INTRODUCTION
Ludwig's angina is a sub- mandibular space infection ( lower jaw ) in the form of cellulitis inflammation of the superior part suprahioid space ( Around the neck ) , which is characterized by swelling ( edema ) at the bottom of the submandibular space , which includes tissue that covers the muscles of the larynx and floor of the mouth , without any swelling of the lymph nodes .
Swelling is usually hard and reddish or brownish . This space causes inflammation of excessive force on the tissues of the mouth and tongue pushed upwards and backwards . Thus it can cause airway obstruction potentially .
The word angina should be differentiated from angina pectoris which is a pain due to ischemic state of the heart muscle . ( about angina pectoris I have discussed HERE )
Ludwig's angina or also known as angina Ludovici , is one form of an abscess in the neck . Neck abscess in itself an abscess formed in the potential space between the fascia of the neck as a result of the course of infection from various sources such as the teeth , mouth , throat , paranasal sinuses , middle ear and neck . Depending on which area is involved , the symptoms and signs
tengorok local clinic include pain , fever and swelling will show the location of the infection . That
included abscess is an abscess in the neck peritonsil , parafaring abscess , abscess retrofaring and angina ludovici ( Ludwig's angina ) or submandibular abscess .
Etiology OR CAUSE
Ludwig's angina is most often occurs as a result of infection of the tooth root , the molars and premolars , may also be due to trauma to the inside of the mouth , dental caries , and , piercing the tongue which causes suppurative process ( inflammation ) of the cervical lymph nodes in the submandibular space .
If the infection comes from the teeth , types of anaerobic gas -forming organisms are very dominant .
If the infection is not originating from the teeth , usually caused by streptococcus and staphylococcus
TRAVEL PROCESS DISEASE
The cause of these abscesses are the most common dental infections . Pulp necrosis due to caries in untreated periodontal pocket and in a way the bacteria to reach the periapical tissues . As the number of bacteria that much , then the infection will spread to the bone cortical bone spongiosa . If the bone is thin , then the infection will penetrate and get into the soft tissue . The spread of this infection depends on the resistance of body tissues . Odontogen can spread through the connective tissue ( perkontinuitatum ) , blood vessels ( hematogenous ) , and lymph vessels ( limfogenous ) .
The most common is due to propagation in perkontinuitatum gap / space between the networks as a potential gathering place pus or pus .
The spread of infection in the maxillary palatal abscess can form , submucosal abscess , gingival abscess , cavernous sinus thrombosis , abscess labial and facial abscess .
The spread of infection in the lower jaw can form subingual abscess , abscess submental , submandibular abscess , abscess submaseter , and Ludwig's angina . End of the second and third molar roots situated at the lower back of the linea mylohyoidea ( point of attachment of m . Mylohyoideus ) located in the aspect of the mandible , so that if the second and third molar infection and abscess formation , pusnya can spread to the submandibular space and can be extended to space parafaringal .
In addition to an abscess tooth infection can also be caused by pericoronitis , which is an infection of the gums caused by the eruption of the third molars is not perfect . The most frequent bacterial infection by streptococcus or staphylococcus . Since the development of antibiotics , Ludwig's angina a disease that is rarely encountered .
Infection is usually confined to the submental space because there is unity the deep cervical fascia hard from the anterior m.digastricus and hyoid bone . Edema can be formed with a clear chin .
Infection is usually confined to the space submaksilar in the space itself , but can also be down along the duct submaksilar Whartoni and follow the structure of the glands to the sublingual space or can also extend down to the m.hyoglossus along fascial spaces of the neck . In the sublingual space infection , edema present in the weakest region superior and posterior section , thereby inhibiting airway .
Clinical Symptoms
Clinical symptoms that arise are fever, sore throat and neck accompanied by swelling in the submandibular region that looks hyperemia ( red ) , drooling ( saliva flowing outside the mouth ) , and trismus ( inability to open the mouth in the normal range ) .
Tenderness and hard on palpation ( like wood ) . Swelling of the mouth , the tongue can push up the rear , causing shortness of breath due to airway obstruction .
DIAGNOSIS OF ANGINA LUDOVICI
Diagnosis based on : History ( Interview in patients ) , clinical features , investigation . History obtained from symptoms such as pain in the neck .
History was also obtained from the usual history of toothache , picking , and pulling teeth .
Infection in Ludwig's angina must meet the following criteria:
Occurs bilaterally on more than one cavity .
Produce gangrene - serosanguineous infiltration with or without pus .
Includes fascia connective tissue and muscles but not involving glands .
Perkontinuitatum deployment and not in lymphatic
TREATMENT
Basically if the main principles of airway obstruction , it should be solved .
The main treatment is to ensure a stable airway through the tracheostomy is performed with local anesthesia . Tracheostomy done without having to wait for the occurrence of dyspnea or cyanosis due to signs of airway obstruction that has been advanced . If airway obstruction occurs , the patient in a state of emergency .
Then given high doses of antibiotics and intravenous broad spectrum of gram-positive organisms and gram - negative aerobic and anaerobic bacteria as well . Antibiotics were given according to the results of culture and sensitivity results pus .
Ludwig's angina treatment in children for airway protection used intravenous antibiotics , but it can also be used surgical therapy . Antibiotics Penicillin G is used high doses , it can sometimes be combined with anti- staphylococcal drugs or metronidazole . If the patient is allergic pinicillin , then clindamycin hydrochloride is the best option . Dexamethasone were injected intravenously , administered within 48 hours to reduce edema and airway protection .
Additionally exploration is done for the purpose of decompression ( less strain ) and evaluation pussy , Ludwig's angina is rarely found in pus or tissue necrosis . Deeper exploration can be carried out using a blunt pliers .
If formed incision and drainage of pus . The incision is made in the midline horizontally as high os . hyoid ( 3-4 fingers under the mandible ) . Incisions made under and parallel to the corpus of the mandible through the fascia down to a depth of gland submaksilar . Additional vertical incision can be made on the os . hyoid to the limit under the chin . There should also be the treatment of dental infection to prevent recurrence . Patients were hospitalized until the infection subsides .
PREVENTION
Dental examination to the doctor regularly and routine dental treatment and oral infections can prevent the proper conditions that will increase the occurrence of Ludwig's angina .
