Miscellaneous
Join the EMGuideWire Crew from CMC EM Residency Program as they discuss Ludwig's Angina and the management Priorities!!! BACKGROUND Angina = “Strangling” Bilateral infection of submental, submandibular, and sublingual spaces 70-85% of cases arise from odontogenic source Periapical abscesses of mandibular molars Piercings (frenulum) URI more common cause in children Source of infection often polymicrobial Most commonly viridans; also Staphylococcus and Bacteroides species Patients usually 20-60 years-old; more common in males1 Mortality in treated Ludwig’s Angina = 8%7 ***Airway compromise = leading cause of death8 Who Is At Risk? Diabetes mellitus Chronic alcohol abuse IVDA HIV/AIDS Malnutrition Poor oral hygiene Smokers Anatomy & Pathophysiology Mylohyoid subdivides submandibular space: Sublingual space Submaxillary (submylohyoid) space Infection extends posteriorly and superiorly, elevating tongue against hypopharynx If left untreated, can extend inferiorly to retropharyngeal space and into superior mediastinum3 Clinical Signs & Symptoms Dysphagia Odynophagia Trismus Edema of upper midline neck and floor of mouth Raised tongue "Woody" or brawny texture to floor of mouth with visible swelling and erythema Late Findings Drooling Tongue protrusion Trismus Dysphonia Cyanosis Acute laryngospasm Stridor Patients may demonstrate signs of systemic toxicity → fever, tachycardia, and hypotension How Do I Make the Diagnosis? Clinically! Consider CT head/neck Can help evaluate extent of infection if clinical situation persists CBC Chemistry Lactate Blood Cultures Management Emergent ENT/OMFS consult for I&D in OR and extraction of dentition if source is dental abscess Airway Management Intubation will be VERY difficult due to trismus and posterior pharyngeal extension Ideal situation = awake fiberoptic intubation in OR ALWAYS have a surgical airway ready as your back up plan Blind insertion devices (e.g. intubating LMA) are NOT recommended Management - Antibiotics Must cover typical polymicrobial oral flora Immunocompetent 3rd-generation Cephalosporin + (Clindamycin or Metronidazole) Ampicillin/Sulbactam Penicillin G + Metronidazole Clindamycin (allergic to penicillin) Immunocompromised → *Need MRSA and GNR coverage!3 Cefepime + Metronidazole Meropenem Piperacillin-tazobactam Add Vancomycin if concern for MRSA risk factors Steroids Dexamethasone 10 mg IV Thought to chemically decompress for airway protection and increase antibiotic penetration6 Nebulized epinephrine Resuscitation and pain control Complications Intracranial infections (e.g. CST, brain abscess) IJ thrombophlebitis (Lemirre’s Syndrome) Mediastinitis Mandibular osteomyelitis Empyema Pearls Three characteristics of Ludwig’s angina can be remembered as the 3 Fs: Feared Often Fatal Rarely Fluctuant ABCs—Sit upright Early notification of ENT/OMFS and anesthesia to facilitate definitive airway management Arrange for the patient to be admitted to ICU Priorities!!! Secure the airway EARLY! Prepare and be ready for a difficult airway — expect that the patient will require a surgical airway Prevent the development of septic shock and multi-organ failure — give antibiotics early References Lin HW, O’Neil A, Cunningham MJ. Ludwig’s Angina in the Pediatric Population. Clin Pediatr (Phila) 2009;48:583-7. Baez-Pravia, Orville V. et al. “Should We Consider IgG Hypogammaglobulinemia a Risk Factor for Severe Complications of Ludwig Angina?: A Case Report and Review of the Literature.” Medicine. 2017;96(47):e8708. Pandey M, Kaur M, Sanwal M, Jain A, Sinha SK. Ludwig’s Angina in children anesthesiologist’s nightmare: Case series and review of literature. J Anaesthesiol Clin Pharmacol. 2017 Jul-Sep;33(3):406-409. Botha A, Jacobs F, Postma C. Retrospective analysis of etiology and comorbid diseases associated with Ludwig’s Angina Ann Maxillofac Surg. 2015 Jul-Dec;5(2):168-73. Parhiscar A, Har-El G. Deep neck abscess: a retrospective review of 210 cases. Ann Otol Rhinol Laryngol 110: 1051, 2001. Saifeldeen K, R Evans. Ludwig’s Angina. Emerg Med J 2004; 21: 242-243 Nanda N, Zalzal HG, Borah Gl. Negative-Pressure Wound Therapy for Ludwig’s Angina: A Case Series.Plast Reconstr Surg Glob Open2017 Nov 7;5(11):e1561. Pak S, Cha D, Meyer C, Dee C, Fershko A.Ludwig’s Angina. Cureus. 2017 Aug 21;9(8):e1588.