Ludwig angina: a review of current airway management

Ludwig angina and sudden death

A 27-year-old man presented to hospital with neck swelling and difficulty breathing following a recent tooth extraction. He underwent uncomplicated surgical drainage of the submandibular region after which he became acutely short of breath and collapsed and was not able to be resuscitated. At autopsy the major findings were swelling of the neck due to diffuse cellulitis with edema and neutrophil infiltrates within connective tissue and marked submucosal edema of the epiglottis, glottic inlet and tonsils sufficient to cause airway obstruction. Cultures from the site of surgical intervention showed a mixed growth of Gram positive and negative bacilli and Gram positive cocci. Death was due to airway obstruction resulting from marked submucosal edema of the glottic inlet associated with submandibular cellulitis (Ludwig's angina) following extraction of a right lower first molar tooth. Lethal Lugwig angina, although rare in current forensic practice, may still present as a cause of acute upper airway occlusion and must be considered in the differential diagnosis of significant upper airway compromise.

Management of Ludwig’s angina. When is surgery necessary?

Deep neck space infections are of great risk for patients considering even death in certain cases. Collection of purulent secretions that can accumulate in a particular region of the neck is due to the anatomy of the deep neck fascia, muscles of the neck and compartments for blood vessels and organs in the neck region. Deep neck spaces communicate with each other and in some patients with morbidities like diabetes or other form of immuno-suppression extension can be great. Ludwig's angina is a form of abscess of the floor of the mouth with origin in teeth located on the mandible. Like any other abscess medical and surgical therapy are ways of treatment, but incision and drainage are mandatory. However, surgical management of such a complication might include other type of surgery as tracheostomy, blood vessels ligation, resection of necrotic tissue or even reconstruction.

Ludwig's Angina: Report of a Case and Review of Management Issues

Ludwig's angina, although uncommon, remains a potentially life-threatening condition because of the risk of impending airway obstruction. Effective treatment is based on early recognition of the clinical process, with the appropriate use of parenteral antibiotics, airway protection techniques, and formal surgical drainage of the infection. We present a case of Ludwig's angina together with a brief review of the relevant literature.

Management of Ludwig's Angina in Pregnancy: A Review of 10 Cases

Background:

Ludwig's angina is a rapidly spreading cellulitis that may produce upper airway obstruction often leading to death.

Aim:

The present paper reviews the management of Ludwig's angina in the third trimester of pregnancy. The inherent dangers to the mother and her unborn child are highlighted.

Materials and Methods:

The case files of pregnant patients who had emergent incision and drainage for life-threatening facial cellulitis at the maxillofacial unit of the Murtala Mohammed Specialist Hospital in Kano, Nigeria, over a 2 year period were retrieved and demographic and clinical characteristics were retrospectively obtained and analyzed descriptively using the statistical package for social sciences (SPSS version 13.0, for Windows, September 2004, Chicago, Illinois). Comparative statistics were determined using Pearson's Chi-square, Fisher's exact tests and independent t tests as appropriate. A P value of less than 0.05 was considered significant.

Results:

A total of 10 patients were seen within the study period, age ranges from 23 to 40 years, mean 29.5 (5.3) years. Majority of the women were in their third decade [60% (6/10)] while the remaining 40% (4/10) were in their fourth decade of life. Two of the patients presented within the period of less than 1 week of onset of symptoms while those who presented within the periods of 1-2 weeks and periods of over 2 weeks accounted for 50% (5/10) and 30% (3/10) respectively. All the patients presented during the third trimester of their pregnancy and odontogenic infections were responsible for 80% (8/10) of the Ludwig's angina. There were 20% mortality among the patients and this was significant for those with underlying systemic conditions (P = 0.02). The time of presentation was not significant for the survival rate of the gravid patient (P = 0.36) but was significant for survival of the fetus (P = 0.01).

Conclusion:

During a life-threatening infectious situation such as Ludwig's angina, risks of maternal and fetal morbidity include both septicemia and asphyxia. Attending clinicians must consider the risks that the condition and the possible treatments may cause the mother and her unborn child.

Ludwig's Angina - An emergency: A case report with literature review

Ludwig's angina is a form of severe diffuse cellulitis that presents an acute onset and spreads rapidly, bilaterally affecting the submandibular, sublingual and submental spaces resulting in a state of emergency. Early diagnosis and immediate treatment planning could be a life-saving procedure. Here we report a case of wide spread odontogenic infection extending to the neck with elevation of the floor of the mouth obstructing the airway which resulted in breathlessness and stridor for which the patient was directed to maintain his airway by elective tracheostomy and subsequent drainage of the potentially involved spaces. Late stages of the disease should be addressed immediately and given special importance towards the maintenance of airway followed by surgical decompression under antibiotic coverage. The appropriate use of parenteral antibiotics, airway protection techniques, and formal surgical drainage of the infection remains the standard protocol of treatment in advanced cases of Ludwig's angina.

Pregnancy complicated by Ludwig's angina requiring delivery

At 33 weeks of gestation, a 24-year-old developed Ludwig's angina that worsened despite aggressive therapy. This is the first reported case of Ludwig's Angina in pregnancy that required an emergent cesarean section for fetal indications. Delivery may have contributed to improvement in the mother's health status.

Role of estimation of arterial blood gases in the management of stridor

AIM

We studied the epidemiology and etiology of stridor in our patients along with the role of arterial blood gas (ABG) analysis in their management. We also reviewed their prognostic indices and the clinical outcomes.

MATERIALS AND METHODS

It was a prospective study in a tertiary referral hospital in which 72 patients presenting with stridor, were independently evaluated by 3 different clinicians and clinically classified into mild, moderate and severe. Based on ABG values (pH, PO2, PCO2), we defined 3 groups of patients viz, those in respiratory failure, impending respiratory failure and those with no evidence of failure. Treatment was directed at the cause of stridor. Clinical outcomes were assessed and results classified as resolved, improved, stable and death.

RESULTS

Out of 72 patients, kappa coefficient of agreement between the 3 observers were found to be 0.014, indicating poor interobserver reliability for the working clinical classification. However, ABG analysis indicated otherwise, with 6 patients in respiratory failure, 19 progressing to impending failure. Hence we complied by the more objective ABG analysis in planning management. Laryngomalacia in children and hypopharyngeal malignancies in adults were found to be the most common causes of stridor in our study. As compared to other conditions, laryngomalacia in children had a poorer outcome (p = 0.001).

CONCLUSION

Early detection of impending respiratory failure was instrumental in achieving better clinical outcomes in our patients presenting with stridor. Thus we inferred that ABG analysis is a valuable tool in the effective management of stridor.

Computed tomography imaging of acute neck inflammatory processes

Early diagnosis and management of neck infections and inflammatory processes is a common challenge for emergency and ear, neck and throat physicians, as well as radiologists. Emergency neck infections are diverse in their presentation, ranging from a transient enlargement of a lymph node to a rapidly spreading necrotizing fasciitis. Symptoms and signs, with the clinical history, usually suggest the diagnosis. But complex neck anatomy and sometimes limited physical examination can obscure and delay diagnosis, thus the need for an appropriate imaging exam and correct interpretation. In this pictorial review, we will consider common neck acute inflammatory processes that may be encountered in the emergency room and discuss some of their salient imaging findings.

Ludwig's angina and airway considerations: a case report

INTRODUCTION

Patients with deep neck infections present challenging airways for an anesthesiologist. Patients with Ludwig's angina may die as a result of the inability to effectively manage the airway.

CASE PRESENTATION

Here we discuss the anesthetic management with fiberoptic intubation of a 45-year-old man with Ludwig's angina scheduled for emergency drainage.

CONCLUSION

Awake fiberoptic intubation under topical anesthesia may be the ideal method to secure the airway in advanced cases of Ludwig's angina. When fiberoptic bronchoscopy is not feasible, not available or has failed, an awake tracheostomy may be the preferred option.

An upper airway obstruction emergency: Ludwig angina

Ludwig angina remains a potentially lethal disease, rapidly spreading bilateral cellulitis of the submental, sublingual, and submandibular spaces, which bears the threat for rapid airway obstruction. Since the introduction of antibiotics in 1940s, the mortality was reduced significantly. This resulted in the rare occurrence of the disease, leaving many physicians with limited experience of Ludwig angina. Although the occurrence of Ludwig angina in adults is rare, its presence in the pediatric edentulous population is even more uncommon. Because the unfamiliarity with this disease is now increasing, unnecessary delaying diagnosis or inadequate management may occur and may result in serious complications. This presentation will consist of a historical review, discussion of pathophysiology, followed by clinical presentation, etiology, bacteriology, and management. With early diagnosis, airway observation and management, aggressive intravenous antibiotic therapy, and judicious surgical intervention, the disease should resolve without complications. In addition, the source of infection should be determined and eliminated if possible. A thoughtful, individualized management strategy seems to be the most reasonable approach to the disease.

Surgical management of Ludwig's angina

BACKGROUND

Ludwig's angina (LA) is a dangerous surgical condition that can cause severe airway compromise and death. There is controversy regarding the best way to manage the airway of patients with LA. Options range from conservative management involving close observation and i.v. antibiotics to airway intervention, including tracheostomy and endotracheal intubation using fibre-optic nasoendoscopy. We present evidence supporting a role for conservative airway management in a select subset of patients.

METHODS

This paper reviews 9 years' experience of treating patients with LA at Liverpool Hospital.

RESULTS

Twenty-one out of 29 (72%) of our patients were treated conservatively following initial clinical assessment. One of these patients subsequently deteriorated requiring emergency intubation. Of those treated non-conservatively at initial presentation, seven patients were able to be intubated using fibre-optic nasoendoscopy and one patient required tracheostomy under local anaesthesia.

CONCLUSION

A general discussion of issues related to the management of LA is presented. Based on our experience we conclude that there is a subset of patients with LA who can be managed safely with conservative management.

Severe life threatening maxillofacial infection in pregnancy presented as Ludwig's angina

BACKGROUND

Ludwig's angina is a rapidly spreading cellulitis that may produce upper airway obstruction often leading to death. There is very little published information regarding this condition in the pregnant patient.

CASE

A 24-year old black female was admitted at 26 weeks gestation with tooth pain, submandibular swelling, severe trismus, and dysphagea, consistent with Ludwig's angina. Her treatment included emergent tracheostomy, incision and drainage of associated spaces, teeth extraction, and antibiotic therapy.

CONCLUSIONS

During a life threatening infectious situation such as the one described, risks of maternal and fetal morbidity include both septicemia and asphyxia. Furthermore, the healthcare provider must consider the risks that the condition and the possible treatments may cause the mother and her unborn child.

Airway management in adult patients with deep neck infections: a case series and review of the literature

Patients with deep neck infections, especially those with Ludwig's angina, may die as a result of airway management mishaps. Skillful airway management is critical, but a safe method of airway control in these patients is yet to be established. We subjected patients with deep neck infections to fiberoptic tracheal intubation by using topical anesthesia to provide general anesthesia for surgical interventions. Patient characteristics and techniques for intubations were recorded on a special data-collection form. Of the 26 patients, 17 had Ludwig's angina, and 9 had other types of deep neck infections. Three patients were tracheally intubated while in the sitting position, 2 in Fowler's position, and 21 in the supine position with the head up 10 degrees-15 degrees. Tracheal intubations were successful in 25 patients: 19 nasally and 6 orally. After surgery, seven patients were kept tracheally intubated, and five patients had tracheostomies. Complications were limited to three cases of mild epistaxis and four oversedations with transient hypoxemia. Twelve patients remembered part of the procedure, and two considered it unpleasant. Tracheal intubation with a flexible bronchoscope by using topical anesthesia is highly successful in adult patients with deep neck infections. Tracheostomy using local anesthesia is recommended if fiberoptic intubation is not feasible, if the clinician is not skillful in the use of awake fiberoptic intubation, or if intubation attempts have failed.

Otolaryngologic critical care

In this chapter we have reviewed the complicated medical conditions that exist in many head and neck surgical patients. Common surgical procedures that frequently require postoperative monitoring and several infectious disorders requiring intensive care unit admission were also reviewed. Intensivists need to be familiar with these procedures and diseases. Collaboration with the surgical specialist is required to optimize patient care.

Critical care of the head and neck patient

The patient with head and neck disease has several peculiarities that need to be recognized for the treating team to offer optimal care. These arise from the primary disorders (eg, head and neck cancer or injuries) and the morbidity they might cause, the associated comorbidities, and the possible complications of treatment. A team approach involving the surgeon, the intensivist, and other caretaking personnel is essential to achieve high-quality care and ensure the best results possible.

Bilateral Submandibular Gland Infection Presenting as Ludwig's Angina: First Report of a Case

We diagnosed and treated a case of Ludwig's angina in a 45-year-old man who had edema of the floor of mouth and the tongue along with bilateral submandibular sialadenitis and sialolithiasis. We secured the patient's airway via nasal fiberoptic intubation in the surgical intensive care unit and administered intravenous antibiotics. The edema subsided, and the patient was extubated on the third postoperative day and discharged shortly thereafter. To our knowledge, this is the first reported case of a patient with bilateral submandibular sialadenitis and sialolithiasis presenting as Ludwig's angina. Despite the decreasing incidence of this disease, Ludwig's angina remains an important disease process because a failure to control the airway can have disastrous consequences. Proper diagnosis, airway control, antibiotic therapy, and occasionally surgical management are essential to ensure the safety of the patient.