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Ludwig’s angina

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Ludwig’s angina is a life-threatening infection with associated compromised airway and is an emergency in OMFS. Airway management is the primary concern in this situation

Veröffentlicht in: Gesundheit & Medizin

Ludwig’s angina

  1. 1. -- Dr. Hardik Vora PG OMFS MRADC LUDWIG’S ANGINA
  2. 2. Regional anatomy Ludwig’s angina Etiology Clinical presentation Microflora Investigations Treatment  Airway management  Definitive treatment CONTENTS
  4. 4. First described in 1836 by Wilhelm Frederick von Ludwig as a cellulitis of fast evolution involving the region of the submandibular gland which is disseminated through anatomic contiguity without tendency towards abscess formation 3 Fs It was to be feared Rarely became fluctuant Often was fatal LUDWIG’S ANGINA (LATIN TERM ANGERE = “TO STRANGLE”)
  5. 5. Grodinsky stated in a 1939 paper that Ludwig’s angina was a unique deep neck abscess characterized by  occurrence bilaterally in more than one space,  production of gangrenous serosanguineous infiltration with or without pus,  involvement of connective tissue and muscle but not glandular structures,  Spread by continuity, not via lymphatics Airway compromise has been recognised as the leading cause of death Mortality rate – 50% in preantibiotic era 8% currently LUDWIG’S ANGINA
  6. 6. Dental caries, recent dental treatment, poor dental hygiene (accounts for 75-90% of cases) Trauma: mandibular fracture, facial trauma, tongue piercing, frenuloplasty Infections of oral malignancy Submandibular sialadenitis Systemic compromise such as AIDS, glomerulonephritis, diabetes mellitus, aplastic anemia, transplant recipients, chemotherapy; IVDA (Soares et al. and Tavares et al.) ETIOLOGY
  7. 7. CLINICAL FEATURES Bilateral wood like swelling Double chin appearance Elevation and protrusion of tongue Airway obstruction
  8. 8. Bilateral ‘wood like’ swelling in the submandibular, sublingual and submental spaces Double chin appearance Skin is tense and tends to pit and blanch on pressure Rapidly spreading edema Edema and congestion of floor of the mouth Elevation and protrusion of tongue Elevation of the tongue is associated with dysphagia, odynophagia, dysphonia and cyanosis CLINICAL FEATURES
  9. 9. Dyspnea in supine position impending laryngeal edema Dysphagia and drooling of saliva Septicemia  High grade fever  Malaise  Body aches  Leukocytosis CLINICAL FEATURES Thumb sign on epiglottis indicating laryngeal edema
  10. 10.  Staphylococcus aureus in the pre-antibiotic era  Change in the microbial flora – aerobic streptococcal species and nonstreptococcal anaerobes  The bacteria that commonly cause deep neck infections represent the normal oral flora that becomes pathogenic when normal host defenses are ineffective MICROBIOLOGY Oral Maxillofacial Surg Clin N Am 20 (2008) 353–365
  11. 11. Common organisms •Streptococcus viridans •Streptococcus milleri group species •B-hemolytic streptococci •Neisseria species •Peptostreptococcus •Coagulase-negative staphylococci •Bacteroides Should be considered but are uncommon •Bartonella henselae •Mycobacterium tuberculosis Anaerobic bacteria •Prevotella and Porphyromonas species •Actinomyces species •Bacteroides species •Propionobacterium •Hemophilus •Eikenella MICROBIOLOGY Oral Maxillofacial Surg Clin N Am 20 (2008) 353–365  In diabetic patients, the microbial nature of DSNI shows a higher infection rate of Klebsiella pneumoniae when compared with those who do not have diabetes mellitus
  12. 12. Laboratory tests – hemogram, blood glucose, etc. Panoramic x-ray – to identify possible odontogenic sources Cervical, profile and posterior-anterior radiographs – to observe the volume increasing in the soft tissues and any deviation of the trachea Ultra sound has been recommended to differentiate between cellulitis, abscess and adenopathy in head and neck infection USG has a sensitivity of 95% and specificity of 75% INVESTIGATIONS
  13. 13. INVESTIGATIONS  Measure the distance from the anterior aspect of the vertebral body to the air column of the posterior pharyngeal wall.  At the level of C-2, 7mm  At the level of C-6,  22 mm in adults and  14mm in children . Jain et al. Deep-neck space infections – a diagnostic dilemma! Indian J. Otolaryngol. Head Neck Surg. 350 (October–December 2008) 60:349–352
  14. 14. CT scan is most widely used modality Readily available, can localize abscesses in the head and neck Not as effective as ultrasound in determining abscess from cellulitis Cellulitis  appears as soft-tissue swelling, increased density of surrounding fat, enhancement of involved muscles and obliteration of fat planes Abscess  low density area with a peripheral enhancement CT has been reported to have sensitivity of 91% and specifi city of 60% CT
  15. 15. Ultrasonography is very sensitive in detecting fluid collection Quick, widely available, relatively inexpensive, painless Involves no radiation An effective diagnostic tool to confirm abscess formation in the superficial facial spaces and is highly predictable in detecting the stage of infection ULTRASOUND S. Pallagatti et al. / European Journal of Radiology 81 (2012) 1821–1827
  16. 16. Sufficient airway management Early and aggressive antibiotic therapy Incision and drainage for any who fail medical management or form localized abscesses Adequate nutrition and hydration support TREATMENT GOALS Chou Y Lee Y, Chao H: An upper airway obstruction emergency: Ludwig’s angina, Pediatr Emerg Care 23:892-896, 2007.
  17. 17. Airway management in Ludwig’s angina can be challenging No consensus regarding the airway management in the available literature Suggested methods include tracheostomy, conventional laryngoscopy and intubation (after administration of muscle relaxant), awake blind nasal intubation and awake fibreoptic intubation. AIRWAY MANAGEMENT
  18. 18. Tracheostomy using local anaesthesia was considered as the gold standard in the past Risk of the spread of infection to the mediastinum, aspiration of pus, rupture of the innominate artery, spread of infection to the thorax, airway loss and tracheal stenosis Blind nasal intubation (BNI) is questionable because of infrequent success on first pass and increased trauma with repeated attempts  might necessitate emergency cricothyrotomy AIRWAY MANAGEMENT
  19. 19. The first successful fibreoptic nasotracheal intubation in a patient was first reported in the year 1974 (Schwartz et al) Fibreoptic intubation is a sophisticated and less invasive method of securing airway in patients with deep neck infection AIRWAY MANAGEMENT
  20. 20. Airway Advantages Disadvantages Close clinical observation • No mechanical intervention • Unrecognized impending airway loss • Risk of oversedation with loss of airway • Extension of infection and edema leading to asphyxiation Endotracheal intubation • Speed with which airway control is achieved • Nonsurgical procedure • Potential for failed intubation, • Inability to bypass upper airway obstruction • Requirement for mechanical ventilation • Subglottic stenosis • ET displacement Tracheostomy • Allows for bypass of upper airway obstruction • Very secure airway • Less need for sedation and mechanical ventilation • Earlier transfer out of CCU • Surgical procedure with inherent risks • Pneumothorax • Bleeding, subglottic stenosis, tracheoinnominate or tracheoesophageal fistula, unsightly scar
  21. 21. Journal of Critical Care (2011) 26, 11–14
  22. 22. Intravenous access, fluid resuscitation, and administration of IV antibiotics Antibiotic therapy should be administered empirically and tailored to culture and sensitivity results Antibiotic therapy should be administered empirically and tailored to culture and sensitivity results Other regimens –  Penicillins with β-lactamase inhibitor,  Second, third, or fourth generation Cephalosporins and  Metranidazole MEDICAL MANAGEMENT
  23. 23. Ampicillin/Sulbactam and clindamycin – effective for anaerobic infections Pipercillin/Tazobactam has shown efficacy in treating polymicrobial infections as a single agent Comorbid medical conditions require thorough workup and monitoring because they can be exacerbated by the infection, and can also lead to more severe infections Addition of gentamicin to the empirical therapy should be strongly considered for diabetic patients Control of blood sugar below 200 mg/dL is imperative for good control of infection MEDICAL MANAGEMENT
  24. 24. Principles (Topazian & Goldberg) Incise in healthy skin and mucosa when possible, not at the site of maximum fluctuance, because these wounds tend to heal with an unsightly scar; Place the incision in a natural skin fold; Place the incision in a dependent position; Dissect bluntly; Place a drain; and Remove drains when drainage becomes minimal SURGICAL TREATMENT
  25. 25. Bilateral submandibular incisions as well as a midline submental incision Incision approximately 3 to 4 cm below the angle of the mandible and below the inferior extent of swelling roughly parallel to the inferior border of mandible INCISION & DRAINAGE
  26. 26.  Ludwig’s angina is a life-threatening infection  Early diagnosis and immediate treatment is the key for successful management  Antibiotic therapy should be administered empirically and tailored to culture and sensitivity results Prompt and early surgical intervention is required to provide a higher control of the patient’s health. CONCLUSION
  27. 27.  Topazian RG, Goldberg MH, Hupp JR. Oral and Maxillofacial Infections. 4th ed. Philadelphia, Pa: W. B. Saunders; 2002.  Bagheri SC, Bell RB, Khan HA. Current Therapy in Oral and Maxillofacial Surgery - Saunders; 1 edition;2011  Osborn et al. Deep space neck infection. Oral Maxillofacial Surg Clin N Am 20 (2008) 353–365  Bahl, et al.: Microflora in odontogenic infections. Contemporary Clinical Dentistry | Jul-Sep 2014 | Vol 5 | Issue 3  S. Pallagatti et al. / European Journal of Radiology 81 (2012) 1821– 1827  Jain et al. Deep-neck space infections – a diagnostic dilemma! Indian J. Otolaryngol. Head Neck Surg. (October–December 2008) 60:349–352  M.M. Wolfe et al. Surgical airway in deep neck infections and ludwig angina. Journal of Critical Care (2011) 26, 11–14  Potter, Herford, and Ellis. Tracheotomy Versus Endotracheal Intubation for Airway Management in Deep Neck Space Infections.J Oral Maxillofac Surg 60:349-354, 2002 REFERENCES