It is a life-threatening emergency as airway obstruction can occur rapidly as a result. Urgent medical treatment and airway assessment is required.
- Incidence: 0.50 cases per 100,000 person-years
- Peak incidence: 40-50 years
- Sex ratio: 1:1
|Peritonsillar abscess (quinsy)||60.00|
- Peritonsillar abscesses
- Mandibular fractures
- Oral lacerations/piercings
- Oral malignancy
Predisposing factors include:
- Dental cavities
- Previous dental procedures
- Systemic conditions:
- Diabetes mellitus
- Other immunosuppressive conditions
Infections are typically polymicrobial and can involve various species of oral flora which arise from odontogenic sources. The most commonly isolated pathogens are:
- Streptococcus viridans
- Staphylococcus aureus
- Staphylococcus epidermidis
- Peptostreptococcus spp.
- Bacteroides spp.
- Fusobacterium spp.
Signs on physical examination include:
- Bilateral submandibular swelling
- Elevated or protruding tongue
- Signs of respiratory distress if airway compromise is already present
- Dyspnoea (15%)
- Blood cultures
- To assess for haematogenous spread
Microbial culture and analysis can be attempted
- Needle aspiration of submandibular space
- Often unsuccessful in the absence of abscess formation.
It may also be useful to obtain imaging:
- CT scan with IV contrast
- To identify suppurative complications that require surgical drainage or if the diagnosis is unclear.
- Dental X-ray
- To identify the potential source of infection.
- Peritonsillar abscess
- Uvular deviation, trismus
- Retropharyngeal abscess
- Bulging of pharyngeal wall
- Acute suppurative parotitis
- Unilateral induration from cheek to jaw
It is also important to rule out non-infectious causes of neck swelling:
- Oral carcinoma
- Persistent oral ulcerations, cervical lymphadenopathy, weight loss?
- History of allergies or ACE inhibitor use? Swelling and hives in other parts of the body?
- Submandibular haematoma
- History of trauma and anticoagulation?
There are no specific guidelines for the treatment of Ludwig's angina, however, the following principles are based on retrospective studies and UpToDate recommendations:
- Admission to a high dependency unit (HDU) or ENT ward with close airway observation.
- If respiratory distress is present, immediate intubation or tracheostomy may be necessary.
- Fibreoptic laryngoscopy is useful for airway assessment and assisting intubation.
- Empiric antibiotic regimens with coverage for beta-lactamase producing gram-positive, gram-negative, and anaerobic organisms are advised. However, there are no clinical trials to date to support any particular regimen.
- Options include combinations of ampicillin-sulbactam, clindamycin, and metronidazole.
- If the patient is immunocompromised antibiotic treatment should be extended to involve anti-pseudomonal coverage and vancomycin should be considered if there is an increased risk of MRSA.
- Antibiotics should be continued intravenously for a duration of two to three weeks.
- Surgical drainage should be performed to treat localised abscesses or following failure of medical management.
- If an infected tooth is determined as the source, it should be extracted.
- The most common cause of death.
- Aspiration pneumonia
Other major complications in descending order of frequency include:
- Blood cultures should always be taken.
- Due to spread through the retropharyngeal space and into the superior mediastinum.
- Can be identified using a chest X-ray.
- Cervical necrotizing fasciitis