Ludwig Angina: A Review of Current Airway Management

Ludwig angina is a dreaded infection involving the sublingual, submandibular, and submental spaces. Its pathogenesis is most often related to an odontogenic infection gaining access to these spaces and thereby creating a clinical scenario manifested by painful swelling in the floor of the mouth, tense edema and induration of the submental soft tissues, and progressive elevation and posterior displacement of the tongue. The pain and trismus, along with the swelling of the oral and cervical tissues and tongue displacement, create a severely compromised airway. Marple has addressed the issues surrounding the management of this tenuous airway in a timely and balanced fashion. As he points out, Ludwig angina is seen with decreasing frequency; therefore, physician experience with this potentially life-threatening infection is much less than it was a generation ago. With advances in medical care, we now have better antibiotics, more readily available critical care facilities, and a broader range of airway control options. As pointed out in this review, Ludwig angina, like all diseases, presents a spectrum of severity. Patients with early infections have few airway symptoms and can be effectively treated with intravenous antibiotics and careful observation. More advanced infections require drainage procedures, a controlled airway (ie, intubation or tracheotomy), and intensive care unit treatment. Unfortunately, there is no one set of rules that applies to all patients. Clinical judgment and experience cannot be substituted with clinical pathways. Each surgeon and each hospital have a level of capability that must be coupled to management decisions. Sometimes the most appropriate decision is to transfer the patient to a secondary or tertiary care facility where more expertise and more resources are available. The airway management options include the following: • Observation: This option is perfectly appropriate in selected circumstances (ie, cases of lesser severity). • Blind nasotracheal intubation: Uh, no. • Routine orotracheal intubation: This option is rarely applicable since most patients who are candidates for this approach can be observed. • Fiberoptic nasotracheal intubation: This is a good option in the appropriate setting if undertaken by those with skill and experience in this technique. • Tracheotomy with the patient under local anesthesia: This is a reasonable choice, preferably in the operating room with monitored anesthesia. Of course, each of these options must take into account whether incision and drainage procedures are indicated. Obviously, if a surgical procedure is necessary, then airway control becomes mandatory. In this author’s experience, fiberoptic intubation should be performed with the patient in the sitting or semiFowler position, not in the supine position. In the head-up position, secretions are better managed and both the tongue and larynx are in a more optimal position for proper visualization. If a prolonged course is anticipated, a tracheotomy could also be performed following intubation. In those patients with a stable airway, intravenous antibiotics and observation are appropriate starting points. Patients with a more tenuous airway require an intensive care unit setting as the minimum level of care. In hospitals with little backup for airway emergencies, a controlled airway should be obtained before the surgeon leaves the hospital. When in doubt, taking control of the airway is the most conservative method of treatment. Tracheotomy is still a tried and true method for obtaining and maintaining a safe airway. For those patients requiring a trip to the operating room, the options of fiberoptic intubation vs tracheotomy must be decided before anesthesia induction. Generally, we would perform a fiberoptic intubation, drain the affected spaces, keep the tube in place overnight, and monitor the patient in the intensive care unit. The decision on the timing of extubation rests with the clinician, based on the patient’s clinical course and the physical findings at that time. These patients may progress quickly and airway compromise can occur with little warning. As these critical decisions are made, keep in mind that the discomfort of an intubation or the deformity of a tracheotomy scar will be forgiven much more readily than an anoxic event that occurs during the chaos of an emergency airway crisis.