Ludwig's angina - floor of mouth infection

Introduction

Ludwig's angina is a rapidly progressive, bilateral, gangrenous floor of the mouth cellulitis which can cause airway compromise as well as sepsis and is a medical emergency
involves 3 compartments of the floor of the mouth: sublingual, submental, and submandibular
may spread to spread to retropharyngeal spaces and down to mediastinum
may be complicated by Lemiere's syndrome
1st described by Wilhelm Friedrich von Ludwig, who described it in 1836
the word “angina” is derived from the Latin for “choking”

presence of trismus with inability to open incisors > 1-2cm, or floor of mouth swelling, or swollen tongue, or features of airway compromise should suggest emergent CT scan

90% result from dental infections (usually apical abscesses) of the lower molars - usually 2nd or 3rd ¹⁾
less common etiologies include:²⁾
- oral piercing or laceration
- mandibular fracture
- traumatic intubation
- osteomyelitis
- peritonsillar or parapharyngeal abscess
- submandibular sialadenitis
- otitis media
- infected thyroglossal cysts

poor oral hygiene
- dental caries
- periodontitis
- oral malignancy
recent dental procedures
recent dental traums
immunocompromise:
- diabetes
- chronic alcohol abuse
- malnutrition
- HIV / AIDS
IV drug use

tender swelling of floor of the mouth which may feel “woody” or have crepitus
+/- hot potato voice
+/- unable to protrude tongue
+/- bull neck appearance
+/- fever
+/- trismus
+/- airway compromise if severe trismus or inability to swallow, or sitting in tripod position to assist breathing

emergent CT scan - may need to include chest as it may track down into mediastinum to cause mediastinitis

manage airway as indicated - keep sitting upright
blood cultures and usual bloods
broad spectrum IV antibiotics with anaerobe cover
- eg. IV benzylpenicillin plus IV metronidazole
IV 8mg dexamethasone 6hrly for 1st 48hrs
emergent ENT referral for possible drainage

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