Ludwig Angina

Basics

Description

  • Named for German physician Wilhelm Friedrich von Ludwig, who 1st described this in 1836 as a rapidly progressive, gangrenous cellulitis and edema of soft tissues of the submandibular, submental, and sublingual spaces of the neck
  • Gangrene is serosanguineous infiltration with little or no frank pus or primary abscesses:
    • Contiguous spread may encircle the airway or involve the mediastinum
  • Most deaths are due to airway compromise, occlusion, and resultant asphyxia:
    • Mortality exceeded 50% in preantibiotic era, currently <8%

Etiology

  • Odontogenic in 90% of adult cases, usually from 2nd, and 3rd mandibular molars
  • Less commonly: Mandibular fractures, oral lacerations, contiguous infections, sialadenitis, errant drug injections, tongue piercings
  • Polymicrobial: β-Hemolytic strep commonly associated with anaerobes such as peptostreptococcus, pigmented bacteroides:
    • Microbiologic analyses may guide therapy
  • Predisposing factors:
    • Poor dental hygiene
    • Immunosuppression
    • Comorbidities (diabetes mellitus, hypertension, HIV)
    • Trauma to the mouth or neck

Factors Increasing Morbidity And Mortality

  • Comorbid illness
  • Diabetes mellitus – specifically shown to independently increase life-threatening complications above other comorbidities
  • Pregnancy
  • Large body habitus
  • Alcoholism
  • Involvement of more than one neck space
  • Anterior visceral space involvement (hyoid bone → superior mediastinal space)

Pediatric Considerations

  • Frequently no clear etiology or site of origin
  • Ideally, a destination facility will have specialty expertise available (surgery and subspecialties, anesthesia) and be properly equipped to provide emergent intervention

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