Ludwig`s angina

Definition
• Massive, firm, brawny cellulitis and acute toxic
stage involving Submental Space and bilateral
Sublingual and Submandibular Spaces.
 Described by - Wilhelm Friedrich Von Ludwig (1836)

 Three `F` associated it

 Fear
 Fluctuant
 Fatal
 Other names
– Morbis strangularis
– Angina malignae
– Garitillo
Etiology
• > 90% odontogenic in origin
• Iatrogenic- contaminated needle
• Peritonsillar absecess
• Parapharyngeal abscesses
• Oral lacerations
• Mandibular fractures
• Submandibular sialadenitis
• Cyst ~ infected
 Pathogens and pathology
• Bacterial isolates are often mixed, comprising both aerobes and
anaerobes.
• Mostly alpha-hemolytic streptococci, staphylococci and
bacteroides.
• Hyaluronidase and fibrinolysins
 Presentation- general &
regional
• Generalised poor condition of the pt.
• Fever
• Dysphagia
• Trismus
• Difficulty breathing
• Asphyxia

• Bilateral Neck swelling

• Swelling in the floor of mouth
• Protruding or elevated tongue
• Tooth pain
 Fate

• Asphyxia
• Septicemia/septic shock
• Mediastinitis
• Aspiration pneumonia
 Investigation

• OPG
• Lateral oblique
• CT
• MRI
• Diabetes/ immunodeficency status
• Blood gas analysis
• Pus culture
 Principles of treatment

• early diagnosis
• Maintenance of patent airway
• Intense and prolonged antibiotic therapy
• Extraction of the affected teeth
• Hydration
• Early surgical incision and drainage
• Tracheostomy in case of airway obstruction
• The prudent and experienced surgeon
recognizes the wisdom of the maxim ‘a chance
to cut is a chance to cure’ when confronted with
Ludwig’s angina
Treatment
Primary goal:
• Preserve the oropharyngeal
airway.

Secondary goal:
• Antibiotic agent or incision and
drainage
Airway maintenance
• Airway compromise develops insidiously.
• Early s/s of obstruction may be very subtle
to neglect.
• Whereas actual obstruction is abrupt.

• Routine endotracheal intubation or

trachesotomy
The need for immediate artificial airway:

• Stridor
• Cyanosis
• Retractions
• difficulty managing secretions.
• Rapid progression of edema
• Comorbid health problems, DM
Antibiotic agent
Early aggressive antibiotic therapy:
• largely replaced surgical decompression
• frequently circumvents artificial control of the airway.

Determine the source of infection:

• High-dose penicillin G.
• Sometime combined with metronidazole.
• In penicillin-allergic patients, use clindamycin.
• IV dexamethasone, given for 48 h, has been beneficial in
reducing edema.
 Surgical intervention
• Incision and drainage
-incision in sublingual and bilateral submandibular spaces.
• Removal of odontogenic etiology
-extraction of infected tooth.
• Debridement and placement of rubber drains
• Regular dressing of wound and follow up.
Complication
• Deep neck infection
• Mediastinitis
• Sepsis
• Pneumonia
• Empyema
• Asphyxia
• Pneumothorax