Ludwig's angina: an uncommon cause of chest pain.

Abstract: A 71-year-old male with coronary artery disease, hypertension, diabetes mellitus, tobacco and opioid dependence came to the emergency room complaining of one episode of retrosternal chest pain oppressive in nature of one day of evolution. He had acute respiratory distress and required mechanical ventilation. The initial impression was myocardial ischemia, but electrocardiography and cardiac enzymes ruled it out. During the following hours, neck and tongue edema developed. He was started on broad-spectrum antibiotics empirically. Neck computed tomography scan revealed a left parapharyngeal and submandibular abscess. The abscess was drained. The source of infection was found on the second molar of the left lower jaw. The patient improved and was successfully weaned from mechanical ventilation. Despite advances in therapy, Ludwig's angina remains a potentially lethal infection in which early recognition plays a crucial role.

Key Words: abscess, Ludwig's angina, mediastinitis

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Ludwig's angina is a progressive submaxillary cellulitis of the floor of the mouth, usually polymicrobial, which spreads to adjacent tissues. (1) Most cases occur in healthy hosts, but it has been associated with underlying diabetes mellitus, systemic lupus erythematosus, and neutropenia. Other predisposing factors include poor dental hygiene, intravenous drug abuse, trauma, and tonsillitis. (2-5) It usually results from an odontogenic infection. This case report is used to illustrate an atypical presentation of Ludwig's angina.

Case Report

A 71-year-old male with coronary artery disease, hypertension, diabetes mellitus, and tobacco and opioid dependence came to the emergency room, complaining of retrosternal chest pain oppressive in nature and one episode of 1 day of evolution. He was started on intravenous nitrates and subcutaneous heparin. The electrocardiogram done at the time did not reveal ischemic changes. While being evaluated in the emergency room, he had severe respiratory distress requiring mechanical ventilation and intensive care unit admission. His vital signs were significant for fever and hypertension. The cardiac enzymes and electrocardiography done at the time of admission ruled out myocardial necrosis. Laboratory results were remarkable for leukocytosis and bandemia as well as uncontrolled glycemia. He was started on broad-spectrum antibiotics to cover for possible pneumonia and an insulin infusion. During the next 8 hours, neck and tongue edema developed, and a nonpurulent, foul-smelling fluid was noted in his mouth. A neck computed tomography scan revealed a left parapharyngeal and submandibular abscess extending to the thoracic inlet. Antibiotics were changed to ampicillin, clindamycin, and vancomycin. The abscess was drained in the operating room the same day. The source of infection was found on the second molar of the left lower jaw (Fig. 1). All the remaining teeth were removed. The organisms from the submandibular abscess were Fusobacterium nucleatum, Bacteroides oralis, and Bacteroides bivius. A follow-up computed tomography scan showed bilateral parapharyngeal and anterior neck abscesses and acute mediastinitis more prominent on the posterior mediastinum. A second operation was required to drain smaller pockets of fluid 5 days after the first intervention (Fig. 2). The patient slowly improved, with a decrease in fever and neck edema. He was successfully weaned from mechanical ventilation 30 days after admission and was discharged from the intensive care unit 24 hours later.

Discussion

Dental infections are common in the general population, with a prevalence of more than 40% by age 6 years in the primary dentition and more than 85% by age 17 years in the permanent dentition. (6) They usually have a benign course but sometimes can lead to serious and life-threatening complications. One of these complications is Ludwig's angina. It represents 13% of all the deep neck infections. It is a rare but life-threatening condition that must not be overlooked during the assessment of tooth pain. (4) In 1836, Willhelm Frederick von Ludwig described a gangrenous induration of the connective tissue of the mouth. In 1939, Grodinsky slightly modified Ludwig's definition and established diagnostic criteria. (5,7) The name given to this type of infection comes from its potentially lethal outcome. Angina is derived from the Latin word angere, meaning "to strangle." (3) Other authors have used the terms angina maligna, morbus strangulatoris, and garotillo (Spanish word for hangman's loop). (8) Before the antibiotic era, it usually caused death by asphyxiation. With the advent of antibiotics, its incidence and mortality rates have dramatically decreased from more than 50% to less than 10% mortality. The initial use of penicillin in the therapy of odontogenic infections in the 1940s led to the dramatic decline in the mortality rates. In 1940, Williams (9) published a case series of Ludwig's angina, in which 24 of 44 (54%) patients died. Three years later, Williams and Guralnick (10) published a case series of 20 patients with Ludwig's angina, in which 2 of 20 (10%) patients died. The reduced frequency of these infections makes their diagnosis more difficult for the average practitioner, and therefore careful study of severe odontogenic infections is necessary, or preventable deaths can occur. (11) Deep fascial space infections of the head and neck can rapidly progress to threaten vital structures and to obstruct the airway. Timely consultation with a dentist or dental specialist, such as an oral and maxillofacial surgeon, can be lifesaving. (11)

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The four cardinal signs of Ludwig's angina are bilateral infection in more than one space; gangrene with serosanguineous infiltration; involvement of the connective tissue, fasciae, and muscles but not the glandular structures; and spread by continuity, not by lymphatics. (1-5) The most commonly affected teeth are the lower second and third molar. The roots of these molars extend into the mylohyoid muscle, providing a route to the mandibular spaces. Other causes include fractured mandibles, foreign bodies and lacerations on the floor of the mouth, traumatic procedures, infection of oral malignancies, otitis media, and peritonsillar abscesses, among other causes (5) The usual symptoms include dysphagia, neck swelling, and pain; other symptoms include dysphonia, drooling, tongue swelling, pain in the floor of the mouth, and sore throat. (1-6)

Conclusion

Contrary to the typical presentation, our patient complained of chest pain, most likely due to mediastinal involvement. Although the initial diagnostic impression was incorrect, his airway was promptly secured, preventing a fatal outcome. Over the next 24 hours, the typical swelling and discoloration of the neck were noted, and Ludwig's angina was confirmed by imaging studies. The source of infection was a dental piece, as it is in 50 to 90% of the cases. The treatment of Ludwig's angina is based on three principles: maintenance of a patent airway, antibiotic therapy, and surgical drainage if medical therapy failed or if an abscess has developed. Despite advances in therapy, Ludwig's angina remains a potentially lethal infection in which early recognition plays a crucial role.

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Accepted August 10, 2004.

References

1. Nguyen V, Potter J, Hersh-Schick M. Ludwig's angina: an uncommon and potentially lethal neck infection. AJNR Am J Neuroradiol 1992;12:215-219.

2. Moreland LW, Corey J, McKenzie R. Ludwig's angina: report of a case and review of the literature. Arch Intern Med 1988;148:461-466.

3. Fritsch DE, Klein DG. Curriculum in critical care: Ludwig's angina. Heart Lung 1992;21:39-47.

4. Ferrera P, Busino L, Snyder H. Uncommon complications of odontogenic infections. Am J Emerg Med 1996;14:317-322.

5. Finch R, Snider G, Sprinkle P. Ludwig's angina: medical emergency medicine. JAMA 1980;243:1171-1173.

6. Schafer T, Adair S. Prevention of dental disease: the role of the pediatrician. Pediatr Clin North Am 2000;47:1021-1042.

7. Weisenengreen H. Ludwig's angina: historical review and reflections. Ear Nose Throat J 1986;56:457-461.

8. Muckelston HS. Angina Ludovici and kindred infections: a historical and clinical study. Ann Otol Rhinol Laryngol 1928;37:711-735.

9. Williams AC. Ludwig's angina. Surg Gynecol Obstet 1940;70:140-149.

10. Williams AC, Guralnick WC. The diagnosis and treatment of Ludwig's angina: a report of twenty cases. N Engl J Med 1943;228:445-450.

11. Flynn T. The swollen face: severe odontogenic infections. Emerg Med Clin North Am 2000;18:481-519.

RELATED ARTICLE: Key Points

* Dental infections are common among the general population.

* Their usual course is benign but sometimes can lead to life-threatening complications such as Ludwig's angina.

* Early, aggressive therapy is essential for a successful outcome.

Maria Elena Ocasio-Tascon, MD, Miriam Martinez, MD, Arturo Cedeno, MD, Alfonso Torres-Palacios, MD, Edwin Alicea, MD, and William Rodriguez-Cintron, MD

From the Pulmonary and Critical Care Section, San Juan Veterans Affairs Medical Center, San Juan, Puerto Rico.

Reprint requests to Dr. Maria Elena Ocasio-Tascon, San Juan VA Medical Center, 10 Casia Street, Pulmonary and Critical Care Section (111E), San Juan, PR 00927-5800. Email: [e-mail]