By: Ilya Kott, M.D.
Emergency Medicine Resident
St. John Hospital and Medical Center
He was a bearded man in his fifties. An emesis basin clutched in his
hands was rapidly filling with the oral secretions that he was unable to
control. Every time he spoke it was obvious that he was in pain. His
wife sat nearby. With worry etched on her face and fear in her voice she
said, “He was seen just a couple hours ago and now it’s worse”.
A review of the previous chart was made. He had earlier presented with
five days of right-sided submandibular swelling. A diagnosis of
lymphadenitis was made and he was given a prescription for antibiotics
and NSAIDS. The patient was not able to fill the prescription that night
and returned to the emergency department now with difficulty with
breathing and inability to control his own secretions.
The patient's
past medical/surgical history was positive for hypertension,
hypercholestrolemia, and an appendectomy. Further questioning also
revealed that he had a recent toothache.
On exam, the patient’s vital signs were significant for a fever of 102.4
F and tachycardia of 112 BPM. His blood pressure and respiratory rate
were normal. Oxygen saturation was 94%. General exam showed a mildly
obese male in moderate distress. HEENT exam was positive for brawny
edema of the neck; mild elevation of the tongue and the patient was
unable to protrude his tongue. Cardiovascular, lung, abdominal and
extremity exams were all normal.
Are all the symptoms due to the lymphadenitis, which is now worsening?
Did the patient have a reaction to the medication given during his first
visit? Was he misdiagnosed during his first visit?
As these considerations were being made, the patient was given IV
solumedrol, benadryl, and pepcid. A CT scan of the neck was ordered as
well as a CBC, electrolytes, glucose, BUN, and creatinine. Considering
the rapid onset of the patient’s symptoms and the very real possibility
of airway compromise the difficult airway equipment was prepared, the
patient was given IV clindamycin and oralmaxillofacial surgery was
called. This patient most likely had Ludwig’s angina and needed all
these preparations urgently.
Ludwig’s Angina is a deep space
dental infection, a cellulitis that may develop into an abscess, which
requires airway management, operative drainage, and intravenous
antibiotic treatment. Wilhelm Frederick von Ludwig first described it in
1836. Ironically he died at age 75, possibly from Ludwig’s angina. A
true Ludwig's angina includes infection of the submandibular,
sublingual, and submental spaces, but infection of even one space can be
life threatening. Before the advent of antibiotics and the use of
surgical decompression the mortality rate for Ludwig's angina was close
to 50%. Today it is down to 10% if it is properly and promptly diagnosed
and treated.
Etiology
Ludwig's angina has a male to female prevalence of
3:2. The floor of the mouth contains the mylohyoid muscle. It forms a
sling by attaching to the two medial sides of the mandible. Superficial
to the mylohyoid is the sublingual space. Deep to it is the
submandibular space. Eighty percent of Ludwig's angina is caused by
odontogenic disease or recent tooth extractions. Infections or
extractions of the second or third molars are particularly at risk for
developing Ludwig’s angina. The roots of these teeth extend below the
mylohyoid ridge. Abscesses can therefore penetrate from there through
the lingual plate and reach the submandibular spaces. Additional
etiologies of Ludwig's angina include deep lacerations to the floor of
the mouth, mandibular fractures, and salivary duct calculi.
Signs and symptoms
Symptoms
include tooth pain, neck pain, difficulty in breathing, dysphagia,
dysarthria, neck or chin swelling. Physical exam includes fever, an
elevated tongue, brawny induration of the suprahyoid region, and
trismus.
Complications
Prompt diagnosis of Ludwig's angina is
crucial. Complications of the disease can be severe and deadly. The most
immediate complication can be airway compromise. Further complications
can include further spread of the submandibular infection to the
mediastinum. From there it can then affect the great vessels and the
pericardium as well as the lungs and pleural spaces.
Differential
diagnoses
In order to make the diagnosis rapidly the differential
diagnoses must be carefully considered and quickly excluded. The
differential can include mandibular abscesses, neoplastic masses, or
Lemiere's, a septic thrombophlebitis of the internal jugular vein. Each
of these can be excluded by history or exam alone. Mandibular abscesses
as well as Lemiere's are usually unilateral, Ludwig's angina will
present with bilateral swelling. Tumors, although not always unilateral,
can be excluded by history. Ludwig's has a rapid progression while
tumors are usually slower growing.
Testing
Ludwig's angina is a
clinical diagnosis. Laboratory and radiological testing are not
necessary to make the diagnosis and instead can lead to a delay in
diagnosis and ultimately treatment with disastrous outcomes.
Radiological imaging does play a role in delineating the extent of the
infection allowing better decisions to be made in regards to surgical
intervention. Before sending the patient for imaging studies it is
imperative to secure the patients airway.
Treatment
Airway control
should be the first concern in a Ludwig's patient. The swelling of the
submandibular spaces with the subsequent elevation of the tongue, and
the involvement of the epiglottis, can lead to airway compromise. The
patient should be moved to the resuscitation area of the emergency
department. Endotracheal intubation may not be possible and preparation
for alternative means of airway control should be made. These can
include nasotracheal or surgical airway approaches. Therefore the
appropriate equipment (fiber optics, crichothyroidectomy kits) and
personnel (surgery, anesthesia, or ENT) should be on hand when airway
control begins.
Broad-spectrum antibiotics should be started on all
patients. As mentioned above the mortality rate for Ludwig's angina
before the advent of antibiotics was 50%. The most commonly cultured
bacterial species are staphylococci, streptococci, and bactiroides.
Klebsiella, H. influenza, Proteus and Pseudomonas are also prevalent and
treatment should include coverage against those species as well. IV
penicillin or a third-generation cephalosporin in combination with
clindamycin or metronidazole for anaerobic coverage can be used.
About 50% of patients will improve with airway control and antibiotics
alone. The other 50% percent will require surgical decompression and/or
debridement of the submandibular spaces. No matter whether the patient
gets antibiotics alone, or also requires airway protection and surgery,
they should be sent to an ICU for close monitoring.
The patient never
went for his CT scan. The results of the laboratory studies that were
ordered had not even come back. The consulting physician did not need
them. This patient had a clinical diagnosis of Ludwig’s angina. OMFS
took the patient straight to the OR where he was fiberopticaly
intubated. They then drained abscesses that had formed in the submental,
sublingual, and submandibular spaces (a true Ludwig’s). Additionally
they removed tooth # 17 which was thought to have been the initial
source of infection. He stayed intubated and on IV unasyn until post op
day #2 at which point the edema had gone down enough for him to be
extubated. He was switched from Unasyn to Clindamycin and was finally
discharged on PO clindamycin.
Swift proper diagnosis of Ludwig’s
angina allowed this man to be properly treated with airway control,
antibiotics, and surgical drainage. He got to be part of those ninety
percent of patients who survive Ludwig’s angina with the proper
treatment.
References:
Did Ludwig's angina kill Ludwig? J
Laryngol Otol. 2006 May;120(5):363-5. Wasson J, Hopkins C, Bowdler D.
Tintinalli's Emergency Medicine:A Comprehensive Study Guide, 6e
Judith E. Tintinalli, MD, MS, Gabor D. Kelen, MD, J. Stephan
Stapczynski, MD,
O. John Ma, MD and David M. Cline, MD
The
Atlas of Emergency Medicine, 3e Kevin J. Knoop, Lawrence B. Stack, Alan
B. Storrow, R. Jason Thurman
Emergency Medicine by James G. Adams MD
FACEP, Erik D. Barton MD, Jamie Collings, and Peter M. DeBlieux MD (Jun
10, 2008)
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Posted:
Sunday, November 7, 2010
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