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Ludwig Angina, Emergency Medicine

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Ludwig Angina, Emergency Medicine

Basics

Description

No test will establish the diagnosis; assess severity or direct therapy

Chronic comorbid conditions, chronic medications, less physiologic reserve can all complicate the presentation and treatment

  • 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 abscessesContiguous spread may encircle the airway or involve the mediastinumEmergent interventions rarely include surgical or aspiration techniques
  • Most deaths are due to airway compromise, occlusion, and resultant asphyxiaMortality exceeded 50% in preantibiotic era, currently <8%
  • Contiguous spread may encircle the airway or involve the mediastinum
  • Emergent interventions rarely include surgical or aspiration techniques
  • 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: Ž ²-hemolytic strep commonly associated with anaerobes such as peptostreptococcus, pigmented bacteroidesMicrobiologic analyses may guide therapy
  • 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

  • Nonspecific constitutional symptoms: Fever, malaise, anxiety
  • Pain: Tongue, throat, jaw, chest, neck stiffness
  • Dysphagia, dysphonia
  • Dentition, dental care suboptimal
  • Febrile, toxic, tripod "sniffing "  posture
  • Stridor, "hot potato "  voice
  • HEENT:Tongue progressively displaced upward in both posterior, anterior directions at unpredictable rateAirway increasingly compromisedDrooling, salivary incontinenceTrismus impedes diagnosis and complicates treatment measures
  • Physical exam findings beyond those of the head and neck area are often noncontributory or unrelated
  • 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

Essential Workup

  • The diagnosis is usually clinically evidentNo 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
  • No study or procedure needed to confirm the diagnosis

Diagnosis Tests & Interpretation

  • CT of the neck with IV contrast enhancement is the study of choice:Standard cross-sectional imaging extends from skull base to aortic archBest 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 formationPotential limitations: Patient must remain supine for the study duration. Scanning location often away from optimal resuscitation, intervention capability.
  • 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.
  • 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
  • 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.
  • Potential limitations: patient must remain supine, motionless for the study duration. Scanning location often away from optimal resuscitation, intervention capability.
  • 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

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 comfortAllow adult tripod "sniffing "  position, to suction themselvesAllow 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 oxygenationPotential limitations: Few experienced with device assembly or use.Newer rescue devices easier to place and use.
  • Allow adult tripod "sniffing "  position, to suction themselves
  • Allow pediatric transport, simple interventions (blow-by O2, nebulizer treatments) on mothers lap
  • FIO2 of 100%
  • Consider concurrent O2 delivery systems, such as facemask and nasal cannula
  • Potential limitations: Few experienced with device assembly or use.
  • Newer rescue devices easier to place and use.
  • Minimize patient upset, agitationAllow 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.
  • 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

  • Maximize oxygenation
  • Maintain in position of comfort
  • Gather supplies/personnel for back-up airway techniques
  • See "Airway Management "  below.
  • Vascular access: Provides rapid, titratable, predictable medication deliveryIntraosseus (IO) access useful with poor peripheral access, resuscitations, pediatric access, adverse prehospital conditionsCommercially available device provides IO access rapidly, effectively
  • 2nd access recommended: Rescue backup, concurrent polypharmacy.
  • Intraosseus (IO) access useful with poor peripheral access, resuscitations, pediatric access, adverse prehospital conditions
  • Commercially available device provides IO access rapidly, effectively

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.
  • 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 tubesPrelubricate with gel or viscous lidocaineUse stylet or bougie for tube supportBend 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
  • Smaller ET tubes
  • Prelubricate with gel or viscous lidocaine
  • Use stylet or bougie for tube support
  • Bend distal tube into "hockey stick "  shape
  • 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 airwayNonsurgical intervention attemptedImmediate surgical intervention if unsuccessful or clinical deterioration
  • Intubation: Anticipate distorted anatomy:Sitting, awake a preferred optionSequential topical applications
  • Potential difficulties: Surgeon, specialist availability, facility capabilities not uniform
  • 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
  • Patient in an operating theater equipped, prepared to establish surgical airway
  • Nonsurgical intervention attempted
  • Immediate surgical intervention if unsuccessful or clinical deterioration
  • Sitting, awake a preferred option
  • Sequential topical applications

Medication

  • IV administration: Preferred route of administration as previously outlined
  • IO considerations:Lidocaine flush reduces infusion painFlow rates same as IV for routine fluids, medication administrationAvoid 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/dCefoxitin: 1 " “2 g IV q6 " “8h (peds: 80 " “160 mg/kg/d div. q4 " “6h); max. 12g/dClindamycin: 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:swellinginflammationsystemic stress dose replenishment
  • Hyperbaric oxygen: Consider if mediastinitis or necrotizing fasciitis
  • Lidocaine flush reduces infusion pain
  • Flow rates same as IV for routine fluids, medication administration
  • Avoid hyperosmolar agents, potential marrow injury
  • 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)
  • swelling
  • inflammation
  • systemic stress dose replenishment

Follow-Up

Disposition

  • All are admitted:Airway encroachment and obstruction can be progressive and unpredictable
  • ICU or closely monitored setting due to unpredictable progression of symptoms
  • Airway encroachment and obstruction can be progressive and unpredictable
  • 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
  • Early specialty consultation is necessary for possible assistance with airway management or drainage
  • Mother is susceptible to all aspects and complications as nongravid patients
  • Focus: Airway management, oxygenation, treatment of sepsis if present

Complications

  • Asphyxia
  • Spread into thoracic cavity:EmpyemaMediastinitisLung abscess
  • Pericarditis
  • Internal jugular vein thrombosis
  • Carotid artery erosion and/or infection
  • Sepsis/bacteremia
  • Subphrenic abscess
  • Empyema
  • Mediastinitis
  • Lung abscess

Pearls and Pitfalls

  • 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
  • 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

ICD10

SNOMED

  • 196542004 Ludwigs angina (disorder)