MU university-SOM- LUDWIGS ANGINA.powerpoint

A cellulitis of the submandibular submental and sublingual spaces

1. MULUNGUSHI UNIVERSITY Odontogenic Infection – Ludwig’s Angina Dr. Lukulula E. Mwanza Dip.DS(UNZA), BDS(CBU), MPH(UNZA) Senior Dental Surgeon HoD – Ndola teaching Hosp Department of Dentistry HoD - Oral & Maxillofacial Surgery unit Honorary Lecturer(CBU-SOM) Honorary Lecturer (MU-SOM)

2. Contents Anatomy Definition Etiology Pathophysiology Clinical features Diagnosis Complications Management

3. Anatomy The submandibular space lies within the submental and submandibular triangles between the mucosa of the floor of the mouth and the superficial layer of the deep cervical fascia. It is subdivided by the mylohyoid muscle into the sublingual space (which contains the sublingual gland, hypoglossal nerve, part of the submandibular gland, and loose connective tissue) and the submylohyoid space (which contains the submandibular salivary gland and lymph nodes)

4. What’s Ludwigs angina Comes from a Latin word “Angere” meaning to “strangle” Ludwig’s angina is a diffuse life-threatening cellulitis in the submandibular, sublingual, and submental spaces (floor of the mouth), characterized by its propensity to spread rapidly to the surrounding tissues. It was first described by the German physician, Wilhelm Frederick von Ludwig in 1836 as cellulitis of fast evolution involving the region of the submandibular gland Often occurs in adults

5. Etiology Dental caries, recent dental treatment, poor dental hygiene (75%-90%). 2 nd and 3 rd molar of the lower jaw are affected from infection. Trauma: mandibular fracture, facial fracture, tongue piercing Soft tissue lacerations Puncture wounds of the floor of the mouth Secondary infections from oral malignancy Submandibular sialadenitis Systemic compromise: DM, HIV/AIDs , HTN, glomerulonephritis, transplant patients, chemotherapy patients, etc.

6. Bacteriology Commonly mixed infections involving both aerobes and anaerobes Commonly alpha-hemolytic Streptoccoci, staphylococci and bacteriodes group Rarely does it involve H.Influenza, E. Coli and Pseudomonas.

7. Pathophysiology Mixed infection from alpha hemolytic streptococci, staphylococci and Bacteroide groups owing to poor oral hygiene affects primarily the 2 nd and 3 rd molar teeth of the mandible. The sub mylohyoid space is initially involved, since the roots of these teeth are located below the attachments of the mylohyoid muscle to the mandible. Other sources of infection include contiguous spread from peritonsillar abscess or suppurative parotitis Medial spread of infection is facilitated because the lingual aspects of periodontal bone around these teeth are thin.

8. Clinical features Bilateral “wood like ‘ swelling in the submandibular, sublingual and submental spaces of rapid onset (around the neck and the mandible) Skin is tense and tends to pit and blanch on pressure Rapidly spreading edema Double chin appearance Elevation and protrusion of the tongue, drooling of saliva Elevation of the tongue is associated with dysphagia,odynophagia, dysphonia and cyanosis

9. Clinical features Patients may exhibit muffled voice due to edema of vocal apparatus (hot potato voice) Dysphagia and drooling of saliva Trismus Septicemia: high grade fever, malaise, body arches, leukocytosis Infection spread to involve the masticator space and parapharyngeal space in later stages of the disease Dyspnea in supine position (impending laryngeal edema) The most common cause of death is asphyxiation (angina)

10. Clinical features

11. Diagnosis Clinically FBC: leukocytosis Culture and gram stain Imaging CT Scan : I maging modality of choice for the diagnosis of Ludwig's angina and other deep neck space infections Panoramic X-ray : To identify possible odontogenic sources Cervical, profile and posterior-anterior radiographs : For any tracheal deviation and raising volume in the soft tissues Ultrasound : Has been recommended to differentiate cellulitis, abscess and adenopathy in head and neck infection

12. Differential diagnosis Cellulitis Peritonsillar abscess Sublingual hematoma Lingual CA Lymphadenitis

13. Treatment goals

14. Airway management Tracheostomy: Was the gold standard in the past. Has risk of spreading infection to the mediastinum Cricothyroidotomy: Has a much lower risk of mediastinal infection Blind nasal intubation (BNI) Fiber optic nasotracheal intubation: Useful especially in deep neck infections

15. Surgical management Principles (Topazian and Golberg) Incise in healthy skin and mucosa when possible, not at the site of maximum fluctuance, because wounds tend to heal with an unsighty scar Place the incision in a natural skin fold Place the incision in a dependent position Dissect bluntly Place a drain; and Remove drains when wounds become minimal.

16. Incision and drainage Bilateral submandibular incisions as well as midline submental incisions Incision approximately 5 to 4 cm below the angle of the mandible and below the inferior extent of swelling roughly parallel to the inferior border of mandible Intra oral incision: if localized to sublingual space Extra oral incision: if involving sub maxillary space

17. Medical management IV access, fluid resuscitation and give IV antibiotics Antibiotic therapy should be administered empirically and tailored to the culture and sensitivity results Other regimens include: Penicillins with beta lactamase inhibitor Second, third or fourth generation cephalosporin and metronidazole.

18. Complications Spread of infection to the parapharyngeal ad retropharyngeal spaces Airway obstruction due to laryngeal edema Septicemia Aspiration pneumonia

19. Any questions Thank you

20. References Boscolo -Rizzo P, Da  Mosto MC(2009). Submandibular space infection: a potentially lethal infection. Int J dis. 13: 327 Ovassapian A, Tuncbilek M, Weitzel EK, Joshi CW. Airway management in adult patients with deep neck infections: a case series and review of the literature. Anesth Analg 2005; 100:585. Barton ED, Bair AE. Ludwig's angina. J  Emerg Med 2008; 34:163. Tapazian G and Goldberg M (2002), Oral and maxillofacial infections, 4 th edition, Philadelphia USA. https://www.uptodate.com/contents/submandibular-space-infections-ludwigs-angina/abstract/14 Newlands C, Kerawala C (2010). Oral and maxillofacial surgery. Oxford: Oxford University Press. pp. 374–375. ISBN 9780199204830. “Ludwig's angina at Who Named It?” W. F. Von Ludwig.Stuttgart , 1836, 6: 21-25.