Deep Neck Space Infection / Ludwig's Angina

Algorithm Steps

1. ▶

   Start

   Suspected Deep Neck Space Infection

   Patient with neck/floor of mouth swelling, fever, trismus, dysphagia, voice change. Often recent dental infection or procedure.

   1. ●

      Action

      Identify Ludwig's Angina Features

      Classic Ludwig's: Bilateral submandibular/sublingual/submental space cellulitis. 'Woody' induration of floor of mouth. Tongue elevation/protrusion. Originated from dental infection (70-90% mandibular molars).

      • Bilateral involvement (distinguishes from unilateral abscess)
      • Board-like floor of mouth (brawny induration)
      • No fluctuance initially (cellulitis, not abscess)
      • Rapid progression to airway compromise
      1. ◆

         Decision

         Airway Status?

         Signs of impending obstruction: stridor, inability to handle secretions, tongue protrusion, voice change, respiratory distress, unable to lie flat

         1. ⚠

            Warning

            ⚠️ Airway Emergency

            Call ENT, anesthesia, oral surgery STAT. Awake tracheostomy is safest if severe distortion. Avoid paralytics. Keep patient upright. Do NOT attempt blind intubation.

            1. ●

               Action

               Awake Tracheostomy

               Preferred for fully developed Ludwig's angina. Performed under local anesthesia. Fiberoptic intubation as alternative if anatomy favorable. Surgical airway team must be present.

               1. ●

                  Action

                  CT Neck with IV Contrast

                  MANDATORY for all deep neck infections. Identifies: abscess vs phlegmon, extent of spread (mediastinum?), relationship to vessels. Guides surgical drainage.

                  • Include chest if concern for mediastinal extension
                  • Look for rim-enhancing collections
                  • Assess airway caliber
                  • Identify source (dental, peritonsillar)
                  1. ●

                     Action

                     IV Broad-Spectrum Antibiotics

                     Cover gram-positive, gram-negative, AND anaerobes. Options: Ampicillin-sulbactam 3g IV q6h OR Piperacillin-tazobactam 4.5g IV q6h OR Ceftriaxone 2g IV + Metronidazole 500mg IV q8h. Add Vancomycin if MRSA concern.

                     • Must cover anaerobes (Fusobacterium, Bacteroides)
                     • Continue until afebrile 48 hours
                     • Then transition to oral (Augmentin) for 14 days total
                     1. ◆

                        Decision

                        Surgical Drainage Needed?

                        Up to 65% of Ludwig's require surgical drainage. Indications: drainable abscess on CT, no improvement after 24-48h IV antibiotics, worsening despite treatment.

                        1. ●

                           Action

                           Surgical Drainage

                           ENT/OMFS to OR. Drain all involved spaces. May need multiple incisions. Send cultures (aerobic AND anaerobic). Leave drains in place. If dental source: extract offending tooth.

                           • Submandibular approach for Ludwig's
                           • Intraoral for localized abscesses
                           • Consider transcervical drainage
                           • Remove drains after 48-72h when output decreases
                           1. ◆

                              Decision

                              Monitor for Complications

                              Watch for: mediastinal spread (descending necrotizing mediastinitis), aspiration, airway loss, sepsis, Lemierre syndrome (internal jugular thrombosis)

                              1. ⚠

                                 Warning

                                 ⚠️ Descending Mediastinitis

                                 Life-threatening emergency. Requires CT chest, cardiothoracic surgery for mediastinal drainage. Mortality 20-50% if delayed.

                              2. ✓

                                 Outcome

                                 Infection Controlled

                                 Continue antibiotics until afebrile 48h. Transition to oral. Total 10-14 days. Dental follow-up for extraction of source. Consider tonsillectomy if tonsillar origin.

                                 1. ✓

                                    Outcome

                                    Dental/Source Control

                                    After acute infection resolves: definitive dental extraction if odontogenic source. Address periodontal disease. Immunocompromised workup if recurrent.

                        2. ●

                           Action

                           Medical Management

                           If phlegmon without drainable abscess: close monitoring, IV antibiotics. Serial exams every 6-12 hours. Repeat CT if no improvement in 48 hours.

                     2. ◆

                        Decision

                        Consider Steroids?

                        Dexamethasone may reduce edema and potentially avoid intubation. No RCT data but case reports support use. Not universally recommended.

         2. ●

            Action

            IV Access & Labs

            Large bore IV. Labs: CBC (leukocytosis), BMP (dehydration), lactate, blood cultures. Type and screen. Keep NPO.