A 38-year-old woman presents to the emergency department with two days of jaw and neck swelling and a sore throat. Three days before, she had a right lower molar root canal. She complains of fever, odynophagia, drooling, right ear pain, headache, and difficulty opening her mouth, and she says under her jaw feels “swollen.” She denies shortness of breath, hoarseness, neck stiffness, or a history of immunocompromise.
The photograph shows what you see on examination. How would you diagnose and manage this condition in the ED?
Diagnosis: Ludwig's Angina
Ludwig's angina is a potentially life-threatening, rapidly progressive, gangrenous, and necrotizing cellulitis of the mouth floor (submandibular space), typically attributed to a primary dental infection, and it can lead to death within hours. The term comes from the Latin angere, meaning to strangle. (J Laryngol Otol 2006;120:363.) Patients with the highest risk of life-threatening complications include those with immunocompromising conditions, such as diabetes mellitus and HIV (Otolaryngol Clin North Am 2008;41:459, vii) and those with anterior visceral space extension or bilateral submandibular involvement. (Int J Infect Dis 2009; 13:327.)
The submandibular space, which includes the sublingual and submaxillary spaces, is the area from the mucosa of the floor of the mouth to the superficial layer of the deep cervical fascia that encloses the space from the mandible to the hyoid bone. This area contains the submandibular and sublingual glands, lymph nodes, and the submental branches of the facial vein, nerve, and artery. Submandibular space infections are particularly apt to extension along facial planes, with expansion into the parapharyngeal space, retropharyngeal space (deep space), and superior mediastinum, which escalate potential complications.
Nearly one-third of cases occur in children and adolescents (Clin Pediatr [Phila] 2009;48: 583), with some occurring de novo. (Laryngoscope 1982; 92:370.) Extension from a dental infection (primarily second or third molar) is the most common etiology, although other infection etiologies are tongue piercing, mandibular fracture, other traumatic disruption of mandibular tissues, extension from other deep space neck infections, sialadenitis, and seeding from bacteremia or sepsis.
Patients are typically toxic or ill-appearing, and tend to prefer to sit upright. They possess constitutional symptoms including fever, chills, and myalgias, and they present with dysphagia, odynophagia, “hot potato voice,” globus, trismus, pain, swelling and elevation of the tongue, neck swelling, painful or restricted neck movements, drooling, and stridor. Patients with Ludwig's are classically described as having tense edematous brawny or woody submandibular skin changes (“bull neck”), often with tongue protrusion and mouth floor elevation secondary to edema in severe cases. Tenderness to palpation and subcutaneous emphysema may be present. Asymmetric swelling is a worrisome sign and suspicious for parapharyngeal extension.
The differential diagnosis for Ludwig's includes malignancy, other infections or abscesses of deep space of the neck, glandular swelling, angioedema, hematoma, and diphtheria.
Diagnosis and treatment protocols initially should address airway stabilization, and they depend in part on the severity of infection. Stabilization of the airway should be the top priority, with planning for rescue airway devices or techniques (including awake nasotracheal or fiberoptic intubation) or consult. In severe cases, emergent cricothyroidotomy or tracheostomy may be necessary. It is preferable to avoid these procedures if possible because of the high likelihood of technical difficulties from landmark derangement and the possibility of contributing to infection extension distally into the mediastinum.
Once the airway is determined to be secure, broad-spectrum parenteral antibiotics should be initiated to cover oral flora including aerobic and anaerobic bacteria (including Streptococcus, Staphylococcus, and Bacteroides) because most infections ultimately are polymicrobial. Fungi are also possible infectious etiologies but are less common. (Am J Forensic Med Pathol 2008; 29:255.)
Computerized tomography with contrast enhancement can help delineate the extent of infection and identify any drainable fluid collections. Operative intervention was once the mainstay, but is now reserved for draining fluid and removing the inciting tooth if that was the underlying etiology, for those with anterior infection extending into the visceral space, and for those refractory to antibiotic management. Operative cultures of aspirated pus should be obtained to tailor antibiotic management. The role of corticoidsteroids in Ludwig's is unclear at this time. (Oral Health 1992;82:23.)
Before the advent of antibiotic treatment and operative drainage, the mortality rate of Ludwig's was as high as 60 percent, but is now estimated to be 17 percent in children and adolescents (Clin Pediatr [Phila] 2009;48 :583) and as low as four percent in adults. (J Can Dent Assoc 2001;67 :324.)
This patient was started on broad-spectrum parenteral antibiotics. A CT scan confirmed a large sublingular fluid collection with extension into the buccal and parapharyngeal space. The patient's fluid collections were drained in the operating room.