193 Ludwig’s angina-a case report

Background Ludwig’s angina was first reported by Wilhelm Frederick von Ludwig in 1836. It is a severe and quickly spreading cellulitis characterized by significant involvement of the sub-mandibular, sublingual and occasionally sub-mental space. This condition is potentially fatal if not treated aggressively and promptly due to the cellulitis leading to airway compromise. Prior to antibiotics in the middle of the 20th century, mortality rates were more than 50%. Most cases of Ludwig’s angina documented occur more commonly in adult males and secondary to dental infection (70–90%) with mandibular molars (unilateral or bilateral involvement) as the main cause. When Ludwig’s angina occurs in the paediatric population, odontogenic cause is only 50%. Some reported causes include salivary gland infection due to sialadenitis, oral tumour infection and infection following intraoral soft tissues surgery. A precipitating aetiology may be difficult to determine, the most frequently involved microorganism is streptococci and staphylococci species. Diagnosis of the condition is normally made through history and physical examination, other findings include fever and raised white cell count and raised CRP. Objectives The patient presented here shows a severe case of a Ludwig’s angina found in a healthy adolescent male, an age group in which the condition is less common. Methods electronic case records were used to collect data Results 13-year-old boy presented with increased facial swelling, drooling, swollen protruding tongue, unable to speak, soft stridor and unable to open mouth. Had had root canal treatment 7 days prior and had also attended A&E 2 days previously with fever, pain on swallowing associated with puffiness around cheeks and eyes. He was assessed and sent home on oral antibiotics. He had no significant past medical history (extraction of 10 deciduous teeth at 7 yrs). On presentation to A&E he had a obstructed airway, maintaining saturations 96% room air, febrile, he was tachyopneic, tachycardiac(122/min) and hypertensive (113/99 mmHg). He was managed with nebulized adrenaline, dexamethasone and IV antibiotics. Clinical diagnosis was Ludwig’s angina He underwent awake fibro-optic intubation, in theatre he underwent dental extraction LL6 (noted to have copious pus) +UL6, underwent tracheostomy for airway management. Was transferred to HDU post procedure. CT scan showed - fluid collection containing flecks of air within the left para-pharyngeal space, extending antero-superiorly to left postnasal space, laterally insinuating between the masseter and left medial pterygoid muscle. Posteriorly, extending to lie just below left bony external acoustic canal. Had a stormy post- operative course with two incidents of peri-arrest due to blocked tracheostomy. These two incidents caused significant anxiety and distress for the child, for which he received psychology input. Decannulation done day 5 post-op, discharged home on post-op day 10, with a course oral antibiotics. Conclusions The present case describes a typical but severe case of Ludwig’s angina in a relatively atypical age group. This is a life -threatening condition, which requires early intervention along with a multidisciplinary team input. While relatively uncommon in the paediatric population, clinicians should be aware and understand the urgency of immediate treatment when it does present.