Ludwig Angina

Securing the airway is the whole case - Airway first, before imaging and before antibiotics. Act before stridor or cyanosis appear — those are late findings, not warnings. Once the airway is secure, a neck CT with IV contrast defines the extent and looks for abscess.

Awake, seated, flexible nasotracheal - The favored technique is awake flexible nasotracheal intubation with the patient sitting up, using a flexible intubating endoscope. It takes an experienced operator; if that operator is not available, a surgical airway becomes the plan rather than the backup.

Surgical airway ready before you touch anything - Arrangements for cricothyrotomy or tracheostomy must be in place before any airway attempt, with the surgeon present and the neck prepped. In advanced infection, awake tracheostomy is a primary option and has been done under bilateral superficial cervical plexus block.

No blind nasal intubation - Passing a tube without a view can cause bleeding, rupture an abscess, worsen the edema, and trigger laryngospasm. Do not do it here.

A supraglottic device will not rescue you - SGAs get displaced as the swelling progresses and are to be avoided in this condition. Do not build a plan that ends in one.

Mask ventilation and oral airways are unreliable - Neck swelling complicates mask ventilation and the elevated tongue plus trismus blocks an oral airway. Preoxygenate by whatever route works, and give supplemental oxygen the moment they are hypoxic.

Read the stage off the exam - Tripod positioning, drooling, and dysphagia mean respiratory involvement. Trismus means the infection has reached the parapharyngeal space — more advanced disease. The rest of the picture is floor-of-mouth swelling with tongue elevation, brawny submental induration, a "bull neck" with loss of the mandibular angle, hoarse voice, and stiff neck, typically without lymphadenopathy. Point-of-care ultrasound can help assess the floor of the mouth and the airway.

Medical adjuncts - IV steroids and nebulized epinephrine are used to reduce facial and airway edema and improve antibiotic penetration. Broad-spectrum IV antibiotics follow airway control, not the other way around.

Cover the right organisms - The infection is polymicrobial oral flora: Staphylococcus, Streptococcus, Peptostreptococcus, Fusobacterium, Bacteroides, and Actinomyces. Streptococcus anginosus progresses faster than the rest. More than half of diabetic patients grow Klebsiella pneumoniae, and diabetes, hemodialysis, or hospitalization within the past year raises MRSA risk.

Know who gets this - Most patients were previously healthy, but diabetes, alcoholism, malnutrition, poor oral hygiene, recent dental treatment, and immunosuppression from AIDS or transplant all predispose. In children the usual precursor is an upper respiratory infection. Less common routes in are oral piercing or laceration, mandibular fracture, and traumatic intubation.

Plan a delayed extubation - The edema that made intubation hard is still there when the case ends. The airway you hand back is the one you have to get again if it fails, so leave the tube in and let the swelling settle before you commit.

Complications that bring them back - Aspiration pneumonia, carotid sheath abscess or arterial rupture, and descending mediastinitis from spread into the superior mediastinum.

Ludwig angina is a rapidly progressive cellulitis of the floor of the mouth involving all three compartments — sublingual, submental, and submandibular. Over 90% of cases start as a periapical abscess of a mandibular second or third molar. The roots of those molars sit below the mylohyoid attachment, which is precisely what lets the infection cross into the submandibular space.

It is not a drainable abscess. It is a woody, non-fluctuant cellulitis that enlarges and elevates the tongue, pushing it up and back. Edema of the epiglottis, aryepiglottic folds, and vocal cords can appear within half an hour of presentation, and the infection tracks along the styloglossus into the parapharyngeal and retropharyngeal spaces and the superior mediastinum.

Airway obstruction is the leading cause of death. Mortality exceeded 50% before antibiotics and sits around 8% today.