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Year : 2014 | Volume : 2 | Issue : 1 | Page : 42 - 44  


Case Reports
Ludwig’s Angina in Children – Case Report

ChiyaduPadmini1, K. Yellamma Bai2, K. R. Parameshwar Reddy3

1Senior lecturer, Department of Pedodontics and Preventive dentistry, Malla Reddy Institute of Dental Sciences. 2Principal,Professor and Head of the Department of Pedodontics and Preventive dentistry, Malla Reddy College of dental sciences for women. 3Senior lecturer,Department of Oral and Maxillo Facial surgery, Malla Reddy Institute of Dental Sciences.

Abstract:

Ludwig’s angina is a potentially life-threatening, rapidly spreading, bilateral cellulitis of the submandibular spaces. It uncommonly occurs in adults and children and its early recognition is paramount especially in children due respiratory obstruction by neck swelling. With early diagnosis, airway observation and management, aggressive intravenous antibiotic therapy, and judicious surgical intervention, this disease should resolve without any complications. Here, we report a case of Ludwig’s angina in a 14-year-old girl. We also review the relevant anatomy and discuss the clinical presentation and current management of this disease.

Key words: Ludwig's angina, caries, airway, and children.

Corresponding Author: Dr. Chiyadu Padmini, Senior Lecturer, Department of Pedodontics & Preventive Dentistry. Malla Redyy Institute of Dental Sciences. Email: abcdentalhospital@gmail.com

Introduction:

Ludwig’s angina is a potentially life-threatening, rapidly spreading, bilateral cellulitis of the submandibular spaces. [1] During pre antibitotic era, there was mortality rate of 50%, which is mainly attributed to sepsis.

It was during early 1900s, it was appreciated that respiratory obstruction is main reason for mortality. [2] The German physician Wilhelm Frederick von Ludwig initially described Ludwig’s anginain 1836 as a rapidly progressive, gangrenous cellulitis and edema of the soft tissues of the neck and floor of the mouth. [3]

In 1939, Grodinskyproposed four criteria to distinguish Ludwig’s angina from other forms of deep neck abscesses in that the infection must have following features. [4]

(1) Occur bilaterally in more than one facial spaces of the submandibular space

(2) produce a gangrenous serosanguinous infiltrate with or without pus;

(3) Involve connective tissue fascia and muscle but not glandular structures and

(4) Spread by continuity rather than by the lymphatics.

Here, we report a case of Ludwig’s angina in a 14-year-old girl. Present study reviews the relevant anatomy and discusses the clinical presentation and current management on Ludwig’s angina.

Case Report:

A 14-year-old girl reported to our pediatric emergency department with progressive submandibular neck swelling that began 6 days back. There was initially a small nodule over the left submandibular area, and patient experienced an intermittent high fever up to 39.0 C. The lesion was hard, immovable, and tender. She had toothache that affected her right first molar just 2 days back the nodule appeared.

Patient complained of odynophagia, dysphagia, and dysphonia and trismus (patient mouth could only open 2.5 cm) and tongue elevation were found, but no signs of breathing difficulty were noted on extra oral examination (figure 1 & 2).

On examination of OPG (figure3), there was generalized attrition, grossly decayed lower right and left 2nd molars with peri apical radiolucency androot stumps of lower right and left first molars, lower right and left second premolars are recorded.

Figure -1, 2 showing bilateral submandibular and submentalswelling, which is producing typical double chin appearance.

   

 

Figure -3 showing grossly decayed lower right and left premolars and molars

The diagnosis of Ludwig’s angina was clinically established. Patient kept on oral amoxicillin and clavulenic acid BIDand metronidazole 500mg TDS for 5 days.

Chlorhexidinemouth wash was also prescribed for mouth rinsing. Patientwas observed for any potential upper airway obstruction. After five days, the symptoms improved. Dental extractions of the right lower first molar and lower left second premolar was done and she wasdischarged. She was advised to continue withoral antibiotics for one week. Two weeks later,the patient had a follow-up visit atthe outpatient clinic and was well without anyresidual symptoms (figure 4 & 5).

 Figure 4, 5 showing resolution of submandibualar swelling and relief of trismus.