Today we discussed a case of deep neck space infection! Our patient was a middle-aged man with diabetes and poor oral hygiene who presented with right facial pain and swelling with stiff neck and trismus after seeing his dentist for a tooth infection.

We commonly see patients complaining of tooth aches or sore throats before diagnosing them with pharyngitis or dental caries, but how can we know when to suspect a deeper infection??

Signs and Symptoms that should make you think of deep neck space infection:

• Trismus (inability to open the mouth fully)
• Drooling
• Muffled voice (“hot potato voice”)
• Neck swelling or swelling of the floor of the mouth
• Bulging of the pharyngeal wall, soft palate, or floor of the oropharynx
• Neck pain or stiffness, torticollis
• Crepitus
• Respiratory distress: stridor, tripoding, cyanosis

When evaluating a patient with dental complaints, especially if any signs or symptoms of infection are present, it is VERY important to palpate the floor of the mouth for any tenderness or swelling. Over 70% of Ludwig’s angina cases are due to dental infections (most commonly the molars) and if we do not palpate the floor of the mouth, we may assume symptoms are due solely to dental problems. Ludwig’s angina is an infection of the submandibular space that is rapidly progressive and life threatening.  

On physical exam, you should feel a bilateral, tense edema of the floor of the mouth with possible neck swelling and tenderness usually without lymphadenopathy. Buzz words for this condition are “woody” or “brawny” cellulitis, similar to necrotizing fasciitis. Our patient exhibited 1cm trismus, poor dentition with many dental caries, fullness and tenderness to palpation in the floor of the mouth, as well as neck tenderness and swelling.

Initial evaluation should include rapid and thorough assessment of respiratory status, including asking about respiratory distress at night because these patients often occlude their airway when laying down. Some cases of Ludwig’s angina do not require intubation and can be managed with IV antibiotics and close monitoring in the ICU. However, any signs of respiratory distress should prompt immediate intubation as this can progress rapidly to airway occlusion. Fibreoptic nasotracheal intubation is preferred, often awake and upright, due to the risk of laryngospasm with oral intubation. Whenever intubating a patient with Ludwig’s angina, all preparations for a possible surgical airway should be made in advance due to the often difficult nature of these intubations. Anesthesia and ENT should be consulted emergently whenever Ludwig’s angina is suspected. These patients should always be admitted to the intensive care unit. Although controversial, many otolaryngologists recommend IV glucocorticoid use to decrease airway edema in the emergent period.

The condition is usually polymicrobial with a variety of oral flora, but when an agent is identified, Group A strep is most prevalent. Empiric coverage should consist of gram positive, gram negative, and anaerobic coverage. Unasyn is the drug of choice empirically, but if any MRSA risk factors are present, vancomycin should be added. These risk factors include IVDU, diabetes, ESRD on HD, residence in long-term care facility, hospitalization in the past year). If the patient is septic and at risk of rapid deterioration, MRSA coverage should be included regardless of risk factors. Pseudomonal coverage should be added for any immunocompromised patients. 

The diagnosis of Ludwig’s angina is clinical, but imaging (CT with contrast) may be performed to rule out abscess and determine the need for surgical drainage. This conditions usually does not include focal purulent collections, but is more typical of an aggressive nonpurulent cellulitis with diffuse infection so surgery is not always indicated.

When extubating these patients, throughout evaluation of airway patency must be performed, often including laryngoscopy prior to extubation and extubating over a guidewire.

Why did Ludwig name it “angina”???

Traditionally, we use angina to describe chest pain of cardiac origin. However, the word comes from the Latin angere and Gree ankhone, which mean choke and strangle. Before the discovery of penicillin, the mortality of Ludwig’s angina was over 50%, many due to asphyxiation.