V.N. Okoje, O.O. Ambeke and O.O. Gbolahan
Department of Oral and Maxillofacial Surgery, University College Hospital, Ibadan, Nigeria
Background: Ludwig’s angina (LA) is defined as a rapidly spreading cellulitis involving submandibular, sublingual and submental tissue spaces bilaterally and simultaneously.
Aim: The aim of this study was to determine the causes, complications, duration of hospital stay and outcome of cases that presented within a 2- year period in the University College Hospital Ibadan and reviewing the management protocols used for such cases.
Materials and Methods: All cases of LA seen in the department of Oral and Maxillofacial Surgery from January 2015 to December 2016 were studied. Information retrieved from patients’ case files included the aetiology, signs and symptoms at presentation, possible predisposing factors, results of laboratory investigations, duration of hospital stay and treatment outcome. Data obtained was analysed using SPSS 22.0 statistical software package (SPSS Inc., Chicago, IL, USA) to present descriptive statistics.
Results: There were 13 cases of LA, consisting of 7 males and 6 females with a mean age of 47.7 + 16.8 years (age range 24-80 years). An odontogenic focus was noted in all cases. Almost all patients underwent surgical treatment, which consisted of an extraction of the offending teeth as well as incision and drainage of abscesses. Length of hospital stay ranged from 1 to 30days (Mean 10 days) with all but 2 patients surviving.
Conclusion: This Study recorded an 84.6% survival rate because our management is handled as a surgical emergency with early recognition and attention paid to the airway in collaboration with the Otorhinolaryngology Unit in our center.
Keywords: Ludwig’s Angina, Underlying medical conditions, Treatment outcome
Dr. O.O. Ambeke
Dept. of Oral and Maxillofacial Surgery,
University College Hospital,
Ludwig’s Angina also known as morbus strangularis and angina maligna was first described in 1836 by the German surgeon Wilhelm Friedrich Von Ludwig as a fast spreading, nearly always fatal infection involving the connective tissues of the neck and the floor of the mouth1, 2. However over the decades with better understanding of the condition coupled with advances in medical and surgical care, morbidity and mortality has been reduced drastically in many centres 3,4,9. In spite of improved knowledge and better management, the potential to be fatal still remains in every case of Ludwig’s angina and most centres still record a number of fatalities and morbidities although higher in the face of suboptimal management.
Regarding the aetiology, a variety of sources have been implicated, however, it most commonly arises from an odontogenic foci arising typically from the roots of the second and third molar3,6 teeth with previous studies reporting 78% and 90% respectively as odontogenic foci1,7. The roots of these teeth extend below the mylohyoid line of the mandible. This allows for progression of infection from these teeth into the submandibular space which is usually the primary space in most cases 5 and from there to the sublingual and submental spaces. Other aetiological sources though not as common include iatrogenic such as following procedures like frenuloplasty8, from clinical conditions like mandibular fractures9, floor of the mouth infections from an oral malignancy10,11 as well as a bizarre case of a migrating fish bone.12
The bacterial aetiology is mostly polymicrobial involving both aerobic and anaerobic organisms with the spread being as a result of a synergistic action between these two groups as well as their combined virulence,3. Commonly isolated microorganisms include Streptococcus viridans, Staphylococcus aureus, Enterococcus, Escherichia coli, Bacteroides, Actinomyces spp and Pseudomonas13 with Streptococcus being the most common organism cultured14.
Although most cases of Ludwig’s Angina are seen in immunocompetent persons, there are several factors that can predispose an individual to coming down with the disease. Examples include Diabetes Mellitus, HIV and Hypertension with Diabetes being the most common as predisposing factor as seen in a study1. Other factors include immune suppression from chronic use of steroids as well as malnutrition have also been implicated15,16.
Airway management is of prime importance in the management of these patients. Options for managing the airway include blind nasotracheal intubation, retrograde intubation, fiberoptic intubation and the creation of a surgical airway.5
Airway management alongside proper antibiotic coverage, thorough surgical drainage of the involved spaces as well as adequate supportive therapy by way of fluid resuscitation, pain control and nutritional support are the pillars upon which modern management of these cases are based upon1. These have helped reduce fatalities associated with these cases from 54% in the pre antibiotic era to around 0-8% today.3,5
The aim of this publication is to determine the causes, complications, duration of hospital stay and treatment outcome of cases of Ludwig’s Angina presenting within a two year period in the University College Hospital (UCH) Ibadan whilst reviewing the management protocols used for these cases.
MATERIALS AND METHODS
An audit was conducted of all cases of Ludwig’s Angina that was seen in the Department of Oral and Maxillofacial Surgery from January 2015 – December 2016. Information retrieved from the patients’ case files included the demographics, aetiology, signs and symptoms at presentation and possible predisposing factors. Laboratory investigations that were done including Full Blood Count, Electrolytes and Urea, Blood Sugar profile and Microscopy, culture and sensitivity (MCS) of all aspirates obtained. In addition, predisposing factors, complications and duration of hospital stay and treatment outcome were also noted. Those patients with comorbid conditions were jointly managed with physicians of appropriate specialty. For the sake of this study, a period of admission greater than 6 days was considered prolonged. Data analysis was done using SPSS version 22.0 statistical software package (SPSS Inc., Chicago, IL, USA) to present descriptive statistics and frequency charts.