Basics
Description
- Named for German physician Wilhelm Friedrich von Ludwig, who 1st described this in 1836 as a rapidly progressive, gangrenous cellulitis and edema of soft tissues of the neck, floor of the mouth
- Gangrene is serosanguineous infiltration with little or no frank pus or primary abscesses
- Contiguous spread may encircle the airway or involve the mediastinum
- Emergent interventions rarely include surgical or aspiration techniques
- Most deaths are due to airway compromise, occlusion, and resultant asphyxia
- Mortality exceeded 50% in preantibiotic era, currently <8%
Etiology
- Odontogenic in 90% of adult cases, usually from 2nd, 3rd mandibular molars
- Less commonly: Mandibular fractures, oral lacerations, contiguous infections, errant drug injections, tongue piercings
- Polymicrobial: ²-hemolytic strep commonly associated with anaerobes such as peptostreptococcus, pigmented bacteroides
- Microbiologic analyses may guide therapy
- Frequently no clear etiology or site of origin
- Ideally, a destination facility will have specialty expertise available (surgery and subspecialties, anesthesia) and be properly equipped to provide emergent intervention
Diagnosis
Signs and Symptoms
History
- Nonspecific constitutional symptoms: Fever, malaise, anxiety
- Pain: Tongue, throat, jaw, chest, neck stiffness
- Dysphagia, dysphonia
- Dentition, dental care suboptimal
Physical Exam
- Febrile, toxic, tripod "sniffing " posture
- Stridor, "hot potato " voice
- HEENT:
- Tongue progressively displaced upward in both posterior, anterior directions at unpredictable rate
- Airway increasingly compromised
- Drooling, salivary incontinence
- Trismus impedes diagnosis and complicates treatment measures
- Physical exam findings beyond those of the head and neck area are often noncontributory or unrelated
Essential Workup
- The diagnosis is usually clinically evident
- No study or procedure needed to confirm the diagnosis
- Loss of airway patency can be unexpected, precipitous, and calamitous
- Securing airway patency and initiating treatment take precedent over workup considerations
Diagnosis Tests & Interpretation
Lab
No test will establish the diagnosis; assess severity or direct therapy
Imaging
Contrast-enhanced CT:
- CT of the neck with IV contrast enhancement is the study of choice:
- Standard cross-sectional imaging extends from skull base to aortic arch
- Best for evaluating the mediastinum, deep space infection location and extent, degree of airway involvement.
- Findings include streaky or "dirty " fat in areas of inflammation; adenopathy (submandibular, submental, anterior and posterior cervical chains); perhaps pus or gas formation
- Potential limitations: Patient must remain supine for the study duration. Scanning location often away from optimal resuscitation, intervention capability.
Plain Radiographs:
- Soft tissue lateral neck x-ray may demonstrate altered anatomy, especially in the upper airway
- Chest x-ray of little utility, including detecting presence and extent of mediastinal involvement
- Panorex may detect odontogenic or mandibular pathology, but of no use imaging soft tissue
Contrast-enhanced MRI:
- Information obtained is the same, of no greater value than contrast-enhanced CT:
- Potential limitations: patient must remain supine, motionless for the study duration. Scanning location often away from optimal resuscitation, intervention capability.
Ultrasound:
- Detects gas in tissues, abscesses, reactive lymphadenopathy
- May locate, outline the airway amongst edematous, distorted tissues of the anterior neck
- A guide for abscess or fluid aspiration
Diagnostic Procedures/Surgery
No surgery or invasive procedure will establish the diagnosis, assess severity, or direct therapy
Differential Diagnosis
- Infectious: Cellulitis, epiglottitis, tracheitis, peritonsillar abscess
- Traumatic: Penetrating injury, sublingual hematoma from fracture, soft tissue injury
- Angioneurotic edema
- Neoplasia
Treatment
Pre-Hospital
- Transport in position of comfort
- Allow adult tripod "sniffing " position, to suction themselves
- Allow pediatric transport, simple interventions (blow-by O2, nebulizer treatments) on mothers lap
- Maximize oxygenation:
- FIO2 of 100%
- Consider concurrent O2 delivery systems, such as facemask and nasal cannula
- Jet insufflation: An infrequently used temporizing rescue device for oxygenation
- Potential limitations: Few experienced with device assembly or use.
- Newer rescue devices easier to place and use.
- Minimize patient upset, agitation
- Allow transport, simple interventions (blow-by O2, nebulizer treatments) in parent's embrace.
- Question the necessity for any interventions: IV access, blood draws, O2 mask, monitor leads.
- Transport to facility best able to care for this complex patient if possible.
Initial Stabilization/Therapy
Airway Measures
- Maximize oxygenation
- Maintain in position of comfort
- Gather supplies/personnel for back-up airway techniques
- See "Airway Management " below.
Vascular Access
- Vascular access: Provides rapid, titratable, predictable medication delivery
- Intraosseus (IO) access useful with poor peripheral access, resuscitations, pediatric access, adverse prehospital conditions
- Commercially available device provides IO access rapidly, effectively
- 2nd access recommended: Rescue backup, concurrent polypharmacy.
Ed Treatment/Procedures
- Immediate priorities are to secure the airway and to institute medical treatment. Diminishing consensus on need for acute surgical intervention other than airway related.
- Infrequently see treatable abscess formation, fluid collections on initial presentation.
Airway management:
- Rescue airway devices may be difficult to place, altered effectiveness due to anatomy distortion, trismus, excessive secretions
- Avoid blind intubation techniques to reduce laryngospasm, iatrogenic injury, bleeding, further tissue distortion
- Equipment considerations:
- Smaller ET tubes
- Prelubricate with gel or viscous lidocaine
- Use stylet or bougie for tube support
- Bend distal tube into "hockey stick " shape
- Rapid-sequence intubation (RSI) agents may cause abrupt loss of muscle tone, airway architecture, or precipitate airway compromise
- Concern for impending respiratory failure increases with stridor, voice change, trismus, tripod posture, sialorrhea
Definitive management:
- Traditional surgical gold standard: Tracheostomy using local anesthesia:
- Potential difficulties: Surgeon, specialist availability, facility capabilities not uniform
- Traditional nonsurgical gold standard intubation using fiberoptic guidance:
- Potential difficulties: Fiberoptic scopes expensive, fragile, require specific cleaning regimens. Short scopes often lack suction or irrigation ports, visualization easily impaired. Their use is not intuitive to the infrequent operator
- Best management option "double setup "
- Patient in an operating theater equipped, prepared to establish surgical airway
- Nonsurgical intervention attempted
- Immediate surgical intervention if unsuccessful or clinical deterioration
- Intubation: Anticipate distorted anatomy:
- Sitting, awake a preferred option
- Sequential topical applications
Medication
- IV administration: Preferred route of administration as previously outlined
- IO considerations:
- Lidocaine flush reduces infusion pain
- Flow rates same as IV for routine fluids, medication administration
- Avoid hyperosmolar agents, potential marrow injury
- Antibiotics: Empiric use of broad-spectrum antibiotics justifiable, for use until return of culture and antibiogram results, which should direct further therapy:
- Ampicillin/sulbactam: 1.5 " 3 g IM/IV q6h (peds: 300 mg/kg/d div. q6 if <1yr, <40 kg; 1.5 " 3 g IV q6h if >1 yr, >40 kg); max. 12 g/d
- Cefoxitin: 1 " 2 g IV q6 " 8h (peds: 80 " 160 mg/kg/d div. q4 " 6h); max. 12g/d
- Clindamycin: 600 " 900 mg IM/IV q8h (peds: 15 " 25 mg/kg/d div. q6 " 8h)
- Piperacillin/tazobactam: 3.375 g IV q6h (peds: If >9 mo, <40 kg; 300 mg/kg/d IV div. q8h)
- Ticarcillin/clavulanate: 3.1 g IV q4 " 6h (peds: If >3 mo, <60 kg; 200 " 300 mg/kg/d div. q4 " 6h)
- Analgesia: Pain control should be a primary concern
- Antiemetics: Proactive, prophylactic use for medication-related or condition-induced symptoms
- Steroids: Recommend empiric use of longer acting steroids to reduce:
- swelling
- inflammation
- systemic stress dose replenishment
- Hyperbaric oxygen: Consider if mediastinitis or necrotizing fasciitis
Follow-Up
Disposition
Admission Criteria
- All are admitted:
- Airway encroachment and obstruction can be progressive and unpredictable
- ICU or closely monitored setting due to unpredictable progression of symptoms
Issues for Referral
- This is a clinical diagnosis with unpredictable progression:
- Early specialty consultation is necessary for possible assistance with airway management or drainage
- Early transfer to higher level of care if the illness acuity exceeds the clinicians level of expertise or if the facility is not adequately equipped for such management
- Mother is susceptible to all aspects and complications as nongravid patients
- Focus: Airway management, oxygenation, treatment of sepsis if present
Chronic comorbid conditions, chronic medications, less physiologic reserve can all complicate the presentation and treatment
Complications
- Asphyxia
- Spread into thoracic cavity:
- Empyema
- Mediastinitis
- Lung abscess
- Pericarditis
- Internal jugular vein thrombosis
- Carotid artery erosion and/or infection
- Sepsis/bacteremia
- Subphrenic abscess
Pearls and Pitfalls
Pearls:
- Prepare to manage airway immediately
- Consult appropriate medical specialists as soon as possible, whether for transfer to a higher level of care, or to the operating suite for "double setup " management
- Video laryngoscopy is intuitive and easy to use, provides rapid, safe, high probability intubation success
Pitfalls:
- Failure to appreciate the progressive nature, unpredictable rate, extent of advancement
- Diagnostic testing and/or imaging should not delay definitive airway management or other therapy
Additional Reading
- Candamourty R, Venkatachalam S, Babu MR, et al. Ludwigs Angina " An emergency: A case report with literature review. J Nat Sci Biol Med. 2012;3(2):206 " 208.
- Ludwig BJ, Foster BR, Saito N, et al. Diagnostic imaging in nontraumatic pediatric head and neck emergencies. Radiographics. 2010;30(3):781 " 799.
- Mckellop JA, Bou-Assaly W, Mukherji SK. Emergency head & neck imaging: Infection and inflammatory processes. Neuroimaging Clin N Am. 2010;20:651 " 661.
- Tobias JD, Ross AK. Intraosseous infusions: A review for the anesthesiologist with a focus on pediatric use. Anesth Analg. 2010;110:391 " 401
- Weingart SD, Levitan RM. Preoxygenation and prevention of desaturation during emergency airway management. Ann Emerg Med. 2012;59:165 " 175.e1.
- Wolfe MM, Davis JW, Parks SN. Is surgical airway necessary for airway management in deep neck infections and Ludwig angina? J Crit Care. 2011:26:11 " 14.
Codes
ICD9
528.3 Cellulitis and abscess of oral soft tissues
ICD10
K12.2 Cellulitis and abscess of mouth
SNOMED
- 196542004 Ludwigs angina (disorder)