Ludwig’s Angina/Cervico-Facial Abscess
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It is a spreading infection originating usually from a molar tooth into the fascial spaces of the sub-lingual, sub-mandibular and para-pharynx. This happens when a periapical abscess erodes through the lingual cortical plate of the mandible and gains access to these neck fascial spaces. The infection can then track down and enter the thorax. Another source of infection is the tonsillar crypt abscess. The initial presentation with swelling of the floor of the mouth and spread, with upper neck involvement is termed Ludwig’s angina. As it spreads down the neck, the term cervico-facial abscess is used. This condition is an emergency and must be treated as such.
Cause
- Odontogenic infection
- α-haemolytic Streptococci
- Staphylococci
- Bacteriodes
- Tonsillar crypt abscess
Symptoms
- Facial swelling with floor of the mouth elevated with oedema
- Protruding tongue
- Drooling of saliva
- Fever
- Chills
Signs
- Tense and tender jaw swelling
- Board-like firmness of jaw swelling
- Severe systemic upset
- Raised floor of the mouth with limitation of mouth-closing and saliva drooling
- Dehydration
Investigations
- FBC
- BUE/CR
- X-ray of jaw
TreatmentTreatment Objectives
- To treat the infection
- To prevent dehydration
- To control fever and pain
Non-pharmacological treatment
- Adequate hydration
- Intubation if airway obstruction present
- Incision and drainage as appropriate
- Extraction of tooth if it is the source of infection
Pharmacological treatment
For treatment of infection in patients unable to swallow and toxaemic
1st Line Treatment
Evidence Rating: [B]
- Amoxicillin + Clavulanic Acid, IV,
Adults
1.2 g 8 hourly for 7-10 days
Children
3 months-18 years; 30 mg/kg 8 hourly (max. 1.2 g 8 hourly for 7-10 days)
< 3 months; 30 mg/kg 12 hourly for 7-10 days
And
- Ceftriaxone, IV,
Adult
2 g daily for 7-10 days,
Children
All ages 25 mg/kg 12 hourly (max. 75 mg/kg daily)
2nd Line Treatment
Evidence Rating: [B]
- Clindamycin, IV,
Adults
300-600 mg 6 hourly for 7-10 days
Children
3-6 mg/kg 6 hourly for 7-10 days
And
- Ceftriaxone, IV,
Adult
2 g daily for 7-10 days
Children
All ages 25 mg/kg 12 hourly (max. 75 mg/kg daily)
3rd Line Treatment
Evidence Rating: [C]
- Procaine Penicillin, IM,
Adult
600,000-1,000,000 units daily
Children
> 27 kg; 600,000 units daily
< 27 kg 25,000-50,000 units/kg daily
Neonates; not recommended
And
- Gentamicin, IV,
Adults
40-80 mg 8 hourly for 7-10 days
Children
1-12 years; 2.5 mg/kg 8 hourly for 7-10 days
< 1 year; 2.5 mg/kg 12 hourly for 7-10 days
And
- Metronidazole, IV,
Adults
500 mg 8 hourly for 7-10 days
Children
7.5 mg/kg 8 hourly for 7-10 days
Referral CriteriaRefer to the specialist as soon as possible.