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Year : 2021  |  Volume : 19  |  Issue : 3  |  Page : 191-193

Ludwig's angina – Is management possible in a resource-limited rural surgical setup?

1 Department of General Surgery, Gudalur Adivasi Hospital, The Nilgiris, Tamil Nadu, India
2 Department of Dental Surgery, Gudalur Adivasi Hospital, The Nilgiris, Tamil Nadu, India

Date of Submission27-Feb-2021
Date of Decision20-Mar-2021
Date of Acceptance17-Apr-2021
Date of Web Publication05-Jul-2021

Correspondence Address:
Dr. Royson Jerome Dsouza
Gudalur Adivasi Hospital, The Nilgiris - 643 212, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/cmi.cmi_22_21

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Ludwig's angina is a rapidly progressive gangrenous cellulitis of the soft tissues of the neck and floor of the mouth which can cause airway compromise. The management involves a multidisciplinary approach consisting of intensivists, otolaryngologists, head-and-neck surgeons, and anesthesiologists. Consequently, the patients with Ludwig's angina are mostly managed at tertiary care centers. Although early surgical intervention for drainage of the abscess and securing the airway is recommended, many subsets of these patients can be managed conservatively. These include hemodynamically stable patients, without stridor and respiratory distress. A 41-year-old lady with no known comorbidities presented with a rapidly progressive swelling over the submandibular region following dental extraction. There were severe trismus and dysphagia but without clinical evidence of airway compromise. She was successfully managed in a rural secondary tribal health-care center with intravenous antibiotics, analgesics, and serial clinical examination. The patient improved symptomatically and recovered well. Through this case report, the authors would like to highlight that Ludwig's angina can be managed in resource-limited rural surgical centers through early intervention along with adequate monitoring and surgical drainage if required.

Keywords: Conservative management of Ludwig's angina, Ludwig's angina, Ludwig's angina in resource-limited settings

How to cite this article:
Dsouza RJ, Venkatesan M, Stephen JH, Rao M. Ludwig's angina – Is management possible in a resource-limited rural surgical setup?. Curr Med Issues 2021;19:191-3

How to cite this URL:
Dsouza RJ, Venkatesan M, Stephen JH, Rao M. Ludwig's angina – Is management possible in a resource-limited rural surgical setup?. Curr Med Issues [serial online] 2021 [cited 2022 May 18];19:191-3. Available from: https://www.cmijournal.org/text.asp?2021/19/3/191/320646

  Introduction Top

Ludwig's angina is a rapidly progressive gangrenous cellulitis of the soft tissues of the neck and floor of the mouth which can increasingly lead to fatality.[1] The patients often present with acute symptoms and can rapidly deteriorate due to potential airway compromise. It usually starts as a dental infection from the second or third molar which then spreads to the sublingual and submandibular space that can cross over to the opposite side.[2] This infection can spread posteriorly to involve the hyoglossus and genioglossus muscles and reach the epiglottis which can then cause laryngeal edema and airway obstruction.[3] Early airway management is critical in treating Ludwig's angina, and hence, patients are always managed at a tertiary care center with available expertise. However, not all patients are prone to develop airway compromise and can be managed conservatively. In this report, we describe a 41-year-old lady who was diagnosed with Ludwig's angina and managed successfully in a resource-limited rural surgical center. Her clinical presentation, relevant investigations, and management have been discussed with a review of the literature.

  Case Report Top

A 41-year-old housewife with no known comorbidities presented with painful progressive swelling in the neck for 2 days after a right lower molar extraction the day before. It was associated with high-grade fever, dysphagia, and trismus, but there was no difficulty in breathing or change in voice.

On general examination, she was hemodynamically stable with a respiratory rate of 24/min and oxygen saturation of 98% in room air. There was no stridor or respiratory distress. Local examination of the neck revealed a diffuse erythematous swelling involving bilateral submandibular regions. The swelling was warm and tender on palpation with surrounding induration [Figure 1]. The cervical lymph nodes were not enlarged. The mouth opening was severely restricted with an inter-incisor distance of 1.5 cm. There was no visible bulge over the floor of the mouth but was tender on palpation.
Figure 1: Local examination of the neck showing diffuse swelling occupying bilateral sub mandibular regions

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With a clinical diagnosis of Ludwig's angina, the patient was further evaluated. Her routine blood investigations were within normal limits. The patient was started on intravenous antibiotics (piperacillin-tazobactam 4.5 g 6th hourly and metronidazole 500 mg 8th hourly), hydration, and analgesics. As our center is not equipped with a mechanical ventilator or a resident anesthesiologist, the complications related to airway compromise were explained to the family. Due to financial constraints and COVID-19 pandemic-associated travel restrictions, the patient and family expressed their wish to continue treatment at our secondary care facility. The patient was closely monitored over the next 48 h with serial clinical examination for features of sepsis and signs of airway compromise. As there was no progression of the swelling or respiratory distress, surgical intervention was deferred. On day 3 of admission, there was a spontaneous discharge of pus from the floor of the mouth into the oral cavity. The patient was taught to gently massage the area of induration in the neck to facilitate drainage of pus. She then improved symptomatically and had a clinically evident reduction in the swelling with improvement in mouth opening. She was discharged on day 6 with oral antibiotics and analgesics. On follow-up, she was doing well, and the swelling had completely subsided [Figure 2]. A written informed consent was obtained from the patient for publication of this case.
Figure 2: Clinical image of the patient during follow up showing a complete resolution of the swelling

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  Discussion Top

The purpose of this case report was to emphasize that appropriate management of apparent emergencies like Ludwig's angina can be done even in rural surgical centers with resource constraints. Conservative management is seldom considered a treatment option in Ludwig's angina with studies concluding the superiority of the surgical approach over the conservative approach.[4],[5],[6] The presence of tenderness, warmth, and fluctuation is characteristics of an abscess and mandate drainage. This, however, is not so in the case of Ludwig's angina as the lack of fluctuation is a typical finding. The classical woody hard feeling due to the underlying cellulitis was also noted in our patient. Hence, the characteristics of the abscess cannot be the predictor for conservative management in Ludwig's angina but multiple other factors such as airway compromise, sepsis, and hemodynamic state of the patient play a role.

Airway management is the single most predictor of survival in patients with Ludwig's angina.[3],[7],[8] The consensus is to immediately intubate the patient and secure the airway when the diagnosis is made followed by surgical drainage.[4],[8] However, not all patients will progress to have airway compromise. We do not disregard elective intubation in patients with Ludwig's angina. But instead, it should be dealt with on a case-to-case basis. The patients who are unable to swallow and have stridor warrant an emergent intervention to secure the airway.[7],[8] Similarly, a few subsets of patients like ours can be managed expectantly. We hence recommend that serial clinical examination and careful observation of patients should be the main emphasis, especially in resource-limited settings.

The introduction of fiber optic intubation has resulted in a reduction in the need for tracheostomy by making it possible to secure the airway more reliably and has gained prominence in tertiary care centers.[4],[8] This, however, is unavailable in most rural surgical centers, and the rural surgeons must be competent to perform an emergency tracheostomy as conventional intubation is difficult in patients with trismus.

We did a thorough literature search on outcomes of conservative management in patients with Ludwig's angina. Greenberg et al. and Larawin et al. reported successful management with medical therapy in 72% and 34% of the patients, respectively.[9],[10] Kurien et al. reported a good outcome in pediatric patients managed conservatively.[11] There are many other case reports on successful conservative treatment of patients with Ludwig's angina.[12],[13] Our case adds to the existing literature but also particularly highlights that the management is possible even in resource-constrained settings.

  Conclusion Top

Ludwig's angina although is a surgical emergency necessitating immediate airway management and drainage, many subsets of patients can be managed conservatively. These include the ones who are hemodynamically stable, without stridor or respiratory distress. A serial clinical examination and careful observation are essential to initiate timely intervention. A considerable number of these patients can be managed with this approach in resource-limited rural surgical centers.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Hyde WP. Ludwig's Angina and cervical cellulitis (differential diagnosis). J Am Dent Assoc 1933;20:2046-51.  Back to cited text no. 1
An J, Madeo J, Singhal M. Ludwig Angina. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020. Available from: http://www.ncbi.nlm.nih.gov/books/NBK482354/. [Last accessed on 2021 Feb 12].  Back to cited text no. 2
Balasubramanian S, Elavenil P, Shanmugasundaram S, Himarani J, et al. Ludwig's angina: A case report and review of management. SRM J Res Dent Sci 2014;5:211-4.  Back to cited text no. 3
  [Full text]  
Edetanlen BE, Saheeb BD. Comparison of outcomes in conservative versus surgical treatments for Ludwig's Angina. Med Princ Pract 2018;27:362-6.  Back to cited text no. 4
Iwu CO. Ludwig's angina: Report of seven cases and review of current concepts in management. Br J Oral Maxillofac Surg 1990;28:189-93.  Back to cited text no. 5
Flynn TR, Shanti RM, Hayes C. Severe odontogenic infections, part 2: Prospective outcomes study. J Oral Maxillofac Surg 2006;64:1104-13.  Back to cited text no. 6
Moreland LW, Corey J, McKenzie R. Ludwig's angina. Report of a case and review of the literature. Arch Intern Med 1988;148:461-6.  Back to cited text no. 7
Dowdy RA, Emam HA, Cornelius BW. Ludwig's Angina: Anesthetic management. Anesth Prog 2019;66:103-10.  Back to cited text no. 8
Greenberg SL, Huang J, Chang RS, Ananda SN. Surgical management of Ludwig's angina. ANZ J Surg 2007;77:540-3.  Back to cited text no. 9
Larawin V, Naipao J, Dubey SP. Head and neck space infections. Otolaryngol Head Neck Surg 2006;135:889-93.  Back to cited text no. 10
Kurien M, Mathew J, Job A, Zachariah N. Ludwig's angina. Clin Otolaryngol Allied Sci 1997;22:263-5.  Back to cited text no. 11
Hasan W, Leonard D, Russell J. Ludwig's angina-A controversial surgical emergency: How We Do It. Int J Otolaryngol 2011;2011:231816.  Back to cited text no. 12
Mehrotra M, Mehrotra S. Decompression of Ludwig angina under cervical block. Anesthesiology 2002;97:1625-6.  Back to cited text no. 13


  [Figure 1], [Figure 2]


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