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Ludwigs Angina


LUDWIG’S ANGINA

DEFINITION

It is defined as the acute toxic swelling with bilateral involvement of the sublingual,submandibular,and submental spaces.

HISTORIC BACKGROUND:

It is a distinct clinical entity known since the time of Hippocrates.
It was first described by ‘Wilhelm Friedrich Von Ludwig’
But the name was coined by ‘Cramer’ in 1837 who presented cases which include classical description of entity by W.F.Ludwig.

AETIOLOGY:
1.Odontogenic infections:
a.Acute dentoalveolar abscess
b.Acute periodontal abscesss
c.Acute pericoronal abscess
most commonly teeth involved are mandibular second & third molars
2.usage of contaminated needles
3.traumatic injuries of orofacial regions
4.submandibular & sublingual sialadenitis
5.secondary infections of oral malignancies
CLINCAL FEATURES:

GENERAL FEATURES:
Constitutional features like pyrexia ,anorexia,chills and malaise.
Patient looks toxic very ill and dehydrated.

SPECIFIC FEATURES:
1. Swelling develops and spreads rapidly involving submental & submandibular lymph nodes bilaterally which soon extends into the anterior part of the neck into the clavicles.
2. It is described as the brawny, non-pitting, non-fluctuant swellingassociated with severe tenderness.
Classically it shows ill defined borders with induration.
3.Because of its location ,the floor of the mouth and tounge becomes elevated causing difficulty in breathing.
4. in extreme cases tounge may actually protrude from the mouth and its movements are reduced.
5. deglution and speech may also become difficult.
6. saliva may drool from the mouth.
7. this situation may be compounded by the edema of glottis causing  STRIDOR which is the alarming sign of this fatal extension needing emergency intervention.
8. signs and symptoms of respiratory obstruction:
a.increased respiratory rate
b.breathing being shallow with use of accessory muscles of respiration.
c.dilation of external nares
d.raising of thoracic inlets
e.indrawing of tissues above clavicles
f.cyanosis may be seen because of the progressive hypoxia.

Pathology:
It is a diffuse inflammation of soft tissues which is not circumscribed to one area in contrast to an abscess.
Usually caused by microbes which produce hyaluronidases and fibrinolysins which break tissue continuity.

Microbiology:
A plethora of microbes were identified as the causative organisms.
Streptococci the potent producers of hyaluronidase are always associated with classical ludwigs angina.
While the others are
-Staphylococci
-Gram negative entric organisms like..e.coli, pseudomonas.
Anerobes like..bacteriods(B.melanogenicus, B.oralis, B.corrodense).

Investigations:


 1.   General medical examination
 2.   Evaluate laboratory data for blood count, haemoglobin and proteins.
 3.   Pus samples sent for culture.
 4.   Chest radiograph to rule out pneumonia

Management:
 a.   Early diagnosis
 b.   Maintanence of patent airway
 c.    Intense and prolonged antibiotic therapy
 d.   Extraction of offending tooth/teeth
 e.   Surgical drainage or decompression of fascial spaces
 Commonly used antibiotics:

Bactericidal:
1.Aminoglycosides
amikacin                                                              
gentamycin                                                     
streptomycin                                                       
tobramycin                                                           
2.cephalosporins
3.penicillins

Bacteriostatic:

Chloramphenicol
clindamycin
erythromycin
lincomycin
tetracylines

SURGICAL MANAGEMENT:
It is by surgical decompression. The advantages of early surgical intervention are:
a. reduces pressure of the edematous tissue on the respiratory tract.
b. allows samples and specimens for culture and lab diagnosis.
c. allows for the placement of the drains
d. allows prompt drainage.
Following  adequate  anesthesia bilateral sub-mandibular  incisions and if required a midline submental incision  1cm below the inferior border of mandible are sufficient to drain the spaces.
                                  To be effective it is essential to divide deep fascia and mylohoid muscle, then only it will drain sublingual space.
In most of the cases of the ludwig’s angina little or no pus can be drained by surgical intervention.But,in later stages or during post-operative period profuse pus may be seen draining.
Care should be taken to prevent injury to following:
1.   Facial vessels near angle
2.   Lingual nerve
3.   Jugular vein laterally below angle region.

Apart from this patient should be hydrated because he might be dehydrated because of the following reasons:
1.   Diminished liquid intake due to dysphagia
2.   Due to toxic nature of the condition there might be excessive urination and perspiration with elimination of body fluids.

COMPLICATIONS:
a.   Osteomyelitis
b.   Maxillary sinusitis
c.    Localized respiratory tract disturbances
d.   Digestive tract disturbances
More serious complications include:
e.   Septicaemia
f.      Mediastinitis
g.   Neurological complications
h.   Cavernous sinus thrombosis
i.      Brain abscess
j.      Death…if untreated with in 12-24 hours after acute attack  due to asphyxia.

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