What is the workup and management for a patient with Ludwig's angina?

Ludwig's Angina Workup and Management

Ludwig's angina requires immediate airway assessment, broad-spectrum antibiotics, and early surgical intervention to prevent life-threatening complications. 1

Clinical Presentation and Initial Assessment

Immediate Airway Evaluation

• Assess for signs of airway compromise:
  • Elevated floor of mouth
  • Tongue displacement
  • Drooling
  • Stridor
  • Dyspnea
  • Voice changes
  • Difficulty swallowing

Physical Examination

• Bilateral submandibular, sublingual, and submental space involvement
• Firm, "woody" induration of the floor of the mouth
• Limited mouth opening and neck movement
• Evaluate for fluctuance or abscess formation
• Check for dental infections (present in 86% of cases) 1

Diagnostic Workup

Laboratory Studies

• Complete blood count with differential
• Blood cultures
• C-reactive protein and ESR to assess inflammation severity

Imaging

• CT scan of neck with contrast: gold standard to determine extent of infection and abscess formation
• Ultrasound of floor of mouth and neck: can help identify collections requiring drainage and assess airway structures 2
• Panoramic dental radiographs: to identify dental source of infection

Management Algorithm

1. Airway Management (Highest Priority)

• Mild cases with minimal airway compromise:

  • Close monitoring with frequent reassessment
  • Prepare for possible airway intervention

• Moderate to severe cases with signs of airway compromise:

  • Secure airway immediately through one of these methods: a. Awake fiberoptic intubation (preferred first-line approach) 3 b. Video-assisted laryngoscopy if fiberoptic not available 3 c. Surgical airway (tracheostomy under local anesthesia) if severe distortion or failed intubation attempts 4

2. Antimicrobial Therapy

• Start immediately after securing airway and obtaining cultures
• First-line regimen:
  • High-dose intravenous penicillin plus metronidazole
  • OR ampicillin-sulbactam
  • ADD aminoglycoside in severe cases 1
• Alternative for penicillin-allergic patients:
  • Clindamycin plus third-generation cephalosporin
  • OR moxifloxacin

3. Surgical Intervention

• Indications for immediate surgical drainage:

  • Fluctuance
  • Abscess formation on imaging
  • Worsening clinical status despite antibiotics
  • Airway compromise 1, 4

• Surgical approach:

  • External incision and drainage of involved spaces
  • Extraction of causative tooth if dental origin
  • Placement of drains

Monitoring and Follow-up

Inpatient Monitoring

• ICU admission for airway monitoring
• Serial clinical examinations to assess:
  • Respiratory status
  • Swelling progression/regression
  • Response to antibiotics
• Daily laboratory tests to track inflammatory markers

Criteria for Improvement

• Decreased swelling and induration
• Improved mouth opening
• Resolution of fever
• Normalization of white blood cell count
• Ability to tolerate oral intake

Special Considerations

Conservative vs. Aggressive Management

While 72% of patients in one study were managed conservatively without immediate airway intervention 5, this approach should only be considered in:

• Mild cases
• No respiratory distress
• Minimal floor of mouth elevation
• Good response to initial antibiotics
• Continuous monitoring capability

Common Pitfalls to Avoid

• Delaying airway management in progressive cases
• Inadequate surgical drainage
• Inappropriate antibiotic selection
• Failure to identify and address the source of infection
• Premature discharge before adequate resolution

Complications

• Airway obstruction
• Mediastinitis
• Necrotizing fasciitis
• Septicemia
• Aspiration pneumonia
• Jugular vein thrombosis

Ludwig's angina remains a potentially life-threatening condition that requires prompt recognition and aggressive management to prevent serious complications and death. The cornerstone of treatment involves securing the airway, administering appropriate antibiotics, and performing surgical drainage when indicated.