Introduction:
Ludwig angina is a life-threatening cellulitis (a common bacterial skin infection that causes swelling, redness, and pain in the infected area of the skin) of the soft tissue concerning the floor of the mouth and neck. Ludwig angina involves three compartments of the mouth's base: submental, sublingual, and submandibular. The infection is progressive quickly, leading to probable airway obstruction. Dental infections in the lower molars, mainly second and third, account for over 85 percent of cases and are the most common etiology. Any current infection or injury to the area can predispose the patient to form Ludwig's angina. Predisposing factors include conditions such as oral malignancy, diabetes, dental caries, alcoholism, malnutrition, and immunocompromised status.
What Is Ludwig’s
Ludwig angina is a rare life-threatening diffuse cellulitis of the soft tissue of the base of the mouth and neck. The condition is named after a German physician. In the 1830s, Wilhelm Friedrich Von Ludwig was the one to describe the condition. Angina comes from the Latin word "angere," meaning getting choked in the Latin language. Ludwig's angina is a serious and rare skin infection that forms on the floor of the mouth and the neck. It results from bacteria that are present due to other problems, such as a mouth injury or a tooth abscess. Most Ludwig's angina infections are odontogenic (from the tissues that form the teeth), usually from the second or third mandibular molar. Other causes comprise para pharyngeal abscesses (a deep neck abscess or pus) or peritonsillar (around the tonsils), mandibular fracture (fracture of the upper jaw), oral lacerations or piercing, and rarely submandibular sialadenitis (inflammation occurring in one or more salivary glands). Predisposing factors include:
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Recent dental treatment.
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Dental caries.
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Recent dental treatment.
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Systemic medical conditions (such as diabetes mellitus).
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Malnutrition (absence of proper nutrition).
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Alcoholism.
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Immunocompromised system (such as in acquired immunodeficiency disease, also known as AIDS).
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Organ transplantation.
What Is the Pathophysiology of Ludwig’s Angina?
Understanding regional anatomy is crucial for understanding how the spread of the infection of Ludwis's angina takes place. Ludwig's angina generally starts at the floor of the mouth and quickly rises to the submandibular space. The floor of the mouth is separated by the mylohyoid muscle into the sublingual area above the muscle and the submandibular area below the muscle. The roots of the mandibular molars are found inferior to the attachment of the mylohyoid muscle, which permits the spread of odontogenic infections into the submandibular space. Extension of the infection to these two spaces enlarges or elevates the tongue and obstructs the airways if there is no intervention. The condition may also result in edema (caused by excess trapped fluid in tissue) of the airway structures, such as vocal cords, epiglottitis, and aryepiglottic folds, which can appear after 30 minutes of initial presentation. The infection may someday extend to the retropharyngeal space, parapharyngeal space, and superior mediastinum via the styloglossus muscle. The infection extends to the neck throughout the spaces between the fascial layers and not via the lymphatic system. The advancement of the infection to the neck is frequently seen clinically as a "bull neck".
Which Microorganisms Are Responsible for Ludwig’s Angina?
The disease is generally polymicrobial (caused by several microorganisms) and affects oral flora, both aerobes and anaerobes. Streptococcus, Staphylococcus, Fusobacterium, Peptostreptococcus, Bacteroides, and Actinomyces are the most common organisms. Infection with Streptococcus anginosus moves the disease more rapidly than other bacteria. Cultures from more than 50 percent of the patients presenting with Ludwig's angina, who have systemic illnesses like diabetes, present Klebsiella pneumonia (a gram-negative bacteria that commonly induce nosocomial infections). Patients with hemodialysis, diabetes, and recent hospitalization (less than a year) are more at risk of methicillin-resistant Staphylococcus aureus (MRSA) infection.
What Is the Treatment and Management of Ludwig’s Angina?
The preliminary objective in treating Ludwig's angina is to ensure the airway, as asphyxiation (deprivation of oxygen that may result in syncope or even death) resulting from airway obstruction is the highest occurring cause of mortality. The next steps comprise controlling the infection with intravenous broad-spectrum antibiotics and also surgical drainage in some cases of chronic infections. Nebulized adrenaline and intravenous steroids can be adjuvant treatments to improvise the condition of the facial and airway edema, and antibiotic penetration can also be used. The following steps are taken to manage Ludwig's angina:
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Management of the airway.
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Antibiotics are given intravenously.
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Steroids can be administered intravenously.
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Draining the infection with surgical means.
Surgical decompression is marked in cases of Ludwig’s angina when there is a perceptible abscess on imaging, the existence of fluctuance on examination, or when antibiotic treatment has been verified to be ineffective.
What Should Patients Know About Ludwig’s Angina?
Odontogenic infection is the highest observed cause of Ludwig's angina. Delivering safety education to patients with dental infections is important in reducing the risk of extreme complications. Red flag symptoms that may indicate the worsened stage of the infection is swelling and potentially indicating emergency management incorporates the following:
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Restrictive mouth opening.
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Submandibular bilateral swelling.
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Hot potato-like voice (a thick, muffled voice yielded by pharyngeal or laryngeal diseases.)
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The swollen and firm floor of the mouth.
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Mobility of the tongue gets restricted.
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Drooling.
Patients should know about the symptoms and risk factors to avoid the serious manifestations of the condition. Patient education and awareness may help in eradicating deaths due to Ludwig’s angina.
Conclusion:
Ludwig's angina is quickly progressive cellulitis that can rapidly induce airway obstruction. Risk factors for increased complications and mortality include people of age older than 60 years, diabetes, immunosuppression, and alcohol consumption. The condition demands immediate intervention and close and tight monitoring to avert death from asphyxiation. It can also result in mediastinitis (swelling and irritation between the area of the lungs, which is also known as mediastinum), necrotizing cellulitis of the neck, and aspiration pneumonia. Due to the rarity of the condition, many emergency physicians have little to no experience in handling Ludwig's angina. Maintaining and securing the airway is the main objective for all Ludwig's angina patients. Instantaneous participation of the anesthesiology, otolaryngology, or oral maxillofacial teams is critical to deliver the best probable outcome and assure patient safety.
