Pediatric head and neck infections are encountered commonly in the Emergency Department. While most often these will be relatively simple (although still annoying to the patient and family) like Acute Otitis Media, Otitis Externa, Sinusitis, or Pharyngitis, they can also become complicated. Certainly we must be adept at managing the straight forward cases, but we need to remain vigilant for the potential complications (ex. Gradenigo’s Syndrome, Orbital Cellulitis, Periorbital Cellulitis, Mastoiditis). One such complication deserves great respect. Let us review Ludwig’s Angina in Children:

Ludwig’s Angina: Basics

• What’s in a name?
  • Attributed to Wilhem Frederick von Ludwig – hence “Ludwig’s”
  • Swollen submandibular space and tongue can lead to airway compromise – hence “Angina,” derived from Latin’s “Angere,” meaning “to strangle“

• Describes a rapidly progressive infectious / inflammatory process of the floor of the mouth.
  • In pre-antibiotic era, had mortality rates of >50%. [Britt, 2000]
  • Current mortality rates have improved to 0-10%. [Britt, 2000]

• Location / Anatomy Matters
  • When the tongue gets swollen and displaced, we all get nervous. That important breathing hole can become obstructed easily.
  • The submandibular space has “boundaries,” but some are less restrictive to spread of infection / inflammation.
    • Superior border = oral floor mucosa
    • Inferior border = superficial layer of the deep cervical fascia that extends from hyoid bone to mandible.
    • Submandibular space divided by the mylohyoid muscle:
      • Makes the submaxillary and sublingual spaces.
      • These spaces are not isolated from each other.
  • Infection / Inflammation of the submandibular space:
    • Displaces of the tongue superiorly and base of tongue posteriorly.
      • Can encroach upon the airway.
      • The swollen, firm, and displaced tongue will also make intubation more than challenging.
    • Can spread along fascial planes to local structures, like: [Lin, 2009; Britt, 2000]
      • Retropharyngeal space
      • Superior Mediastinum

• Often considered in adults, but ~1/4 to 1/3 of cases are in children. [Britt, 2000; Kurien, 1997]
  • Ages of cases range from neonates to adults.
  • Mean age for children with Ludwig’s Angina = 9.7 yrs

Ludwig’s Angina: Causes

• Often thought of being due to odontogenic source:
  • Roots of 2nd and 3rd molars extend below mylohyoid line into the submandibular space.
  • Common cause in adults, but less so in young children. [Britt, 2000; Kurien, 1997]

• May occur without clear etiology. [Lin, 2009; Britt, 2000]
• Other causes in children to consider:
  • Oral trauma (lacerations and mandible fractures)
  • Sialadenitis
  • Gingivostomatitis
  • Lymphatic and vascular malformations
  • Conditions that predispose kids to severe infections:
    • Immunosuppression (Congenital or Acquired)
    • Neutropenia
    • Diabetes Mellitus
• Infection
  • Often mixed flora of aerobic and anaerobic species.
  • Strep and Staph and Bacteroides are seen.
  • May not be associated with defined abscess.
  • In one series, 35% had positive blood cultures. [Britt, 2000]
  • Can become associated with pneumonia, mediastinitis, pericarditis, and sepsis.

Ludwig’s Angina: Presentation

Ludwig’s is much more than the standard swollen submandibular lymphnodes children often get, but obviously, we’d like to detect it before it gets to the point of airway compromise.

• Focal Symptoms [Lin, 2009]
  • Tongue pain, throat pain
  • Trismus
  • Dysphonia, Dysphagia, and Drooling

• Focal Symptoms [Lin, 2009]
  • Firm induration of oral floor
  • Edema and displacement of the tongue
  • Limited tongue mobility

• Systemic symptoms and signs can also present as the condition worsens and may include:
  • Toxic appearance
  • Overt respiratory distress

Ludwig’s Angina: Management

• Given the potential for rapid airway compromise, early recognition is imperative (remain vigilant!).
• Should have a low threshold stabilizing the airway, but:
  1. It will not be an “easy” task
     • Mobilize all resources (similar to epiglottis)
     • Awake intubation may be best option
     • Nasotracheal intubation may help avoid large, firm tongue.
     • Be ready with surgical plans – Transtracheal and Cricothyrotomy.
     • Prepare all options… and hope to need none.
  2. Intubation is not always necessary [Lin, 2009; Britt, 2000]
     • > 50% did not require airway intervention in Britt’s series.
     • There has been a trend toward airway observation / expectant management. [Chou, 2007; Britt, 2000]

• IV antibiotics should be given.
  • Penicillins, aminoglycosides
  • Consider adding anaerobic coverage with metronidazole or clindamycin.

• Surgical drainage 
  • Ludwig’s Angina is often considered a “process without purulence.” [Britt, 2000]
  • Required if there is localized abscess or if patient fails to improve after IV antibiotics. [Lin, 2009]
  • Britt found ~50% did not require any surgery.

• Steroids (?)
  • Often ordered to help reduce local swelling…
  • No conclusive evidence…

Moral of the Morsel:

• Examine the mouth carefully! Is that tongue displaced, firm, and immobile? That is a problem!
• It’s not the heart. This angina is a strangulation from infection in the submandibular region.
• Be vigilant and call for help! It is rare, but if you encounter it, the child will need all sub-specialists present and accounted for.
• Abx and Airway! While each case will require tailored care (some just requiring close monitoring and preparation) to safely manage the airway, they all need IV antibiotics as soon as possible.

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