Ludwigs Angina

Question 1

What is Ludwig’s Angina?

Answer 1

A rapidly progressing, life-threatening bacterial infection of the submandibular, sublingual, and submental spaces, typically originating from an infected tooth.

Question 2

What are the common spaces affected in Ludwig’s Angina?

Answer 2

The submandibular space, including the sublingual and submental spaces.

Question 3

What is the most common cause of Ludwig’s Angina?

Answer 3

Odontogenic infections, particularly from the second or third molar teeth.

Question 4

Name common pathogens associated with Ludwig’s Angina.

Answer 4

Streptococcus viridans, Staphylococcus aureus, Bacteroides, and Fusobacterium.

Question 5

List three key symptoms of Ludwig’s Angina.

Answer 5

Rapid neck swelling, difficulty breathing, and tongue elevation.

Question 6

What type of antibiotics are used to treat Ludwig’s Angina?

Answer 6

Broad-spectrum intravenous antibiotics covering both aerobic and anaerobic bacteria, such as penicillin + metronidazole, clindamycin, or ampicillin-sulbactam.

Question 7

What are some serious complications of Ludwig’s Angina?

Answer 7

Mediastinitis, sepsis, and necrotizing fasciitis.

Question 8

Diagnostic tools

Answer 8

1. CT scan with contrast (neck):
   This is the gold standard for assessing the extent of infection, abscess formation, and involvement of deep neck spaces.
2. Laboratory Tests:
   Complete Blood Count (CBC):
   To assess for leukocytosis (increased white blood cells), indicating infection or sepsis.
   C-Reactive Protein (CRP):
   A marker of inflammation and infection severity.
   Erythrocyte Sedimentation Rate (ESR):
   Another inflammatory marker that can be elevated in infection.
   Blood cultures:
   To identify the causative organism, especially if bacteremia or sepsis is suspected.
   Electrolytes, renal and liver function tests (BMP or CMP):
   To evaluate the patient’s overall health and organ function, especially important if intravenous medications or prolonged treatments are needed.

Question 9

Admission notes

Answer 9

Patient Information:
- Name: [Patient’s Name]
- Age: 12 years
- Weight: 34 kg
- Gender: [Male/Female]
- Date of Admission: [Date]
- Reason for Admission: Ludwig’s Angina (severe neck swelling, potential airway compromise)

Chief Complaint:
- “Neck swelling and difficulty breathing for [duration, e.g., 2 days].”

History of Present Illness (HPI):
- 12-year-old child presented with a 2-day history of rapidly progressive, painful swelling in the submandibular region.
- Associated symptoms include:
- Difficulty breathing
- Dysphagia (difficulty swallowing)
- Trismus (jaw stiffness)
- Drooling
- No recent trauma or fever reported [or describe if present].
- Recent history of dental infection involving the lower molars.

Past Medical History:
- [Document relevant medical history here—e.g., asthma, allergies].
- No known drug allergies.

Medications:
- [List any medications the patient is currently taking].

Allergies:
- NKDA (No Known Drug Allergies) [or specify any allergies].

Family/Social History:
- Non-contributory (or specify any relevant details).

Physical Examination:
- General: Alert, but in mild respiratory distress.
- Vital Signs:
- Temperature: [e.g., 38°C]
- Heart rate: [e.g., 110 bpm]
- Blood pressure: [e.g., 115/70 mmHg]
- Respiratory rate: [e.g., 22/min]
- Oxygen saturation: [e.g., 94% on room air]
- Head and Neck:
- Bilateral submandibular swelling extending to the floor of the mouth.
- Tongue elevation with poor mobility.
- Trismus present.
- Drooling noted.
- Respiratory: Airway sounds slightly muffled; no audible stridor.
- Cardiovascular: Heart sounds normal.
- Abdomen: Soft, non-tender.
- Neurological: Alert and oriented.

Diagnosis:
- Ludwig’s Angina, likely odontogenic in origin (suspected dental infection).

Plan:

1. Airway Management:
   
   • Immediate ENT consult for airway assessment.
   • Consider bedside laryngoscopy or fiberoptic evaluation if there is a risk of airway compromise.
   • Prepare for intubation or tracheostomy if respiratory distress worsens.
2. Antibiotic Therapy (IV):
   
   • Ampicillin-Sulbactam 1,700 mg IV every 6 hours
     OR
   • Clindamycin 450 mg IV every 8 hours (if penicillin allergy).
   • Metronidazole 340 mg IV every 8 hours (for anaerobic coverage if needed).
   • Adjust antibiotics based on culture results and clinical response.
3. Laboratory Tests:
   
   • CBC with differential.
   • CRP and ESR to monitor inflammation.
   • Blood cultures.
   • BMP/CMP to assess organ function.
4. Imaging:
   
   • CT scan of the neck with contrast to assess the extent of infection and rule out abscess formation.
5. Surgical Management:
   
   • Consider incision and drainage if abscess is identified on imaging.
   • Consult Oral Maxillofacial Surgery (OMFS) for dental source management.
6. Fluids and Supportive Care:
   
   • IV fluids: Start normal saline at maintenance rate.
   • Pain control: IV paracetamol or NSAIDs.
   • Monitor for sepsis: Frequent vital signs, strict input/output monitoring.
7. Nutritional Support:
   
   • NPO (nothing by mouth) until airway and swallowing are fully assessed.
   • Consider NG tube if prolonged NPO status is expected.
8. Monitoring:
   
   • Admit to a monitored bed (ICU if airway concerns are significant).
   • Monitor oxygen saturation, respiratory effort, and airway status closely.
   • Frequent reassessments by ENT and pediatric team.
9. Follow-up:
   
   • Daily clinical reviews.
   • Repeat labs (CBC, CRP) after 48 hours to assess response to treatment.
   • Update plan based on imaging and clinical progress.

Disposition:
- Admission to pediatric ICU or step-down unit for close airway monitoring and IV antibiotics.

This admission note covers the key details for managing a child with Ludwig’s angina and ensures that airway protection, infection control, and monitoring are prioritized.