LUDWIG'S ANGINA

Question 1

Approach to the Critically Ill Ludwig’s Angina

Answer 1

Monitor
Oxygen
Vitals
IV Access
Equipment: Airway

AIRWAY
Rapid Bedside Assessment:
Drooling
Voice change
Stridor
Inability to speak
Tripod or sniffing positioning
Hypoxia
Swelling of the posterior oropharynx
Inability or unwillingness to lie flat

Position upright, head tilt / chin lift

Secure Airway in patients with impending airway obstruction

Awake / Nasal Intubation if Limited oral access

Fiberoptic Visualization > Video Laryngoscopy > Direct

Prepare for surgical airway PRIOR to non-surgical airway

Dexamethasone 10 mg
OR
Methylprednisone 125 mg

Serial Airway Assessment

Abx: Peds
Ampicillin-sulbactam 50 mg/kg intravenous every 6 hours (maximum dose 3,000 mg)

Clindamycin 15 mg/kg intravenous every 8 hours (maximum dose 900 mg)

Piperacillin-tazobactam (dose by age):
Age 2 months to 9 months: 80 mg/kg/dose (based on piperacillin component) intravenous every 8 hours (maximum dose 3,000 mg piperacillin)
Age >9 months, children, and adolescents weighing <40 kg: 100 mg/kg/dose (based on piperacillin component) intravenous every 6 hours (maximum dose 4,000 mg piperacillin)
Children and adolescents weighing >40 kg: 4,500 mg piperacillin intravenous every 6 hours

Abx: Adults
Pip-Tazo 3.375 g IV q 6 hr
OR
Clindamycin 900 mg IV q 8 hr

Urgent ENT Consult for further visualization/urgent nasopharyngeal scope/laryngoscopy in stable patients

BREATHING
Administer supplemental oxygen as needed for hypoxia and pre-oxygenation

CIRCULATION
Bolus 30 ml / kg Crystalloid if needed

Question 2

Critical DDx

Answer 2

Angioedema
Bacterial Tracheitis
Diphtheria
Epiglottitis
Lemierre Syndrome
Ludwig Angina
Mononucleiosis
Peritonsillar Abscess
Retropharyngeal Abscess
Uvulitis

Question 3

History & Physical

Answer 3

Tongue Elevation
Trismus and Protrusion
Brawny Neck
Drooling

Question 4

Investigations

Answer 4

Clinical Diagnosis

Consider CT or Ultrasound

Question 5

Disposition

Answer 5

Admission

Emergent ENT Consult