Spot diagnosis?
Hint: Swelling of the floor of mouth after a toothache?
A 68-year-old man presented to the emergency department with complaints of neck swelling for the past 2 days. The swelling was preceded by a history of toothache, fever, pain on swallowing, and progressive difficulty in swallowing both solids and liquids around 1 week back. The patient had no other complaints. His voice and breathing remain unaffected.
On examination of the oral cavity, the swelling was noted in the right submandibular and submental regions with marked edema of the floor of the mouth. Consequently, the tongue was displaced superiorly and posteriorly. Multiple dental caries and poor dentition were observed.
A flexible nasopharyngolaryngoscopy was performed, which showed patent airway, edema of the valleculae, and swollen epiglottis.
A diagnosis of Ludwig’s angina was made.
Broad-spectrum antibiotics were started intravenously. The patient was closely observed for any signs of airway obstruction. While the patient was under local anesthesia, the carious teeth were extracted
The patient had completely recovered at the 1-month follow-up, with no residual symptoms.
Ludwig’s angina is a rapidly progressive swelling of the
submandibular space, which can subsequently displace the tongue and obstruct
the airways, therefore a life-threatening emergency.
Thanks to the antibiotics and surgical techniques, the mortality of Ludwig’s angina
has declined from 50% before the antibiotics’ era to as low as 8% in the
current world.
Mostly it is secondary to odontogenic infections, the infection of the 2nd and 3rd molar teeth.
While other causes include: tongue piercing, peritonsillar/parapharangeal abscesses, neck trauma, mandibular fractures, sialadenitis, oral lacerations/piercing, and oral malignancy.
The patients may present with a history of toothache or infection followed by pain in throat, difficulty in swallowing and mouth opening, muffled voice, fever, displaced, protruded tongue, and bull neck appearance.
Are there any risk factors:
Yes, surely there are!
- Diabetes mellitus
- Recent dental treatment,
- Dental caries
- Alcoholism
- Intravenous drug abuse
- HIV/ AIDS
- Malnutrition
- Poor oral hygiene
- Organ transplantation
Immediate and adequate treatment is indispensable. The patient should be observed for signs of airway obstruction. There is a high mortality rate of 50% due to asphyxia if not treated. Therefore, the management of the airway is the main therapeutic concern.
Other complications include sepsis and mediastinitis.
In some cases, needle drainage is necessary to avoid the spread of infection.
References
“Double Tongue” Appearance in Ludwig’s Angina. (2019, July 11). Retrieved from The New England Journal of Medicine: https://www.nejm.org/doi/full/10.1056/NEJMicm1814117
Nickson, D. C. (2019, April 23). Ludwig angina. Retrieved from LITFL: https://litfl.com/ludwig-angina-ccc/
Candamourty, R., Venkatachalam, S., Babu, M. R., & Kumar, G. S. (2012). Ludwig’s Angina – An emergency: A case report with literature review. Journal of natural science, biology, and medicine, 3(2), 206–208. https://doi.org/10.4103/0976-9668.101932
