page_title: Ludwig's angina
section_title: Airway management
hierarchical_section_title: Ludwig's angina / Treatment / Airway management
caption_attribution_description: English: Illustration of an endotracheal tube.
context_page_description: Ludwig's angina is a type of severe cellulitis involving the floor of the mouth. Early on the floor of the mouth is raised and there is difficulty swallowing saliva, which may run from the person's mouth. As the condition worsens, the airway may be compromised with hardening of the spaces on both sides of the tongue. This condition has a rapid onset over hours.
  The majority of cases follow a dental infection. Other causes include a parapharyngeal abscess, mandibular fracture, cut or piercing inside the mouth, or submandibular salivary stones. It is a spreading infection of connective tissue through tissue spaces, normally with virulent and invasive organisms. It specifically involves the submandibular, submental, and sublingual spaces.
  Prevention is by appropriate dental care including management of dental infections. Initial treatment is generally with broad-spectrum antibiotics and corticosteroids. In more advanced cases endotracheal intubation or tracheostomy may be required.
  With the advent of antibiotics in 1940s, improved oral and dental hygiene, and more aggressive surgical approach, the rates and risk of death among those infected has significantly reduced.
context_section_description: Airway management has been found to be the most important factor in treating patients with Ludwig's Angina, i.e. it is the “primary therapeutic concern”. Airway compromise is known to be the leading cause of death from Ludwig's 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 should never be left unattended, particularly if there is an absence of intubation or a surgical airway in place.
  Methods of airway management range from conservative airway management – consisting of close observation and intravenous antibiotics, to airway intervention with endotracheal intubation or tracheostomy.
  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 Ludwig's Angina over 15 years old.
  Airway control is compulsory if a surgical procedure is required.
  Flexible 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 Ludwig's 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 Ludwig's Angina.
  Fibre-optic nasoendoscopy can also be used, especially for patients with floor of mouth swellings.
  It is important that incision and drainage are preceded by consulting the anaesthesiologist about possible airway problems at intubation. A tracheostomy set should always be present in the operating room in case there is requirement for local tracheostomy or an emergency cricothyrotomy.
caption: Placement of an endotracheal tube to aid breathing.
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