[Angina De Ludwig Pdf Download
Hanne Rylaarsdam
Ludwig angina is a type of bacterial infection that occurs in the floor of the mouth, under the tongue. It often develops after an infection of the roots of the teeth (such as tooth abscess) or a mouth injury.
If the swelling blocks the airway, you need to get emergency medical help right away. A breathing tube may needed to be placed through your mouth or nose and into the lungs to restore breathing. You may need to have surgery called a tracheostomy that creates an opening through the neck into the windpipe.
Antibiotics are given to fight the infection. They are most often given through a vein until symptoms go away. Antibiotics taken by mouth may be continued until tests show that the bacteria have gone away.
Chow AW. Infections of the oral cavity, neck, and head. In: Bennett JE, Dolin R, Blaser MJ, eds. Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases. 9th ed. Philadelphia, PA: Elsevier; 2020:chap 64.
Updated by: Josef Shargorodsky, MD, MPH, Johns Hopkins University School of Medicine, Baltimore, MD. Also reviewed by David C. Dugdale, MD, Medical Director, Brenda Conaway, Editorial Director, and the A.D.A.M. Editorial team.
Ludwig's angina (Latin: Angina ludovici) is a type of severe cellulitis involving the floor of the mouth[2] and is often caused by bacterial sources.[1] Early in the infection, the floor of the mouth raises due to swelling, leading to difficulty swallowing saliva. As a result, patients may present with drooling and difficulty speaking.[3] As the condition worsens, the airway may be compromised and hardening of the spaces on both sides of the tongue may develop.[4] Overall, this condition has a rapid onset over a few hours.
The majority of cases follow a dental infection.[3] Other causes include a parapharyngeal abscess, mandibular fracture, cut or piercing inside the mouth, or submandibular salivary stones.[5] The infection spreads through the connective tissue of the floor of the mouth and is normally caused by infectious and invasive organisms such as Streptococcus, Staphylococcus, and Bacteroides.[6]
Prevention is by appropriate dental care including management of dental infections. Initial treatment is generally with broad-spectrum antibiotics and corticosteroids.[1] In more advanced cases endotracheal intubation or tracheostomy may be required.[1]
With the advent of antibiotics in 1940s, improved oral and dental hygiene, and more aggressive surgical approaches for treatment, the risk of death due to Ludwig's angina has significantly reduced. It is named after a German physician, Wilhelm Frederick von Ludwig, who first described this condition in 1836.[7]
Ludwig's angina is a form of severe, widespread cellulitis of the floor of the mouth, usually with bilateral involvement. Infection is usually primarily within the submandibular space, and the sublingual and submental spaces can also be involved. It presents with an acute onset and spreads very rapidly, therefore early diagnosis and immediate treatment planning is vital and lifesaving.[8] The external signs may include bilateral lower facial swelling around the jaw and upper neck. Signs inside the mouth may include elevation of the floor of mouth due to sublingual space involvement and posterior displacement of the tongue, creating the potential for a compromised airway.[8] Additional symptoms may include painful neck swelling, drooling, tooth pain, dysphagia, shortness of breath, fever, and general malaise.[9] Stridor, trismus, and cyanosis may also be seen when an impending airway crisis is nearing.[9]
Other causes such as oral ulcerations, infections secondary to oral malignancy, mandible fractures, sialolithiasis-related submandibular gland infections,[10] and penetrating injuries of the mouth floor[15] have also been documented as potential causes of Ludwig's angina. Patients with systemic illness, such as diabetes mellitus, malnutrition, compromised immune system, and organ transplantation are also commonly predisposed to Ludwig's angina.[13] A review reporting the incidence of illnesses associated with Ludwig angina found that 18% of cases involved diabetes mellitus, 9% involved acquired immune deficiency syndrome, and another 5% were human immunodeficiency virus (HIV) positive.[16]
Infections originating in the roots of teeth can be identified with a dental X-ray.[17][18] A CT scan of the neck with contrast material is used to identify deep neck space infections.[19] If there is suspicion of the infection of the chest cavity, a chest scan is sometimes done.[18]
There are a few methods that can be used for determining the microbiology of Ludwig's angina. Traditionally, a culture sample is collected although it has some limitations, primarily being the time-consuming and sometimes unreliable results if the culture is not processed correctly.[21] Ludwig's angina is most often found to be polymicrobial and anaerobic.[2][22] Some of the commonly found microbes are Viridans streptococci, Staphylococci, Peptostreptococci, Prevotella, Porphyromonas and Fusobacterium.[2][22]
For each patient, the treatment plan should be consider the patient's stage of infection, airway control, and comorbidities. Other things to consider include physician experience, available resources, and personnel are critical factors in formulation of a treatment plan.[23] There are four principles that guide the treatment of Ludwig's angina:[24] Sufficient airway management, early and aggressive antibiotic therapy, incision and drainage for any who fail medical management or form localized abscesses, and adequate nutrition and hydration support.
Airway management has been found to be the most important factor in treating patients with Ludwig's angina,[25] i.e. it is the "primary therapeutic concern".[26] Airway compromise is known to be the leading cause of death from Ludwig's angina.[5]
Adequate nutrition and hydration support is essential in any patient following surgery, particularly young children.[24] In this case, pain and swelling in the neck region would usually cause difficulties in eating or swallowing, hence reducing patient's food and fluid intake. Patients must therefore be well-nourished and hydrated to promote wound healing and to fight off infection.[29]
Extubation, which is the removal of endotracheal tube to liberate the patient from mechanical ventilation, should only be done when the patient's airway is proved to be patent, allowing adequate breathing. This is indicated by a decrease in swelling and patient's capability of breathing adequately around an uncuffed endotracheal tube with the lumen blocked.[29]
The term "angina", is derived from the Latin word angere, which means "choke"; and the Greek word ankhone, which means "strangle". Placing it into context, Ludwig's angina refers to the feeling of strangling and choking, secondary to obstruction of the airway, which is the most serious potential complication of this condition.[22]
Ludwig angina is life-threatening cellulitis of the soft tissue involving the floor of the mouth and neck. Ludwig angina involves 3 compartments of the floor of the mouth: sublingual, submental, and submandibular. The infection is rapidly progressive, leading to potential airway obstruction. The most common etiology is a dental infection in the lower molars, mainly second and third, accounting for over 90% of cases. Any recent infection or injury to the area may predispose the patient to develop Ludwig angina. Predisposing factors include diabetes, oral malignancy, dental caries, alcoholism, malnutrition, and immunocompromised status. This review addresses the management and acute treatment of this possibly lethal condition.
Objectives:
- Identify and recognize the clinical signs and symptoms of Ludwig angina.Implement appropriate diagnostic modalities to aid in the diagnosis and assessment of Ludwig angina.Apply evidence-based treatment strategies for Ludwig angina, including airway management, antibiotic therapy, and surgical intervention.Collaborate with all members of the interprofessional team, including specialists such as otolaryngologists, anesthesiologists, and oral maxillofacial surgeons, to provide efficient, comprehensive, and coordinated care.
Ludwig angina is an uncommon life-threatening diffuse cellulitis of the soft tissue of the floor of the mouth and neck. The condition is named after a German physician, Wilhelm Friedrich von Ludwig, who described it in 1836. Angina comes from the Latin "angere," meaning to choke.[1]
Ludwig angina involves 3 compartments of the floor of the mouth: sublingual, submental, and submandibular. Infection of the lower molars is the hallmark cause of true Ludwig angina; however, this term is frequently applied to any floor-of-the-mouth infection with sublingual or submandibular space involvement.[2] It rapidly progresses to the surrounding tissues, leading to potentially lethal complications, such as airway obstruction, aspiration pneumonia, and carotid arterial rupture or sheath abscess.[3] Therefore, early recognition and treatment, including airway protection, antibiotic therapy, and surgical drainage in well-established infections, are crucial.
Ludwig angina mainly originates from dental infections in the mandibular molars, particularly the second and third molars, accounting for 90% of cases.[4] Periapical abscesses in the second or third mandibular molars are primarily responsible for the condition.[5]
Other less common etiologies include oral piercing or laceration, mandibular fracture, traumatic intubation, osteomyelitis, peritonsillar or parapharyngeal abscess, submandibular sialadenitis, otitis media, and infected thyroglossal cysts.[3][6][7]
Predisposing dental factors include poor oral hygiene, dental caries, and recent dental treatment.[5] In most cases, Ludwig angina develops in previously healthy patients; however, some predisposing factors have been suggested, including diabetes, alcohol use disorder, malnutrition, and immunosuppression, such as in patients with AIDS or who have received an organ transplant.[2][8]
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