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LUDWIG'S ANGINA

Ludwig's angina is an infection of the submandibular region, manifested by swelling of the floor of the mouth, and elevation and posterior displacement of the tongue. A brawny edema and cellulitis of the suprahyoid region of the neck develops later.

Deep neck abscesses such as Ludwigs angina are less common now than 50 years ago because of the development of effective antibiotics and improved dental care. Deep neck infections in the antibiotic era most commonly result from odontogenic infections.

The most common predisposing factors for the development of Ludwig's angina are carious and abscessed teeth, periodontal disease, and extractions of the lower molars. Uncommon etiologies include upper respiratory infections, floor-of-mouth trauma, mandibular fractures, and sialadenitis. The second and third mandibular molars have roots which lie at the level of the mylohyoid muscle, either adjacent to or below the submandibular space. Abscesses of these lower molars may perforate the mandible and spread into the submandibular and submental spaces, leading to Ludwig's angina.

All age groups may be affected, but young adults have the highest prevalence rates. The disease is unusual in children. Comorbid conditions predisposing to Ludwig's angina have included diabetes mellitus, malnutrition, alcoholism, neutropenia, lupus erythematosus, aplastic anemia, and glomerulonephritis. Symptoms may persist for several days before the patient seeks medical attention. Oral and neck pain, dental pain, neck swelling, odynophagia, dysphagia, dysphonia, trismus, and tongue swelling are the most common presenting features of Ludwig's angina. Adenopathy is not associated with the disease. The infection begins unilaterally.

The patency of the airway is the main concern with Ludwig's angina, and patients often will require a tracheotomy to prevent or correct airway obstruction. Intravenous antibiotic therapy and selective application of surgical drainage are the other two treatment measures. Although some authors advocate tracheotomy in all cases, Hart believes that awake fiberoptic endotracheal intubation can be accomplished in patients without signs of airway compromise. Management should occur in the intensive care unit to allow for constant monitoring.

Although Ludwig's angina had been associated with mortality greater than 50% in the pre-antibiotic era, some recent series have reported no deaths associated with the disease. Broad-spectrum antibiotics may be chosen initially to combat the typically polymicrobial nature of the infection, but high-dose penicillin (12 million to 20 million U daily for adults, 300,000 U/kg/d for children) still remains a good agent for most oral infections. Clindamycin is acceptable for patients allergic to penicillin. Streptococci, staphylococci, and bacteroides.

In the pre-antibiotic era, surgical drainage of the submandibular space was the recommended treatment for all cases of Ludwig's angina. Incisions into the submandibular space were used to

Infections of the submandibular space may spread to the lateral pharyngeal and retropharyngeal spaces. From the retropharyngeal space, the infection can dissect down fascial planes to the mediastinum. Aspiration of infectious particles and septic embolism to the pulmonary vasculature are other possible modes of extension to the chest.

Cutaneous fistulas arising from chronic dental infections are uncommon, but periapical dental abscesses are the most common cause of suppurative cutaneous lesions of the face and neck.  The fistulous pathway develops as the chronic inflammation erodes through the cancellous alveolar bone, perforates the cortical plate and periosteum, and spreads into the surrounding soft tissues. F1 The diagnosis is often obscured because there is generally a chronic asymptomatic dental infection and the skin lesion is mistakenly thought to arise locally.

The differential diagnosis of suppurative lesions of the face includes foreign bodies, osteomyelitis, branchial cleft or thyroglossal fistulas, granulomatous diseases (eg, actinomycosis, tuberculosis cutis, blastomycosis), dacrocystitis, salivary gland or duct fistulas, pyogenic granuloma, basal.