Treatment of Ludwig's Angina
Ludwig's angina requires immediate airway management, broad-spectrum antibiotics, and surgical drainage as the cornerstone of treatment to prevent life-threatening complications. 1, 2, 3
Initial Management
Airway Management
- Immediate priority: Assess airway patency and secure if compromised
- Warning signs: Tongue elevation, floor of mouth swelling, dysphagia, dysphonia, stridor
- Interventions:
- Elective intubation in early stages (preferred)
- Tracheostomy may be necessary in 20% of cases when significant airway compromise exists 4
- Continuous airway monitoring even if initially stable
Antibiotic Therapy
- Start immediately: Broad-spectrum IV antibiotics covering oral flora
- Recommended regimens:
- Ampicillin-sulbactam + metronidazole OR
- Clindamycin + third-generation cephalosporin OR
- Piperacillin-tazobactam
- Duration: Minimum 2 weeks, extended based on clinical response
- Adjust: Based on culture and sensitivity results when available
Surgical Management
- Timing: Early surgical intervention for any abscess or fluid collection
- Procedures:
- Incision and drainage of submandibular, submental, and sublingual spaces
- Removal of infected teeth (source control)
- Multiple procedures may be required for adequate drainage 3
- Daily wound assessment and repeated drainage if necessary
Comprehensive Care
Source Control
- Dental evaluation: Mandatory to identify and address dental infections
- Extraction: Remove infected teeth during initial surgical intervention
- Follow-up: Regular reassessment for potential spread to deeper spaces
Supportive Care
- Fluid resuscitation: IV fluids to maintain hydration
- Pain management: Appropriate analgesia (avoid NSAIDs as they may mask symptoms)
- Nutritional support: Early enteral or parenteral nutrition if unable to swallow
- Monitoring: Close observation for signs of sepsis or spread to mediastinum, pleura, or CNS 1
Special Considerations
- Diabetic patients: Aggressive glucose control
- Immunocompromised patients: More aggressive surgical approach and broader antibiotic coverage
- Complications monitoring: Watch for necrotizing fasciitis, mediastinitis, sepsis, and pleural/CNS involvement
Follow-up
- Daily clinical assessment during acute phase
- Regular imaging (CT scan) to evaluate treatment response and identify complications
- Transition to oral antibiotics only after significant clinical improvement
- Dental rehabilitation after resolution of acute infection
Prognosis
With early diagnosis, appropriate airway management, aggressive antibiotic therapy, and timely surgical intervention, mortality has decreased from nearly 50% in the pre-antibiotic era to approximately 10% today 5, 4.
Ludwig's angina remains a surgical and medical emergency requiring immediate intervention by an experienced multidisciplinary team including otolaryngology, oral-maxillofacial surgery, and critical care specialists.