Ludwig Angina

Question 1

Ludwig definition

Answer 1

BILATERAL Infection involving the sublingual and submylophoid (submaxillary) spaces

• begins in the floor of the mouth and rapidly spreads “woody” or brawning cellulitis involving the submandibular space
• rapidly spreading cellulitis without lymphatic involvement and generally w/o abscess formation
• both submylophoid and sublingual spaces are involved

Question 2

Ludwig sx

Answer 2

Swelling of tongue, neck pain, and breathing pain 
Mouth pain, drooling, dysphasia 
Fever
Chills 
Malaise

Question 3

Ludwig pathogens

Answer 3

Viridans streptococci

• streptococci anginosus (S. milleri)
• S. constellatus
• anaerobes (abscesses originating from teeth also harbor oral anaerobes- Peptostreptococcus species, Fusobacterium nucleatum, bacteroides, and Actinomyces spp)

IMMUNOCOMPROMISED PATIENTS: gram neg aerobes also may be present
MRSA May contribute to deep neck space infections

Question 4

Ludwig Imaging

Answer 4

CT- soft tissue thickening, increased SQ fat, loss of fat planes in the submandibular space, gas bubbles within soft tissues, focal fluid collections

MRI

Question 5

Ludwig treatment

Answer 5

Airway management

Maybe dexamethasone
ABX
1) immunocompetent patients -
- Unasyn 3 g IV q6 hrs
- ceftriaxone 2g IV q12 hrs + metronidazole 500 mg IV q8 hrs
- clindamycin 600 mg IV q6-8 hrs + levofloxacin 750mg IV q24 hrs

2) immunocompromised patients
- cefepime 2g IV q8hrs + metronidazole 500 mg IV q8 hrs
- imipenem 1 g IV q6-8 hrs
- meropenem 2 g IV q8 hrs
- zosyn 4.5 g IV q6 hrs