Ludwig's Angina: Higher Incidence and Worse Outcomes Associated With the Onset of the Coronavirus Disease 2019 Pandemic

Background: Ludwig's angina (LA) is a diffuse cellulitis of the submandibular space and adjacent tissues. During the coronavirus disease 2019 (COVID-19) pandemic, odontogenic treatments were often delayed because of the implementation of safety measures to avoid the spread of the virus. We hypothesized that delayed odontogenic treatments associated with the onset of the COVID-19 pandemic would be associated with an increase in the incidence of LA and worse outcomes related to these infections. Patients and Methods: Patients from June 2018 to June 2022 with computed tomography images suggestive of LA and confirmed by ear, nose, throat (ENT) consult were included. We abstracted demographics, outcomes, clinical management, and microbiology. Patients were stratified into pre-COVID and COVID-onset. Our primary outcome, incidence of LA, was defined as: (new LA cases) ÷ (ED evaluations of oral or dental infections × 1.5 years). Results: In the pre-COVID group, we identified 32 of 1,301 patients with LA for an incidence of 0.02 per year. The COVID-onset group consisted of 41 of 641 patients, with an incidence of 0.04 per year. In the COVID-onset group, progression to necrotizing fasciitis was more likely (0% vs. 15%; p < 0.024), and they returned to the operating room for repeated debridement (3% vs. 22%; p < 0.020). Likewise, hospital length of stay, intensive care unit (ICU) length of stay, and ventilator days were higher (4.3 ± 3.5 vs. 9.5 ± 11.3; 1.1 ± 1.2 vs. 9.5 ± 7.1; 0.3 ± 1 vs. 3.6 ± 7.1; p < 0.001). Conclusions: Although the prognosis for dental infections diagnosed early is generally favorable, we observed a notable increase in the incidence of LA after the onset of the COVID-19 pandemic. Moreover, complications stemming from these infections became more severe in the COVID-onset era. Specifically, the likelihood of necrotizing fasciitis showed a substantial increase, accompanied by an increased risk of respiratory failure and mediastinitis.

Ludwig's Angina

Ludwig's angina is a severe diffuse cellulitis that presents an acute onset and spreads rapidly and bilaterally. It can affect the submandibular, sublingual or submental spaces resulting in a state of emergency. Early diagnosis and urgent management could be a life-saving procedure. We report a case of wide spread sialadenitis infection extending to the neck with trismus and elevation of the floor of the mouth that caused an obstruction of the airway and resulted in an inspiratory dyspnea and a stridor. The patient was directed to maintain the airway by elective tracheostomy. An appropriate use of parenteral antibiotics, airway protection techniques, and potential surgical drainage of the infection remain the standard protocol of treatment in advanced cases of Ludwig's angina. The aim of this case report is to emphasize on the importance of early diagnosis and appropriate management of Ludwig's angina.

Management of pediatric head and neck infections in the emergency department

Head and neck infections can spread to nearby structures, compromising the airway and progressing to life-threatening events. Pediatric head and neck infections can be difficult to recognize; emergency clinicians must know the signs and symptoms of head and neck infections for early diagnosis and urgent management in order to prevent complications and decrease hospitalization rates. This issue reviews presenting signs and symptoms of pediatric head and neck infections, discusses when diagnostic studies are indicated, and offers evidence-based recommendations for management. Conditions reviewed include mastoiditis, sinusitis, Ludwig angina, peritonsillar abscess, retropharyngeal abscess, Lemierre syndrome, and acute suppurative thyroiditis.

Infections of the Neck

Infection of the neck is a relatively common emergency department complaint. If not diagnosed and managed promptly, it may quickly progress to a life-threatening infection. These infections can result in true airway emergencies that may require fiberoptic or surgical airways. This article covers common, as well as rare but emergent, presentations and uses an evidence-based approach to discuss diagnostic and treatment modalities.

ENT indications for Hyperbaric Oxygen Therapy

ENT indications for Hyperbaric Oxygen Therapy. Hyperbaric Oxygen (HBO) therapy is a treatment where patients breathe 100% oxygen while exposed to high environmental pressure in a hyperbaric chamber. This hyperoxygenation has several beneficial effects as an adjunctive treatment in a number of ENT-related conditions and diseases. These can be summarized as anti-ischaemic effects (delivery of oxygen to otherwise ischaemic tissues, reduction of ischaemia-reperfusion damage), anti-infectious effects (bacteriostasis, improved leucocyte phagocytosis bactericidal activity and optimization of antibiotic therapy) and wound-healing effects (stimulation of granulation tissue formation and stabilization). Since HBO therapy has a clear physiologic rationale, a demonstrated effect (although difficult to "prove" with placebo controlled randomized trials) in certain indications and certain side-effects, it is proposed that it should be considered an integral part of the (combined surgical and pharmacological) treatment of patients, and not simply as a supplementation of oxygen. Furthermore, the importance of a well-trained medical and technical staff to ensure proper selection and the correct follow-up of patients should not be underestimated.

Ludwig's angina as an extremely unusual complication for direct microlaryngoscopy

BACKGROUND

An extremely rare case that to our knowledge has not been reported before is described, in which a patient had a Ludwig's angina as a complication of direct microlaryngoscopy.

METHODS

We report a Ludwig's angina after a direct microlaryngoscopy for a Reinke's edema, due to erosion on the internal face of the mandible produced by compression of the laryngoscope.

RESULTS

The patient underwent placement of 2 drainages, intraoral and cervical, and several incisions on the floor of the mouth, with intravenous corticosteroids and antibiotics and with resolution of the illness without performing tracheostomy.

CONCLUSIONS

Ludwig's angina is an extremely rare complication of microlaryngoscopy, but it is potentially life-threatening. Early diagnosis and treatment resulted in survival of the patient without complications.

Severe soft tissue infections of the head and neck: a primer for critical care physicians

Patients with severe infections of the potential spaces of the head and neck are commonly managed in the ICU. These infections may present with devastating complications such as airway obstruction, jugular septic thrombophlebitis, lung abscess, upper airway abscess rupture with asphyxiation, mediastinitis, pericarditis, and septic shock. A thorough understanding of the anatomy and microbiology of these infections is essential for proper management of these patients. Retropharyngeal, danger, prevertebral, lateral pharyngeal, and submandibular space infections and their site-specific clinical manifestations, complications, and therapeutic interventions are discussed.

Successful conservative management of Ludwig's angina in advanced pregnancy

A 20 year-old female in her 32nd week of gestation presented to the Emergency Department with dysphonia and dysphagia associated to a recent recurrence of a periapical abscess. Her oral examination showed trismus, elevated tongue and neck swelling. A clinical diagnosis of Ludwig's angina was reached, and empirical antibiotic coverage was started. The decompression and drainage placement was performed successfully under local anesthesia without airway compromise. At the moment, no clear guidelines exist for the acute treatment of Ludwig's angina. Establishment of a secure airway has long been considered the gold standard, yet new literature suggests a more conservative management. Ascertaining an early diagnosis at the Emergency Department, and involvement of Anesthesia, Obstetrics, and, Ear, Nose and Throat specialist services is vital for materno-fetal wellbeing. Careful evaluation of the airway status in addition to prompt antimicrobial therapy with surgical decompression may represent a plausible alternative in pregnant patients.

Unusual outcome of Ludwig's angina

This is a report of 2 cases of Ludwig's angina. An Indonesian young female patient developed severe stridor after oral examination. Then she underwent tracheostomy and developed post decannulation dyspnea due to huge surgical emphysema. The second case regards an Indian young male who developed disseminated intravascular coagulation and died from hemorrhage. The objectives of our cases presentation are to avoid mouth examination of Ludwig's angina if we are not ready for performing tracheotomy and to be aware of the possible development of disseminated intravascular coagulation and post decannulation emphysema.

Ludwig's angina in pregnancy

Ludwig's angina is an infectious process involving the submental, sublingual, and submandibular spaces that can rapidly progress to hemodynamic instability and airway loss. Treatment involves antibiotics, incision, drainage and the placement of extraoral drains. This is the first reported recent case of Ludwig's angina in a pregnant patient.

Ludwig angina: forewarned is forearmed

While the incidence of Ludwig angina is decreasing, this is an important disease process because failure to control the airway can have catastrophic consequences. Accurate diagnosis, airway control, antibiotic therapy, and, occasionally, surgical management are essential for patient safety. Ludwig angina is caused by a rapidly expanding cellulitis of the floor of the mouth and is characterized by hardened induration of the floor and suprahyoid region bilaterally with an elevation of the tongue potentially obstructing the airway. In the preantibiotic era, Ludwig angina was frequently fatal; however, antibiotics and aggressive surgical treatment have significantly lowered mortality.

Did Ludwig's angina kill Ludwig?

Wilhelm Frederick von Ludwig first described in 1836 a potentially fatal, rapidly spreading soft tissue infection of the neck and floor of the mouth. The condition was later named 'Ludwig's angina', a term which persists in medicine to this day. A gold medallist at 19 and professor at 25, Ludwig also served as president of the Württemberg Medical Association and chief physician to the royal family. His outstanding contribution to medicine was rewarded with the title Excellence upon retiring in 1855. Ludwig died at the age of 75, ironically, days after developing an inflammation of the neck. Could it be that Ludwig died of his own condition? This article combines a biography of Wilhelm Frederick von Ludwig with an overview of his eponymous condition and its management.

[Phlegmons and abscesses in the floor of mouth. Report of 10 cases and review of the literature]

We report a review about 10 cases of phlegmons-abscesses in the floor of mouth (Ludwig's angina) treated by our Service analyzing the following variables: Age, sex, time of evolution, personal antecedents, E.N.T. exploration, clinical symptoms, type of treatment and clinical evolution. This pathology represents one of the most severe forms of cervicofacial diffuse cellulitis; it requires an early diagnosis and therapy which can include an urgent tracheostomy ifthe airway is compromised.

Use of interventional radiology in the management of mediastinitis of odontogenic origin

Descending necrotising mediastinitis is a rare complication of odontogenic infection. The key to diagnosis is to maintain a high index of suspicion when antibiotics and adequate surgical drainage do not lead to resolution of symptoms. Open thoracic operation to drain mediastinal collections is potentially lethal and interventional radiological techniques are thought to reduce mortality. We report the use of interventional radiology in the diagnosis, monitoring and treatment of this condition and illustrate our experience with three case reports.

Ludwig’s Angina: An Uncommon Cause of Chest Pain

A 71-year-old male with coronary artery disease, hypertension, diabetes mellitus, tobacco and opioid dependence came to the emergency room complaining of one episode of retrosternal chest pain oppressive in nature of one day of evolution. He had acute respiratory distress and required mechanical ventilation. The initial impression was myocardial ischemia, but electrocardiography and cardiac enzymes ruled it out. During the following hours, neck and tongue edema developed. He was started on broad-spectrum antibiotics empirically. Neck computed tomography scan revealed a left parapharyngeal and submandibular abscess. The abscess was drained. The source of infection was found on the second molar of the left lower jaw. The patient improved and was successfully weaned from mechanical ventilation. Despite advances in therapy, Ludwig's angina remains a potentially lethal infection in which early recognition plays a crucial role.

Deep neck infection: Analysis of 185 cases

PURPOSE

This study reviews our experience with deep neck infections and tries to identify the predisposing factors of life-threatening complications.

METHODS

A retrospective review was conducted of patients who were diagnosed as having deep neck infections in the Department of Otolaryngology at National Taiwan University Hospital from 1997 to 2002. Their demographics etiology, associated systemic diseases, bacteriology, radiology, treatment, duration of hospitalization, complications, and outcomes were reviewed. The attributing factors to deep neck infections, such as the age and systemic diseases of patients, were also analyzed.

RESULTS

One hundred eighty-five charts were recorded; 109 (58.9%) were men, and 76 (41.1%) were women, with a mean age of 49.5 +/- 20.5 years. Ninety-seven (52.4%) of the patients were older than 50 years old. There were 63 patients (34.1%) who had associated systemic diseases, with 88.9% (56/63) of those having diabetes mellitus (DM). The parapharyngeal space (38.4%) was the most commonly involved space. Odontogenic infections and upper airway infections were the two most common causes of deep neck infections (53.2% and 30.5% of the known causes). Streptococcus viridans and Klebsiella pneumoniae were the most common organisms (33.9%, 33.9%) identified through pus cultures. K. pneumoniae was also the most common infective organism (56.1%) in patients with DM. Of the abscess group (142 patients), 103 patients (72.5%) underwent surgical drainages. Thirty patients (16.2%) had major complications during admission, and among them, 18 patients received tracheostomies. Those patients with underlying systemic diseases or complications or who received tracheostomy tended to have a longer hospital stay and were older. There were three deaths (mortality rate, 1.6%). All had an underlying systemic disease and were older than 72 years of age.

CONCLUSIONS

When dealing with deep neck infections in a high-risk group (older patients with DM or other underlying systemic diseases) in the clinic, more attention should be paid to the prevention of complications and even the possibility of death. Early surgical drainage remains the main method of treating deep neck abscesses. Therapeutic needle aspiration and conservative medical treatment are effective in selective cases such as those with minimal abscess formation.

Ludwig???s Angina

Ludwig's angina is a serious, often fatal infectious disease process that requires prompt intervention of life-saving therapies. The critical care nurses caring for a patient with Ludwig's angina must be able to recognize subtle changes in the patient's status and intervene quickly to prevent death by airway edema or profound sepsis.

A Review of Ludwig's Angina for Nurse Practitioners

PURPOSE

To discuss the causative factors, clinical course, and current treatment modalities for Ludwig's angina, a submandibular cellulitis, and to raise nurse practitioners' (NPs') awareness of this condition.

DATA SOURCES

Recent clinical articles, research, case studies, and medical texts.

CONCLUSIONS

Ludwig's angina may be fatal. Early diagnosis, aggressive antibiotic therapy, and management involving a multidisciplinary team approach are imperative for the patient to progress without complications.

IMPLICATIONS FOR PRACTICE

Education and awareness are crucial for successful diagnosis of and management of treatment for Ludwig's angina. Although NPs have a limited role in the treatment of Ludwig's angina, their ability to recognize the signs and symptoms will prompt emergency care and treatment and facilitate better outcomes for their clients.

Ludwig's angina: a clinical review

Ludwig's angina is caused by a rapidly expanding cellulitis of the floor of the mouth and is characterized by a brawny induration of the floor and suprahyoid region (bilaterally), with an elevation of the tongue potentially obstructing the airway. In the pre-antibiotic era, Ludwig's angina was frequently fatal; however, antibiotics and aggressive surgical intervention have significantly reduced mortality. We reviewed nine patients with Ludwig's angina between July 1996 and June 2002, all of whom presented with fever, neck swelling, bilateral submandibular swelling and elevation of the tongue. In eight patients (89%) a dental infection appeared to be the underlying cause. High-dosage intravenous antibiotics directed towards the suspected causative microorganisms were given to all of the patients: two were treated successfully with conservative medical management, while seven underwent surgical drainage (a tracheotomy was necessary in one patient). Routine aerobic cultures were done on samples of drained material and the predominant microorganisms were Streptococcus species in two patients; there were none in the other five. Two patients had post-operative complications, but all recovered.

Deep neck abscess: a retrospective review of 210 cases

This study was performed to review our experience with deep neck abscesses (DNAs) and compare it to the experiences in the available literature, and to study changing trends within our patient population. We retrospectively studied 210 patients who had DNAs between 1981 and 1998. Peritonsillar abscesses and limited intraoral abscesses were excluded. Demographics, presentation, etiology, site of abscess, associated systemic diseases, bacteriology, radiology, treatment, airway management, and outcome were reviewed. We compared the entire group to those in the available literature and studied changing trends within this patient population. Dental infection (43%) was the most common cause, followed by intravenous drug abuse (12%) and pharyngotonsillitis (6%). The incidences of intravenous drug abuse and mandibular fractures as causes of DNA were 19% and 8%, respectively, during the period 1981 to 1990, but were only 1% each during the period 1991 to 1998. Streptococcus viridans was the most common pathogen (39% of positive cultures), followed by Staphylococcus epidermidis (22%) and Staphylococcus aureus (22%). Lateral pharyngeal space abscess was the most common DNA (43%), followed by submandibular space abscess, Ludwig's angina, and retropharyngeal space abscess (28%, 17%, and 12%, respectively). Seventy-five percent of patients with true Ludwig's angina underwent tracheotomy. Nondental infections are no longer a significant etiologic factor in DNA. Streptococcus viridans has replaced S aureus and beta-hemolytic streptococci as the most common pathogen. Lateral pharyngeal space abscess was the most common DNA; however, its incidence has progressively decreased over the past decade. Intravenous drug abuse and mandibular fractures are no longer major etiologic factors. Tracheotomy is indicated in patients with Ludwig's angina.

Ludwig's angina in the pediatric population: report of a case and review of the literature

Ludwig's angina is a rapidly progressing cellulitis involving the submandibular neck space. It is characterized by brawny induration of the submental region and floor of mouth, bearing the potential for rapid airway obstruction. Airway management, antibiotics, and judicious surgical intervention are the mainstays of successful therapy. We present a case of Ludwig's angina in a 5-year-old child and offer a meta-analysis of pediatric cases of Ludwig's angina described in the literature over the past 30 years. The presentation, etiology, management, and potential complications of this disorder in the pediatric population are discussed.

Airway management in Ludwig's angina

A 37-year-old 91 kg man presented with features of Ludwig's angina. Anaesthesia for incision and drainage of his submandibular abscess was undertaken by two specialist anaesthetists with an otorhinolaryngological surgeon prepared for immediate tracheostomy. After preoxygenation, gas induction with sevoflurane in oxygen was followed by a gush of pus into the oral cavity and laryngospam causing acute upper airway obstruction. This resolved with 25 mg of suxamethonium and an endotracheal tube was passed into the trachea with difficulty. Options for management of the difficult airway in Ludwig's angina are discussed.

Ludwig's angina in children

Ludwig's angina is a potentially life-threatening, rapidly expanding, diffuse inflammation of the submandibular and sublingual spaces that occurs most often in young adults with dental infections. However, this disorder can develop in children, in whom it can cause serious airway compromise. Symptoms include severe neck pain and swelling, fever, malaise and dysphagia. Stridor suggests an impending airway crisis. Causative bacteria include many gram-negative and anaerobic organisms, streptococci and staphylococci. Initial treatment consists of high doses of penicillin G given intravenously, sometimes in combination with other drugs. Patients usually recover without complications.

Ludwig's angina

A 13 year review of patients diagnosed to have Ludwig's angina admitted to the Christian Medical College and Hospital, Vellore, India, between March 1982 and April 1995 is presented. The patients were either admitted to the ENT or paediatric surgical units. There were 41 patients, 24% being children and 76% adults. The clinical profile and outcome of these two groups were compared. In the paediatric group, none had dental caries while in the adult group, 52% had associated dental caries. In children, 70% were controlled with conservative medical management unlike the adults of whom 81% needed incision and drainage. Tracheostomy was necessary in 10% of the children and in 52% of the adults. The mortality was 10% in both groups.

Ludwig's angina: case report and review

Modern dental care and use of antibiotics for oral infections have made Ludwig's angina rare. To avoid acute airway obstruction, emergency physicians must be able to rapidly recognize and treat this condition. A typical case of Ludwig's angina is presented, followed by a review of clinical findings and therapeutic modalities. Emphasis is made on airway management, antibiotics, and surgical drainage.

Deep neck abscesses--changing trends

A retrospective review was conducted of 64 patients with deep neck abscesses. Based on clinical and operative findings, these abscesses were categorized as retropharyngeal abscess (29 patients), parapharyngeal abscess (10 patients), Ludwig's angina (19 patients), or necrotizing cervical fasciitis (six patients). Regional trauma from an ingested foreign body was the cause for 59 per cent of the patients with a retropharyngeal abscess. In 90 per cent of subjects with Ludwig's angina, an odontogenic cause was established; however, in the majority of cases of parapharyngeal abscess (80 per cent) and necrotizing fasciitis of the neck (85 per cent), aetiology was unknown. Fifty-five patients (86 per cent) required open neck drainage. In the remaining nine (14 per cent) endoscopic drainage of the abscess was possible. Eight patients (12 per cent) needed a tracheotomy for airway control. The overall mortality was eight per cent despite aggressive anti-microbial therapy and early surgical intervention. Thirty-four cultures grew aerobic organisms. Seventy-six per cent of these were gram-negative microorganisms. The bacteriological pattern of deep neck abscesses is changing and may be responsible for the considerable mortality rate with which the abscesses are still associated despite anti-microbial therapy.

Ludwig's angina

Ludwig's angina is a cellulitis frequently occurring as a result of infections of the second and third lower molar. Despite a decrease in mortality from 50% to less than 10% since the introduction of antibiotics, it remains a rare but life-threatening illness. The potential for rapid respiratory obstruction is the greatest concern. Familiarity with the anatomy of the neck and recognition of symptoms are essential for effective treatment. Treatment focuses on maintenance of an airway, antibiotic therapy, and surgery. Asphyxia, aspiration, mediastinitis, pneumonia, empyema, and septicemia are possible complications.

Ludwig's angina--a case report

Ludwig's angina is a potentially lethal oro-facial cellulitis due to oro-dental infection. The aetiology and management of a case of Ludwig's angina are briefly discussed.

Ludwig's angina: an unusual sequel to endodontic therapy

Ludwig's angina is an unusual sequel to endodontic treatment: such a case is described. Principles of management are discussed with emphasis placed on the need to secure the airway early. The literature is reviewed.

Ludwig's angina: an analysis of 14 cases

Ludwig's angina remains a potentially lethal disease entity as it causes rapidly progressive airway obstruction, although the current mortality rate is low. Early surgical intervention should be carried out in severe cases which show signs of fluctuation, abscess formation or other serious complications. We report our experience with 14 cases of Ludwig's angina, 12 of which (86%) were of dental origin. Only one case was complicated with Klebsiella pneumoniae septicemia which resolved upon treatment. There were no deaths. Surgical procedures including incision and drainage and tooth extraction were performed in 11 cases (78%). Antibiotics were administered to all patients. Most of them were treated with crystalline penicillin with or without an aminoglycoside. Only one patient received a tracheostomy in this series. The number of tracheostomies or intubations carried out was much lower than in previous reports. We suggest that an aggressive antimicrobial therapy, early surgical intervention and careful monitoring of the respiratory symptoms would reduce both the need for tracheostomy and the mortality rate.

Ludwig's angina. Report of a case and review of the literature

In the preantibiotic era, Ludwig's angina frequently caused asphyxiation and death. Recognized less often today, this rapidly progressive submaxillary cellulitis may still be fatal. A case associated with Haemophilus influenzae bacteremia in an adult is presented. Twelve additional cases of cellulitis of the neck in adults with H influenzae bacteremia are summarized. One hundred forty-one cases of Ludwig's angina reported since 1945 are reviewed and compared with 315 earlier cases. In the cases reported in the antibiotic era, the mean age of the patients was 29 years. Most patients were previously healthy but had evidence of dental disease. Submandibular swelling, elevation of the tongue, fever, dysphagia, and trismus were each present in more than one half of patients. Streptococci and anaerobes were most frequently isolated from soft-tissue cultures. Untreated, this illness is fatal in one half of patients. Early recognition is therefore essential. Appropriate therapy includes maintenance of the airway, antibiotics, and surgical drainage when indicated.

The anatomy of the fasciae of the face and neck with particular reference to the spread and treatment of intraoral infections (Ludwig's) that have progressed into adjacent fascial spaces

Descriptions of the fasciae of the lower half of the face and of the adjacent cervical fasciae have long been puzzling and descriptively much too complex. For this reason, medical students, young medical and dental practitioners, and at times even senior surgeons frequently do not understand the anatomy of the cervicofacial fasciae, which plays such an important role in the spread and subsequent final localization of primary intraoral infections. This article attempts to simplify the descriptions of these fasciae, in particular, their sites of origin and insertion.