Ludwig's Angina: Review of literature and case report

Article published in the Journal of Dentistry Course Union-Evangelical - Vol 9 N.01 Jan / Jun 2007

INTRODUCTION

The Ludwig's angina is a severe infectious-inflammatory process, the polymicrobial nature of rapidly changing, affecting the submandibular space, submental, and sublingual. (Hueb et al 9 2004).
The term angina originates from the Latin and means anger strangling (Borel et al 1 1998). Patients usually have a feeling of suffocation associated with intense sialorrhea, dysphagia, adinofagia, dyspnea, high fever, anorexia, elevation of language with the voice changes, tachycardia, moderate leukocytosis, presence of secretion serosanguinolenta fetid and trismus. (Maniglia et al 11 1981). Shafer 19 (1985) describes the signs and symptoms as a hard swelling, pain, diffuse and bilateral.
According Graziani 8 (1986) the most common cause is dental, but other factors may contribute to the onset of disease, such as foreign bodies in the oral cavity, the mucosal laceration, mandible fracture, contaminated surgery, penetrating trauma in the oral floor, tonsillitis and to idiopathic causes.
The predisposition to Ludwig's Angina by systemic involvement may come from diseases such as acquired immunodeficiency syndrome, alcoholism, glomerulonephritis, malnutrition, diabetes mellitus, use of hormonal anti-inflammatory or immunosuppressive drugs and aplastic anemia. Other causes are found, such as osteomyelitis, infections of salivary glands, infected oral cancer, peri-tonsil abscess, otitis media, tongue piercing and injecting drug use in the major cervical vessels (Hueb et al 9 2004).
However, as the process unfolds and not being treated, the swelling can reach areas of the neck extending up to the glottis. The infection can extend to the lateral pharyngeal space and thence to the retropharyngeal space. This release may evolve to the mediastinum, with severe consequences can be lethal (NEVILLE et al 12 2004).

The treatment of Ludwig's angina is based on maintaining the airway, incision, drainage or decompression, antibiotic therapy and removal of infectious focus original. (NEVILLE et al 12 2004).
The authors present a literature review and presentation of case
As the majority of cases of Ludwig's Angina has odontogenic causes, the microorganisms are those found in the oral flora, and then the infections caused by mixed flora, involving both aerobic as anaerobic. A typical oral flora contains alpha-hemolytic Streptococcus followed by Staphylococcus, Peptostreptococcus, Fusobacterium nucleatum, Bacteroides melanogenicus, B.oralis, Veilonella and Sperichaeta,. Niche that favors bacterial production of various endotoxins and promotes a combination of rapid evolution in a closed space, with tissue necrosis, local thrombophlebitis, fetid odor and gas production
Currently, treatment of Ludwig's Angina includes early diagnosis of incipient cases, maintaining the airway, intense and prolonged antibiotic therapy, parenteral hydration and early surgical

CLINICAL CASE REPORT

Patient N.S.B. 37 years, Leukoderma, submitted to the department of Maxillo Facial Surgery, Hospital of the Emergency Anápolis with a severe clinical picture associated with hyperemia, dehydration, dyspnea, drooling and difficulty in swallowing and phonation.
During anamnesis have reported increased volume in the chin for approximately two months doing so the use of self-medication.
On clinical examination there was an area with marked edema in the bilateral submandibular region, extending across the neck. (Figure 01)

Also had trismus and difficulty in swallowing. Lymphadenopathy was observed in all cervical and submandibular chains.
The intra-oral examination, noted poor oral hygiene. Many elements dental carious lesions with advanced and severe periodontitis were installed displayed. It was also observed that the region had elements of molars with severe tissue destruction, showing signs of pulpal necrosis, suggesting this is the cause of the infectious process. (Figure 02)

There has been hospitalized, required laboratory tests (complete blood count, TS, TC, TAP, TTPA, urea, creatinine, K, Na and glycemia) and imaging (radiography and computed tomography for dental light).
The tomographic images showed the involvement of the sublingual and submandibular area bilaterally, and the space mentonianos. There is also the commitment of the right submandibular gland swelling diverting the trachea to the left. The lesion extended superiorly up the side wall of the oropharynx inferiorly to the hyoid bone. There is also the infiltration and thickening of the subcutaneous fat in front of the neck, increased volume of the tonsils and pharynx of both sides. (Figure 3)

Laboratory tests showed anemic table, values indicative of the infectious and acute dehydration.
The patient was submitted to antibiotic prophylaxis prior to the drainage, being done, because empirically according to the acute nature of the disease and its relief. Were administered by EV1.000 ml 0.9% saline solution and 500 ml of serum glucose 5%, 25 drops per minute (alternate), to establish the hydration of the patient. Was administered by the same route 2 gr of cefalozolina, 80mg of gentamicin and metronidazole 500mg.
Complementing the medication were administered 2 ml of sodium dipyrone (EV), 2ml of metoclopramide (EV) and 50 mg of ranitidine (EV) of 12 in 12 hours.
The patient was referred to the Surgical Center, where a tracheotomy was performed, then the continuing extra-oral drainage at four points in the submandibular and sublingual due to fluctuating local moment now more consistentes.Figura 4

The line of skin incision was transverse in the junction of the middle third with the upper third of a line between development and the thyroid cartilage, then opened up the folhento of deep cervical fascia surface, then there was the incision of the muscle milo -hyoid, in the direction perpendicular to its fibers, thereby opening the space submandibular complete.
With a hemostatic forceps or Metzembaum, it was divulsionar structures deep. That drain the tissues are hardened relieve, relieving the pressure of the floor of the mouth and tongue
It made a deeper exploration of the shops looking for purulent secretion and placement of drains in Pen Rose was completed. (Figure 5

There was eyepad and even exchanged every twelve hours, and "the drains" removed in 48 hours where it was already a lack of secretion. (Figure 6)

The treatment schedule was maintained for 8 days, and the results of culture and antibiogram confirmed the sensitivity of bacteria to antimicrobial established. The patient was observed for fifteen days, and so restored the mouth opening was shown to cause extraction of the element and all the teeth that were not able to recover. (Figure 7)

DISCUSSION
The case presented is of dental origin, related to the lower right second molar as cited in the reference consulted. There is agreement with Shafer 19, (1985) according to the origin and route of infection via periapical periodontal or because the position of the root apex on the crest milo-hióidea. Also the thickness of most thin alveolar process in the mandibular lingual face has caused the infection to erupt the submandibular space. Depending on the state of oral hygiene by the patient suggests that the septic of the oral environment may have contributed to the onset of infection associated with pulpal necrosis Graziani 8, (1986).

According Graziani 8 (1986), the diagnosis depends on a good clinical examination and the presence of general symptoms. The authors describe a clinical consultation similar to that described by Ludwig in 1836 where the affected individuals had gangrenous induration of the tissues surrounding the muscles of the neck located between the larynx and floor of mouth which emphasize the character of this rapidly progressive cellulitis, with the appearance of edema hard and bilateral sublingual and submandibular areas, minimum involvement of the pharynx and lymph nodes, besides the absence of suppuration (Gonçalves Jr. et al. 7 1987).

A diagnosis is important is the presence of characteristic fetid odor due to the presence of aerobic and anaerobic microorganisms leading to the emergence of a synergistic effect, caused by the production of endotoxins such as collagenase, hyaluronidase and proteases, the combination promotes a rapid progression from infection with necrosis tissue, troboflebite local, putrid odor and formation of gas. (Salaroli et al 18 2000). The fetid halitosis by purulent exudate is cited by Freire Filho et al. (2003); Graziani 8 (1986).

According Shafer 19, (1985) the patient with Ludwig's Angina presents a classic signs and symptoms as a firm swelling, pain and diffuse on the floor of the mouth, with no evidence of fluctuation and depression without lack of tissue when pressed, consistent framework with the case presented.

The CT scan is extremely useful in cervical infections show exactly why the early involvement of the mediastinum allows the ideal location of the surgery. (BROMMELSTROET et al. 2001).

Another important method of diagnosis and laboratory examination, where they observed a moderate leukocytosis (Shafer 19 1985)

Due to complications of respiratory obstruction consulted the authors advocate the tracheostomy to the swelling of the glottis and the deviation of the trachea in some cases. Maniglia et al 11 (1981) describes a tracheostomy noticed where the deviation of the trachea to the left, which was also observed in this case.

The treatment of Ludwig's Angina is mainly based on the triad: maintenance provided upper airway, intravenous antibiotic therapy and surgical drainage, considering however that the extraction of the tooth affected and parenteral hydration is essential, and to ensure an air recommended to perform the tracheostomy or cricotiroidotomia in most acute cases. Other methods can also be tried as a fiber optic laryngoscopy. (Freire son et al. 2003).

The performance of tracheostomy sought to preserve the airway and the prevention of pneumonia broncoaspirativa. According Maniglia et al 11 (1981) to measure the conduct that is often the severity of the case, a tracheostomy in this case is a prophylactic measure, under local anesthesia also avoids the pneumonia broncoaspirativa, removing the risk of more serious complications that could cause failure with acute respiratory stopped breathing.

The case in question was dealt with as the classical authors found, with regard to prophylactic tracheostomy, the surgical drainage and medication use.

Taking into account that this disease is a polymicrobial closing the microorganisms gram positive, gram negative and anaerobic (Manigilia et al. 1997; Bussoloti et al 3 in 1998; Hueb et al 9 in 2004; Videira et al 20 1998; Salaroli et al 18 2000 ) and also opt for empirical therapy in relation to the acute and emergency