Airway management
Airway management has been found to be the most important factor in treating patients with Ludwigs Angina, i.e. it is the “primary therapeutic concern”. Airway compromise is known to be the leading cause of death from Ludwigs Angina. The basic method to achieve this is to allow the patient to sit in an upright position with supplemental oxygen provided by masks or nasal prongs. Patients airway can rapidly deteriorate and therefor close observation and preparation for more invasive methods such as endotracheal intubation or tracheostomy if needed is vital. If the oxygen saturation levels are adequate and antimicrobials have been given, simple airway observation can be done. This is a suitable method to adopt in the management of children, as a retrospective study described that only 10% of children required airway control. However, a tracheostomy was performed on 52% of those affected with Ludwigs Angina over 15 years old. If more invasive or surgical airway control is necessary, there are multiple things to considerFlexible nasotracheal intubation require skills and experience. If nasotracheal intubation is not possible, cricothyrotomy and tracheostomy under local anaesthetic can be done. This procedure is carried out on patients with advanced stage of Ludwigs Angina. Endotracheal intubation has been found to be in association with high failure rate with acute deterioration in respiratory status. Elective tracheostomy is described as a safer and more logical method of airway management in patients with fully developed Ludwigs Angina. Fibre-optic nasoendoscopy can also be used, especially for patients with floor of mouth swellings.
Antibiotics
Antibiotic therapy is empirical, it is given until culture and sensitivity results are obtained. The empirical therapy should be effective against both aerobic and anaerobic bacteria species commonly involved in Ludwigs Angina. Only when culture and sensitivity results return should therapy be tailored to the specific requirements of the patient.Empirical coverage should consist of either a penicillin with a B-lactamase inhibitor such as amoxicillin/ticarcillin with clavulanic acid or a Beta-lactamase resistant antibiotic such as cefoxitin, cefuroxime, imipenem or meropenem. This should be given in combination with a drug effective against anaerobes such as clindamycin or metronidazole. Parenteral antibiotics are suggested until the patient is no longer febrile for at least 48 hours. Oral therapy can then commence to last for 2 weeks, with amoxicillin with clavulanic acid, clindamycin, ciprofloxacin, trimethoprim-sulfamethoxazole, or metronidazole. Incision and drainage
Surgical incision and drainage are the main methods in managing severe and complicated deep neck infections that fail to respond to medical management within 48 hours. It is indicated in cases of:Airway compromise
Septicaemia
Deteriorating condition
Descending infection
Diabetes mellitus
Palpable or radiographic evidence of abscess formation
Bilateral submandibular incisions should be carried out in addition to a midline submental incision. Access to the supramylohyoid spaces can be gained by blunt dissection through the mylohyoid muscle from below. Penrose drains are recommended in both supramylohyoid and inframylohyoid spaces bilaterally. In addition, through and through drains from the submandibular space to the submental space on both sides should be placed as well. The incision and drainage process is completed with the debridement of necrotic tissue and thorough irrigation.