er er

Proposal
writing

Ethical
approval

Data
collection

Data
analysis

Final
report
Submissi
on
ETHICAL CONSIDERATION
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 .

LIMITATIONS
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.

BUDGET
ITEM COST (K)

Ethical Clearance 1,500

Data Collection 500

Miscellaneous 500

TOTAL 2,500
REFERENCES
1. Boamah, M. O., Saheeb, B. D., Parkins, G. E., Nuamah, I., Ndanu, T. A., &
Blankson, P. K. (2019). A 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), 65–69.
https://doi.org/10.4103/aam.aam_22_18

2. Miah, M. R., & Ali, A. S. (2020). Ludwig's angina. British dental journal, 229(5),
268. https://doi.org/10.1038/s41415-020-2132-3

3. An J, Madeo J, Singhal M. Ludwig Angina. [Updated 2021 Oct 18]. In: StatPearls
[Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK482354/

4. Dowdy, R., 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

5. Kawataki, M., Yoshida, H., & Araki, M. (2021). Ludwig's Angina. Internal
medicine (Tokyo, Japan), 60(16), 2707.
https://doi.org/10.2169/internalmedicine.5477-20

6. Pak, S., Cha, D., Meyer, C., Dee, C., & Fershko, A. (2017). Ludwig's Angina.
Cureus, 9(8), e1588. https://doi.org/10.7759/cureus.1588

7. Rakes B.S., Bharathi M.B., Shilpa C., Debayan Dey, Thanzeem Unisa (2020).
Ludwig's Angina: Analyzing Clinical Profile and Microbiology with Antibiotic
Sensitivities at a Tertiary Care Hospital. DOI: 10.21608/ejentas.2020.31859.1219

8. Rama, O. B. et al (2016). Ludwig’s angina: Analysis of 28 cases seen and

managed in Sokoto, Northwest Nigeria. Saudi Surgical Journal | Published by
Wolters Kluwer - Medknow
9. Srirompotong, S., Art-smart, T. (2003). Ludwig's angina: a clinical review. Eur
Arch Otorhinolaryngol 260, 401–403. https://doi.org/10.1007/s00405-003-0588-9

10. Miller WD, Furst IM, Sandor GK, Keller A. A prospective blinded comparison of
clinical exam and computed tomography in deep neck infections. Laryngoscope
1999; 109:1873-79

11. Okoje VN, Ambeke OO, Gbolahan OO. LUDWIG'S ANGINA: AN ANALYSIS
OF CASES SEEN AT THE UNIVERSITY COLLEGE HOSPITAL, IBADAN.
Ann Ib Postgrad Med. 2018;16(1):61-68.

12. Botha A, Jacobs F, Postma C. Retrospective analysis of etiology and comorbid

diseases associated with Ludwig's Angina. Ann Maxillofac Surg. 2015;5(2):168-
173. doi:10.4103/2231-0746.175758

13. 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 Volume 2 Numbers 1 & 2 2005: 16-23

14. Braimah Ramat Oyebunmi, Taiwo Abdurrazaq Olanrewaju, Ibikunle Adebayo

Aremu. Ludwig's angina: Analysis of 28 cases seen and managed in Sokoto,
Northwest Nigeria. Saudi Surgical Journal. 2016, Volume: 4, Issue Number: 2,
Page: 77-83

15. https://www.statpearls.com/ArticleLibrary/viewarticle/24447
 APPENDICES
Appendix 1: Data Collection Tool

General Characteristics Specific Characteristics Patient

1 2 3 4 5 6 ….. n
Sociodemographic Age
information Sex
Residence
Race
Ethnicity
Education
Duration of symptoms at
presentation (Days)
Clinical Presentation Fever
Dysphonia
Drooling
Dysphagia
Malaise
Bilateral cervical swelling
Posterior displacement
Restricted neck movements
Tongue elevation
Risk Factors Prior dental infection
Injury of the floor of the mouth
Fracture of the mandible
Osteomyelitis
Otitis media
Injury to the tongue
Thyroglossal cyst infection
Pertonsilar abscess
Oral piercing
 Chronic alcoholism
Dental caries
IV Drug use
Malnutrition
Organ transplant
Others (specify)
Comorbid conditions Diabetes Mellitus
Sickle Cell Anaemia
HIV/AIDS
Hypertension
Renal disease
Heart disease
Malignancy
Others (specify)
CT Scan findings Swelling of soft tissues
Multiple abscesses in sublingual
space
Multiple abscesses in
submandibular space
Bilateral cervical
lymphadenopathy
Not done
Other (Specify)
Neck and Chest X-Ray Gas in Tissues
findings Not done
Other (specify)
Ultrasound findings Metastatic abscesses

Pus
Not done
Other (Specify)
Organisms identified Staphylococcus species
 Streptococcus species
Fusobacterium
Klebsiella pneumonia
Pseudomonas aeruginosa
Peptostreptococcus
Echerichia coli
Proteus mirabilis
Bacteroides
Actinomyces
Other (specify)
Microscopy & Culture not done
Diagnosis of LA Clinical signs
CT imaging
X-Ray
Ultrasound
Microscopy and Culture
Intervention Securing airways and
resuscitation
Penicillin
Metronidazole
Clinidamycin
Ciprofloxacin
Ampicillin
Gentamicin
Ceftriaxone
Surgical drainage
Analgesia
Steroids
Others (Specify)
Complications Septicaemia
Aspiration pneumonitis
 Diabetic Ketoacidosis
Mediastinitis

Laryngeal spasm

Asphyxia

Cardiac Arrest
Empyema thoracic
Renal Failure
Necrotizing fasciitis
Other (Specify)
Outcomes Patient died
Admitted to intensive care unit
Re-admitted to hospital
Symptoms resolved
Symptoms reduced
Symptoms unchanged
Symptoms worsened
Length of hospital stay (Days)