From the Guidelines
Ludwig's angina is a severe, life-threatening infection of the submandibular space that requires immediate medical attention to prevent airway obstruction and other complications. This condition is characterized by a rapidly progressive bacterial infection of the floor of the mouth and submandibular space, which can lead to significant morbidity and mortality if not promptly treated 1. The infection typically arises from odontogenic sources, such as dental infections, particularly of the second and third molars, and is often polymicrobial, involving oral anaerobes and streptococci.
Key Characteristics and Symptoms
- Bilateral submandibular swelling
- Elevated tongue
- Drooling
- Difficulty swallowing
- Speaking difficulties
- Potential for airway obstruction and sepsis
Treatment and Management
Treatment involves high-dose intravenous antibiotics, such as a combination of penicillin G and metronidazole, or clindamycin for penicillin-allergic patients 1. Airway management is crucial, with some patients requiring intubation or tracheostomy if severe swelling threatens the airway. Surgical drainage may also be necessary to remove purulent material. Hospitalization for 5-7 days with IV antibiotics, followed by oral antibiotics for 7-10 days after discharge, is typically required.
Importance of Prompt Treatment
Without prompt treatment, the mortality rate for Ludwig's angina can be significant due to airway compromise and sepsis 1. Therefore, it is essential to recognize the symptoms and seek medical attention immediately to prevent these complications and improve outcomes. Accurate etiologic diagnosis depends on the collection of an aspirate or biopsy of inflammatory material from affected tissues and tissue spaces, and the use of anaerobic transport containers to support the recovery of anaerobic bacteria 1.
From the Research
Definition and Characteristics of Ludwig's Angina
- Ludwig's angina is a severe infection of the submandibular space, characterized by diffuse bilateral cellulitis with an odontogenic origin 2, 3.
- It presents with an acute onset and spreads rapidly, affecting the submandibular, sublingual, and submental spaces, resulting in a state of emergency 2, 4.
- The infection can cause bilateral diffuse neck swelling, edema of the floor of the mouth, pain, fever, trismus, foul-smelling pus discharge, difficulty in swallowing, airway edema, and tongue displacement, creating a compromised airway with stridor 5.
Clinical Presentation and Diagnosis
- Patients with Ludwig's angina may present with trismus, jaw and neck swelling, mild respiratory distress with tachypnea, hyperthermia, and panic 3.
- Clinical examination and radiographic evaluation, such as computed tomography of the neck soft tissue with contrast, can confirm the diagnosis 3, 6.
- Point-of-care ultrasound can be a useful adjunct, particularly in patients who cannot tolerate lying supine 6.
Treatment and Management
- Early diagnosis and immediate treatment planning are crucial in managing Ludwig's angina, and may be life-saving 2, 4.
- The standard protocol of treatment includes the use of parenteral antibiotics, airway protection techniques, and formal surgical drainage of the infection 2, 4.
- In some cases, tracheostomy may be required to maintain the airway 5, 4.
- Broad-spectrum antibiotics and surgical source control are key in treating the infection, and patients should be admitted to the intensive care unit for close airway observation 6.