Ludwigs angina

Introduction
1863, Wilhelm Frederick Von Ludwig occurrence of a certain type of inflammation of the throat, which, despite the most skillful treatment, is almost always fatal Ludwigs Angina
Angere Latin word throttling

1939, Grodinsky : Criteria dx. Patorn Piromchai, MD

Stuart J. Spitalnic. Ludwigs angina: Case report and review. Journal of emergency medicine,1995, Vol.13 No.4

Definition
Ludwig's angina refers to a potentially Iife-threatening cellulitis of the floor of the mouth with infection extending into submandibular and sublingual spaces

Grodinskys criteria Dx.

1. occur bilaterally in more than one space 2. product gangrenous serosanguinous infiltration with or no pus 3. involve connective tissues fascia and muscle but not glandular structures 4. spread by continuity, not by Iymphatics
Grodinsky, Ludwig's Angina: An Anatomical and Clinical Study with Review of the Literature, Surger, 1939, Vol 5:678-96.

Cummings, Fredrickson, Harker, Krause and Schuller. Otolaryngology Head and Neck Surgery, 2005, Fourth Edition, Vol2:2517.

Criteria for Dx.

Rapidly progressive cellulitis; not an abscess Develops along fascial planes with direct extension; does not involve lymphatic spread Does not involve submandibular gland or lymph nodes Involve both sublingual and submaxillary spaces and is usually bilateral

Pseudo-Ludwigs angina
Pseudoangina ludovici Limited infection involve only the sublingual space, the submandibular lymph node, the submandibular gland or submental space or abscesses involving one or more of these spaces.

Shumrick KA, Deep neck infection, Otolaryngology, Vol3, 1993, p2553

Shumrick KA, Deep neck infection, Otolaryngology, Vol3, 1993, p2553

Anatomy

Submandibular space
Mylohyoid devide submandibular space - Sublingual space (supramylohyoid) - Submaxillary space (inframylohyoid) Ant.belly digastric devide Submaxillary space - medial submental space - lateral submaxillary space

Sublingual space
Boundary : Superior floor of mouth Anterior&Lateral mandible Posterior intrinsic muscle of base of tongue Inferior mylohyoid Component : 1. Anterior extension of hyoglossus m. 2. Lingual nerve, CN 9, CN12 3. Lingual artery and vein 4. Sublingual gland and duct 5. Deep portion of submandibular gland 6. Whartons duct

Submaxillary space
Boundary :
Superior mylohyoid Anterior SLDF Inferior hyoid bone Posterior posterior digastric Component : 1. Anterior belly of digastric muscle 2. Superficial portion of submandibular gland 3. Submental and submandibular LN 4. Facial artery and vein 5. Inferior loop of CN XII 6. Fat

Submental space
Boundary : Lateral ant.belly of digastric Deep mylohyoid m Sup DCF , platysma Source : mandibular incisor Component: LN,CNT

Submandibular space
Sublingual continue submandibular via the posterior margin of the mylohyoid muscle Source infection:oral trauma, submaxillary or sublingual sialadenitis, or abscess of mandibular teeth 1st molarsublingual 2nd,3rd molarsubmandibular Clinical: Ludwig angina drooling,pain, dysphagia, submandibular mass, and dyspnea or airway compromise

Clinical History
80% recent dental work or tooth pain Lacerated of the floor of the mouth Extension of a infection ex. Peritonsillar abscess, sialadenitis, epiglottitis, mandibular fracture

Clinical Finding
Severe dysphagia, Cervical tenderness, swelling, limited range of motion Dysphonia Sitting upright, drooling and tachypnia. Trismus, result of inflammation and edema of the masseter space. Extension to lateral pharyngeal retropharyngeal and prevertebral spaces invariably produces severe trismus. Tense brawny induration of involved spaces with little to no fluctuance

Stuart J. Spitalnic. Ludwigs angina: Case report and review. Journal of emergency medicine,1995, Vol.13 No.4

Imaging
Soft-tissue x-ray of neck may demonstrate swelling of affected area, airway narrowing and gas collections Panorex may demonstrate associated periodontal abscess CT and MRI may be considered Ultrasound is useful in diagnosing abscess and edema
Anish Zachariah, Ludwigs angina, Washington University in St.Louis s interesting case, 2005, p21-22

Bacteriology
Deep neck abscesses generally involve oral flora. The most common anaerobes are anaerobic Streptococci Bacteriodes and Fusobacterium Aerobes and facultative anaerobes are Streptococcus accounting for most oral aerobes
Cummings, Fredrickson, Harker, Krause and Schuller. Otolaryngology - Head and Neck Surgery, 1993, Second Edition, Vol 2: 1199-1215

Management
Adequate airway management
A recent review reported that sixty-seven percent of patients with Ludwig's angina required either anticipitory or emergent intubation

Airway management
If no respiratory diffuculties
Maintain in sitting position Continuous monitoring Must be prepared to intubate Airway complications must be anticipate as concurring supraglottic edema, nuchal rigidity, trismus may interfere with securing the airway
Anish Zachariah, Ludwigs angina, Washington University in St.Louis s interesting case, 2005, p24-25

Har-El, Aroesty, Shaha and Lucente. Changing Trends in Deep Neck Abscesses, Oral Surgery Oral Medicine Oral Pathology, 1994; Vol 77, No. 5, 446-50

Airway management
If signs of impending respiratory compromise
Fiberoptic nasal intubation is preferred route

antibiotic therapy
antibiotic therapy must be designed to cover both anaerobes and Staphylococcus aureus Penicillin with or without metronidazole is the first line therapy Clindamycin, metronidazole alone, or amoxicillin/clavulinic acid are also considered highly effective
Cummings, Fredrickson, Harker, Krause and Schuller. Otolaryngology - Head and Neck Surgery, 1993, Second Edition, Vol 2: 1199-1215

Ludwigs can distort the anatomy to such a degree that there is soft tissue displacement of the trachea
Anish Zachariah, Ludwigs angina, Washington University in St.Louis s interesting case, 2005, p24-25

surgical therapy
Surgical therapy is usually reserved for cases of medical treatment failure(1) Certainly, if the infection is suppurative, with an area of fluctuance, surgical drainage is indicated.(2) One African center, reports the avoidance of tracheostomy with early surgical drainage under local anesthesia(3)
1. Fritsch and Klein. Curriculum in Critical Care: Ludwig's Angina, Heart & Lung, 1992, Vol 21:39-47. 2. Stuart J. Spitalnic. Ludwigs angina: Case report and review. Journal of emergency medicine Vol.13 No.4, 1995 3. Gratiaen SP. Ludwigs angina: a conservative approach to management. Odontostomatol Trop. 1987;1:13-6

Procedure
midline horizontal incision

M.J. Porter, Deep neck space infection, J Hong Kong Med Assoc Vol. 44, No.1,1992, p6.

Procedure
Median, horrizontal incision three to four fingerbreadths below mandibular margin Length of incision usually crosses to submandibular region bilat. Mylohoid m. split in midline and drainage both medially and laterally
Shumrick KA, Deep neck infection, Otolaryngology, Vol3, 1993, p2555-2556

Procedure
The side on which the infection started needs to be explored with decompression of the submandibular capsule and blunt dissection to the mandibular region. Multiple drains are placed, and wound are left open.
Shumrick KA, Deep neck infection, Otolaryngology, Vol3, 1993, p2553

Thanks you.