Tackling Ludwig’s Angina in the Emergency Department: A Junior Doctor’s Guide

Introduction

Ludwig's angina, a potentially life-threatening cellulitis of the floor of the mouth, can escalate rapidly, leading to airway obstruction. As a junior doctor in the Emergency Department (ED), recognizing and managing Ludwig's angina is crucial. This guide provides a structured approach to history taking, examination, investigations, and management, ensuring you’re equipped to handle this critical condition effectively.

History Taking: Key Questions to Ask

When suspecting Ludwig’s angina, a thorough history is paramount. Focus on the following aspects:

• Symptom Onset and Progression:

• When did the symptoms start?

• Have they been progressively worsening?

• Pain and Swelling:

• Are there complaints of pain or swelling in the floor of the mouth, under the tongue, or in the neck?

• Dental History:

• Any recent dental procedures or infections?

• Any history of dental pain or abscess?

• Systemic Symptoms:

• Any fever, chills, or malaise indicating a systemic infection?

• Difficulty in swallowing (dysphagia) or speaking (dysphonia)?

• Respiratory Symptoms:

• Any difficulty breathing (dyspnea)?

• Any stridor or noisy breathing?

• Medical and Surgical History:

• Any history of diabetes, which can predispose to severe infections?

• Previous episodes of similar symptoms?

Physical Examination: What to Look For

A focused physical examination is critical for diagnosing Ludwig's angina. Look for:

• Airway Assessment:

• Check for signs of airway compromise: stridor, drooling, inability to lie flat.

• Assess the patient’s voice for a “hot potato” quality.

• Oral Cavity Examination:

• Look for swelling, especially in the submandibular and sublingual areas.

• Check for elevation of the tongue and floor of the mouth.

• Neck Examination:

• Palpate for bilateral submandibular swelling.

• Assess for tenderness and crepitus, which might indicate gas-forming organisms.

• Vital Signs:

• Monitor for fever, tachycardia, and hypotension as signs of sepsis.

Investigations: Confirming the Diagnosis

Once Ludwig's angina is suspected, prompt investigations are essential:

• Laboratory Tests:

• Complete blood count (CBC) to look for leukocytosis.

• Blood cultures to identify causative organisms.

• C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) for inflammation markers.

• Imaging:

• CT Neck with Contrast: The gold standard for evaluating the extent of the infection and potential airway compromise.

• Lateral Neck X-Ray: Can be used if CT is not immediately available, showing soft tissue swelling.

Management Plan: Steps to Take

Managing Ludwig's angina involves securing the airway, controlling the infection, and addressing the source. Here’s a step-by-step approach:

• Airway Management:

• Immediate Evaluation: Assess the need for airway intervention. If there are signs of airway compromise, call for senior help and anesthesiology early.

• Options: Orotracheal intubation, nasotracheal intubation, or a surgical airway (tracheostomy) may be necessary.

• Antibiotic Therapy:

• Start broad-spectrum IV antibiotics covering oral flora (e.g., ampicillin-sulbactam, clindamycin, or ceftriaxone plus metronidazole) after obtaining cultures.

• Surgical Consultation:

• Early ENT or maxillofacial surgery consultation for possible incision and drainage (I&D).

• Supportive Care:

• Maintain hydration with IV fluids.

• Pain management with appropriate analgesia.

• Monitoring and Follow-Up:

• Continuous monitoring in an ICU setting for severe cases.

• Regular reassessment of the airway and infection status.

Ludwig's angina requires a swift, structured approach to ensure optimal outcomes.