Morning Report: 3/13/2014

Thanks to Dr. Louis for today’s Morning Report!

Ludwig’s Angina

Definition: Progressive cellulitis of the connective tissues of the floor of the mouth and neck beginning in the submandibular space.

Prognosis: Prior to antibiotics and airway adjuncts mortality was greater than 50%. Today estimated mortality about 8%

Causes: Majority of cases (about 90%) secondary to dental disease, i.e infection or recently extracted lower molar. Other causes can include fractured mandible, foreign body or laceration in floor of the mouth, tongue piercing, secondary infections of oral malignancy, and other parapharyngeal infections.

Diagnosis is clinical. U/S, CT, or MRI can help confirm and/or identify suppurative complications.

Presentation: Typically complain of dental pain, history of dental procedures, and neck swelling. Other complaints include dsyphonia, dysphagia, odynophagia, dysarthria, drooling. Some may present with respiratory distress with dyspnea, tachypnea, or stridor.

Physical findings: Bilateral submandibular swelling, elevated or protruding tongue. Can also have elevation of floor of the mouth with posterior displacement of the tongue. The submandibular swelling often described as brawny and tense with overlying erythema. Usually febrile. Can also find trismus and/or crepitus.

Typically polymicrobial. Most commonly cultured organisms include Staphylococcus, Streptococcus, Bacteroides. Immunocompromised patients are at risk for infection with atypical organisms including Pseudomonas, E. coli, Klebsiella, Enterococcus faecalis, Candida, and Clostridium.

Management:

Airway management is the foundation of treatment. Prepare for intubation and cricothyrotomy. Get ENT and anesthesia on board.

Antibiotics should be started ASAP. Should be broad spectrum covering gram positive, gram-negative, and anaerobic organisms. Combo of penicillin, clindamycin, and metronidazole are typically used.

Steroids can be considered. Not much evidence.

References:

Barton E, Blair A. Ludwig’s Angina. J Emerg Med. 2008. 34 (2): 163-169

Winters, Michael. Evidenced-Based Diagnosis and Management of ENT Emergencies. Medscape.com

Marx JA, Hockberger RS, Walls RM, et al., eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice. Philadelphia, PA: Mosby/Elsevier; 2010.