Ludwig Angina: Definition and Etiology

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Questions and Answers

What is the term 'angina' derived from in the Latin language?

To eat

To choke (correct)

To swallow

To breathe

What is the primary cause of true Ludwig angina?

Infection of the gums

Infection of the tongue

Infection of the lower molars (correct)

Infection of the upper molars

What is the name of the German physician who described Ludwig angina in 1836?

Wilhelm Friedrich von Ludwig (correct)

Rudolf Friedrich von Ludwig

Alexander Friedrich von Ludwig

Hans Friedrich von Ludwig

What is a potential complication of Ludwig angina if left untreated?

Carotid arterial rupture Signup and view all the answers

How many compartments of the floor of the mouth are involved in Ludwig angina?

3 Signup and view all the answers

What percentage of Ludwig angina cases originate from dental infections in the mandibular molars?

90% Signup and view all the answers

What is the primary site of Ludwig angina initiation?

Floor of the mouth Signup and view all the answers

Which of the following is a predisposing factor for Ludwig angina?

Diabetes Signup and view all the answers

What is the typical route of infection spread to the neck?

Through the spaces between the fascial layers Signup and view all the answers

Which bacterium is associated with rapid progression of Ludwig angina?

Streptococcus anginosus Signup and view all the answers

What is the typical presentation of Ludwig angina in the neck?

Bull neck Signup and view all the answers

Which of the following is not a common symptom of Ludwig angina?

Tinnitus Signup and view all the answers

What is the role of imaging studies in the immediate assessment of Ludwig angina?

They are not useful in the immediate assessment Signup and view all the answers

Which of the following is a common extraoral finding in Ludwig angina?

Induration of the submental neck Signup and view all the answers

What is the primary method of diagnosing Ludwig angina?

Clinical evaluation Signup and view all the answers

What is the primary objective in treating Ludwig angina?

Securing the airway Signup and view all the answers

Why is a neck CT scan with intravenous contrast recommended in patients with Ludwig angina?

To evaluate the severity of the infection and assess for abscess Signup and view all the answers

What is the role of blood cultures in the diagnosis of Ludwig angina?

To determine if the infection has a hematogenous spread Signup and view all the answers

Why should flexible nasotracheal intubation be performed in a seated position and awake?

To minimize the risk of laryngospasm and other complications Signup and view all the answers

What is the purpose of using intravenous steroids and nebulized adrenaline in the treatment of Ludwig angina?

To improve the penetration of antibiotics into the fascial spaces Signup and view all the answers

Why should supraglottic airway devices be avoided in patients with Ludwig angina?

They may displace due to the progression of the swelling Signup and view all the answers

What is the recommended antibiotic coverage for immunocompromised patients with Ludwig angina?

A combination of a, b, and c Signup and view all the answers

What is the most common antibiotic used in the treatment of Ludwig angina?

Ampicillin-sulbactam Signup and view all the answers

Why should blind nasotracheal intubation be avoided in patients with Ludwig angina?

All of the above Signup and view all the answers

What is the purpose of obtaining cultures from the affected area through swab or needle aspiration in patients with Ludwig angina?

None of the above Signup and view all the answers

What is the goal of surgical decompression of the submandibular space in Ludwig angina?

To allow the tongue to move into a more anteroinferior position Signup and view all the answers

Which of the following is an indication for elective intubation in Ludwig angina?

The presence of airway symptoms or the inability to manage oral secretions Signup and view all the answers

What is a potential benefit of surgical decompression of the floor of the mouth in Ludwig angina?

Avoiding the need for prolonged airway intubation Signup and view all the answers

Who should be involved in the management of Ludwig angina to ensure the best possible outcome?

The otolaryngology, anesthesiology, or oral maxillofacial teams Signup and view all the answers

What is the main objective in managing Ludwig angina patients?

Securing and maintaining the airway Signup and view all the answers

Which of the following is a risk factor for increased mortality and complications in Ludwig angina?

Age older than 65 Signup and view all the answers

¿Cuál es la característica principal de la angina de Ludwig?

Es una infección de los tejidos blandos del suelo de la boca y el cuello Signup and view all the answers

¿Cuál es el resultado de la progresión rápida de la angina de Ludwig?

La obstrucción del tracto respiratorio Signup and view all the answers

¿Qué es esencial para el tratamiento de la angina de Ludwig?

La protección de las vías respiratorias Signup and view all the answers

¿Cuál es el resultado de la infección de los molares inferiores en la angina de Ludwig?

La infección se propaga a los tejidos circundantes Signup and view all the answers

¿Por qué es importante el tratamiento temprano de la angina de Ludwig?

Para prevenir la obstrucción del tracto respiratorio Signup and view all the answers

¿Cuál es el objetivo principal en el tratamiento de la angina de Ludwig?

Reducir la obstrucción de la vía aérea Signup and view all the answers

¿Cuál es el beneficio potencial de la descompresión quirúrgica del espacio submandibular en la angina de Ludwig?

Reducir la estancia hospitalaria Signup and view all the answers

¿Cuál es la indicación para la intubación electiva en la angina de Ludwig?

Síntomas de vía aérea o imposibilidad de manejar secreciones orales Signup and view all the answers

¿Qué es el objetivo principal en la gestión de pacientes con angina de Ludwig?

Securar y mantener la vía aérea Signup and view all the answers

¿Quiénes deberían participar en la gestión de la angina de Ludwig para garantizar el mejor resultado posible?

Equipo de salud, incluyendo otolaringología, anestesiología y maxilofacial Signup and view all the answers

¿Cuál es un factor de riesgo para la mortalidad y las complicaciones en la angina de Ludwig?

Inmunocompromiso Signup and view all the answers

¿Cuál es la principal causa de la angina de Ludwig?

Infecciones odontológicas en los molares mandibulares Signup and view all the answers

¿Qué estructura anatómica divide el piso de la boca en dos espacios?

Músculo milohioideo Signup and view all the answers

¿Cuál es la principal vía de propagación de la infección en la angina de Ludwig?

A través de los espacios fasciales Signup and view all the answers

¿Cuál es el síntoma más comúnmente reportado en la angina de Ludwig?

Fiebre Signup and view all the answers

¿Qué bacteria es asociada con la progresión rápida de la angina de Ludwig?

Streptococcus anginosus Signup and view all the answers

¿Cuál es el nombre de la presentación clínica más común de la angina de Ludwig en el cuello?

Cuello de toro Signup and view all the answers

¿Cuál es el método diagnóstico principal de la angina de Ludwig?

Examen físico y clínico Signup and view all the answers

¿Qué grupos de personas tienen un mayor riesgo de desarrollar angina de Ludwig?

Diabéticos, alcohólicos y pacientes con enfermedad pulmonar obstructiva crónica Signup and view all the answers

¿Cuál es el objetivo principal del tratamiento de la angina de Ludwig?

Prevenir la obstrucción de las vías aéreas Signup and view all the answers

¿Qué bacteria es comúnmente encontrada en cultivos de pacientes con angina de Ludwig y diabetes?

Klebsiella pneumoniae Signup and view all the answers

¿Cuál es el objetivo principal al tratar a un paciente con angina de Ludwig?

Garantizar la vía aérea segura Signup and view all the answers

¿Qué es lo más apropiado para evaluar la gravedad de la infección en un paciente con angina de Ludwig?

Una tomografía computarizada (TC) con contraste intravenoso Signup and view all the answers

¿Cuál es el papel de los cultivos sanguíneos en el diagnóstico de la angina de Ludwig?

Determinar si la infección se ha diseminado hematógenamente Signup and view all the answers

¿Qué es lo más importante al intubar a un paciente con angina de Ludwig?

Intubar al paciente en una posición sentada y despierto Signup and view all the answers

¿Cuál es el objetivo de la administración de esteroides intravenosos y adrenalina nebulizada en el tratamiento de la angina de Ludwig?

Reducir la inflamación y el edema facial Signup and view all the answers

¿Por qué se debe evitar la intubación nasotraqueal ciega en pacientes con angina de Ludwig?

Ambas opciones a y b Signup and view all the answers

¿Cuál es el papel de la antibioterapia en el tratamiento de la angina de Ludwig?

Controlar la infección bacteriana Signup and view all the answers

¿Por qué se recomienda la realización de una TC del cuello con contraste intravenoso?

Para evaluar la gravedad de la infección Signup and view all the answers

¿Qué es lo más importante en el manejo de la vía aérea en pacientes con angina de Ludwig?

Garantizar una vía aérea segura Signup and view all the answers

¿Por qué se recomienda evitar los dispositivos de vía aérea supraglóticos en pacientes con angina de Ludwig?

Pueden desplazarse debido al crecimiento del edema Signup and view all the answers

Study Notes

Ludwig angina is a rare, life-threatening cellulitis of the floor of the mouth and neck, involving three compartments (sublingual, submental, and submandibular), named after Wilhelm Friedrich von Ludwig who described it in 1836. This condition is characterized by a rapid progression of symptoms, including pain, swelling, and difficulty swallowing. If left untreated, Ludwig angina can lead to airway obstruction, sepsis, and even death. Prompt medical attention is crucial to prevent serious complications and improve outcomes.

Etiology

Mainly originates from dental infections in the mandibular molars, particularly the second and third molars (90% of cases).
Periapical abscesses in the second or third mandibular molars are primarily responsible for the condition.
Other less common etiologies include oral piercing or laceration, mandibular fracture, traumatic intubation, osteomyelitis, peritonsillar or parapharyngeal abscess, submandibular sialadenitis, otitis media, and infected thyroglossal cysts.

Pathophysiology

Knowledge of regional anatomy is essential for understanding the spread of the infection.
Ludwig angina typically initiates at the floor of the mouth and rapidly extends to the submandibular space.
The floor of the mouth is divided by the mylohyoid muscle into the sublingual space above the muscle and the submandibular space below the muscle.
The roots of the mandibular molars are located inferior to the attachment of the mylohyoid muscle, which allows the spread of odontogenic infections into the submandibular space.
The infection may also result in edema of the airway structures (epiglottitis, vocal cords, and aryepiglottic folds), which can occur after half an hour of initial presentation.

Clinical Presentation

Patients may report a history of recent dental pain.
Common symptoms include fever, fatigue, chills, and weakness.
Trismus is a typical complaint, indicating a more advanced stage of the disease.
Signs of respiratory involvement include tripod positioning, drooling, and dysphagia.
Other signs or symptoms include mouth pain, hoarse voice, drooling, tongue swelling, and stiff neck.

Diagnosis and Evaluation

Ludwig angina is primarily diagnosed based on clinical evaluation.
Imaging studies do not play a direct role in the immediate assessment of the patient.
A neck CT with intravenous contrast is the most appropriate imaging modality to evaluate the severity of the infection and assess for abscess.
Blood cultures should be obtained to determine if the infection has a hematogenous spread.

Treatment and Management

The primary objective in treating Ludwig angina is to secure the airway.
Next steps include controlling the infection with intravenous broad-spectrum antibiotics and surgical drainage in some cases.
Intravenous steroids and nebulized adrenaline can be adjuvant treatments to improve facial and airway edema and antibiotic penetration.

Complications

Ludwig angina can cause airway obstruction requiring immediate intervention.
The presence of airway symptoms or the inability to manage oral secretions are clear indications for elective intubation.
Close monitoring is essential to prevent the spread of cellulitis to adjacent areas, which can lead to complications such as mediastinitis or neck cellulitis.
Additionally, Ludwig angina can progress to aspiration pneumonia, descending necrotizing mediastinitis, and sepsis resulting in multiple organ failure.