Ludwig's angina is an acute, potentially life-threatening infection of the submandibular space that causes severe swelling and difficulty opening the mouth or swallowing. It usually stems from dental infections. Clinical features include bilateral swelling of the submandibular region, elevated tongue, and difficulty speaking or swallowing. Management involves securing the airway through tracheostomy or intubation, administering IV antibiotics, and incising and draining any abscesses through bilateral submandibular and submental incisions. Early diagnosis, antibiotic treatment, and surgical drainage are crucial for successful treatment.
4. Boundaries-
Roof: mylohyoid muscle.
Inferior: deep cervical fascia, platysma,
superficial fascia & skin.
Laterally: anterior belly of digastric.
Posteriorly: submandibular space.
Contents-
Lymph nodes, anterior jugular vein.
Etiology of infection-
Infected mandibular incisors.
Anterior extension of submandibular space.
5. Boundaries-
Superiorly: mucosa of floor of mouth.
Inferior: mylohyoid muscle.
Posteriorly: body of hyoid bone.
Anteriorly & laterally: inner aspect of
mandibular body.
Medially: geniohyoid, styloglossus,
genioglossus muscle.
Etiology of infection-
Infected mandibular premolar & 1st molar
6. Submandibular Space
Boundaries-
Superiorly: mylohyoid muscle, inferior border of
mandible.
Inferior: anterior & posterior belly of digastric.
Laterally: deep cervical fascia, platysma,
superficial fascia & skin.
Medially: hyoglossus,styloglossus,mylohyoid
muscle.
Posteriorly: to hyoid bone.
Anteriorly: submental space.
Etiology of infection-
Infected mandibular 2nd & 3rd molars.
From submental,sublingual spaces.
7. S Ludwig's angina’What
An acute spreading , potentially life-threatening form of cellulitis in
the region of the submandibular glands, causing severe swelling and
tenderness, with fever, pain and difficulty in opening the mouth and in
swallowing. There is some danger that the swelling might extend to
the voice box (LARYNX) and cause ASPHYXIA. The usual source of
infection is grossly neglected teeth. Antibiotics are necessary.
(Wilhelm Friedrich von Ludwig, 1790–1865, German surgeon).
8. Etiology
Dental caries, recent dental treatment, poor dental hygiene (accounts for
75-90% of cases)
Oral soft tissue lacerations.
Puncture wounds of the floor of the mouth.
Secondary Infections of oral malignancy
Submandibular sialadenitis
Systemic compromise such as AIDS, glomerulonephritis, diabetes mellitus,
aplastic anemia, transplant recipients, chemotherapy etc…..
9. Clinical features
Bilateral ‘wood like’ swelling in the submandibular, sublingual and
submental spaces (rapid onset )
Skin is tense and tends to pit and blanch on pressure
Rapidly spreading edema
Double chin appearance
10. Clinical features
Elevation and protrusion of tongue, drooling of saliva
Elevation of the tongue is associated with dysphagia, odynophagia, dysphonia and
cyanosis
Patients may exhibit muffled voice due to edema of vocal apparatus (hot potato voice)
Septicemia, High grade fever, Malaise, Body aches, Leukocytosis
Infection can spread to involve the masticator space and Para pharyngeal space
in the latter stages of the disease
12. INVESTIGATIONS
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
14. Ultrasound
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
16. Treatment goals
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
19. Tracheostomy using local anaesthesia was considered as the gold
standard in the past , but
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
20. cricothyroidotomy
sometimes performed instead of tracheostomy
perceived lower risk of spreading infection to mediastinum
Fibreoptic intubation is a sophisticated and less invasive method of
securing airway in patients with deep neck infection
21.
22. Medical management
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
23. SURGICAL MANAGEMENT
INCISION & DRAINAGE
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
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
26. CONCLUSION
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.