ludwigs angina & anaesthetic management

Ludwig’s AnginaLudwig’s AnginaDr pn reddy

nellore

Dr pn reddy

nellore

Ludwig’s AnginaLudwig’s Angina

Extension of localized periapical infection Anterior mandibular Sublingual Posterior mandibular (molar)

Submandibular

Fascial planes

Extension of localized periapical infection Anterior mandibular Sublingual Posterior mandibular (molar)

Submandibular

Fascial planes

Historical cuesHistorical cues

Recent dental extraction or work Dental caries Fever Swelling of mouth, face, neck Compromised host Co-morbidities (diabetes)

Recent dental extraction or work Dental caries Fever Swelling of mouth, face, neck Compromised host Co-morbidities (diabetes)

Physical examPhysical exam

Toxicity Brawny bilateral boardlike edema Submandibular, submental, sublingual Trismus Tongue elevation No fluctuance

Toxicity Brawny bilateral boardlike edema Submandibular, submental, sublingual Trismus Tongue elevation No fluctuance

Figure 66-32 A, Ludwig angina may initially appear benign. B, In Ludwig angina, rapid progression may compromise the airway in a few hours.

Figure 66-32 A, Ludwig angina may initially appear benign. B, In Ludwig angina, rapid progression may compromise the airway in a few hours.

Roberts and Hedges, p. 1339

EtiologyEtiology

Streptococcus Staphylococcus Mixed aerobic/anaerobic infection

B. Fragilis

ß-lactamase resistance (<= 40%)

Streptococcus Staphylococcus Mixed aerobic/anaerobic infection

B. Fragilis

ß-lactamase resistance (<= 40%)

DiagnosisDiagnosis

Clinical CT scan

Clinical CT scan

4-month-old with fever, irritability, and decreased oral intake x 24 hours. Swelling x 10 hrs (Maimon et al, Ann Emerg Med, 2006)

4-month-old with fever, irritability, and decreased oral intake x 24 hours. Swelling x 10 hrs (Maimon et al, Ann Emerg Med, 2006)

TreatmentTreatment

Airway control - EARLY Fiberoptic Deterioration may be rapid Cricothyrotomy or tracheostomy may be

necessary Surgical consultation mandatory

Oral maxillofacial surgeon or ENT Definitive surgical drainage and debridement

ICU

Airway control - EARLY Fiberoptic Deterioration may be rapid Cricothyrotomy or tracheostomy may be

necessary Surgical consultation mandatory

Oral maxillofacial surgeon or ENT Definitive surgical drainage and debridement

ICU

AntibioticsAntibiotics

Extended spectrum penicillins Ampicillin/Sulbactam (Unasyn) Ticarcillin/Clauvulate (Timentin) Piperacillin/Tazobactam (Zosyn)

Clindamycin + Cipro (PCN allergy) Flagyl (B. Fragilis)

Extended spectrum penicillins Ampicillin/Sulbactam (Unasyn) Ticarcillin/Clauvulate (Timentin) Piperacillin/Tazobactam (Zosyn)

Clindamycin + Cipro (PCN allergy) Flagyl (B. Fragilis)

SteroidsSteroids

Reduce edema “Used routinely when airway

compromise suspected” (Larawin et al.) Dexamethasone 10-20 mg IV

Then 4-6 mg Q6 for 8 doses (Busch)

Reduce edema “Used routinely when airway

compromise suspected” (Larawin et al.) Dexamethasone 10-20 mg IV

Then 4-6 mg Q6 for 8 doses (Busch)

Deep Neck Space InfectionsDeep Neck Space Infections

103 patients (1993 - 2005) Ludwig’s Angina (n=38, 37%) Odontogenic (n=25, 67%) Tracheostomy (n=4) Medical management (n=13) Medical and surgical management

(n=25)

103 patients (1993 - 2005) Ludwig’s Angina (n=38, 37%) Odontogenic (n=25, 67%) Tracheostomy (n=4) Medical management (n=13) Medical and surgical management

(n=25)Larawin et al. Head and neck space infections. Otolaryngol Head Neck Surg. 2006, 135(6):899-993.

Deep Neck Space InfectionsDeep Neck Space Infections Complications

Upper airway obstruction (n=4) Reinfection (n=3) Asphyxiation (n=1) Descending mediastinitis (n=1) Spread to other spaces (n=1) Death (n=2)

Complications Upper airway obstruction (n=4) Reinfection (n=3) Asphyxiation (n=1) Descending mediastinitis (n=1) Spread to other spaces (n=1) Death (n=2)

Larawin et al. Head and neck space infections. Otolaryngol Head Neck Surg. 2006, 135(6):899-993.

Ludwig’s Angina - SummaryLudwig’s Angina - Summary Serious deep space infection Potentially fatal Aggressive manage airway as indicated Surgical consultation Antibiotics and steroids ICU

Serious deep space infection Potentially fatal Aggressive manage airway as indicated Surgical consultation Antibiotics and steroids ICU

ANAESTHETIC MANAGEMENT

1. Pre-op optimization/starvation

2. Investigations

3. Antibiotics

4. Evaluation of airway

5. See for comorbid conditions

6. Planning of anaesthetic technique

Anesthetic management conti……

1. Control of airway before any intervention 2. Under anaesthesia, infection can spread and can block

airway3. Regional anesthesia A. Bilateral superficial and deep cervical plexus block if it possible

4. General anaesthesia A.Blind nasal with topical anaesthesia or GA not advisible b/c

unexpected bleeding, spread of edema or pus may come out due to trauma

B.Best is awake fiberoptic endoscopic intubation & surgical intervention, if not possible, surgical airway by elective tracheostomy

ReferencesReferences Larawin V, Naipao J, Dubey SP. Head and neck space infections. Otolaryngol Head Neck

Surg. 2006 Dec;135(6):889-93. Marple BF. Ludwig angina: a review of current airway management. Arch Otolaryngol Head

Neck Surg. 1999;125:596-599. Busch RF. Ludwig angina: early aggressive therapy. Arch Otolaryngol Head Neck Surg.

1999 Nov;125(11):1283-4. Maimon MS, Janjuh AS, and Goldman RD. Images in emergency medicine. Ludwig’s

Angina in a 4 Month Old Infant. Ann Emerg Med, 2006 May;47(5):503, 507. Amsterdam J. Chapter 65: Oral Medicine. In Marx J, Hockberger R, Walls R: Rosen's

Emergency Medicine, Concepts and Clinical Practice, 5th ed. St. Louis, Mosby, 2002, 892-908 pp.

Benko, K. Chapter 66: Emergency Dental Procedures. In Roberts J, Hedges J: Clinical Procedures in Emergency Medicine, 4th ed. 4th ed, Philadelphia, Saunders, 2004, 1317-1340 pp.

Larawin V, Naipao J, Dubey SP. Head and neck space infections. Otolaryngol Head Neck Surg. 2006 Dec;135(6):889-93.

Marple BF. Ludwig angina: a review of current airway management. Arch Otolaryngol Head Neck Surg. 1999;125:596-599.

Busch RF. Ludwig angina: early aggressive therapy. Arch Otolaryngol Head Neck Surg. 1999 Nov;125(11):1283-4.

Maimon MS, Janjuh AS, and Goldman RD. Images in emergency medicine. Ludwig’s Angina in a 4 Month Old Infant. Ann Emerg Med, 2006 May;47(5):503, 507.

Amsterdam J. Chapter 65: Oral Medicine. In Marx J, Hockberger R, Walls R: Rosen's Emergency Medicine, Concepts and Clinical Practice, 5th ed. St. Louis, Mosby, 2002, 892-908 pp.

Benko, K. Chapter 66: Emergency Dental Procedures. In Roberts J, Hedges J: Clinical Procedures in Emergency Medicine, 4th ed. 4th ed, Philadelphia, Saunders, 2004, 1317-1340 pp.

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