Indian Journal of Basic and Applied Medical Research; March 2015: Vol.-4, Issue- 2, P.

266-269

Case Report:

Ludwigs angina: a case report and review of airway management

options
DR. ANISHA NAGARIA1, DR. ANURADHA MALLIWAL2, DR.C.M. DOSHI3 , DR. MUKUL PADHYE4

1P.G.

STUDENT , 2ASSOCIATE PROFESSOR , 3PROFESSOR, DEPARTMENT OF ANAESTHESIOLOGY, D.Y. PATIL

UNIVERSITY SCHOOL OF MEDICINE, NERUL, NAVI MUMBAI, MAHARASHTRA, INDIA

4PROFESSOR AND

HOD, DEPARTMENT OF OMFS, D.Y.PATIL SCHOOL OF DENTISTRY, NERUL, NAVI MUMBAI,

MAHARASHTRA, INDIA
Corresponding author: DR.Anisha Nagaria

Abstract:
Ludwig's angina is a rare, but potentially life-threatening, diffuse cellulitis of the neck and the floor of the
mouth, usually secondary to odontogenic infection. It has an acute onset and spreads rapidly,affecting the deep
spaces of the neck and leading to oedema, distortion and obstruction of the airway.Early diagnosis and
immediate treatment are essential to avoid complications. The appropriate use of antibiotics, airway protection
techniques, and formal surgical drainage of the abscess remains the standard protocol of treatment in cases of
Ludwig's angina.We report a case of a 65 year old male, diagnosed with Ludwigs angina ofodontogenicorigin,
which later got complicated with necrotising fasciitis, along with a review of the available airway management
options during surgical drainage.
Keywords: Ludwig's angina, odontogenic infection, surgical drainage, airway management

Introduction

inability to open the mouth since eight days. He

Ludwig's angina, first described in 1836, is a

had difficulty in breathing and swallowing since

rapidly progressive, gangrenous cellulitis of the

two days.

floor of the mouth and bilateral submandibular and

He gave history of recurrent dental infection since

sublingual regions, leading to progressive and often

two

months.On

examination,

he

had

fatal airway obstruction .It is characterised by

fever(101F),tachycardia(heart rate110/min), blood

fever,malaise,dyspnoea,

pressure140/90

dysphagia

and

tender,hard, indurated swelling of the neck and the

1

mmHg,

tachypnoea

(25breaths/min), restricted mouth opening (inter-

floor of the mouth .Early stages of the disease can

incisordistance1.5cm). Extra-oral swelling was

be controlled with intravenous antibiotics, but

indurated, nonfluctuant, extending over subma-

advanced infections necessitate surgical drainage.

ndibular

Pain,

trismus,

displacement

airway
make

oedema
securing

and

sublingual

glands

bilaterally.

and

tongue

Extension and flexion of neck were restricted due

the

airway

to pain.Systemic examination and routine blood

challenging.

investigations were unremarkable,except leuco-

Case report

cytosis.Emergency surgical drainage of neck

A 65-year male, weighing 75 kg presentedwith pain

abscessunder local anaesthesia with intravenous

and swelling in the lower jaw and neck and

sedation was planned.

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Indian Journal of Basic and Applied Medical Research; March 2015: Vol.-4, Issue- 2, P. 266-269

Anticipating airway difficulty, difficult airwaycart

tocauseabrawny supra-hyoid induration2. Dental

was kept ready.Procedure was explained to the

infection (especially affecting the second and third

patient,high

lower molar teeth) is responsible for approximately

risk

tracheostomy

consent

taken.

andconsent

Aspiration

for

prophylaxis,

80%

of

the

cases3.

Other

causes

include

dexamethasone and adrenaline nebulisationgiven

sialadenitis, peritonsillar abscess, open mandibular

30minutes pre-operatively and intravenous broad-

fractures, trauma, tongue piercing, compromised

spectrum

ASA

immune status, sickle cell disease, etc2,4,5,6. The

monitors wereattached, head-up position and

causative organisms usually are -haemolytic

oxygen through nasal prongs given.

streptococci, staphylococci and bacteroides group2.

After

antibiotics

started.Standard

premedication

with

intravenous

inj.

The initial stages of the disease are treated with

glycopyrrolate 0.2mg, inj. hydrocortisone 100mg

intravenous broad spectrum antibiotics(typically,

andincremental doses of inj.midazolam andinj.

combinations

fentanyl,aspiration with 18G needle revealed pus.

metronidazole)

of

penicillin

and

clindamycin,

steroids,

but

and

advanced
8

8ml of 2% lignocaine with adrenaline(1:200,000)

infections require surgical drainage . Use of

was

the

antibiotics has reduced the mortality from 54% to

swelling, stab incisions made in submandibular and

0-8.5%4. Hyperbaric oxygen therapy is indicated in

submental spaces bilaterally and pus drained.Pus

severe infections like necrotizing fasciitis7.

trickling into the oral cavity was immediately

Various anaesthetic techniques suggested for the

sucked out. The wound was irrigated with normal

drainage of abscess include local infiltrative

saline

was

anaesthesia, cervical plexus block and general

inserted.Infected molars were removed under local

anaesthesia. Choice of anaesthesia depends on

anaesthesia.

severity of disease and available resources. There is

Intra-operatively, vitals were stable.SpO2remained

no consensus regarding airway management in

between 95-100%. Patient was able to obey verbal

such cases airway associated with neck swelling

commands

and restricted mouth opening.Airway may be

infiltrated

and

circumferentially

separate

around

tube

drain

and upper airway reflexes were

preserved.Analgesia

was

supplemented

with

secured

by

tracheostomy,

conventional

inj.paracetamol1g and inj.diclofenac75mg intrave-

laryngoscopy and intubation, awake blind nasal

nous infusion. Patient was comfortable and

intubation and awake fibre-optic intubation 8. The

swelling

method

subsided

postoperatively.

On

tenth

preferred

depends

on the available

postoperative day, patient developed necrotizing

resources and the personal experience of the

fasciitis,which was successfully treated with eight

anaesthesiologist. However, emergency surgical

cycles

airway access like cricothyrotomy/ tracheostomy

of

hyperbaric

oxygen

therapy

and

antibiotics. Patient recovered well.

should always be ready.

Discussion

Conventional laryngoscopy and intubation is

progressive,

difficult due to limited mouth opening,oedema in

potentially lethal cellulitis of the soft tissues of the

neck, distorted anatomy, tissue immobility and

neck and floor of the mouth.Beginning in the

chances of rupture of the abscess9 resulting

vicinity of submandibular space,it spreads in

aspiration ofblood, pus and secretions, if airway is

Ludwigs

continuity

angina

rather

is

than

rapidly

bylymphatic

in

spread

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Indian Journal of Basic and Applied Medical Research; March 2015: Vol.-4, Issue- 2, P. 266-269

not secured. Securing the airway in the awake state

Ludwigs

therefore, is the safest option.

challenge, due to difficulty in administering local

Blind nasal intubation should be avoided due to

infiltrative anaesthesia.Arun k. Gupta etalreported

high failure rate and risk of laryngospasm, airway

use of cervical plexus block in such patients9.It can

oedema, catastrophic bleeding and drainage of pus

be a safe alternative in adult patients, too.

angina

in

children

poses

special

into the oral cavity . Complete airway obstruction

Recent trend in terms of management in cases of

may necessitate an emergency cricothyrotomy.

Ludwigs angina has evolved from aggressive

Elective tracheostomy under local anaesthesia was

airway management into a more conservative

considered gold standard for establishment of a

one14.In a retrospective analysis of all deep neck

definitive airway. However, anatomical distortion

abscesses within a seven year period conducted by

of the

Wolfe

anterior

neckmay make it

difficult

10

et

al,65%

patients

had

airway

/impossible in advanced cases .Further,there is risk

compromise,42% of which required advanced

of spread of infection to the thorax/mediastinum,

airway control techniques.No surgical airway was

rupture of innominate artery, aspiration of pus, loss

required.

11,12

of airway and tracheal stenosis

Awake fibre-optic intubation(FOB)with topical

10

Our patient had severely restricted neck extension

and limited mouth opening due to huge painful

anaesthesia has high successrate in skilled hands,

swelling over neck. Due to unavailability of fibre-

though distorted anatomy, airway oedema and

optic bronchoscope and intentional avoidance of

secretions make it challenging. CO2 monitoring

elective tracheostomy, surgical drainage (extra-

during FOB is difficult andcan be overcome by use

orally) was planned under local anaesthesia with

of awakefibrecapnic intubation (AFcI), wherein a

intravenous

suction catheter advanced through the working

preserved, patient could cough out the pus that

channel of the bronchoscopeallows repeated CO2

drained intra-orally during the surgery.

13

sedation.

Airway reflexes

measurements .

Multidisciplinary

Intravenous dexamethasone and adrenaline nebul-

meticulouspre-operative

isationreduce upper airway oedema andairway

tcooperation, proper planning and preparation of

irritation duringanaesthesia .

team

being

approach,
counselling,

with
patien-

anaesthesia technique are key to successful

outcome.

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