Ludwig’s Angina

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This is a serious life threatening generalized septic cellulitis of the fascia spaces found on the floor of  the mouth and tongue. It is an extension of infection from mandibular molar teeth into the floor of the  mouth covering the submandibular, sublingual, and submental spaces bilaterally. 

Clinical presentation 

  • Brawny induration
  • Tissues are swollen, board like, not pitted and no fluctuance  
  • Respiratory distress
  • Dysphagia
  • Tissues may become gangrenous with a peculiar lifeless appearance on cutting
  • Three fascia spaces are involved bilaterally (submandibular, submental and sublingual)

Non-pharmacological Treatment 

  • Incision and drainage is done (even in absence of pus) to relieve the pressure and allow irrigation
  • Only when the airway distress is significant and there is evidence that it is not relieved by incision and drainage then tracheostomy is needed. Supportive care includes high protein diet and fluids for rehydration and detoxification. During incision and drainage pus should be taken for culture and sensitivity. Offending tooth should be removed at the same sitting if the patient can open the mouth.

Pharmacological Treatment 

B: ceftriaxone (IV) 1g 24hourly for 5days 

OR 

B: amoxicillin + clavulanic acid (FDC) (PO) 625mg 8hourly for 5days 

AND 

B: metronidazole (IV) 500mg 8hourly for 5days 

If allergic to penicillin use 

A: erythromycin (PO) 500mg 6hourly for 5days 

Once the patient can swallow, replace IV medication with oral treatment. 

Note: For  this  condition  and  other  life-threatening  oral  conditions  consultation  of  available  specialists  (especially oral and maxillofacial surgeons) should go parallel with life saving measures.