Ludwig's Angina: Higher Incidence and Worse Outcomes Associated With the Onset of the Coronavirus Disease 2019 Pandemic.

Background: Ludwig's angina (LA) is a diffuse cellulitis of the submandibular space and adjacent tissues. During the coronavirus disease 2019 (COVID-19) pandemic, odontogenic treatments were often delayed because of the implementation of safety measures to avoid the spread of the virus. We hypothesized that delayed odontogenic treatments associated with the onset of the COVID-19 pandemic would be associated with an increase in the incidence of LA and worse outcomes related to these infections. Patients and Methods: Patients from June 2018 to June 2022 with computed tomography images suggestive of LA and confirmed by ear, nose, throat (ENT) consult were included. We abstracted demographics, outcomes, clinical management, and microbiology. Patients were stratified into pre-COVID and COVID-onset. Our primary outcome, incidence of LA, was defined as: (new LA cases) ÷ (ED evaluations of oral or dental infections × 1.5 years). Results: In the pre-COVID group, we identified 32 of 1,301 patients with LA for an incidence of 0.02 per year. The COVID-onset group consisted of 41 of 641 patients, with an incidence of 0.04 per year. In the COVID-onset group, progression to necrotizing fasciitis was more likely (0% vs. 15%; p < 0.024), and they returned to the operating room for repeated debridement (3% vs. 22%; p < 0.020). Likewise, hospital length of stay, intensive care unit (ICU) length of stay, and ventilator days were higher (4.3 ± 3.5 vs. 9.5 ± 11.3; 1.1 ± 1.2 vs. 9.5 ± 7.1; 0.3 ± 1 vs. 3.6 ± 7.1; p < 0.001). Conclusions: Although the prognosis for dental infections diagnosed early is generally favorable, we observed a notable increase in the incidence of LA after the onset of the COVID-19 pandemic. Moreover, complications stemming from these infections became more severe in the COVID-onset era. Specifically, the likelihood of necrotizing fasciitis showed a substantial increase, accompanied by an increased risk of respiratory failure and mediastinitis.

Unusual Case of Ludwig Angina Caused by Clostridium sporogenes in an Immunocompromised HIV-Positive Patient with Alcoholism and Dental Abscess.

BACKGROUND Ludwig angina is a cellulitis of the soft tissues of the neck and floor of the mouth. It is most commonly caused by Viridans streptococcal species, but other bacterial species have been shown to lead to this severe infection. Clostridium sporogenes is an anaerobic gram-positive, spore-producing bacillus found in soil and the human gastrointestinal tract. This report is of a case of a 49-year-old HIV-positive man with alcoholism and poor dental hygiene leading to a molar abscess who presented with Ludwig angina due to C. sporogenes. CASE REPORT A 49-year-old man presented with severe left molar pain, fever, and worsening neck swelling for 5 days. His medical history was significant for AIDS; he was not on antiretroviral therapy. Computed tomography of the neck was positive for extensive subcutaneous emphysema of the left sublingual space. Ludwig angina was diagnosed, and he was taken urgently for incision and drainage of the bilateral neck fascial space. On day 6 of hospitalization, 1 of 2 blood cultures grew C. sporogenes. He left the hospital on day 13 and was readmitted 6 days later with progression of the disease and alcohol withdrawal. CONCLUSIONS This case illustrates the need for rapid diagnosis and treatment of Ludwig angina and the importance of considering commonly pathogenic and rarely pathogenic bacteria when considering the underlying bacterial cause of an infection in an immunocompromised patient. To the best of our knowledge, this is the first case of Ludwig angina caused by C. sporogenes reported in the medical literature.

Ludwig's Angina.

Ludwig's angina is a severe diffuse cellulitis that presents an acute onset and spreads rapidly and bilaterally. It can affect the submandibular, sublingual or submental spaces resulting in a state of emergency. Early diagnosis and urgent management could be a life-saving procedure. We report a case of wide spread sialadenitis infection extending to the neck with trismus and elevation of the floor of the mouth that caused an obstruction of the airway and resulted in an inspiratory dyspnea and a stridor. The patient was directed to maintain the airway by elective tracheostomy. An appropriate use of parenteral antibiotics, airway protection techniques, and potential surgical drainage of the infection remain the standard protocol of treatment in advanced cases of Ludwig's angina. The aim of this case report is to emphasize on the importance of early diagnosis and appropriate management of Ludwig's angina.

Severe Ludwig's angina caused by an unknown insect bite.

Hereby, we report a case of a 75-year-old man who presented with a 3-day history of facial swelling and choking sensation. The only history of note was an insect bite on the left parotid gland area 3 days prior. The patient was later diagnosed with insect-bite-induced Ludwig's angina. Enterococcus faecalis was detected on blood cultures and was presumed the source of infection. Intravenous antibiotics and corticosteroids were initiated. The patient was intubated and was subsequently made to undergo a tracheostomy insertion to establish a definitive airway. He was admitted to the intensive care unit and when his condition improved, he was transferred to the ward for full recovery. The patient spent a total of 66 days in hospital before being discharged. This case suggests that Ludwig's angina can be caused by insect bites. However, further similar cases are needed to be documented to explore this theory.

Life-threatening complications of Ludwig's angina: a series of cases in a developed country.

Ludwig's angina is a deep neck space infection defined as a rapidly progressive bilateral cellulitis of the submandibular space. In spite of being an uncommon entity in developed countries and the reduction of mortality and morbidity due to modern era of antibiotics, improved imaging and airway management, it is still an important and potentially life-threatening condition. The authors present 3 cases of Ludwig's angina that occurred in a developed country, and that required admission in intensive care unit and extensive surgical and medical treatment.

Unilateral pectoralis major muscle flap for the treatment of sternal wounds due to Ludwig's angina.

Necrotising descending mediastinitis may rarely originate from Ludwig's angina, which is an infection of the submandibular space. The use of the bilateral pectoralis major muscle flap for the treatment of sternal wound dehiscence is common, but reports of the unilateral application of this flap are scarce. This study aims to report the use of the unilateral pectoralis major muscle flap for the treatment of sternotomy dehiscence in a patient with mediastinitis due to Ludwig's angina. A 21-year-old male patient underwent an exploratory cervicotomy and median sternotomy for drainage of a submandibular infection that extended to the anterior, retropharyngeal and mediastinal cervical spaces. The patient had dehiscence of the sternal wound, and the unilateral pectoralis major muscle flap was used for reconstruction of the defect. This flap was able to completely cover the area of dehiscence of the sternotomy, and the patient presented a good postoperative evolution, without complications. The reconstruction technique using the unilateral pectoralis major muscle flap was considered a good option for the treatment of sternotomy dehiscence. It is an adjuvant method in the treatment of infections such as mediastinitis and osteomyelitis of the sternum secondary to Ludwig's angina, allowing a stable coverage of the sternum.

Should we consider IgG hypogammaglobulinemia a risk factor for severe complications of Ludwig angina?: A case report and review of the literature.

RATIONALE: Cervical necrotizing fasciitis (CNF) and descending necrotizing mediastinitis (DNM) are rare forms of complication of Ludwig angina. These potentially lethal infections are difficult to recognize in early stages and are often associated with predisposing factors like diabetes and immunocompromised states. Moreover, IgG hypogammaglobulinemia (hypo-IgG) is considered to be a risk factor of mortality in patients with septic shock; however, it is not routinely quantified in patients with extremely serious infections, particularly in cases with no history or evidence of immunocompromising disorders. PATIENT CONCERNS: We present a case of a 58-year-old woman who survived Ludwig angina, complicated by CNF and DNM. Despite a rapid diagnosis, aggressive surgical debridement and broad-spectrum antibiotics, the infection and necrosis advanced, requiring multiple surgical interventions and long intensive care unit (ICU) support. CONCLUSION: We hypothesize that detecting a low level of endogenous IgG and treating with adjuvant passive immunotherapy was key in determining a favorable outcome.

Infections and edema.

Infectious and inflammatory conditions of the head and neck may present with impaired airways. An understanding of the pathophysiology will allow for accurate diagnosis and prompt intervention. Preintervention discussion and planning by members of the airway team are crucial in developing a primary and backup plans for safely securing the airway.