its otolaryngology clinical scenerio based presentation

1. Ludwig`s Angina
By
Dr Ansar Javed
PGR ENT BVH Bahawalpur

2. Contents
Introduction
Applied anatomy
Etiology
Clinical presentation
Micro flora
Investigation
Treatment
Airway management
Definitive treatment

3. Ludwig`s angina
• Diffused cellulitis of the soft
tissue of floor of mouth and neck.
• named after a German physician,
Wilhelm Friedrich von Ludwig,
in 1836.
• Involves sublingual, submental,
and submandibular spaces
• Infection of the lower molars is
the hallmark cause most of the
times.

4. Submandibular space
• Anterolateral >mandible
• Superiorly. Floor of
mouth.
• Inferiorly. Superficial
layer of deep cervical
fascia extending between
hyoid and mandible

5.  Submandibular space divided into
two spaces by mylohyoid muscle
 Sublingual space ( above
mylohyoid attachment)
 Submaxillary space (below
mylohyoid attachment)
 Two spaces communicate each
other at posterior border of
mylohyoid.

6. Etiology
 dental infections in the mandibular molars,
particularly the second and third molar, 90% of
cases
 injury or laceration to the floor of the mouth.
 mandible fracture.
 tongue injury.
 oral piercing.
 submandibular sialadenitis or sialolithiasis.

7. Epidemiology
• No significant gender predilection .
• Approximately 13% of all deep neck infections.
• Generally from dental and periodontal infection.
• More common in immune compromised pts such as
DM , HIV.
• With rapid airway management and antibiotic
therapy, along with advanced imaging and surgical
procedures, mortality has decreased to around 8%

8. Clinical features
• Bilateral wood like
swelling in sublingual,
submandibular and
submental space.
• Skin is tense and tends to
blench on pressure.
• Rapidly spreading edema
• Double chin appearance.
• Drooling of saliva.

9. Clinical features
• Tongue pushed upward
and backwards.
• Elevation of tongue is
associated with
dysphagia, odynophagia
and cyanosis.

10. Clinical features
• patient may exhibit muffled voice due to edema
of vocal apparatus(hot potato voice).
• Systemic, high grade fever, malaise, body aches,
leukocytosis.
• Infection can spread to involve the masticator
space and parapharyngeal space in the later stage
of disease.
• Dyspnea in supine position , impending laryngeal
edema

11. Micro flora
• The disease is usually polymicrobial, involving oral
flora, both aerobes, and anaerobes.
• The most common organisms are Staphylococcus,
Streptococcus, Peptostreptococcus, Fusobacterium,
Bacteroides, and Actinomyces.

12. Investigations
• Panoramic x ray to identify possible odontogenic
sources.
• Radiographs to observe the volume increasing in
the soft tissues and any deviation of trachea
• Ultrasound has been recommended to
differentiate between cellulitis , abscess and
lymphadenopathy in head and neck infections.

13. Ultrasound
• Ultrasound is very sensitive in detecting fluid collection
• Quick, widely available, relatively inexpensive, painless
• Involves no radiation
• Any effective diagnostic tool to confirm abscess formation in
the superficial facial spaces and highly predictable in
detecting the stage of infection

14. Ct scan
Ct scan is most widely used modality.
Axial CT, showing abscess formation in the bilateral submandibular space
and the submental space.

16. Management
Airway management
Medical management
Surgical management

17. Airway management
Trachostomy
Cricothyrpidectomy
BNI
Fiber optic nasotracheal
Intubation

20. Medical management
Fluid resuscitation according to dehydration status of pt.
Aggressive empiric high dose IV antibiotics are
recommended.
Definitive antibiotic therapy should be given according to
culture and sensitivity results.

23. 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

24. Complications
• Spread of infection to parapharyngeal and
retropharyngeal spaces and hence to the
mediastinum
• Airway obstruction due to laryngeal edema
• Septicemia
• Aspiration pneumonia