Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 3, May-July 2012518 519Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 3, May-July 2012Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 3, May-July 2012518 519Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 3, May-July 2012Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 3, May-July 2012518 519Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 3, May-July 2012

*Senior Lecturer, Dept. of Oral and Maxillofacial Surgery**Professor, Dept. of Oral and Maxillofacial PathologyReader, Dept. of Oral and Maxillofacial SurgeryReader, Dept. of Oral and Maxillofacial PathologyChettinad Dental College and Research Institute, ChennaiAddress for correspondenceDr S Vijay ParthibanE-mail: drvijayparthiban79@gmail.com

AbstrAct

Ludwigs angina is a rapidly progressing cellulitis characterized by the bilateral involvement of the submandibular, sublingual and submental spaces. It typically originates from an infected or recently extracted tooth, commonly the lower second and third molars. We present a case of Ludwigs angina in a 50-year-old man.

Key words: Induration, airway obstruction, incision and drainage

Ludwigs angina is a potentially life-threatening infection of the neck and floor of the mouth. It is a rapidly progressing cellulitis of the floor of the mouth characterized by firm induration and elevation of the tongue leading to severe airway obstruction. This was described by William Frederick Von Ludwig in 1836,1 when he presented a clinical observation and necropsy finding of a patient with the same clinical condition. He described a firm connective tissue tumefaction that extends uniformly about the periphery of the neck, under the chin region of the jaw and beyond to involve the tissues between larynx and floor of the mouth.

Criteria for accurate diagnosis of Ludwigs angina have been described by Ludwig and Grodinsky. They describe Ludwigs angina as cellulitic infection of submandibular space, usually involving more than one neck space, producing firm induration of floor of mouth and posterior displacement of tongue. It spreads by continuity along the fascial planes, then by lymphatics and rarely involves the glandular structures. The condition is known for its aggressive course, airway compromise and high mortality when not treated promptly.2-6 We report a case of Ludwigs

angina in a 50-year-old and review the presentation and management of this disease.

Case Presentation

A 50-year-old man weighing 60 kg and 165 cm in height, presented with complaints of swelling of lower- half of face and neck with difficulty in breathing and swallowing and inability to open the mouth for the past three days, and had been spitting out saliva. He had pain in the right back tooth region one week before swelling appeared. He was nil by mouth for more than eight hours. On physical examination, he had no respiratory distress, but was uncomfortable because of pain and intraoral drainage of pus. Patient was febrile (38.80 C) with the pulse rate of 106 beats/minute, blood pressure of 140/90 mmHg and a respiratory rate of 25 breaths/minute. The mouth opening was restricted with inter-incisal gap of 1 cm. There was a diffuse, tender and indurated neck swelling, warm on palpation particularly in submandibular and submental space. Neck extension was painful and limited. On intraoral examination, floor of the mouth was erythematous and indurated. Tongue was elevated from the floor of the mouth and he was not able to protrude the tongue beyond the corner of mouth, which is characteristics of Ludwigs angina.

A diagnosis of Ludwigs angina was made and he was scheduled for emergency drainage of abscess. He was admitted and observed for 10 days in the ward. Submental and sublingual incision and drainage was done and the pus was sent for culture and antibiotic sensitivity. Corrugated rubber drain was placed through

Ludwigs Angina: A Rare Case Report

S Vijay Parthiban*, R Sathish Muthukumar**, M Alagappan, M KarthiM KarthiKarthi

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Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 3, May-July 2012518 519Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 3, May-July 2012Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 3, May-July 2012518 519Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 3, May-July 2012Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 3, May-July 2012518 519Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 3, May-July 2012

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Figure 1. Photograph showing submandibular, submental swelling.

Figure 2. Restricted mouth opening, tongue protrusion.

Figure 3 and 4. Photograph showing submental incision and drain in place.

Figure 5 and 6. Photograph showing improved tongue protrusion and mouth openi ng, respectively.

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Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 3, May-July 2012520 521Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 3, May-July 2012

a submental incision. Periodontally affected 44, 47 and 48 were extracted. Empirical antibiotic regimen IV cefotaxime 1 g b.i.d., metronidazole 500 mg b.i.d, IV dexamethasone 8 mg was started immediately. The culture and antibiotic sensitivity test reported a predominant growth of Staphylococcus aureus that was sensitive to amikacin and ofloxacin. Based on the antibiotic sensitivity test, the drug regimen was altered. The patient was kept under observation for 10 days and discharged following complete recovery.

Discussion

While described as far back as the writings of Hippocrates and Galen, necrotizing fasciitis Ludwigs angina was first detailed by Wilhelm Frederick Von Ludwig in 1836.7 Ludwigs angina is a rapidly progressing cellulitis involving the submandibular, sublingual and submental space.8 Ludwigs angina is odontogenic in origin in 90% of cases. Various other causes are oral lacerations, mandible fracture and infection of oral malignant tumor. Recent infection or extraction of lower 2nd or 3rd molar are the most common cause for Ludwigs angina as their roots extend below the mylohyoid line of the mandible. To understand the pathophysiology of Ludwigs angina requires the knowledge of anatomy of submandibular space. This space is bounded superiorly by the mucosa of floor of the mouth and inferiorly by superficial layer of deep cervical fascia as it extends from hyoid bone to mandible. This space is subdivided by mylohyoid

Figure 7. Photograph of the patient on the day of discharge.

muscle into to submaxillary space below and sublingual space above. The infection spreads among both the spaces via the posterior edge of mylohyoid muscle. Further progression occurs superiorly from submaxillary space to the sublingual space producing firm induration of floor of the mouth, elevation and posterior displacement of tongue leading to airway compromise. If untreated, it can spread posteriorly along the intrinsic tongue muscles to parapharyngeal and retropharyngeal spaces, which may progress to the mediastinum.

Ludwigs angina originates from infected or recently extracted tooth, most commonly mandibular second and third molars.8 Various other causes reported are mandible fracture, submandibular sialadenitis, peritonsillar abscess, epiglottitis and oral malignancy. It begins as a moderate infection and can progress rapidly to brawny bilateral swelling of upper neck with pain, trismus and tongue elevation accompanied with dysphagia and fever. The most serious complication of Ludwigs angina is asphyxia due to expanding edema of soft tissues of neck.9 Another common cause of death is acute loss of airway during intervention to control the condition.10 Stridors, anxiety, cyanosis, sitting posture are late signs of impending airway obstruction and indicate the need for immediate airway management.3 Spread of infection to mediastinum, carotid sheath, skull base and meninges are other complications. Ludwigs angina was formerly fatal, but now with adequate medical and surgical treatment, has a reduced rate of mortality.11 Even after the advent of newer antibiotics Ludwigs still remains a potentially life-threatening infection because of the impending airway crisis.5 So, the early recognition, diagnosis and treatment of Ludwigs angina is very important. The cornerstone of medical management is the use of antibiotics active against streptococci, staphylococci and anaerobic species. Steroid therapy has been suggested as an adjunct to halt the progression of edema and prevent the need for artificial airway.

ConclusionLudwigs angina is a life-threatening infection of floor of the mouth and neck. Early diagnosis and immediate treatment is the key for successful management of Ludwigs angina. In advanced cases, securing the airway, surgical drainage and antibiotics following culture and sensitivity test are important.

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