Ludwig's angina (LA) is a gangrenous cellulitis of the neck that spreads via continuity of the fascial planes. Treatment of LA includes aggressive antibiotic therapy as well as surgical drainage in many cases. The most common cause of infection is odontogenic and can be due to both aerobic and anaerobic bacteria. Signs and symptoms of LA include bilateral cervical swelling, dysphagia, drooling, neck tenderness, elevation and posterior distension of the tongue, restricted neck movement, trismus, dyspnea, and stridor, which can result in difficult airway management. Proper preoperative assessment of patients with LA should include identifying features that may cause difficulties with mask ventilation, direct laryngoscopy, and intubation. Alternative methods of ventilation should be considered and immediately accessible, including a plan on how and when they would be used in the event that a patient cannot be mask ventilated or intubated. Marking external anatomical airway landmarks prior to manipulating the airway can save vital time if an emergent airway becomes necessary.
Fascial layers of the neck: 1, investing layer of deep cervical fascia; 2, pretracheal fascia; 3, carotid sheath; 4, superficial fascia; 5, prevertebral fascia. 20
Pathways for spread of odontogenic infections. (A) Coronal section at first molars: a, maxillary antrum; b, nasal cavity; c, palatal plate; d, sublingual space (above mylohyoid muscle); e, submandibular space; f, intraoral presentation with infection spreading through the buccal plates inside the attachment of the buccinator muscle; and g, extraoral presentation to buccal space with infection spreading through the buccal plates outside the attachment of the buccinator muscle. (B) Lingual aspect of the mandible: a, tooth apices above the mylohyoid muscle with spread of infection into sublingual space; b, tooth apices below the mylohyoid muscle (mandibular third molars) with spread of infection into submandibular space. 2
Mallampati views. (A) Class I: soft palate, uvula, fauces, and tonsillar pillars are visible. (B) Class II: soft palate, uvula, and fauces are visible. (C) Class III: soft palate and base of uvula are visible. (D) Class IV: hard palate is visible.
Difficult airway algorithm. 15
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