A 39-year-old man with no chronic medical problems presented with three days of tooth pain and swelling to his right jaw with associated chills. He reported no recent facial or dental trauma, and he had no difficulty breathing, speaking, or swallowing but said the pain had prevented him from eating that day.
The patient was afebrile with normal vital signs. He had moderate right submandibular tenderness, edema, and erythema with a carious and tender tooth #31. He also had moderate edema to the sublingual space.
He was speaking in full sentences with no changes in phonation. He had no trismus, drooling, or stridor at presentation, but the submandibular and sublingual swelling progressed over three hours in the ED while awaiting consultation by oral and maxillofacial surgery and a contrast CT of the neck.
He subsequently developed a muffled voice and severe trismus, and his tongue was elevated. Labs were notable for a white blood cell count of 32,500 cells per cubic millimeter. The patient's CT revealed phlegmonous changes of the sublingual space with a large submandibular abscess. How would you manage this patient in the ED?
Find a case discussion on the next page.
Diagnosis: Ludwig Angina Complicated by Submandibular Abscess
Ludwig angina is a life-threatening cellulitis involving the submandibular space and the floor of the mouth that can rapidly lead to airway obstruction. It is most often caused by disease of the lower molars, although less common causes include peritonsillar abscess, mandibular fracture, sialadenitis, and tongue piercing.
The infection is classically polymicrobial, and causative organisms include oral anaerobes, Streptococcus, Escherichia coli, Enterococcus, and even methicillin-resistant Staphylococcus aureus and Klebsiella in immunocompromised patients. (Am J Emerg Med. 2021;41:1; https://bit.ly/3WppSp4.) Ludwig angina can progress to abscess or spread to adjacent structures including the parapharyngeal and retropharyngeal spaces and the mediastinum. Left untreated, it has a mortality approaching 50 percent, although a recent study reported that modern antibiotics, airway techniques, and surgical management have reduced fatalities to less than one percent. (Laryngoscope. 2019;129:2041; https://bit.ly/3ZPpNhm.)
Patients often present with pain and swelling of the jaw or neck, dysphagia, and drooling along with fever and malaise. External exam findings include symmetric, tense swelling, and induration of the submandibular space. Oropharyngeal exam may show edema and elevation of the oral floor with an enlarged, lifted tongue. Trismus and stridor are late findings signaling impending airway compromise. (Am J Emerg Med. 2021;41:1; https://bit.ly/3WppSp4.)
Diagnosing Ludwig angina is clinical, but a CT of the neck with contrast can be useful in early cases or to assess for drainable fluid collections when safe to do so. Routine laboratory studies have limited utility in the diagnosis, but blood cultures should be obtained.
The most important step for ED management of Ludwig angina is airway assessment. Patients with significant oral swelling, stridor, dyspnea, hypoxia, or other concerns for airway compromise should be intubated for airway protection. The optimal intubation technique will depend on resource availability and should be guided by a difficult-airway algorithm.
Standard direct laryngoscopy has a high rate of failure in Ludwig angina because of oral swelling, so an awake, upright fiberoptic nasotracheal intubation with adequate topical anesthesia such as nebulized or atomized lidocaine is a common primary strategy. (Am J Emerg Med. 2021;41:1; https://bit.ly/3WppSp4.)
A sedative agent may also be required. Preparing for possible intubation failure should include marking landmarks for cricothyrotomy if not too distorted by infection, and otolaryngology should be consulted for a potential emergent tracheostomy. Supraglottic airways are unlikely to be helpful because of anatomical distortion and difficulty inserting past the tongue. (Anesth Prog. 2019;66:103; https://bit.ly/3GPtXx7.)
All patients should be started on broad-spectrum parenteral antibiotics to cover oral anaerobes and gram-negative bacteria. Ampicillin-sulbactam or ceftriaxone plus metronidazole can be used in immunocompetent patients. Clindamycin monotherapy is no longer recommended for patients allergic to penicillin because of resistance, so levofloxacin should be added. Cefepime plus metronidazole or piperacillin-tazobactam can be used for immunocompromised patients. Vancomycin should be added for patients at-risk for MRSA, including patients with diabetes, those on dialysis, intravenous drug users, and residents of long-term care facilities. (Am J Emerg Med. 2021;41:1; https://bit.ly/3WppSp4.)
Treatment includes IV steroids and inhaled racemic epinephrine in addition to antibiotics. The use of steroids—commonly dexamethasone 10 mg IV—to reduce airway inflammation and allow increased antibiotic penetration has limited evidence, yet is backed by expert recommendations. Inhaled racemic epinephrine is sometimes used to improve airway edema, although the extent of its benefit is uncertain. Early surgical intervention may reduce the need for intubation. (Am J Emerg Med. 2021;41:1; https://bit.ly/3WppSp4.) Consider prompt transfer to a higher level of care if otolaryngology or oral and maxillofacial surgery is unavailable.
Our patient was started on IV ampicillin-sulbactam in the ED. His airway was still patent for transport, but he was quickly taken to the operating room because of how rapidly his disease progressed. The otolaryngologist successfully intubated him via nasotracheal route before the oral and maxillofacial surgery team performed an incision and drainage with washout, as well as dental extractions. The patient was extubated two days later and discharged five days after that.
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Dr. Barrettis an emergency medicine resident physician at LAC + USC Medical Center. Dr. Burkholderis an assistant professor of clinical emergency medicine at the Keck School of Medicine at the University of Southern California. Follow him on Twitter@tayburkholder. Read past Quick Consult columns athttp://bit.ly/EMN-QuickConsult.