Ludwig's Angina- more than a toothache

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In this episode we dive into the nasty, gnarly infection that is Ludwig's Angina. It's a bad player with complications including mediastinitis, epiglottitis, and asphyxiation- it's one you need to know. In this vodcast we highlight a case of Ludwig's Angina, showing some important images and videos of its presentation, and dive into the finer points of the disease.

Recognition

In order to diagnose this disease, you have to know the definition of the disease, which involves maxillofacial anatomy.

Ludwig’s has three important components:

1)      Infection of the submandibular space (composed of the submylohyoid and sublingual spaces)

2)      The infection is bilateral

3)      The infection is aggressive and rapidly spreading

Don’t get lost in the terminology and all the potential spaces of the mouth. Remember K.I.S.S. (kept it simple, stupid)- Ludwig’s is a fast and mean floor of the mouth infection. See the image on the right for a rough outline of the spaces we are

Mechanisms and Spread- “It’s your rotten tooth”

Source: Storyblocks

Two thirds of the time the infection is odontogenic, usually from the mandibular teeth. As a general principle, maxillary tooth infections tend to spread up and/or out, involving the infraorbital region or buccal area, whereas mandibular teeth will create infectious spread out or down.[1] 

With all the fascial planes and potential spaces of the mouth, things can get confusing. We care about two spaces in Ludwig’s: Sublingual and Submylohyoid.  The scrawny little mylohyoid muscle separates these two potential spaces which actually communicate in the back of the mouth.  The cellulitis of Ludwig’s tears right through this area, involving both spaces bilaterally.[2]

Once in the submandibular region, the cellulitis occupies the potential space and fills it with infection. The tongue is displaced by this and can head out, up, or back - all of which are bad. Further communication can occur with the paraphyarngeal and then the retropharyngeal spaces. Epiglottitis, retropharngeal infections and even mediastinitis have been described.[1,3] 

Manifestations- “Your double chin looks reeeeal angry”

Source: Our actual patient, reproduced with consent.

Ludwig’s is a gnarly infection- fevers, chills, and mouth pain are kind of a given. As the cellulitis fills potential spaces and makes them real, certain things have to get displaced:

Floor of the mouth- the submandibular face is swollen, exquisitely tender and has a classic “woody” feel to it, meaning it is taut and hard.[2]  If the patient didn’t have a double chin before, they will now.

Tongue­- This is part of the life-threat and why we are scared of this disease. The tongue gets elevated and can occlude the airway. A slow suffocation from airway occlusion is the end outcome. In the pre-antibiotic era, this led to Ludwig’s having a near 50% mortality rate.[4] Today numbers are cited in the single digits.[3,5]

Other clinical features of the disease basically stem from the above anatomic changes:

Muffled voice- Talking with your tongue pressed firmly against the roof of your mouth is no easy task.

Drooling- Swallowing, too, can be a tall order with tongue mechanics so disrupted.

Sniffing position- Just like children with epiglottitis, when we want to maximize airway diameter as our throat starts to close, we may take a sniffing position.

Stridor- A step past the sniffing position (though not always a progression of symptoms), if you patient has stridor you better be prepping your ETT… and your scalpel.

Diagnosis- “Your mouth is being eaten, which is ironic”

The diagnosis of Ludwig’s is via the constellation of symptoms. While CT is the imaging modality of choice, never send a tenuous airway to the scanner. As mentioned above, there are a few definitions that need to be met for it to be Ludwig’s:

1. Submandibular (submylohyoid + sublingual) infection

2. Bilateral

3. Aggressive and mean

Abscesses are typically not present in Ludwig’s given the rapidity of spread and early presentation of patients. However, in patients presenting later in the course (typically greater than 24-48 hours), abscesses can be present and do not preclude the diagnosis.[5]

As noted above, concurrent infection of the surrounding structures (epiglottis, parapharngyeal areas, etc) can occur.

Treatment- “A is for Asphyxia”

source: https://www.pikist.com/free-photo-icfir

Airway Control- It’s back to them good ol’ ABCs. And with Ludwig’s it’s a hard stop at A. From an EM perspective, the cornerstone of treatment is airway protection. As noted, this is a fast movin’ infection, and any signs of airway compromise is a four alarm fire. Preparation for securing a difficult airway should commence.  While prior recommendations were for an awake surgical airway, advanced techniques including fiberoptic awake intubations have put this practice into antiquity.[6,9]

Fight the Bugs- Antibiotics are the corner stone of management once the airway is controlled (ideally concurrently). It’s a mouth infection, so you are dealing with aerobes and anaerboes. This is not a time to skimp on antibiotic coverage. Activity against gram positives, gram negatives, aerobes and anaerobes should be present.[7] Combination penicillins like ampicillin-sulbactam or piperacillin-tazobactam are a great starting point.[5,7] Clindamycin is an option in your penicillin-allergic patients. Additionally, vancomycin or linezolid will need to be added if MRSA is suspected.

Source Control- Given most Ludwig’s stems from mandibular odontogenic infections, source teeth often have to be extracted.[8] Abscesses, though uncommon and late in presentation, require incision and drainage. While surgical flaying of the submandibular space to decompress the region was a common practice, it has fallen out of favor.[10]

Check out the Vodcast with a case review below:

Diagnosis: Ludwig’s requires three elements for definitive diagnosis.

1. Cellulitis of the submandibular (composed of sublingual and submylohyoid) space.

2. A bilateral infection

3. Aggressive or rapidly spreading

Source: 2/3 of the time the source is a mandibular molar, often molar #2 or #3.

Manifestations: Ludwig’s is a scary disease because it displaces normal anatomy, most notably the tongue. The submandibular space classically is very swollen, erythematous, incredibly painful and with a “woody” feel. The swelling and tongue displacement leads to symptoms and signs that include but are not limited to muffled voice, drooling, and maintenance of a sniffing position.

Treatment: In the pre-antibiotic era, Ludwig’s had a ~50% mortality, which is wild. Patients died from asphyxiation, hence the name angina which means “to strangle.” In the modern day, treatment is focused on early initiation of antibiotics that cover aerobic, anaerobic, gram (+) and gram (-) pathogens. A good start is a beta-lactamase combination penicillin. Surgical intervention, which used to be more of a mainstay of therapy, is now best reserved for those who fail antibiotic therapy or are progressing to airway compromise. Awake nasal fiberoptic intubation, when available, is likely the safest and best approach.

References

1. Fehrenbach MJ, Herring SW. Spread of Dental Infections. Practical Hygeine. 1997: 13-19. [Pdf]

2. Srirompotong S, Art-Smart T. Ludwig’s angina: a clinical review. Eur Arch Otorhinolaryngol, 260 (2003), pp. 401–403. [Pubmed]

3. Furst IM, Ersil P, Caminiti M. A rare complication of tooth abscess--Ludwig's angina and mediastinitis. J Can Dent Assoc 2001; 67:324. [Pubmed]

4. Williams AC, Guralnick WC. The diagnosis and treatment of Ludwig’s angina: a report of twenty cases. N Engl J Med 1943;228:443–50. [NEJM]

5. Reynolds SC, Chow AW. Life-threatening infections of the peripharyngeal and deep fascial spaces of the head and neck. Infect Dis Clin North Am 2007; 21:557. [Pubmed]

6. Wolfe M, Davis J, Parks S. Is surgical airway necessary for airway management in deep neck infections and Ludwig angina? J Crit Care. 2011 Feb;26(1):11-4. [Pubmed]

7. Brook I. Microbiology and principles of antimicrobial therapy for head and neck infections. Infect Dis Clin North Am 2007; 21:355. [Pubmed]

8. Rothwell BR. Odontogenic infections. Emerg Med Clin North Am. 1985 Feb;3(1):161-78. [Pubmed]

9. Ovassapian, A; Tuncbilek, M; Weitzel, E; Joshi, C. Airway Management in Adult Patients with Deep Neck Infections: A Case Series and Review of the Literature Anesth Analg. 2005 Feb;100(2):585-9. [Pubmed]

10. Bross-Soriano D, Arrieta-Gómez JR, Prado-Calleros H, Schimelmitz-ldi J, Jorba-Basave S. Management of Ludwig's angina with small neck incisions: 18 years experience. Otolaryngol Head Neck Surg 2004;130:712-7. [Pubmed]