Ludwig's angina

There are a few methods that can be used for determining the microbiology of Ludwig's angina. Traditionally, a culture sample is collected although it has some limitations, primarily being the time-consuming and sometimes unreliable results if the culture is not processed correctly.[21] Ludwig's angina is most often found to be polymicrobial and anaerobic.[2][22] Some of the commonly found microbes are Viridans Streptococci, Staphylococci, Peptostreptococci, Prevotella, Porphyromonas and Fusobacterium.[2][22]

Placement of an endotracheal tube to aid breathing.

Airway management has been found to be the most important factor in treating patients with Ludwig's Angina,[25] i.e. it is the “primary therapeutic concern”.[26] Airway compromise is known to be the leading cause of death from Ludwig's Angina.[5]

• The basic method to achieve this is to allow the patient to sit in an upright position with supplemental oxygen provided by masks or nasal prongs.[25] Patient's airway can rapidly deteriorate and therefor close observation and preparation for more invasive methods such as endotracheal intubation or tracheostomy[25] if needed is vital.
• If the oxygen saturation levels are adequate and antimicrobials have been given, simple airway observation can be done.[25] This is a suitable method to adopt in the management of children, as a retrospective study described that only 10% of children required airway control. However, a tracheostomy was performed on 52% of those affected with Ludwig's Angina over 15 years old.[27]
• If more invasive or surgical airway control is necessary, there are multiple things to consider[5]
  • Flexible nasotracheal intubation require skills and experience.[5]
  • If nasotracheal intubation is not possible, cricothyrotomy and tracheostomy under local anaesthetic can be done. This procedure is carried out on patients with advanced stage of Ludwig's Angina.[5]
  • Endotracheal intubation has been found to be in association with high failure rate with acute deterioration in respiratory status.[5]
  • Elective tracheostomy is described as a safer and more logical method of airway management in patients with fully developed Ludwig's Angina.[28]
  • Fibre-optic nasoendoscopy can also be used, especially for patients with floor of mouth swellings.[25]

• Antibiotic therapy is empirical, it is given until culture and sensitivity results are obtained.[25] The empirical therapy should be effective against both aerobic and anaerobic bacteria species commonly involved in Ludwig's Angina.[25] Only when culture and sensitivity results return should therapy be tailored to the specific requirements of the patient.[25]
  • Empirical coverage should consist of either a penicillin with a B-lactamase inhibitor such as amoxicillin/ticarcillin with clavulanic acid or a Beta-lactamase resistant antibiotic such as cefoxitin, cefuroxime, imipenem or meropenem.[25] This should be given in combination with a drug effective against anaerobes such as clindamycin or metronidazole.[25]
• Parenteral antibiotics are suggested until the patient is no longer febrile for at least 48 hours.[25] Oral therapy can then commence to last for 2 weeks, with amoxicillin with clavulanic acid, clindamycin, ciprofloxacin, trimethoprim-sulfamethoxazole, or metronidazole.[25]

• Surgical incision and drainage are the main methods in managing severe and complicated deep neck infections that fail to respond to medical management within 48 hours.[25]
• It is indicated in cases of:[25]
  • Airway compromise
  • Septicaemia
  • Deteriorating condition
  • Descending infection
  • Diabetes mellitus
  • Palpable or radiographic evidence of abscess formation
• Bilateral submandibular incisions should be carried out in addition to a midline submental incision. Access to the supramylohyoid spaces can be gained by blunt dissection through the mylohyoid muscle from below.[25]
• Penrose drains are recommended in both supramylohyoid and inframylohyoid spaces bilaterally. In addition, through and through drains from the submandibular space to the submental space on both sides should be placed as well.[25]
• The incision and drainage process is completed with the debridement of necrotic tissue and thorough irrigation.[25]
• It is necessary to mark drains in order to identify their location. They should be sutured with loops as well so it will be possible to advance them without re-anaesthetizing the patient while drains are re-sutured to the skin.[25]
• An absorbent dressing is then applied. A bandnet dressing retainer can be constructed so as to prevent the use of tape.[25]

Adequate nutrition and hydration support is essential in any patient following surgery, particularly young children.[24] In this case, pain and swelling in the neck region would usually cause difficulties in eating or swallowing, hence reducing patient's food and fluid intake. Patients must therefore be well-nourished and hydrated to promote wound healing and to fight off infection.[29]

Extubation, which is the removal of endotracheal tube to liberate the patient from mechanical ventilation, should only be done when the patient's airway is proved to be patent, allowing adequate breathing. This is indicated by a decrease in swelling and patient's capability of breathing adequately around an uncuffed endotracheal tube with the lumen blocked.[29]

During the hospital stay, patient's condition will be closely monitored by:

• carrying out cultures and sensitivity tests to decide if any changes need to be made to patient's antibiotic course
• observing for signs of further infection or sepsis including fevers, hypotension, and tachycardia
• monitoring patient's white blood cell count - a decrease implies effective and sufficient drainage
• repeating CT scans to prove patient's restored health status or if infection extends, the anatomical areas that are affected.[29]

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