Ludwig’s angina

ludwigs angina is a life threatening disease

1. LUDWIG’S ANGINA PRESENTED BY :- DR. NAZMUN NAHAR HAFSA DR. KAMRUNNAHAR JEBIN DR. FATEMA-TUZ-ZOHRA DIPA

2. CONTENT INTRODUCTION HISTORICAL BACKGROUND DEFINITION AETIOLOGY MICROFLORA PATHOPHYSILOGY CLINICAL FEATURE INVESTIGATION HISTOPATHOLOGY PRINCIPLES OF TREATMENT FATE OF LUDWIGS ANGINA

3. INTRODUCTION Infection of oro -facial and neck region have been one of the most common diseases in human beings. Despite great advancement in healthcare, these infections remain a major problem. Ludwig’s angina is one of the life threatening complications among these oro -facial infections.

4. HISTORICAL BACKGROUND: First described in 1836 by Wilhelm Friedreich Von Ludwig The word angina derived from the latin word “ angere ” means suffocation or chocking sensation “Ludwig” comes from the person to whom the credit goes for its description

5. DEFINITION: Ludwig’s angina is a massive, firm, brawny cellulitis or induration and acute, toxic stage , involving simultaneously , the submandibular, sublingual & submental spaces bilaterally. Cellulitis is a common, potentially serious bacterial skin infection. Cellulitis appears as a swollen, red area of skin that feels hot and tender.

6. AETIOLOGY: ODONTOGENIC: 1) acute dentoalveolar abscess 2) acute periodontal abscess 3) acute pericoronal abscess NON-ODONTOGENIC: 1) iatrogenic 2) traumatic injuries to oro -facial regions 3) osteomyelitis 4) submandibular & sublingual sialadenitis

7. MICROFLORA: Commonly mixed infections involving both aerobes & anaerobes- streptococci staphylococci E.coli pseudomonas bacteroids

8. PATHOPHYSIOLOGY: This is a spreading type of infection in which organisms produce hyaluronidase & fibrinolysin which dissolve hyaluronic acid and fibrin. Thus the inflammation of soft tissue , not being confined to one area , spread through the fascial planes and tissue spaces.

9. CLINICAL FEATURE: GENERAL: -patient is toxic & dehydrated - pyrexia -anorexia -chills -malaise - dysphagia -respiratory rate increased

10. CLINICAL FEATURE: LOCAL: - firm, brawny swelling -bilateral - extends down anterior part of neck - non-pitting , non-fluctuant -severe tenderness - trismus -mouth remains open due to sublingual tissue edema leading to raised tongue -airway obstruction

11. INVESTIGATION: Panoramic x-ray- to identify possible odontogenic sources Cervical, profile and posterior-anterior radiograph- to observe the volume increasing in the soft tissues and any deviation of the trachea Ultra sound

12. HISTOLOGICAL FEATURES: A microscopic section though an area of cellulitis shows a diffuse exudation of polymorphoneuclear leukocyte and lymphocyte. With considerable serous fluid and fibrins causing separation of connective tissue and muscle fibres

13. TREATMENT GOALS: Sufficient airway management Early & aggressive antibiotic therapy Incision and drainage Adequate nutrition and hydration support

14. PRINCIPLES OF TREATMENT: Airway maintenance Medical management Surgical management

15. Airway maintenance Airway management in Ludwig’s angina can be challenging Suggested methods include – tracheostomy , fiberoptic laryngoscopy and nasoendotracheal intubation

16. MEDICAL MANAGEMENT Intravenous access, fluid resuscitation and administration of IV antibiotics Antibiotic therapy should be administered empirically and according to c/s regimens: - penicillin with beta lactamase inhibitor - cephalosporin - metronidazole

17. Surgical management Extraction: extraction of offending tooth, if present Incision & Drainage: - bilateral submandibular incision and if required a midline sub-mental incision 1cm below the inferior border of mandible - place a drain tube and fix - remove the tube when the drainage become minimal CARE: care should be taken to preserve or avoid trauma to – facial vessels, lingual nerve and jugular vein laterally below the angle region

18. Irrigation: copious irrigation of the wound drains with an antibacterial solution

19. Fate of Ludwig’s angina If untreated it can be fatal within 12 to 24 hours , death arising from asphyxia Other cause of death are septicemia , septic shock, mediastinitis and aspiration pneumonia.

20. COMPLICATION Osteomyelitis Maxillary sinusitis Localized respiration tract disturbances Digestive tract disturbances