Ludwig’s Angina

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Description

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.

Signs and Symptoms

  • Brawny induration
  • Tissues are swollen, board like, not pitted and no fluctuance
  • Respiratory distress
  • Dysphagia

Treatment

Supportive

  • Quick assessment of airway
  • 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

  • Benzylpenicillin 1 to 2 MIU (600mg to 1200 mg) by IV injection 6 hourly for 5 days

OR

  • Amoxicillin + clavulanic acid 625mg (PO) 8 hourly for 5 days AND
  • Metronidazole 500mg IV 8 hourly for 5 days
  • If allergic to penicillin use A: Erythromycin (PO) 500mg 6 hourly for 5 days

OR

  • Ceftriaxone 1g-2g IV once a day for 5 days in case of severe infection

Once the patient is able to swallow replace IV medicines with oral treatment