What is the management of Ludwig's angina?

Ludwig's Angina Management

Ludwig's angina requires immediate airway assessment and protection, broad-spectrum intravenous antibiotics, and urgent surgical drainage—this is a life-threatening emergency where airway compromise is the primary cause of mortality. 1, 2

Immediate Airway Management (Priority #1)

The airway is the most critical concern and must be secured before any other intervention. 1, 3

• Emergently consult anesthesia and otolaryngology if available, as airway compromise can occur rapidly and unpredictably 1
• First-line airway approach in the emergency department is flexible intubating endoscopy (awake fiberoptic intubation) with preparation for immediate surgical airway 1
• Avoid bag-mask ventilation and standard laryngoscopy as these can precipitate complete airway obstruction in patients with distorted anatomy 1
• Elective tracheostomy should be performed in advanced cases with significant floor of mouth elevation, breathlessness, or stridor before attempting other interventions 2, 4
• Do not allow the patient to lie supine if they are maintaining their airway in an upright position, as this can precipitate obstruction 1

Diagnostic Evaluation

Computed tomography of the neck with IV contrast is the preferred imaging modality if the patient can safely leave the ED and tolerate lying supine 1

• Point-of-care ultrasound can be used as an adjunct, particularly in patients who cannot tolerate supine positioning or when CT would delay critical management 1
• Clinical diagnosis is based on: woody or indurated floor of mouth, bilateral submandibular swelling, and potential trismus (though trismus is a late finding) 1, 2
• Do not delay treatment for imaging if airway compromise is imminent 3

Antibiotic Therapy

Initiate broad-spectrum intravenous antibiotics immediately covering oral flora including anaerobes, streptococci, and staphylococci 1, 2, 3

• Empiric regimen should include: ampicillin-sulbactam, piperacillin-tazobactam, or a combination of clindamycin plus a third-generation cephalosporin 2, 3
• Obtain bacterial culture and sensitivity during surgical drainage to guide antibiotic de-escalation 4
• Continue parenteral antibiotics until clinical improvement is evident, typically requiring several days of IV therapy 2

Surgical Management

Surgical drainage and debridement is mandatory and should be performed urgently once the airway is secured 1, 2, 3

• Drain all involved spaces: submandibular, sublingual, and submental spaces bilaterally 2
• Remove the offending tooth (typically odontogenic source) during the same procedure 4
• Multiple surgical debridements may be required if necrotic tissue persists or collections re-accumulate 3
• Optimal surgery with complete drainage of all collections and excision of all necrotic tissue is essential for antibiotic efficacy and healing 3
• Early surgical decompression can prevent the need for emergency airway intervention if performed before significant airway compromise develops 4

Critical Pitfalls to Avoid

Never underestimate the rapidity of airway deterioration—this infection spreads quickly and can progress from stable to complete obstruction within hours 1, 2, 3

• Avoid NSAIDs for pain management, as they have been associated with more severe necrotizing cervical cellulitis 3
• Do not attempt standard intubation techniques without preparation for surgical airway 1
• Do not delay surgical drainage waiting for antibiotics to work—antibiotics alone are insufficient 2, 3

Disposition

All patients must be admitted to the intensive care unit for close airway monitoring even after initial stabilization 1

• Continuous monitoring is required as the infection can progress despite initial treatment 2
• The prognosis is directly related to early surgical debridement and the experience of the managing team 3