This patient has Ludwig's angina, and you should begin immediate management steps for this potentially life-threatening infection by ensuring an adequate airway and treating the infection.
Ludwig's angina was first described by Wilhelm Fredrick von Ludwig in 1836 as a rapidly progressive gangrenous cellulitis of the submandibular space, which can further be divided into the sublingual space and the submylohyoid space. The sublingual space is bounded by the oral mucosa superiorly and the mylohyoid muscle inferiorly. The submylohyoid space is bounded by the mylohyoid muscle superiorly and the skin and superficial fascia of the neck inferiorly. Swelling and edema in these spaces cause the floor of the mouth to feel woody and subsequently causes the tongue to elevate and protrude upward and outward. The infection also can spread laterally and posteriorly to occlude the airway, the most serious complication.
In this patient, the precipitating event was the dental infection and subsequent dental extraction of his second mandibular molar. Other causes include fracture of the mandible, trauma to the mucosal floor of the mouth, peritonsillar abscess, oral malignancies with secondary infection, salivary gland infections, infected thyroglossal cysts, and osteomyelitis. The most common organism isolated from wound cultures is viridans streptococci although infections may be polymicrobial. Other pathogens include Staphylococcus aureus, Staphylococcus epidermidis, Bacteroides sp., Hemophilus influenzae, Klebsiella pneumoniae, and Pseudomonas aeruginosa.
Patients often present complaining of anterior neck pain and swelling with a sore throat, and they may have fevers and chills. As the source is often dental caries and abscess, they may complain of prior tooth and jaw pain. Patients may report dysphagia, odonophagia, and dysarthria, may have pain in the floor of the mouth, and may feel it is difficult to handle their secretions. Patients may report trismus as the muscles of mastication become irritated. As the degree of edema increases, patients will feel short of breath.
On physical exam, patients are often febrile and may be tachypneic, tachycardic, and hypoxic, all signs of impending airway collapse. Patients may assume an upright position and sit forward with the neck extended. There may be drooling. If the patient is able to open his mouth, there may be dental caries with surrounding edema and tenderness. The tongue is elevated from the floor of the mouth. The floor of the mouth is tender and swollen, and is described as being woody in consistency.
The swelling and induration of the anterior neck, described as brawny edema, begins under the mandible and extends down to the level of the hyoid bone. A discrete fluctuant abscess will not be appreciated after causing the clinician to mistakenly consider this as a minor dental infection. There may be subcutaneous emphysema if the organism involved is gas producing. There is usually no associated lymphadenopathy.
The most important feature in the management of Ludwig's angina is maintaining a patent airway. Patients should be placed on the cardiac monitor with continuous pulse oximetry and given supplemental oxygen. Close observation is required because their airway can rapidly occlude. If tachypnea, hypoxia, or stridor develop, the patient's airway will need to be secured. Fiberoptic-guided nasotracheal intubation is the preferred method if available. The degree of airway obstruction may not permit intubation and a tracheostomy may be required.
Patients should have blood sent for a complete cell count and blood culture. A lateral neck radiograph may demonstrate soft tissue swelling, subcutaneous air, and occlusion of the airway. For those patients who are hemodynamically stable and with minimal complaints, a CT scan with IV contrast may be done to localize the degree of tissue involvement and abscess formation. Because airway compromise may develop rapidly, patients should be accompanied by an appropriate health care provider and monitored at all times.
IV antibiotic treatment with ampicillin-sulbactam or piperacillin-tazobactam in addition to metronidazole for anaerobic coverage is sufficient. Clindamycin alone may be used in patients allergic to penicillin.
The role of corticosteroids is controversial. Surgical drainage may be required. Because this is not a discrete abscess that can be cured by simple I&D, an appropriate surgeon (ENT, dental) should be consulted in all cases of Ludwig's angina. Multiple drains are often required. In general, these patients should be admitted to an intensive care setting for continuous airway monitoring. They can decompensate rapidly. Complications include aspiration, pneumonia, empyema, mediastinitis, pericarditis, carotid artery or internal jugular vein thrombosis or erosion, and sepsis.