Treatment of Ludwig’s Angina

Ludwig’s angina is a bilateral cellulitis of the floor of the mouth, involving the submandibular, sublingual, and submaxillary spaces.  70% of the time it is odontogenic in origin, usually from the 2nd or 3rd molars.  Other causes include mandible fractures and piercing of the lingual frenulum.  The classic appearance is a male between 20 and 60 with a “bull-neck” appearance due to the infection pushing upward and backward on the tongue.  This obviously can cause odynophagia, difficulty speaking, and more importantly, respiratory distress.  Some have described a “woody” induration under the tongue and possibly crepitance.

The major aspect of treatment for Ludwig’s angina is airway management.  If the patient is currently maintaining their airway, then you need to set yourself up for success for the time when intubation is necessary.  However, not everyone needs intubated immediately or in the ED!  The operating room might be a better place.  First off, the most experienced person with airway should take the first look, as it may be your only look.  Having anesthesia and ENT colleagues available and present is advised. Direct laryngoscopy is probably not the best option.  Many airway experts have argued about this, but the consensus is for an awake intubation using fiberoptic nasotracheal intubation.  Many experts have also suggested the “double setup,” which involves prepping the neck for an emergent cricothyroidotomy in case the first attempt is not successful and airway collapse becomes imminent.  This involves identifying the cricothyroid membrane (mark it with a pen), prepping with betadine, and possibly anesthetizing the skin.

After the airway is either deemed to be sufficient (either without intervention vs intubation/surgical airway), the focus needs to be on starting IV antibiotics and involving ENT to evaluate for possible surgical drainage.  As the source is usually from teeth, it’s no surprise that group A strep such as strep viridans is the  most common etiology.  However, these infections are coming from a dirty mouth and are therefore usually polymicrobial.  The other common pathogens include anaerobes such as peptostreptococcus, fusobacterium, bacteroides, and actinomyces species.  The antibiotic choices include the following:

-penicillin G (2 to 4 MU IV) plus metronidazole (500 mg IV) OR

-ampicillin-sulbactam (i.e. Unasyn, at a dose of 3 g IV) OR

-clindamycin (600 mg IV)

If the patient is immuncompromised, the antibiotics will need to be expanded to cover MRSA and gram-negative rods.  The mortality for Ludwig’s angina was approx 50% before the era of powerful antibiotics and fantastic airway adjuncts, and the mortality is now therefore 0 to 4%.

Barton E, Blair A.  Ludwig’s Angina.  J Emerg Med. 2008. 34(2): 163-169.

Buckley M, O’Connor K.  Ludwig’s angina in a 76-year-old man.  Emerg Med J. 2009;26:679-680

Chow A. Submandibular space infections (Ludwig’s angina). Uptodate.  Jun, 2011.

Costain N, Marrie T. Ludwig’s Angina. American Journal of Medicine. Feb 2011. 124(2):  115-117.

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