Ludwig’s Angina: A Rapid Review

In the Rapid Review series, we briefly review the key points of a clinical review paper. The topic this time: Ludwig’s angina.

The paper:

Bridwell R, Gottlieb M, Koyfman A, Long B. Diagnosis and management of Ludwig’s angina: An evidence-based review. Am J Emerg Med. 2021 Mar;41:1-5. doi: 10.1016/j.ajem.2020.12.030. Epub 2020 Dec 23. PMID: 33383265

What is Ludwig’s Angina?

Ludwig’s Angina is a deep space infection of the neck that involves the floor of the mouth.

Why is it important?

The infection can spread rapidly, causing tongue enlargement and elevation, and ultimately airway obstruction. It also causes edema of other airway structures, including the epiglottis, true and false vocal cords, and aryepiglottic folds. Airway edema can progress very rapidly.

Who gets it? 

Although Wilhelm Fredrick von Ludwig did die shortly after the onset of neck inflammation, sources indicate it is unlikely he had the infection he named.

Patients at high risk for Ludwig’s angina include those with local sources of infection, such as piercings or dental infections, and those who have a systemic predisposition to infection, such as diabetes, malnutrition, or IV drug use.

How do patients typically present?

Patients present with submandibular swelling and induration, and may also have generalized weakness, fever, malaise, and chills. The outer neck can be erythematous and edematous, and there may be sublingual, submental, and/or cervical lymphadenopathy.

Trismus and meningismus are late signs and are associated with parapharyngeal and retropharyngeal expansion, respectively. Other late signs include drooling, dysphagia, dysphonia, and respiratory distress. 

What is the initial ED management?

1. Airway assessment and management
2. Broad Spectrum Antibiotics
3. Dexamethasone (to reduce edema and improve antibiotic penetration)
4. Surgical debridement of any necrotic tissue and drainage of any abscess  

Swabs of the involved area are low yield and likely to have multiple contaminants. There is limited evidence for nebulized epinephrine.

A brief (important) note on airway management

Neck anatomy can be very distorted, resulting in difficulty for both intubation and rescue techniques such as supraglottic airways and cricothyrotomy. Definitive management is best done in the OR where a tracheotomy can be done if required; consult ENT and anesthesia early.

If a surgeon or anesthesiologist is not available, an awake fibreoptic intubation can be a good choice. During intubation pay careful attention to avoid airway trauma that will worsen airway edema and/or cause laryngospasm. A supraglottic airway is a poor choice as it can get displaced as swelling progresses.

Imaging of choice?

Ludwig’s angina is a clinical diagnosis and does not require imaging. A CT of the neck with contrast can be done in stable patients who can tolerate lying supine to assess for the location and extent of involvement, and to help determine the need for surgical intervention.

POCUS may also have utility. It will show hypoechoic lesions within the face and neck. Subglottic airway diameter can also be estimated by ultrasound.

What bugs need to be covered?

Infections are polymicrobial including gram positive, gram negative, and anaerobic bacteria. In immunocompetent hosts recommended antibiotics regimens include:

• Ceftriaxone 2g IV q12h + metronidazole 500mg IV q8h
• Clindamycin 600mg IV q6-8h + levofloxacin 750mg IV q24h

Additional coverage should be considered for immunocompromised patients and those with risk factors for MRSA (diabetes, IV drug use, hemodialysis, recent hospitalizations, and long-term care residents).

Disposition

Patients should be admitted to ICU and have serial airway assessments along with monitoring for complications including descending mediastinitis and necrotizing fasciitis.

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