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Ludwig’s Angina Ernest E. Wang MD, FACEP Evanston Northwestern Healthcare Northwestern University Medical School Ernest E. Wang MD, FACEP Evanston Northwestern.

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Presentation on theme: "Ludwig’s Angina Ernest E. Wang MD, FACEP Evanston Northwestern Healthcare Northwestern University Medical School Ernest E. Wang MD, FACEP Evanston Northwestern."— Presentation transcript:

1 Ludwig’s Angina Ernest E. Wang MD, FACEP Evanston Northwestern Healthcare Northwestern University Medical School Ernest E. Wang MD, FACEP Evanston Northwestern Healthcare Northwestern University Medical School

2 Ludwig’s Angina  Extension of localized periapical infection  Anterior mandibular  Sublingual  Posterior mandibular (molar)  Submandibular  Fascial planes  Extension of localized periapical infection  Anterior mandibular  Sublingual  Posterior mandibular (molar)  Submandibular  Fascial planes

3 Historical cues  Recent dental extraction or work  Dental caries  Fever  Swelling of mouth, face, neck  Compromised host  Co-morbidities (diabetes)  Recent dental extraction or work  Dental caries  Fever  Swelling of mouth, face, neck  Compromised host  Co-morbidities (diabetes)

4 Physical exam  Toxicity  Brawny bilateral boardlike edema  Submandibular, submental, sublingual  Trismus  Tongue elevation  No fluctuance  Toxicity  Brawny bilateral boardlike edema  Submandibular, submental, sublingual  Trismus  Tongue elevation  No fluctuance

5 Figure A, Ludwig angina may initially appear benign. B, In Ludwig angina, rapid progression may compromise the airway in a few hours. Roberts and Hedges, p. 1339

6 Etiology  Streptococcus  Staphylococcus  Mixed aerobic/anaerobic infection  B. Fragilis  ß-lactamase resistance (<= 40%)  Streptococcus  Staphylococcus  Mixed aerobic/anaerobic infection  B. Fragilis  ß-lactamase resistance (<= 40%)

7 Diagnosis  Clinical  CT scan  Clinical  CT scan

8 4-month-old with fever, irritability, and decreased oral intake x 24 hours. Swelling x 10 hrs (Maimon et al, Ann Emerg Med, 2006)

9 Treatment  Airway control - EARLY  Fiberoptic  Deterioration may be rapid  Cricothyrotomy or tracheostomy may be necessary  Surgical consultation mandatory  Oral maxillofacial surgeon or ENT  Definitive surgical drainage and debridement  ICU  Airway control - EARLY  Fiberoptic  Deterioration may be rapid  Cricothyrotomy or tracheostomy may be necessary  Surgical consultation mandatory  Oral maxillofacial surgeon or ENT  Definitive surgical drainage and debridement  ICU

10 Antibiotics  Extended spectrum penicillins  Ampicillin/Sulbactam (Unasyn)  Ticarcillin/Clauvulate (Timentin)  Piperacillin/Tazobactam (Zosyn)  Clindamycin + Cipro (PCN allergy)  Flagyl (B. Fragilis)  Extended spectrum penicillins  Ampicillin/Sulbactam (Unasyn)  Ticarcillin/Clauvulate (Timentin)  Piperacillin/Tazobactam (Zosyn)  Clindamycin + Cipro (PCN allergy)  Flagyl (B. Fragilis)

11 Steroids  Reduce edema  “Used routinely when airway compromise suspected” (Larawin et al.)  Dexamethasone mg IV  Then 4-6 mg Q6 for 8 doses (Busch)  Reduce edema  “Used routinely when airway compromise suspected” (Larawin et al.)  Dexamethasone mg IV  Then 4-6 mg Q6 for 8 doses (Busch)

12 Deep Neck Space Infections  103 patients ( )  Ludwig’s Angina (n=38, 37%)  Odontogenic (n=25, 67%)  Tracheostomy (n=4)  Medical management (n=13)  Medical and surgical management (n=25)  103 patients ( )  Ludwig’s Angina (n=38, 37%)  Odontogenic (n=25, 67%)  Tracheostomy (n=4)  Medical management (n=13)  Medical and surgical management (n=25) Larawin et al. Head and neck space infections. Otolaryngol Head Neck Surg. 2006, 135(6):

13 Deep Neck Space Infections  Complications  Upper airway obstruction (n=4)  Reinfection (n=3)  Asphyxiation (n=1)  Descending mediastinitis (n=1)  Spread to other spaces (n=1)  Death (n=2)  Complications  Upper airway obstruction (n=4)  Reinfection (n=3)  Asphyxiation (n=1)  Descending mediastinitis (n=1)  Spread to other spaces (n=1)  Death (n=2) Larawin et al. Head and neck space infections. Otolaryngol Head Neck Surg. 2006, 135(6):

14 Ludwig’s Angina - Summary  Serious deep space infection  Potentially fatal  Aggressive manage airway as indicated  Surgical consultation  Antibiotics and steroids  ICU  Serious deep space infection  Potentially fatal  Aggressive manage airway as indicated  Surgical consultation  Antibiotics and steroids  ICU

15 References  Larawin V, Naipao J, Dubey SP. Head and neck space infections. Otolaryngol Head Neck Surg Dec;135(6):  Marple BF. Ludwig angina: a review of current airway management. Arch Otolaryngol Head Neck Surg. 1999;125:  Busch RF. Ludwig angina: early aggressive therapy. Arch Otolaryngol Head Neck Surg Nov;125(11):  Maimon MS, Janjuh AS, and Goldman RD. Images in emergency medicine. Ludwig’s Angina in a 4 Month Old Infant. Ann Emerg Med, 2006 May;47(5):503, 507.  Amsterdam J. Chapter 65: Oral Medicine. In Marx J, Hockberger R, Walls R: Rosen's Emergency Medicine, Concepts and Clinical Practice, 5th ed. St. Louis, Mosby, 2002, pp.  Benko, K. Chapter 66: Emergency Dental Procedures. In Roberts J, Hedges J: Clinical Procedures in Emergency Medicine, 4th ed. 4th ed, Philadelphia, Saunders, 2004, pp.  Larawin V, Naipao J, Dubey SP. Head and neck space infections. Otolaryngol Head Neck Surg Dec;135(6):  Marple BF. Ludwig angina: a review of current airway management. Arch Otolaryngol Head Neck Surg. 1999;125:  Busch RF. Ludwig angina: early aggressive therapy. Arch Otolaryngol Head Neck Surg Nov;125(11):  Maimon MS, Janjuh AS, and Goldman RD. Images in emergency medicine. Ludwig’s Angina in a 4 Month Old Infant. Ann Emerg Med, 2006 May;47(5):503, 507.  Amsterdam J. Chapter 65: Oral Medicine. In Marx J, Hockberger R, Walls R: Rosen's Emergency Medicine, Concepts and Clinical Practice, 5th ed. St. Louis, Mosby, 2002, pp.  Benko, K. Chapter 66: Emergency Dental Procedures. In Roberts J, Hedges J: Clinical Procedures in Emergency Medicine, 4th ed. 4th ed, Philadelphia, Saunders, 2004, pp.


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