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Maxillofacial & Dental

Question 132 of 300

A 68 year old woman presents to the Emergency Department with a 2 day history of fever, dysphagia and mouth pain. On examination she has a tender, symmetrical induration of the submandibular area. Her tongue is slightly protruded. What is the most likely source of infection to explain this patient's condition?

Answer:

The patient has Ludwig's angina. Over two-thirds of patients with Ludwig’s angina have a dental source of infection, usually involving the second or third mandibular molar teeth.

Ludwig's Angina

Maxillofacial & Dental

Last Updated: 12th February 2021

Ludwig's angina is a bilateral infection of the submandibular space that consists of two compartments in the floor of the mouth, the sublingual space and the submental space. It is an aggressive, rapidly spreading cellulitis, without lymphatic involvement and with the potential for airway obstruction necessitating an urgent tracheostomy.

Over two-thirds of patients with Ludwig’s angina have a dental source of infection, usually involving the second or third mandibular molar teeth. Other sources of infection include contiguous spread from peritonsillar abscess or suppurative parotitis.

Clinical 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 submental space (which contains the submandibular salivary gland and lymph nodes). The two divisions can be considered as a single unit, however, as they directly communicate posteriorly around the mylohyoid muscle. This accounts for the bilateral involvement by contiguous spread of infection within the submandibular space in Ludwig’s angina.

Clinical features

  • Symptoms
    • Fever, rigors and malaise
    • Mouth pain
    • Stiff neck
    • Drooling
    • Dysphagia
    • Muffled voice/aphasia
    • Dyspnoea, stridor, cyanosis
  • Signs
    • Tender, symmetrical, 'woody' induration in submandibular area (+/- palpable crepitus)
    • Tenderness over neck and throat
    • Tongue appears displaced superiorly and anteriorly - tongue protrusion
    • Tripod position and respiratory distress
    • Fever, tachycardia, and progression to septic shock

Management

  • The diagnosis of Ludwig's angina is established based on the presence of suggestive clinical findings, usually with the support of imaging studies (CT is imaging of choice).
  • The treatment of Ludwig's angina involves timely assessment and management of the airway, and empiric broad-spectrum antibiotics.
  • Surgery is not usually necessary since it is uncommon to have a drainable collection in the early stages of infection. Surgical drainage is important once abscesses are identified by CT or MRI.

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  • Biochemistry
  • Blood Gases
  • Haematology
Biochemistry Normal Value
Sodium 135 – 145 mmol/l
Potassium 3.0 – 4.5 mmol/l
Urea 2.5 – 7.5 mmol/l
Glucose 3.5 – 5.0 mmol/l
Creatinine 35 – 135 μmol/l
Alanine Aminotransferase (ALT) 5 – 35 U/l
Gamma-glutamyl Transferase (GGT) < 65 U/l
Alkaline Phosphatase (ALP) 30 – 135 U/l
Aspartate Aminotransferase (AST) < 40 U/l
Total Protein 60 – 80 g/l
Albumin 35 – 50 g/l
Globulin 2.4 – 3.5 g/dl
Amylase < 70 U/l
Total Bilirubin 3 – 17 μmol/l
Calcium 2.1 – 2.5 mmol/l
Chloride 95 – 105 mmol/l
Phosphate 0.8 – 1.4 mmol/l
Haematology Normal Value
Haemoglobin 11.5 – 16.6 g/dl
White Blood Cells 4.0 – 11.0 x 109/l
Platelets 150 – 450 x 109/l
MCV 80 – 96 fl
MCHC 32 – 36 g/dl
Neutrophils 2.0 – 7.5 x 109/l
Lymphocytes 1.5 – 4.0 x 109/l
Monocytes 0.3 – 1.0 x 109/l
Eosinophils 0.1 – 0.5 x 109/l
Basophils < 0.2 x 109/l
Reticulocytes < 2%
Haematocrit 0.35 – 0.49
Red Cell Distribution Width 11 – 15%
Blood Gases Normal Value
pH 7.35 – 7.45
pO2 11 – 14 kPa
pCO2 4.5 – 6.0 kPa
Base Excess -2 – +2 mmol/l
Bicarbonate 24 – 30 mmol/l
Lactate < 2 mmol/l
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