The daily educational pearl – Ludwig’s angina

 Ludwig’s angina

With thanks to Yusuf.

= progressive cellulitis of the floor of the mouth and neck that begins in the submandibular space

– potentially fatal disease – can progress to death within hours, usually by sudden asphyxiation

Cause: usually dental cause, such as an extraction or dental abscess; it can also complicate mandibular fractures, foreign body or laceration of the floor of the mouth, tongue piercings

Signs / symptoms: dysphagia, odynophagia, neck pain and swelling, drooling; bilateral submandibular swelling, “wooden” consistency of the floor of the mouth, tongue swelling, elevation and protrusion; a tense oedema and induration of the neck may occur – the “bull neck” sign; trismus, fever; in severe cases – dysphonia, stridor, respiratory distress

Imaging: CT with IV contrast or MRI

Management :
– potential airway emergency – DIFFICULT AIRWAY that might need urgent airway management in ED; seek early help from the Anaesthetics department – preferred method is fiberoptic naso- or orotracheal intubation; crycothyroidotomy will be difficult due to the disrupted anatomy, and also increases the risk of spreading the infection into the mediastinum

– IV antibiotics – same regimen as for peritonsillar abscesses

– urgent Maxillo-facial or ENT consult

Definitive management is still debated, whether these patients should be managed surgically with incision and drainage or medically only with antibiotics.

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