Applied Anatomy Etiology of Ludwig’s Angina Clinical Picture of Ludwig’s Angina Differential Diagnosis Complications of Ludwig’s Angina Management of Ludwig’s Angina If Ludwig's angina is diagnosed, the patient should be intubated immediately. Imaging has no role in the immediate assessment of the patient - the decision to intubate is made solely on clinical parameters, as sending a patient with an impending airway to the CT scanner will delay treatment and may be lethal. Once the airway is secured, a CT scan of the neck with intravenous (IV) contrast can then be used to evaluate the severity of the infection and assess for any abscess. In addition, CT scans and MRI can be used to identify mediastinal fluid cumulus and corroborate the airway edema. Neck and chest x-rays may demonstrate gas in the tissues in the case of infections caused by anaerobic microflora. Lastly, metastatic abscesses and pus may be seen with ultrasonography. Blood cultures should be obtained to determine if there is a hematogenous spread of the infection.

1. LUDWIG’S ANGINA
DR AWAIS IRSHAD
Fazaia
Ruth
Pfau
Medical
College
Department
of
ENT
1

2. Learning Objectives
 Applied Anatomy
 Etiology of Ludwig’s Angina
 Clinical Picture of Ludwig’s Angina
 Differential Diagnosis
 Complications of Ludwig’s Angina
 Management of Ludwig’s Angina
Fazaia
Ruth
Pfau
Medical
College
Department
of
ENT
2

3. Fazaia
Ruth
Pfau
Medical
College
Department
of
ENT
3
• Submandibular space
• Divided into two compartments
1. Sublingual compartment
2. Submaxillary & Submental compartment
• Ludwig’s angina is infection of submandibular space.
Applied Anatomy

4. Fazaia
Ruth
Pfau
Medical
College
Department
of
ENT
4
• Dental Infections
• Submandibular sialadenitis
• Inuries of oral mucosa
• Fractures of mandible
Bacteriology
• Streptococcus
• Staphylococcus
• Bacterioides
• H. influenzae., E.coli, Pseudomonas
Etiology

5. Fazaia
Ruth
Pfau
Medical
College
Department
of
ENT
5
• Massive, firmy & brawny cellulitis or induration involving spaces bilaterally:
Submandibular
Sublingual
Submental
• Trismus
• Marked difficulty in swelling (Odynophagia)
• When infection is localized to sublingual space, structures in the floor of mouth are
swollen & tongue seems to be pushed up and back.
• When infection spreads to submaxillary space, submental and submandibular
regions become swollen and tender.
• Tongue is progressively pushed upwards and backwards threatening airway.
• Laryngeal edema may appear.
Clinical Picture

6. Fazaia
Ruth
Pfau
Medical
College
Department
of
ENT
6
• Tooth Pain
• Tachypenia & tachycardia & fever
• Patients may exhibit dysphonia.

7. Fazaia
Ruth
Pfau
Medical
College
Department
of
ENT
7
• Cellulitis
• Lingual carcinoma
• Lymphadenitis
• Salivary gland abcess
• Sublingual hematoma
• Peritonsillar abcess
Differential Diagnosis

8. Fazaia
Ruth
Pfau
Medical
College
Department
of
ENT
8
History
Examination
Investigations
Treatment
Management of Ludwig’s Angina

9. Fazaia
Ruth
Pfau
Medical
College
Department
of
ENT
9
• Onset
• Pain
• Tooth Extraction
• Tooth Infection
• Neck Pain
• Difficulty in speaking
• Hoarseness of voice
• Trismus
• Tongue swelling
• Stiff neck
• Stridor
History

10. Fazaia
Ruth
Pfau
Medical
College
Department
of
ENT
10
• Fever
• Submental & Submandiular swelling
• Tenderness
• Swelling of floor of mouth
• Elevation of tongue
• Tenderness of involved teeth
• Induration of submental neck
• Edema of upper neck
• The patient will not typically have lymphadenopathy.
Examination

11. Fazaia
Ruth
Pfau
Medical
College
Department
of
ENT
11
• If Ludwig's angina is diagnosed, the patient should be intubated immediately.
Imaging has no role in the immediate assessment of the patient - the decision to
intubate is made solely on clinical parameters, as sending a patient with an
impending airway to the CT scanner will delay treatment and may be lethal.
• Once the airway is secured, a CT scan of the neck with intravenous (IV) contrast can
then be used to evaluate the severity of the infection and assess for any abscess.
• In addition, CT scans and MRI can be used to identify mediastinal fluid cumulus and
corroborate the airway edema.
• Neck and chest x-rays may demonstrate gas in the tissues in the case of infections
caused by anaerobic microflora.
• Lastly, metastatic abscesses and pus may be seen with ultrasonography.
• Blood cultures should be obtained to determine if there is a hematogenous spread
of the infection.
Investigations

12. Treatment
• The treatment of Ludwig's angina is aimed principally at protecting the airways - the
most common cause of death is asphyxiation from airway obstruction - controlling
the infection with antibiotic therapy, and in some cases of well-established
infections surgical draining.
• Incision and drainage of abscess.
Intraoral
Extra-oral
Tracheostomy, if airway is endangered.
Fazaia
Ruth
Pfau
Medical
College
Department
of
ENT
12

13. Fazaia
Ruth
Pfau
Medical
College
Department
of
ENT
13
• Spread of infection to parapharyngeal and retropharyngeal spaces & then to
mediastinum.
• Airway obstruction due to laryngeal edema.
• Septicemia.
• Aspiration pneumonia.
Complications

14. Fazaia
Ruth
Pfau
Medical
College
Department
of
ENT
14
A 48 years old female presented to the ER with complaints of progressive, diffuse neck
swelling over the submental area and high grade fever for the past 4 to 5 days. As an
ENT doctor:
• What specific questions you would ask in history to aid and elicit the diagnosis?
• Give differential diagnosis.
• Give management plan of most probable diagnosis.
• Differentiate between neck swellings of various causes.
• What impending emergencies do you need to e aware of and how to manage them?
• Write the labs and prescription for above issue.
CBL 16

15. Fazaia
Ruth
Pfau
Medical
College
Department
of
ENT
15