A 60-year-old male with a history of type 2 diabetes and prior alcohol use presents to the emergency room with complaints of shortness of breath and mouth pain. His initial temperature is 102°F; he has a heart rate of 110, a blood pressure of 120/60, and a respiratory rate of 30. He states he recently had dental work performed. On examination, he appears uncomfortable with increased work of breathing. He is noted to have a swollen submandibular gland with surrounding erythema at the base of his face extending onto the proximal portion of his neck. His oropharyngeal examination is notable for poor dentition and one tooth with increased erythema along the gum line. There is a high-pitch wheeze with inspiration. The rest of his pulmonary examination is clear. His cardiac examination is notable for sinus tachycardia without murmurs. His labs were notable for an elevated white cell count of 16 000 and an elevated ESR and CRP.
What is the next best step in management?
A. Nasotracheal intubationCorrect Answer: A
Ludwig angina is characterized by cellulitis and edema of the floor of the mouth and soft tissues of the neck. Mortality is close to 8%. Risk factors for developing Ludwig angina include recent dental treatment, dental infections, diabetes, alcoholism, and immunosuppression. This patient is demonstrating evidence of airway compromise with increased respiratory rate, submandibular swelling, and stridor. The leading cause of death in Ludwig angina is airway compromise; therefore, the primary concern is securing the airway. Given that this patient appears to already have upper airway swelling, there is a high risk of failing with endotracheal intubation. If nasotracheal intubation is not an option or fails, then cricothyrotomy and tracheostomy should be performed. Once the airway has been secured, the focus should then switch to treating the underlying infection with antibiotics. Streptococcus and Staphylococcus are the most common bacteria that have been associated with Ludwig angina. A CT neck and chest would not be a good option for this patient given his tenuous airway.
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