Management of Ludwig′s angina in pregnancy: A review of 10 cases

Abstract

Background:Ludwig's angina is a rapidly spreading cellulitis that may produce upper airway obstruction often leading to death.Aim:The present paper reviews the management of Ludwig's angina in the third trimester of pregnancy. The inherent dangers to the mother and her unborn child are highlighted.Materials and Methods:The case files of pregnant patients who had emergent incision and drainage for life-threatening facial cellulitis at the maxillofacial unit of the Murtala Mohammed Specialist Hospital in Kano, Nigeria, over a 2 year period were retrieved and demographic and clinical characteristics were retrospectively obtained and analyzed descriptively using the statistical package for social sciences (SPSS version 13.0, for Windows, September 2004, Chicago, Illinois). Comparative statistics were determined using Pearson's Chi-square, Fisher's exact tests and independent t tests as appropriate. A P value of less than 0.05 was considered significant.Results:A total of 10 patients were seen within the study period, age ranges from 23 to 40 years, mean 29.5 (5.3) years. Majority of the women were in their third decade [60% (6/10)] while the remaining 40% (4/10) were in their fourth decade of life. Two of the patients presented within the period of less than 1 week of onset of symptoms while those who presented within the periods of 1-2 weeks and periods of over 2 weeks accounted for 50% (5/10) and 30% (3/10) respectively. All the patients presented during the third trimester of their pregnancy and odontogenic infections were responsible for 80% (8/10) of the Ludwig's angina. There were 20% mortality among the patients and this was significant for those with underlying systemic conditions (P = 0.02). The time of presentation was not significant for the survival rate of the gravid patient (P = 0.36) but was significant for survival of the fetus (P = 0.01).Conclusion:During a life-threatening infectious situation such as Ludwig's angina, risks of maternal and fetal morbidity include both septicemia and asphyxia. Attending clinicians must consider the risks that the condition and the possible treatments may cause the mother and her unborn child.

A fatal case of empyema thoracis: the price for underestimating odontogenic infections

“…The shortage of skilled manpower in Nigeria (with a population of >170 million) for the management of odontogenic infections is a large problem and may contribute to the morbidity and mortality often associated with this infection in our environment. A mortality rate of 20%-28.5% has been reported in our local environment [33][34][35]. Poverty, shortage of skilled personnel, and a poorly implemented national health insurance scheme are the main contributory factors for the mortality recorded in this case report.…”

Ludwig Angina in Pregnancy: Treatment Outcome in 12 Patients and Review of Literature

“…Trismus makes challenging intra oral examination which frequently shows an odontogenic origin of the infection as noted in all the patients in this study. This is classically an untreated carious tooth of the second or the third mandibular molar [10][11]. From the roots of these teeth which are close to the insertion of the mylohyoid muscle, a periapical abscess following caries progresses to invade successively the thin inner cortex of mandible, the posterior margin of the mylohyoid muscle and the submandibular space.…”

“…As in any infection, physiological changes during pregnancy of which diminished immune response place the mother at a higher risk of death in Ludwig angina. Osunde et al report a maternal mortality rate of 20% in 10 patients [11]. Fetus is in a context of high vulnerability which may result in a diversity of adverse pregnancy outcomes including among other, intrauterine death, premature delivery, spontaneous abortion, low birth weight, intrauterine growth restriction, malformation, and neonatal infection [1].…”

“…Fetus is in a context of high vulnerability which may result in a diversity of adverse pregnancy outcomes including among other, intrauterine death, premature delivery, spontaneous abortion, low birth weight, intrauterine growth restriction, malformation, and neonatal infection [1]. In their study, Osunde et al report 3 fetal deaths [11]. Intra uterine death may result from consequences of the infection in the mother, fetal direct infection via the placenta damaging a vital organ such as the lung or heart of the fetus, the placenta infection resulting in a fatal congenital anomaly by reduced blood flow to the fetus, a preterm labor with the fetus unable to tolerate delivery, generally due to an infection of the membranes [26].…”

Anaesthetic management of Ludwig’s angina in a full term pregnant patient

“…Such cases have a high mortality ranging from 8-25%. 7,8 Pregnancy with its anatomical and physiological changes makes the airway management further difficult. Also, CT scan is contraindicated in pregnancy due to which, extent of the infection cannot be assessed with certainty adding to the difficulty in airway management.…”