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Ludwig's angina
L17DWIG’S IHVIKG J. WALKER,
ANGINA M.D.,
BOSTON, X4ss.
L
UDWIG’s angina, as you realize, is a condition which should intcrcst both the surgeon and the dentist. Historically, the condition has been recognized clinically for about 100 years. In 1836 Queen Catherine of Wiirttemberg died of a condition called a sublingual phlegmon. As in the case of any chief executive who dies of an acute condition, there was a lot of comment by both the laity and the medical profession concerning the Queen’s death. About one year later a German surgeon, Wilhelm Friedrich von Iludwig, presented a leaper based on the death of the Queen. The paper was very well received by the profession at large. X year later another physician, (lamerer, suggested that the condition be called “Ludwig’s Angina,!’ since which time the name has become a fixture. Ludwig postulated that the followin g requisites must bc present in order to establish the diagnosis of Ludwig’s angina: 1. 2. 3. and the 4. twelve
Inflammation of the deep tissues under the t,ongue. This inflammation should begin around the submaxillary gland. This inflammation should then have invaded the upper part, of the neck floor of the mouth. The condition should gradually grow worse, with dcnt,h in from ton to days, or result in a gradual rccovcry.
My early contact with Ludwig’s angina dates back some thirty odd >--cars to the time when I was an intern in the hospital. I have recollection of a few patients being brought to the hospital with a tremendous swelling of the These patients, rccogupper part of the neck, diagnosed as Ludwig’s angina. nized as being seriously ill, were at once taken to the operating room, anesthetized, and operated on. Occasionally one died on the table from respiratory embarrassment or succumbed after a few 110~~s. Rarely a case recovered. Until comparatively rccent,ly the mortality has remained in the neighborhood of 50 per cent. I can also recall a typical case in my early practice. I \VilS called to a Af t,er suburban hospital to attend a man sufferin, ~7 from Tludwig ‘s angina. removing a lot of loose t,eeth without an anesthetic, the patient was anesthetized and the neck opened. After I had left t,he hospital, I began to worry about After whether or not the patient would have any respiratory cmbarrassmcnt. driving a few miles I decided to return to the hospital. It was fortunate that I did so, for I found the patent gasping for breath. Luckily for the patient his life was saved by a tracheotomy. I ment,ion this because up until the last few years the danger of a general an&h&c administered to a I);rticnt with Tdudwig ‘s angina was not recognized.
Ludwig’s
Angina
397
This condition should be of interest to t,hc dentists inasmuch as from T,l to v’s angina arc associated with infections of man82 per cent of cases of Ludwi, dibular molar teeth, usually following extraction of such t,eeth. Other conditions which may result in Ludwig’s angina are (1) fractures of the jaw with SWondary osteomyelitis, (2) trauma of the floor of the mouth, and (3) infection of t,lie pharynx or tonsils. In my personal experience I have seen two instances of Ludwig’s angina which I feel quit,e sure could be attributed to faulty local injection of novocain. I would suggest, therefore, for your consideration that block anesthesia should be used in removal of infected mandibular teeth rather than local injection. It is interesting to speculate from a dental standpoint as well as an anatomic one why infect,ions of the incaisor teeth usually result in superficial submental absccssrs, while infections of the mandibular molar teeth may result in deep cervical infection. I believe I am correct when I state that the roots of the incisor lccth point forward and arc not inserted in the center of the lower portion of the mandible, also that the roots of the molar teeth tend to be insert,ed l)osteriorly on the same bone. You will recall also that the mylohyoid muscle which arises from the hpoid bone is inserted on the lower border of the mandible toward its posterior aspect. Therefore, if one has infections of the roots of the incisor teeth and such infection breaks through the bony structure an abscess is apt to develop superficially in the submental region. On the other hand, if the same infectious process involves the roots of the mandibular molar teeth and lends to extend through the bone, the infectious process will be confined beneath tlrc myloll?-oid muscle. I,et us analyze what happens when the lat,ter takes place. The infection is confined beneath the floor of the mouth bp the mylohyoid musrles which prevents the infection from present,in g itself superficially in the nccak. LiIl infection on one side of the neck can, however, pass readily to the opljosite side bcncath the mylohyoid muscle. Since the structures on the floor of the mouth are rather flexible the infection tends to push the floor of the mouth and the tongue upward so that the tongue may fill the mouth and even project bet,ween the teeth, which cannot be closed. It is quite easy to see that the airway is thus markedly encroached upon. Of itself this air passage being diminished in size can readily be obliterated if a general anesthetic is given and spasm of the muscles of the pharynx ensues. Such briefly is the hcst reason for not administering a zenera anesthetic in I,udwig’s angina.
The condition when it occurs usually follows ext,raction of infected molar teeth, twenty-four to fort>--eight hours after removal of these teeth. The conThis swelling dition first demonstrates itself by swelling on one side of the neck. will gradually increase, and wit,11 this the tongue and floor of the mouth as noted above will be raised. Beneath the tongue, lying on the floor of the mouth may be a foul smelling exudate. As the swelling increases in the neck there will be edema of the superficial tissues. There will, however, be no evidence of fluclnation, since the pus will be beneath the mylohyoid muscle. There
will be difficulty in speech and also in swallowing, and often respiratory difficulty, chiefly that of inspiration with retraction of muscles of the neck. Even the slightest respiratory difficulty should he a danger signal, indicating the possibility of respirat,ory failure during or following surgery. It is usually high, from 102” to 103” The temperature in these cases varies. F., and the pulse is correspondingly rapid. If left alone, the rare case may result. in cure by the evacuation of pus through the floor of the mouth. However, one should never assume this to be 1)robable. In other words, once the diagnosis of ldudwig’s angina is made, the case should be approached by srn~gcry. In the neglected cast, the infection which Ijrimarily was located in one side of the neck will shortly spread to the opposite side and then downward into the mcdiastinum. The patient may dcvclop septicemia or pneumonia. Sl~K(;Ic2\r,
‘rKE.\T,ZIl’:NT
By way of suggestion it would seem feasible to me that individuals who have infected molar teeth which are to be extracted should bc given sornc 011~ of the sulfonamides previous to extraction of these teet,h. Theoretically it, should be given in amounts sufficient to raise the blood level t,o 1 mg. per cent Perhaps 120 mx. given during the twentyfour at the time of extraction. hours previous to the dental operation should be a practical way of administcring the drug, such dosage to be followed lat,cr by a smaller amount of the drug. The organisms usually found in liudwi g’s angina are about 72 per’ cent hemolytic streptococcus, and also pncumococcus, staphylococcus, and various anaerobes. Based on the frequency of the 1)resence of the hemolytic strcptococcus, probably sulfanilamide should bc the drug of choice. So much for suggestions regarding prevention of liudwl, ‘V’S ~lllgillil ill dcIlta1 surgerv . . I wish to st,ress four points in the surgical treatment of Iludwig’s angina. should accomplish 1-he following : 1. Establishment of an airway so that, the patient m;lS breathe durin,rr and after surgery. 2. Relief of tension on the neck. They
3. Establishment
of drainage.
4. Treatment of infection. I have already mentioned the fact that a general anesthetic in Ludwig’s angina is contraindicated, giving my reason. A local anesthetic is not usual13 satisfactory or sufficient. Therefore one is left a selection of an intravenous These of course should be administcrcd anesthetic, either pentothal or evipal. only by a skilled anesthetist,. Furthermore, the patient should be draped for surgery as soon as the intravenous anesthesia is started, thereby obviating any delay. Some years ago, following certain undesirable rCsu11.s, I came to the conclusion that probably every case of Tludwi g’s angina should be prepared for a tracheotomy, should such bc necessary, tither at the time of operation or during convalescence. With this in mind, at, the time of operation T now make a low
transrcrse tracheotomy incision as a first step in surgery. The dissection is carried down to the trachea. If there is indication during the surgical procedure of marked respiratory embarrassment, the trachea is opened. If the trachea is not opened during the surgery, this tracheotomy incision is packed with a boric strip, but not sutured. Should tracheotomy be made necessary on the ward it can be easily done by removing the boric strip and making a small opening in the trachea. It seems almost unnecessary to state that where tracheotomy is not done in the operating room, a tracheotomy kit should be kept at the bedside and someone able to do tracheotomy should be available if such should be necessarr. Incision for the drainage of t,he infected area should start about 2 cm. below the angle of the jaw on the afleeted side and should be carried around to the midline beneath the chin if the infection is unilateral. On the other hand, if the infection has progressed beyond the midline, incision should 1~ carried from the angle of the jaw on one side around the neck to the opposite angle of the jam. It is very important that this incision be carried deeI, enough to completely divide all fibers of the mylohyoid muscle. Personally, I also remove the submaxillary gland on one or both sides, according to the cstent of the infection. Anatomically, there are no structures that should worry the surgeon particularly. Of course one naturally has to divide the facial artery and vein. The hypoglossal nerve is located sufficiently below the incision as to require little consideration. It may be necessary to divide the anterior bell\- of the digastric muscle, and this should bc done wit,hout hesitation if it seems advisable. The lingual artery will lit in the fibers of the muscles of the floor of the mouth and will not bc encountered. The same is true of the lingual nerve. After surgery, the area is packed with gauze sufficient to control oozing. The dressing should be held in place by a bandage not too tightly applied. During the immediate convalescence the patient should be given one of t,he sulfonamide group either by mouth or parentcrally. The packing in the neck should be removed in twenty-four to thirty-six hours, and the wound thrn dressed with zinc peroxide paste, such to care for anaerobic organisms. I feel quite sure that in the future, having in mind that int,rarenous anesthcsia should be the anesthesia of choice, recognizing the possible accessit!- for a tracheotomy by preparation for it by a preliminary incision, the use of chemotherapy, together with the realization that adequate surgery by comljletc division of the mylohyoid muscle is essential, the mortalit,p in Ludwig’s angina will be far lower than it has been in the past. 520 COMMONWEALTH AI-EXTGE
ANGINA M.D.,
BOSTON, X4ss.
L
UDWIG’s angina, as you realize, is a condition which should intcrcst both the surgeon and the dentist. Historically, the condition has been recognized clinically for about 100 years. In 1836 Queen Catherine of Wiirttemberg died of a condition called a sublingual phlegmon. As in the case of any chief executive who dies of an acute condition, there was a lot of comment by both the laity and the medical profession concerning the Queen’s death. About one year later a German surgeon, Wilhelm Friedrich von Iludwig, presented a leaper based on the death of the Queen. The paper was very well received by the profession at large. X year later another physician, (lamerer, suggested that the condition be called “Ludwig’s Angina,!’ since which time the name has become a fixture. Ludwig postulated that the followin g requisites must bc present in order to establish the diagnosis of Ludwig’s angina: 1. 2. 3. and the 4. twelve
Inflammation of the deep tissues under the t,ongue. This inflammation should begin around the submaxillary gland. This inflammation should then have invaded the upper part, of the neck floor of the mouth. The condition should gradually grow worse, with dcnt,h in from ton to days, or result in a gradual rccovcry.
My early contact with Ludwig’s angina dates back some thirty odd >--cars to the time when I was an intern in the hospital. I have recollection of a few patients being brought to the hospital with a tremendous swelling of the These patients, rccogupper part of the neck, diagnosed as Ludwig’s angina. nized as being seriously ill, were at once taken to the operating room, anesthetized, and operated on. Occasionally one died on the table from respiratory embarrassment or succumbed after a few 110~~s. Rarely a case recovered. Until comparatively rccent,ly the mortality has remained in the neighborhood of 50 per cent. I can also recall a typical case in my early practice. I \VilS called to a Af t,er suburban hospital to attend a man sufferin, ~7 from Tludwig ‘s angina. removing a lot of loose t,eeth without an anesthetic, the patient was anesthetized and the neck opened. After I had left t,he hospital, I began to worry about After whether or not the patient would have any respiratory cmbarrassmcnt. driving a few miles I decided to return to the hospital. It was fortunate that I did so, for I found the patent gasping for breath. Luckily for the patient his life was saved by a tracheotomy. I ment,ion this because up until the last few years the danger of a general an&h&c administered to a I);rticnt with Tdudwig ‘s angina was not recognized.
Ludwig’s
Angina
397
This condition should be of interest to t,hc dentists inasmuch as from T,l to v’s angina arc associated with infections of man82 per cent of cases of Ludwi, dibular molar teeth, usually following extraction of such t,eeth. Other conditions which may result in Ludwig’s angina are (1) fractures of the jaw with SWondary osteomyelitis, (2) trauma of the floor of the mouth, and (3) infection of t,lie pharynx or tonsils. In my personal experience I have seen two instances of Ludwig’s angina which I feel quit,e sure could be attributed to faulty local injection of novocain. I would suggest, therefore, for your consideration that block anesthesia should be used in removal of infected mandibular teeth rather than local injection. It is interesting to speculate from a dental standpoint as well as an anatomic one why infect,ions of the incaisor teeth usually result in superficial submental absccssrs, while infections of the mandibular molar teeth may result in deep cervical infection. I believe I am correct when I state that the roots of the incisor lccth point forward and arc not inserted in the center of the lower portion of the mandible, also that the roots of the molar teeth tend to be insert,ed l)osteriorly on the same bone. You will recall also that the mylohyoid muscle which arises from the hpoid bone is inserted on the lower border of the mandible toward its posterior aspect. Therefore, if one has infections of the roots of the incisor teeth and such infection breaks through the bony structure an abscess is apt to develop superficially in the submental region. On the other hand, if the same infectious process involves the roots of the mandibular molar teeth and lends to extend through the bone, the infectious process will be confined beneath tlrc myloll?-oid muscle. I,et us analyze what happens when the lat,ter takes place. The infection is confined beneath the floor of the mouth bp the mylohyoid musrles which prevents the infection from present,in g itself superficially in the nccak. LiIl infection on one side of the neck can, however, pass readily to the opljosite side bcncath the mylohyoid muscle. Since the structures on the floor of the mouth are rather flexible the infection tends to push the floor of the mouth and the tongue upward so that the tongue may fill the mouth and even project bet,ween the teeth, which cannot be closed. It is quite easy to see that the airway is thus markedly encroached upon. Of itself this air passage being diminished in size can readily be obliterated if a general anesthetic is given and spasm of the muscles of the pharynx ensues. Such briefly is the hcst reason for not administering a zenera anesthetic in I,udwig’s angina.
The condition when it occurs usually follows ext,raction of infected molar teeth, twenty-four to fort>--eight hours after removal of these teeth. The conThis swelling dition first demonstrates itself by swelling on one side of the neck. will gradually increase, and wit,11 this the tongue and floor of the mouth as noted above will be raised. Beneath the tongue, lying on the floor of the mouth may be a foul smelling exudate. As the swelling increases in the neck there will be edema of the superficial tissues. There will, however, be no evidence of fluclnation, since the pus will be beneath the mylohyoid muscle. There
will be difficulty in speech and also in swallowing, and often respiratory difficulty, chiefly that of inspiration with retraction of muscles of the neck. Even the slightest respiratory difficulty should he a danger signal, indicating the possibility of respirat,ory failure during or following surgery. It is usually high, from 102” to 103” The temperature in these cases varies. F., and the pulse is correspondingly rapid. If left alone, the rare case may result. in cure by the evacuation of pus through the floor of the mouth. However, one should never assume this to be 1)robable. In other words, once the diagnosis of ldudwig’s angina is made, the case should be approached by srn~gcry. In the neglected cast, the infection which Ijrimarily was located in one side of the neck will shortly spread to the opposite side and then downward into the mcdiastinum. The patient may dcvclop septicemia or pneumonia. Sl~K(;Ic2\r,
‘rKE.\T,ZIl’:NT
By way of suggestion it would seem feasible to me that individuals who have infected molar teeth which are to be extracted should bc given sornc 011~ of the sulfonamides previous to extraction of these teet,h. Theoretically it, should be given in amounts sufficient to raise the blood level t,o 1 mg. per cent Perhaps 120 mx. given during the twentyfour at the time of extraction. hours previous to the dental operation should be a practical way of administcring the drug, such dosage to be followed lat,cr by a smaller amount of the drug. The organisms usually found in liudwi g’s angina are about 72 per’ cent hemolytic streptococcus, and also pncumococcus, staphylococcus, and various anaerobes. Based on the frequency of the 1)resence of the hemolytic strcptococcus, probably sulfanilamide should bc the drug of choice. So much for suggestions regarding prevention of liudwl, ‘V’S ~lllgillil ill dcIlta1 surgerv . . I wish to st,ress four points in the surgical treatment of Iludwig’s angina. should accomplish 1-he following : 1. Establishment of an airway so that, the patient m;lS breathe durin,rr and after surgery. 2. Relief of tension on the neck. They
3. Establishment
of drainage.
4. Treatment of infection. I have already mentioned the fact that a general anesthetic in Ludwig’s angina is contraindicated, giving my reason. A local anesthetic is not usual13 satisfactory or sufficient. Therefore one is left a selection of an intravenous These of course should be administcrcd anesthetic, either pentothal or evipal. only by a skilled anesthetist,. Furthermore, the patient should be draped for surgery as soon as the intravenous anesthesia is started, thereby obviating any delay. Some years ago, following certain undesirable rCsu11.s, I came to the conclusion that probably every case of Tludwi g’s angina should be prepared for a tracheotomy, should such bc necessary, tither at the time of operation or during convalescence. With this in mind, at, the time of operation T now make a low
transrcrse tracheotomy incision as a first step in surgery. The dissection is carried down to the trachea. If there is indication during the surgical procedure of marked respiratory embarrassment, the trachea is opened. If the trachea is not opened during the surgery, this tracheotomy incision is packed with a boric strip, but not sutured. Should tracheotomy be made necessary on the ward it can be easily done by removing the boric strip and making a small opening in the trachea. It seems almost unnecessary to state that where tracheotomy is not done in the operating room, a tracheotomy kit should be kept at the bedside and someone able to do tracheotomy should be available if such should be necessarr. Incision for the drainage of t,he infected area should start about 2 cm. below the angle of the jaw on the afleeted side and should be carried around to the midline beneath the chin if the infection is unilateral. On the other hand, if the infection has progressed beyond the midline, incision should 1~ carried from the angle of the jaw on one side around the neck to the opposite angle of the jam. It is very important that this incision be carried deeI, enough to completely divide all fibers of the mylohyoid muscle. Personally, I also remove the submaxillary gland on one or both sides, according to the cstent of the infection. Anatomically, there are no structures that should worry the surgeon particularly. Of course one naturally has to divide the facial artery and vein. The hypoglossal nerve is located sufficiently below the incision as to require little consideration. It may be necessary to divide the anterior bell\- of the digastric muscle, and this should bc done wit,hout hesitation if it seems advisable. The lingual artery will lit in the fibers of the muscles of the floor of the mouth and will not bc encountered. The same is true of the lingual nerve. After surgery, the area is packed with gauze sufficient to control oozing. The dressing should be held in place by a bandage not too tightly applied. During the immediate convalescence the patient should be given one of t,he sulfonamide group either by mouth or parentcrally. The packing in the neck should be removed in twenty-four to thirty-six hours, and the wound thrn dressed with zinc peroxide paste, such to care for anaerobic organisms. I feel quite sure that in the future, having in mind that int,rarenous anesthcsia should be the anesthesia of choice, recognizing the possible accessit!- for a tracheotomy by preparation for it by a preliminary incision, the use of chemotherapy, together with the realization that adequate surgery by comljletc division of the mylohyoid muscle is essential, the mortalit,p in Ludwig’s angina will be far lower than it has been in the past. 520 COMMONWEALTH AI-EXTGE