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.