What are the signs and treatment of Ludwig's angina?

Ludwig's Angina: Signs and Treatment

Ludwig's angina is a rapidly progressive, potentially life-threatening cellulitis of the floor of the mouth and neck that requires immediate recognition and treatment to prevent airway compromise and death.

Clinical Presentation and Signs

Key Diagnostic Features

• Bilateral submandibular swelling with elevation of the floor of the mouth
• Woody or indurated floor of the mouth with rapid spread of infection
• Tongue protrusion/elevation due to sublingual space involvement
• Dysphagia and drooling due to pain and swelling
• Dysphonia (voice changes) from swelling
• Limited neck range of motion 1, 2

Advanced Signs (Concerning for Airway Compromise)

• Trismus (limited mouth opening) - a late finding
• Stridor or breathlessness
• Muffled voice ("hot potato" voice)
• Inability to swallow saliva
• Respiratory distress 1, 3

Associated Findings

• Poor dentition (present in 86% of cases)
• Fever, chills
• Pain in ears and throat
• Erythematous oropharynx and tonsils
• Tenderness to palpation in submandibular area 2, 4

Risk Factors

• Poor dental hygiene or recent dental procedures
• Immunocompromised states (diabetes, alcoholism, malnutrition, AIDS)
• Chronic diseases (diabetes is particularly common)
• Recent oral trauma or procedures 1, 5

Diagnostic Approach

1. Clinical diagnosis is primarily based on physical examination findings
2. Imaging studies if patient is stable:
   • CT neck with contrast (preferred if patient can tolerate lying supine)
   • Point-of-care ultrasound (useful when patient cannot tolerate lying flat)
3. Laboratory studies:
   • Complete blood count
   • Blood cultures
   • Culture and sensitivity of any drainage 1

Treatment Algorithm

1. Airway Management (Highest Priority)

• Immediate consultation with anesthesia and otolaryngology (if available)
• For impending airway compromise:
  • First-line approach: Flexible intubating endoscopy (awake fiberoptic intubation)
  • Prepare for surgical airway (tracheostomy) if intubation fails
  • Avoid blind nasotracheal intubation due to risk of trauma and bleeding 1, 3

2. Antimicrobial Therapy

• Start immediately with broad-spectrum antibiotics:
  • First-line: High-dose penicillin plus metronidazole
  • Alternative: Clindamycin or ampicillin-sulbactam
  • For severe cases: Add an aminoglycoside
• Continue for at least 2 weeks or until clinical resolution 1, 4

3. Surgical Intervention

• Incision and drainage of any identifiable abscess or collection
• Dental extraction of causative teeth
• Early surgical intervention for cases showing:
  • Fluctuation
  • Abscess formation
  • Signs of spreading infection
  • Failure to improve with antibiotics 3, 4

4. Supportive Care

• ICU admission for close airway monitoring
• IV fluids and electrolyte management
• Pain control
• Nutritional support
• Elevation of head of bed to reduce edema 1, 2

Complications to Monitor

• Airway obstruction
• Spread of infection to mediastinum, pleura, or CNS
• Septicemia
• Necrotizing fasciitis
• Carotid artery rupture or jugular vein thrombosis 2

Prognosis

With early recognition and appropriate treatment, mortality has decreased significantly from historical rates of 50% to current rates of less than 8%. However, Ludwig's angina remains a medical emergency that requires immediate intervention to prevent life-threatening complications 1, 4.

Key Pitfalls to Avoid

• Delaying airway management in progressive cases
• Underestimating the speed of progression
• Failing to provide adequate surgical drainage
• Using inadequate antibiotic coverage
• Discharging patients prematurely before adequate resolution 1, 5