Ludwig's Angina

Angina Ludwig is one of the forms phlegmon of the floor of mouth rotten-necrotic nature, caused by anaerobic pathogens, coming usually from gangrenous teeth or injuries of soft tissues of the floor of mouth. The inflammatory process in angina Ludwig characterized by necrosis of muscles without the formation of pus. The process starts in submandibular region and quickly moves to the muscles of the floor of mouth. Appears solid, dense tumor, swallowing difficult, the temperature at first about 38. Infiltrate down on the neck. Language lifted, swollen, covered with dark brown tinge, sedentary. From the mouth of a putrid smell. Entrance into the throat constricted, voice hoarse. Fast developing intoxication: decreases the content of hemoglobin, ROE - 60-70 mm/hour, lakopenia, a sharp shift leukocyte left. The skin over the hearth gradually turns red spots appear bronze tint. Perhaps the appearance of lesions softening and spontaneous opening in the oral cavity emitting liquid color meat slops. The symptoms of intoxication grow rapidly, the mind is darkened, fall cardiac activity, and by the end of the first week of may occur death.
Treatment of the patient with angina Ludwig urgently need to send in the surgical hospital for urgent surgical intervention should wide dissection of tissues in the skin. At the same time prescribed injections of antibiotics in high doses and serum against all pathogens anaerobic infection subcutaneously or intramuscularly in the way of Besedki (see Besedki method); give high doses isotonic (physiological) solution of sodium chloride, do transfusion of whole blood (250-300 ml), required excessive drinking and heart drugs. In the hospital the patient should be isolated, appropriate measures for disinfection.

Angina Ludwig (W. F. Ludwig; angina Ludovici) - rotten-necrotic cellulitis bottom of the mouth.
A number of authors considers Ludwig's angina to the number of pathological processes caused by anaerobes (Cl. perfringens, Cl. oedematiens, Cl. histolyticum, Cl. septicum). However, a significant role in causing the disease play anaerobic streptococci and staphylococci. Compared with rotten-necrotic phlegmon another location, for example with rotten-necrotic extremity cellulitis, with the flu Ludwig find more diverse anaerobic microorganisms, including bacteria fotospuredee Association (You. fusiformis, Spirochaeta buccalis), E. coli and other Penetrates infection is more of infected caries and periodontal tissues, tonsil crypts and contaminated wounds and abrasions of the mucous membranes of the oral cavity and pharynx.
Postmortem Ludwig's angina is characterized by extensive necrosis of the subcutaneous fat bottom of the mouth, swelling, and often necrosis located here muscles, the presence of gas bubbles and sharp ihoroznym smell. The affected muscles in the beginning are pale red, later brown and dark brown with a greenish tint, then turn into a loose, easily torn fabric. Preserved tissue on the context of dry and only detected a small clusters ihorozny liquid color meat slops. No pus - significant feature of Ludwig's angina. Some authors make a mistake, bringing the Ludwig's angina cases phlegmon of the floor of mouth, accompanied by the formation of pus. The view that Ludwig's angina always starts with the defeat of submandibular salivary gland, was not confirmed.
Early typical clinical manifestation of angina Ludwig - dense woody swelling in submandibular region. Hence the inflammation in severe cases quickly moves to the area of the floor of mouth and down to the neck, concentrated in the hyoid bone. On the neck swelling stretches to collarbones; simultaneously, swelling of the face. The skin over the home defeat in the first 2-3 days is not changed in color, then becomes pale; later there was a bluish-purple and bronze spots.
The disease usually severe, sometimes moderate. Most of the patients at the beginning of the disease are chills, General malaise, painful swallowing, headache, lack of appetite. The temperature of the first 1-2 days remains low grade or exceed 38o, then reaches 39 degrees and above. Inflammatory edema arising in the area of the floor of mouth spreads on the wall of the pharynx and the entrance to the larynx, causing the voice becomes hoarse, speech and swallowing difficult. Sublingual fold and carunculae sublinguales edema, elevated, mucous membrane over them covered with fibrinous flight. Language increased, covered with dark brown tint, dry, sedentary. Her mouth was open, breath, her face pale, with a cyanotic shade or earthy colors. Breathing is interrupted, the patient is not enough air, his face expresses fear, pupils dilated. The situation forced, poluciaetsea, sometimes patients initiated, in some cases apathetic. With each day, the condition becomes more severe, there sweats, stunning vomiting, darkened minds, delirium. Decreases the amount of hemoglobin. Expressed lakopenia, a sharp shift leukocyte left. With increasing weakness, the phenomena of decadence cardiac activity and the picture of sepsis often to the end of the first, less often in the middle or the end of the second week of death can occur. Complications include inflammation and lung abscess, asphyxia, and mediastinum. Before the use of antibiotics forecast for sore throat Ludwig was heavy, lethality reached 40-60%.


Treatment. Early broad and deep cuts of lesions. If infiltrate captures all of the floor of mouth, you need to open the submandibular space on 1,5-2 cm below and parallel to the edge of the lower jaw on both sides; it is also advisable to spend a cut along the middle line between the hyoid bone and chin, penetrating between the muscles of the right and left side with dissection m. mylohyoideus to the mucous membranes of the oral cavity. To the best of audit the state of the muscles of the floor of mouth should resort to the so-called collar section on the upper cervical the crease. Usually scant number of malodorous liquids, gas filled bubbles discovered necrotic foci in the tissue and muscles. In the propagation process on the neck carried out incision along the front edge sternoclavicular-liners muscles, exposing in the carotid hole neurovascular bed; sometimes you have to resort to surgery and supraclavicular region. The wound thoroughly drain, preferably slim rubber strips to avoid damage to blood vessels.
Difficulty breathing - tracheotomy (see). Due to the risk of General anesthesia because of difficulty breathing, all operations performed under local anesthesia. Necrotic tissue 2 to 3 times a day irrigate pipettes solution of peroxide of hydrogen and 1% solution of potassium permanganate. Sometimes effectively the introduction into the skin or intramuscular sera against the four major anaerobic microbes. Enter serum every day, and on the testimony and 10-12 hour. within three days. Significant success is the use of antibiotics: penicillin, streptomycin and other
It is also shown and sulfa drugs. From the very beginning of the disease - heart funds and a small dose of bromide. Intravenous - 40% solution of hexamethylenetetramine (hexamine), 10% solution of calcium chloride. To ensure regular action of the bowels. Diet mainly vegetable and milk, drink plenty of water, vitamins. It is necessary hygienic content of the oral cavity; at least two times a day, rinse mouth with a weak stream of solution of potassium permanganate 1 : 2000 from mugs esmarkha. Bed rest must be observed until the complete exclusion of necrotic tissue and the establishment of normal temperature.
Since angina Ludwig is mostly related to the presence of caries of teeth, it is necessary sanation of oral cavity in children and adults.