46 year-old female with diabetes presents for sore throat and facial swelling for the past 3 – 4 days. Patient states she’s been experiencing difficulty with chewing due to pain. The patient also endorses tactile fevers. On exam, you notice multiple dental caries and submandibular swelling.
What do you see? What do you think is the diagnosis?
The patient pictured above has significant submandibular swelling consistent with Ludwig’s angina.
What is Ludwig’s angina?
Ludwig’s angina is a soft tissue infection of the submental, sublingual, and submandibular spaces. It is usually caused by oral flora seeding into submental, sublingual, and submandibular spaces from dental infections, notably the lower molars. Patients who are immunocompromised are at greater risk. Ludwig’s angina is a life-threatening infection with a mortality rate of about 5%.
What is the treatment?
The treatment for Ludwig’s Angina is threefold:
- Airway protection: Tracheostomy is the definitive management for airway compromise in Ludwig’s angina, but it also has the highest complication rate. Another airway management technique is upright, awake, fiberoptic nasal intubation. This should be performed in the operating room where it can be escalated to a tracheostomy if intubation fails.
- Antibiotics: All patients with Ludwig’s Angina should receive high-dose antibiotics: 2nd or 3rd generation cephalosporin or ampiciliin-sulbactam with the addition of clindamycin or metronidazole for anaerobic coverage.
- Abscess drainage: Surgical drainage is recommended for severe cases or patients who do not respond to antibiotics.
- (Steroids): Dexamethasone has been recommended to help decrease soft tissue swelling. It is given along with antibiotics.
Why are we concerned about airway protection? Is this a patient you would intubate in the emergency department?
Ludwig’s angina involves soft tissue swelling under the tongue. It can progress quickly and displace the tongue posteriorly to obstruct the airway. Stridor, drooling, and cyanosis are all signs of airway compromise, and this requires immediate management. Endotracheal intubation may be a challenge due to these changes in anatomy. Patients with Ludwig’s angina should not be intubated in the emergency department. They should be taken to the operating room for definitive airway management if needed.
How should our patient be dispositioned?
At the very least, our patient should be admitted to a critical care unit (where surgical airway can be performed quickly if needed) and given IV antibiotics. Ideally, if our patient needs airway managed, it should be done in the operating room with a double set-up, allowsing for tracheostomy or cricothyrotomy if necessary.
Remember, what we do in practice may not always be the right answer on the exam.
Shah, Rupali N., et al.. “Chapter 241. Infections and Disorders of the Neck and Upper Airway.” Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 7e. Eds. Judith E. Tintinalli, et al. New York, NY: McGraw-Hill, 2011, http://accessmedicine.mhmedical.com.newproxy.downstate.edu/content.aspx?bookid=348&Sectionid=40381727.
Stewart, Charles. “A Killer Sore Throat: Inflammatory Disorders Of The Pediatric Airway.” EB Medicine.
Special thanks to Dr. Silverberg and Dr. deSouza