What is the management of Ludwig angina?

Management of Ludwig's Angina

Ludwig's angina is a rapidly spreading cellulitis of the floor of the mouth requiring immediate intervention to secure the airway, administer antibiotics, and perform surgical drainage to prevent mortality.

Definition and Pathophysiology

• Ludwig's angina is a rapidly spreading diffuse cellulitis that presents with acute onset, bilaterally affecting the submandibular, sublingual, and submental spaces 1
• It is characterized by woody or indurated floor of the mouth with submandibular swelling, with trismus being a late finding 2
• The infection typically has an odontogenic origin, often related to poor dentition 2, 3

Clinical Presentation

• Patients present with jaw and neck swelling, trismus (limited mouth opening), and floor of mouth elevation 3
• Respiratory distress with tachypnea, stridor, and anxiety/panic may be present due to airway compromise 3
• Hyperthermia and signs of systemic infection are common 3
• The condition can rapidly progress to airway obstruction if not treated promptly 1

Diagnostic Approach

• Diagnosis is primarily clinical, based on the characteristic presentation of bilateral submandibular swelling and elevated floor of mouth 2
• Computed tomography (CT) of the neck soft tissues with contrast is the preferred imaging if the patient can safely leave the emergency department and tolerate lying supine 2
• Point-of-care ultrasound can be a useful adjunct, particularly for patients who cannot tolerate lying supine 2
• Bacterial cultures should be obtained to guide antibiotic therapy 4

Management Algorithm

1. Airway Management (Highest Priority)

• Immediate assessment of airway patency is critical 1, 2
• For impending airway compromise:
  • Obtain emergent consultation with anesthesia and otolaryngology if available 2
  • First-line approach for airway intervention is flexible intubating endoscopy with preparation for a surgical airway 2
  • Elective tracheostomy may be necessary in cases with significant airway obstruction 1

2. Antibiotic Therapy

• Initiate broad-spectrum antibiotics immediately 2, 4
• Recommended regimens include:
  • High-dose penicillin plus metronidazole, or
  • Clindamycin plus a third-generation cephalosporin, or
  • A carbapenem for severe cases 4
• Antibiotics should cover oral anaerobes and aerobic organisms 4

3. Surgical Intervention

• Early surgical decompression is essential and should not be delayed 1, 3
• Surgical management includes:
  • Incision and drainage of all involved spaces 4
  • Removal of the offending tooth if identified 3
  • Excision of all necrotic tissues 4
  • Multiple surgical interventions may be required 4

4. Supportive Care

• Admission to intensive care unit for close airway observation 2
• Intravenous fluid resuscitation and electrolyte management 4
• Pain control and anti-inflammatory therapy 4
• Regular reassessment of airway status and infection spread 2

Special Considerations

• Caution with use of non-steroidal anti-inflammatory drugs (NSAIDs) as they may mask symptoms or worsen infection 4
• Immunocompromised patients and those with poor dentition are at higher risk 2
• Early intervention can prevent the need for emergency airway management 3
• Multiple surgical interventions may be necessary for complete resolution 4

Prognosis

• With prompt diagnosis and appropriate management, mortality has significantly decreased in the antibiotic era 5
• Prognosis is directly related to early surgical debridement and the experience of the managing team 4
• Delayed treatment can lead to life-threatening complications including airway obstruction, mediastinitis, and sepsis 1, 5