Case Study of the Week: Ludwig's Angina

No matter how experienced you are in your practice, it feels good to get a pat on the back from time to time.  The other evening I diagnosed a case of Ludwig's angina and was congratulated by my supervising physician on a good catch.  While I have heard of this potentially life-threatening condition, this was the first case I have seen in practice.  What do you need to know about diagnosing and treating Ludwig's Angina?

Ludwig's angina is a rapidly progressing cellulitis of the neck and floor of the mouth with the potential for airway obstruction.  Most cases originate as a dental infection.  As nurse practitioners and physician assistants, it's important that we don't mistake this serious condition for a simple dental abscess.

Case Study

A 33 year old female patient presents to the emergency department with pain and swelling to the submandibular space and upper neck. Swelling is present on both sides but more prominent on the left.  She states she has been running a low grade fever and is in significant pain.  Her symptoms began upon waking and have progressed rapidly throughout the day.  She states she has difficulty swallowing.  The patient is tachycardic with a pulse of 114 and a low grade fever is noted with a temperature of 100.4 F.  

On exam, you immediately note submandibular swelling and swelling to the left side of the face and to the left sublingual space.  Palpation of the submandibluar space is exquisitely painful.  The patient has tenderness to the left mandibular teeth and gum swelling.  The patient is able to swallow with difficulty.  Based on your exam, you suspect a deep neck infection and order a CT scan of the soft tissues of the neck.

Management and Outcome

When a deep neck infection such as Ludwig's angina is suspected, CT scan is the gold standard for imaging.  CT scans show the extent, severity and exact location of the infection.  Labs including blood chemistries and a complete blood cell count may also be useful in diagnosis and management. 

Swelling associated with Ludwig's angina can cause airway compromise.  In patients with difficuty breathing or severe swelling, a physician should be notified immediately, especially since swelling can progress rapidly.  Intubation can be difficult in patients with Ludwig's due to swelling, to tracheostomy may be necessary in cases of airway compromise.

IV antibiotics are the treatment of choice for Ludwig's angina.  About 50 percent of infections resolve with IV antibiotics alone.  In other cases, if an abscess is present and does not improve within 48 hours it may need to be surgically drained.  Most commonly prescribed IV antibiotics include clindamycin, ampicillin and cefuroxime.  Once the patient is improving and has been afebrile for at least 48 hours, IV antibiotics may be discontinued and replaced with oral antibiotics.

Discussion

Ludwig's angina is a serious medical condition.  Nurse practitioners and physician assistants must be thorough in examining patients with facial swelling to prevent mistaking this life-threatening condition for a simple dental abscess.  Due to it's potential for complications, a physician must be notified and airway precautions taken in patients presenting with respiratory distress.  Ludwig's angina can affect both pediatric and adult patients so the diagnosis should be considered in patients of all ages.

 

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