Ludwig's Angina—A Controversial Surgical Emergency: How We Do It

Abstract

Objectives. To review the current protocols used for management of Ludwig's angina and to assess the efficacy of conservative measures in these cases. Methods. A retrospective review of patients who were admitted to our institution for management of Ludwig's angina between 2003 and 2010. Results. Two patients were identified. Both were managed successfully with conservative measures and close airway observation. None needed an emergency intubation or surgical tracheostomy. There were no mortalities, and both had a short hospital stay. Conclusion. Recently, management of Ludwig's angina has evolved from aggressive airway management into a more conservative one. This is based on close airway observation on a specialised airway unit and a serial clinical airway assessment. Improved imaging modalities, antibiotic therapy, surgical skills, and clinical experience are the key factors behind this change in practice.

“Air” on the side of caution: The importance of early recognition and intervention in Ludwig’s angina

“…[1] As shown in our case, however, with early recognition and medical intervention, escalation to tracheostomy can often be avoided. [10,11] IV steroids, application of a cool humidified face tent, and epinephrine nebulizers may also assist in controlling edema that may progress to obstruct the airway. [8] IV ampicillin-sulbactam was started immediately on presentation, though IV clindamycin or penicillin with metronidazole are alternatives.…”

Ludwig’s Angina: Emergency Treatment

“…Traditionally, aggressive airway management by securing the airway with endotracheal intubation or surgically with a surgical tracheostomy was the norm. 7 The use of intravenous steroids has been proposed as a mean of reducing soft tissue swelling and edema and minimizing the likelihood for the need of a surgical airway in Ludwig's angina. This remains controversial, as up to this date no randomized controlled trials that demonstrate the efficacy of corticosteroids in these patients exist.…”

Superior Vena Cava Syndrome vs Ludwig's Angina: A Diagnostic Dilemma

“…3 Ludwig's angina is a life-threatening cellulitis of the floor of mouth and neck; characterized by progressive submandibular swelling leading to elevation and posterior displacement of the tongue. 4,5 spreading edema may cause airway compromise.…”

“…Odontogenic infections are the source of infection in majority of the cases. 3,6 Staphylococcus, Streptococcus, and Bacteroides species are the most commonly cultured organisms. 3,7 The main stay of treatment is incision and drainage, removal of the focus of infection (most often caries teeth) and broad spectrum antibiotics.…”

“…3,6 Staphylococcus, Streptococcus, and Bacteroides species are the most commonly cultured organisms. 3,7 The main stay of treatment is incision and drainage, removal of the focus of infection (most often caries teeth) and broad spectrum antibiotics. 8 Superior vena cava syndrome is obstruction to the flow of svc leading to increases in venous pressure, interstitial edema and retrograde collateral flow.…”