Case Report on Rapidly Progressive Ludwig’s Angina

Abstract

Ludwig’s angina is a rapidly progressive, potentially life- threatening cellulitis of the submandibular, submental and sublingual spaces. It is characterized by inflammatory oedema in submandibular, submental or sublingual region rather than abscess which can lead to airway obstruction. Patients with comorbid conditions like diabetes mellitus are at higher risk because of delayed wound healing and higher risk of infections due to impaired immune system. Other factors such as trauma, poor oral hygiene and dental infections can lead to deep neck space infections. Ludwig’s angina is considered as medical and surgical emergency which requires continuous monitoring and airway intervention. Early diagnosis and management of disease can prevent airway obstructions and fatal life-threatening complications. Airway obstruction is the most serious complication which can occur suddenly and this can even occur in patients who were clinically stable initially. The risk of developing airway obstruction is due to increased oedema which extends to the surrounding tissues and epiglottis. These further leads to dysphagia, muffled voice, and potentially respiratory distress. After a recent fall, a 65-year-old man with a history of type 2 diabetes mellitus and hypertension developed increasing pain and oedema in the right submandibular area. He showed extensive oedema and induration over the right submandibular and submental regions without initial airway obstruction, but he was hemodynamically stable upon evaluation. Significant leukocytosis with neutrophilic predominance, raised ESR and CRP levels, elevated blood sugar levels, and accelerated prothrombin time were also found in laboratory examinations. Diffuse infectious inflammatory oedema was seen on neck ultrasonography. Broad spectrum antibiotics, corticosteroids, an emergency incision, drainage, and stringent glucose control and monitoring were administered to the patient. The patient was treated with oral antibiotics, insulin treatment, and supportive drugs after demonstrating clinical improvement with a decrease in swelling and inflammatory markers. In order to minimize life-threatening consequences, this case emphasizes the significance of early detection, active multidisciplinary management, and careful airway monitoring in diabetic patients with deep neck space infections.

Keywords

Introduction

Fig:1

DISCUSSION:

In this instance, an older patient with poorly managed diabetes mellitus has the characteristic manifestation of Ludwig's angina. The patient's symptoms included diffuse edema that extended to the floor of the mouth without the formation of an abscess, increased submandibular swelling, discomfort, and elevated inflammatory markers. Because hyperglycaemia affects neutrophil activity, lowers host immunity, and slows wound healing, diabetes most certainly contributed to the infection's quick progression. ^[1-3]

Comparison with other cases:

Odontogenic infections, particularly those originating from the second or third mandibular molars, account for the majority of documented occurrences of Ludwig's angina. On the other hand, the patient's recent history of soft tissue injuries and falls may have contributed to the infection. This patient showed significant leukocytosis, elevated CRP, high ESR, and poor glycemic control—all of which are linked to severe illness and a higher risk of complications—much like previously documented diabetic instances. This patient's ultrasonography revealed generalized cellulitis and edema without a well-formed abscess, contrary to several documented examples that report abscess formation necessitating drainage. Despite this, fascial space decompression is frequently required even in non-suppurative diseases, hence emergency incision and drainage were carried out. This strategy is in line with other serious cases where prompt surgery prevented mediastinal spread and airway compromise. ^[4-6]

Ludwig's angina frequently manifests as bilateral submandibular edema, elevation of the floor of the mouth, dysphagia, and possible airway impairment, according to earlier research. On the other hand, the patient in this instance had inflammatory edema and unilateral submandibular swelling, but there was no visible abscess formation on imaging. Similar case studies have demonstrated the usefulness of imaging modalities like computed tomography and ultrasonography in detecting diffuse cellulitis and assessing the degree of fascial space involvement. ^[7-8]

Prognosis:

Ludwig's angina prognosis primarily depends on how quickly the condition is identified and treated. Airway blockage, septicaemia, descending mediastinitis, and even mortality might result from delayed detection. Due to the possibility of severe systemic involvement, patients with diabetes, advanced age, high inflammatory markers, and prolonged prothrombin time typically have a worse prognosis. ^[9-11]

CONCLUSION:

This case demonstrates that Ludwig's angina is a deep neck area infection that progresses quickly and can be fatal if left untreated. This patient's advanced age and uncontrolled diabetes mellitus exacerbated the severity and danger of complications. Diffuse inflammatory edema including the submandibular and submental areas was sufficient to require immediate attention even in the absence of a well-formed abscess. A successful outcome was achieved by early diagnosis backed by laboratory results and ultrasound, timely surgical decompression, broad-spectrum antibiotic therapy, corticosteroids, and rigorous glycemic control. In order to lower morbidity and avoid airway compromise, this case highlights the significance of keeping a high index of suspicion in high-risk patients and implementing a multidisciplinary strategy.

PATIENT CONSENT:

Written informed consent was obtained from the patient for publication of this case report.

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