Ludwig angina

Diagnostic approach

• ABCDE approach
• Focused clinical evaluation
• Blood cultures
• CT neck with IV contrast if patient is stable
• POCUS if supine positioning is not possible

Management checklist

• Prepare for definitive airway.
• Emergency ENT and anesthesia consults
• IV access, O₂, continuous monitoring
• Empiric antibiotic therapy for deep neck infections
• Consider dexamethasone.
• Admit to ICU for close airway monitoring.

Airway compromise can occur rapidly.

Ludwig angina is a rare, life-threatening, and rapidly spreading soft tissue infection of the floor of the mouth that can lead to airway compromise. It is most commonly caused by polymicrobial odontogenic infections and occurs more frequently in individuals with poor dentition and/or immunosuppression. The classic presentation includes a woody or indurated floor of the mouth, submandibular swelling, and tongue elevation. Ludwig angina is a medical emergency because of the high risk of rapid airway compromise. Treatment priorities include securing the airway, administering broad-spectrum antibiotics, and surgical consult for source control. The preferred method for airway intervention is awake fiberoptic intubation while preparing for a surgical airway. Patients require admission to an intensive care unit for close airway monitoring.

• Periapical abscess (most common in adults)
• Upper respiratory tract infection (most common in children)
• Typically polymicrobial, including oral flora
• Common pathogens
  • Viridans streptococci
  • Staphylococcus aureus, e.g., MRSA
  • Staphylococcus epidermidis
  • Gram-negative aerobes (e.g., Escherichia coli, Klebsiella pneumoniae)
  • Oral anaerobes (e.g., Fusobacteriaceae, Actinomyces, Peptostreptococcus, Bacteroides)
• Risk factors
  • Immunosuppression
  • Diabetes mellitus
  • Malnutrition
  • Injection drug use
  • Chronic heavy alcohol use
  • Oral piercings (e.g., recent tongue piercing)
  • Poor dentition
  • Oral or dental trauma

Patients with immunocompromise are at increased risk of infection with MRSA and/or gram-negative aerobes.

• Fever, chills, weakness, malaise
• Signs of airway compromise
• Signs of respiratory distress
• Symmetrical tenderness and woody induration of the submandibular area
• Erythematous, tender, and elevated floor of the mouth
• Tongue swelling may prevent the mouth from closing.
• Neck erythema and edema
• Sublingual, submental, and cervical lymphadenopathy (less common)
• Trismus, meningismus

Ludwig angina is primarily a clinical diagnosis, with imaging used as an adjunct in stable patients or for diagnostic uncertainty. ^[1]

• Obtain blood cultures.
• Local culture via swab or needle aspiration is not recommended.
• CT of the neck with IV contrast is the imaging modality of choice; findings include:
  • Soft tissue thickening
  • Subcutaneous fat attenuation
  • Soft tissue gas
  • Focal fluid collections
  • Muscle edema
• Point-of-care ultrasound can be used if supine positioning is not possible.

General principles ^[1]

• ABCDE approach
• Supplemental oxygen for hypoxia
• Emergency ENT and anesthesia consults
• Serial airway assessments and definitive airway management as needed
• Hemodynamic monitoring
• Empiric antibiotic therapy for deep neck infections
• Surgical source control
• Patients should be admitted to an intensive care unit.

Complete airway obstruction can occur rapidly in Ludwig angina.

Airway management ^[1]

• Indications
  • Signs of airway compromise
  • Signs of respiratory distress
• Definitive airway
  • Pre-oxygenate.
  • Preferred technique: awake fiberoptic intubation while preparing for a surgical airway
  • Surgical airway
    • Cricothyrotomy may be challenging due to distorted neck anatomy.
    • Awake tracheotomy may be necessary in patients with severe edema.

Empiric broad-spectrum antibiotics ^[1]

• Suggested regimens for immunocompetent patients
  • Ampicillin/sulbactam
  • Ceftriaxone PLUS metronidazole
  • Clindamycin PLUS levofloxacin
• Suggested regimens for immunocompromised patients
  • Cefepime PLUS metronidazole
  • Imipenem
  • Meropenem
  • Piperacillin/tazobactam
• Add one of the following if MRSA is suspected:
  • Vancomycin
  • Linezolid
• See “Empiric antibiotic therapy for deep neck infections” for dosages.

Clindamycin monotherapy is not recommended because of high resistance rates. ^[1]

Adjunctive therapy ^[1]

• Glucocorticoids such as dexamethasone (off-label) may be considered. ^[1]
• Nebulized epinephrine may be used to reduce airway obstruction, although there is limited evidence to support this.

Surgical management ^[1]

• Early debridement of necrotic tissue and drainage of fluid collections may improve airway status and reduce rates of airway compromise, although there is limited evidence to support this.
• Indications
  • No or insufficient improvement with antibiotics
  • Fluctuance on examination
  • Abscesses on imaging

Acute complications

• Descending necrotizing mediastinitis
• Necrotizing fasciitis of the neck and chest
• Pericarditis
• Carotid artery rupture
• Jugular vein thrombosis
• Pleural empyema
• Pneumonia
• Acute respiratory distress syndrome

Acute complications occur in over 25% of patients. ^[1]

Late complications

• Tracheal stenosis (e.g., after prolonged intubation)
• Fibrosis of the floor of the mouth and/or neck
• Scarring and/or cosmetic deformity
• Cranial nerve deficits

We list the most important complications. The selection is not exhaustive.

The mortality rate for Ludwig angina is ∼ 10% with adequate treatment and up to 50% if untreated. ^[1]