surg

• Life-threatening complication of orofacial infections
• Related to lower jaw: Ludwig’s angina, Mediastinitis, Involvement of carotid sheath
• Related to upper jaw: Intracranial complications like cavernous sinus thrombosis, brain abscess, dural meningitis, and osteomyelitis of the skull, Retrobulbar cellulitis leading to blindness
• Ludwig’s angina: Firm, acute, toxic, and severe diffuse cellulitis/induration that spreads rapidly, bilaterally affecting the submandibular, sublingual, and submental spaces
• Wilhelm Friedreich Von Ludwig in 1836 termed ‘Ludwig’s angina’, coined by Camerer in 1837
• Classic Ludwig angina: Definite bilateral involvement of all three spaces i.e., submandibular, sublingual, and submental spaces
• Three ‘F’: Feared, rarely becomes fluctuant, often fatal
• Other names for Ludwig’s angina

  • Marbus strangulatorius: choking effect of the disease, Angina maligna, Garrotillo: Spanish version for Hangman’s knot (noose)
• Aetiology of Ludwig’s angina: Odontogenic infection in 90% of cases, traumatic injuries of orofacial region, submandibular and sublingual sialadenitis, secondary infections of oral malignancies, pharyngeal infection or tonsillitis, iatrogenic causes, cervical lymphoid tissues, miscellaneous causes like foreign bodies
• Pseudo-Ludwig’s angina/pseudo-Ludwig’s phenomena: Applied to cases of non-dental origin
• Microbiology of Ludwig’s angina: Streptococci, mixed oral flora, presence of staphylococci, E. coli, Pseudomonas, anaerobes including Bacteroides, Peptostreptococcus, Prevotella species, fusospirochetes
• Clinical features of Ludwig’s angina: General constitutional symptoms, chills and malaise, marked pyrexia, difficulty in swallowing (dysphagia), impaired speech and hoarseness of voice
• Extraoral examination findings: Bilateral suprahyoid swelling, swelling is firm/hard, brawny, nonpitting
• Types of bacteria

  • fusospirochetes
  • Anaerobes
• Clinical features

  • General constitutional symptoms: looks toxic, very ill, dehydrated
  • Chills and malaise
  • Marked pyrexia
  • Difficulty in swallowing (dysphagia)
  • Impaired speech and hoarseness of voice
• Extraoral examination

  1. Bilateral suprahyoid swelling

  2. Swelling is firm/hard, brawny, nonpitting, not-fluctuating and tender on palpation

  3. Airway obstruction and cyanosis may occur

  4. Difficulty in swallowing and breathing

  5. Early presentation has no suppuration but...
• Extraoral examination

  • Mouth remains open
  • Shallow breathing
  • Restricted mouth opening
  • Fatal death, 10–24 h due to asphyxia
• Intraoral examination

  1. Swelling develops rapidly

  2. Increased salivation, stiffness of tongue, difficulty in swallowing with hot potato speech is noted

  3. Drooling of saliva

  4. Backward spread of infection leading to oedema of the glottis

  5. Development of Stridor
• Potential complications

  • Septicaemia, upper respiratory airway obstruction and provoke oedema of the epiglottis
  • Mediastinum, producing thoracic empyema
  • Aspiration pneumonia and vascular erosion
  • Common cause of mortality is acute obstruction of the airways
  • Reach close to carotid sheath
  • Pterygopalatine fossa, leading to cavernous sinus thrombosis
  • Fatal within 12–24 h due to asphyxia
• Diagnosis


  Clinical findings, although CT studies
• Treatment

  1. Early with administration of antibiotics

  2. Prophylactic incision

  3. Airway must also be controlled
• Surgical management

  1. In case of rise of tissue tension, little amount of pus is evacuated

  2. Bilateral drainage of submandibular spaces with the drainage of sublingual and submental spaces

  3. Drain sublingual and submental spaces separately to avoid perforation of the mylohyoid muscle
• Distant spread

  1. Spread can occur by means of the bloodstream

  2. Via internal jugular vein

  3. Cardiac colonization

  4. Cavernous sinus

  5. Encephalic abscesses and meningitis
• Thirteenth Edition of McCracken’s REMOVABLE PARTIAL PROSTHODONTICS
• Authors: Alan B. Carr, DMD, MS and David T. Brown, DDS, MS
• Alan B. Carr is a Professor in the Department of Dental Specialties at Mayo Clinic, Rochester, Minnesota
• David T. Brown is the Chair of the Department of Comprehensive Care and General Dentistry at Indiana University School of Dentistry, Indianapolis, Indiana
• ISBN: 978-0-323-33990-2
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