Ludwig Angina in Pregnancy: Treatment Outcome in 12 Patients and Review of Literature
International Journal of Clinical Oral and Maxillofacial Surgery
Volume 5, Issue 1, June 2019, Pages: 5-9
Received: Nov. 6, 2018;
Accepted: Jan. 25, 2019;
Published: Mar. 11, 2019
Views 425 Downloads 91
Ibraïma Traoré, Department of Stomatology and Maxillofacial Surgery, Université Nazi Boni, Bobo-Dioulasso, Burkina Faso
Rasmané Béogo, Department of Stomatology and Maxillofacial Surgery, Université Nazi Boni, Bobo-Dioulasso, Burkina Faso
Toua Antoine Coulibaly, Department of Stomatology and Maxillofacial Surgery, Université Nazi Boni, Bobo-Dioulasso, Burkina Faso
Der Adolphe Some, Department of Obstetrics and Gynecology, Université Nazi Boni, Bobo-Dioulasso, Burkina Faso
Alain Ibrahim Traore, Department of Anaesthesiology and Intensive Care, Université Nazi Boni, Bobo-Dioulasso, Burkina Faso
Gandaaza Euthyme Armel Poda, Department of Infectious Disease, Université Nazi Boni, Bobo-Dioulasso, Burkina Faso
Ludwig angina is a rare but severe life-threatening cellulitis, classically of odontogenic origin, characterized by an extensive and a rapidly progressive inflammation of subcutaneous tissue of the face and severe systemic toxicity. Its prognosis is potentially worse in pregnancy given the higher vulnerability of both mother and fetus to infection and to the consequences of therapies. Early diagnosis and timely treatment are of paramount importance in the prognosis of this condition but could be however challenging as it is infrequently observed in current daily practice. Moreover, literature dealing with Ludwig’s angina in pregnancy is scarce, consisting mostly in isolated case reports from developed countries. The aim of this article was to improve awareness on Ludwig angina in pregnancy through a report of experience in 12 patients and a literature review on the diagnosis and treatment of this clinical entity. To this end, medical records of 12 patients with Ludwig angina in pregnancy were analysed retrospectively and the diagnosis and treatment approaches discussed through a literature review. Age of pregnancy ranged from 27 to 37 weeks. In all the patients, the cellulitis origin was a carious molar of the mandible. The infection spread extended to the neck (4 patients), the thorax (3 patients) and the temporal fossa (2 patients). One patient presented with necrotizing fasciitis extending from the submandibular and submental regions to the thorax. Bacteriological examination of pus which was possible and successful in 4 patients only, showed staphylococcus aureus (2 patients) staphylococcus SP (1 patient) and staphylococcus epidermidis (1 patient). Death occurred in 2 mothers and in 7 fetus giving mortality rates of 16.7% and 58.3% respectively. Direct causes of death in mothers were sepsis shock and air way compromise. In 6 out of the 7 mothers who had dead fetus, the infection extended beyond the mouth floor. Oral health care providers should be aware for proper treatment of dental infections. They should also be alert for early recognition and multidisciplinary treatment of Ludwig angina in pregnancy in collaboration with obstetricians, specialists of intensive care and infectious diseases.
Toua Antoine Coulibaly,
Der Adolphe Some,
Alain Ibrahim Traore,
Gandaaza Euthyme Armel Poda,
Ludwig Angina in Pregnancy: Treatment Outcome in 12 Patients and Review of Literature, International Journal of Clinical Oral and Maxillofacial Surgery.
Vol. 5, No. 1,
2019, pp. 5-9.
Jeffery HE and Lahra MM (2009). The impact of infection during pregnancy on the mother and baby. DOI: 10.1007/978-1-84628-743-5_16.
Abramowicz S, Abramowicz JS and Dolwick MF (2006) Case Report: Severe Life Threatening Maxillofacial Infection in Pregnancy Presented as Ludwig’s Angina. Hindawi Infect Dis Obstet Gynecol 2006: 1-4.
Kassam K Messiha A and Heliotis M. (2013) Ludwig’s Angina: The Original Angina. Case Rep Surg doi: 10.1155/2013/974269.
Saifeldeen K and Evans R (2004) Ludwig’s angina. Emerg Med J 21: 242-243.
Bansal A, Miskoff J and Lis RJ (2003) Otolaryngologic critical care. Crit Care Clin 19: 55-72.
World Health Organization (2004) A strategic framework for malaria prevention and control during pregnancy in the African region Brazzaville: WHO regional office for Africa.
Kavarodi AM (2011) Necrotizing fasciitis in association with Ludwig’s angina – A case report. The Saudi Dental Journal 23, 157–160.
Medard de Chardon, V Guevara, N Lattes L, Converset-Viethel S, Riah Y, Lebreton E, Santini J, and Balaguer T (2008) Necrotizing fasciitis: complication of patient positioning? Ann Chir Plast Esthet. 53 (4): 372-377.
Jee HS, Won-Hee J, Kyung-Ah C, Ji-Young K, Chan-Kwon J, Yang RK, Wan-Kyu E, Yang-Soo K, and Yang GC, (2009) Necrotizing fasciitis versus pyomyositis: discrimination with using MR imaging. Korean J. Radiol. 10, 121–28.
Pak S, Cha D, Meyer C, Dee C and Fershko A (2017) Ludwig’s Angina. Cureus 9 (8): e1588. DOI 10.7759/cureus.1588.
Osunde OD, Bassey GO, Ver-or N (2014) Management of Ludwig’s Angina in Pregnancy: A Review of 10 Cases. Ann Med Health Sci Res. 4 (3): 361-4. doi: 10.4103/2141-9248.133460.
Topazian RG, Goldberg MH and Hupp JR (2002): Oral and Maxillofacial infections. 4th ed. Philadelphia, Pa:W. B. Saunders.
Botha A, Jacobs F and Postma C (2015) Retrospective analysis of etiology and comorbid diseases associated with Ludwig's Angina. Ann Maxillofac Surg 5 (2): 168–173.
Peron JM and Mangez JF (2002) Cellulites et fistules d’origine dentaire Encycl Méd Chir (Editions Scientifiques et Médicales Elsevier SAS, Paris), Stomatologie/Odontologie 22-033-A-10, 14 p.
Brook I (2007) Microbiology and principles of antimicrobial therapy for head and neck infections. Infect Dis Clin North Am, 21: 355-91.
Rutkauskas JS (1999) Oral infection. Infect Dis Clin North Am 13: 757-923.
Spitalnic SJ and Sucov A (1995) Ludwig’s angina: case report and review. J Emerg Med 13: 499–503.
Hasan W, Leonard D and Russell J (2011) Ludwig’s Angina-A Controversial Surgical Emergency: How We Do It. Int J Otolaryngol. doi: 10.1155.
Bado F, Fleuridas G, Lockhart R, Chikhani L, Favre-Dauvergne E and Bertrand JC (1997) Cellulites cervicales diffuses, à propos de 15 cas. Rev Stomatol Chir Maxillofac 98: 266-268.
Larawin V, Naipao J and Dubey SP (2006) Head and neck space infections. Otolaryngology—Head and Neck Surgery 135 (6): 889–893.
Caplan RA, Benumof JL, Berry FA, Blitt CD, Bode RH, Cheney FW, Connis RT, Guidry OF, Nickinovich DG and Ovassapian A. (2003) An updated report by the American Society of Anesthesiologists Task Force on management of the difficult airway. Anesthesiology 98 (5): 1269–1277.
Al Harbi M, Thomas J, Khalil HN, Said HN, Wannous S, Abouras C, Al Harthi A and Dimitrou V (2016) Anesthetic Management of Advanced Stage Ludwig's Angina: A Case Report and Review With Emphasis on Compromised Airway Management. Middle East J Anaesthesiol 23 (6): 665-73.
Freund B and Timon C (1992) Ludwig’s angina: a place for steroid therapy in its management? Oral Health 82, 5: 23–25.
Chueng K, Clinkard DJ, Enepekides D, Yousef Peerbaye Y, and Lin VY (2012) An Unusual Presentation of Ludwig’s Angina Complicated by Cervical Necrotizing Fasciitis: A Case Report and Review of the Literature. Case Rep Otolaryngol doi: 10.1155/2012/931350
Parhiscar A and Har-El G (2001) Deep neck abscess: a retrospective review of 210 cases. Ann Otol Rhinol Laryngol 110 (11): 1051-4.
McClure EM, Dudley DJ and Goldenberg RL (2010) Infectious Causes of Stillbirth: A Clinical Perspective. Clin Obstet Gynecol. 53 (3): 635–645.
Gordijn SJ, Korteweg FJ, Erwich JJ, Holm JP, van Diem MT, Bergman KA, and Timmer A (2009) A multi-layered approach for the analysis of perinatal mortality using different classification systems. Eur J Obstet Gynecol Reprod Biol 44: 99–104.
Steketee R, Nahlen BL, Parise ME, and Menendez C (2001) The burden of malaria in pregnancy in malaria-endemic areas. Am J Trop Med Hyg 64S: 28–35.
van Geertruyden J-P, Thomas F, Erhart A, and D’Alessandro U (2004) The contribution of malaria in pregnancy to perinatal mortality. Ann Trop Med Hyg 71 (2): 35–40.
Smaill F (2001) Antibiotics for asymptomatic bacteruria in pregnancy. Cochrane Database of Systematic Reviews 2:CD000490.
Offenbacher S, Katz V, Fertik G, Collins J, Boyd D, Maynor G, Mckaiq R and Beck J (1996) Periodontal infections as a possible risk factor for preterm low birth weight. J Periodontal 67: 1103–1113.
Newnham J, Shub A, Jobe A, Bird PS, Ikeqami M, Nitsos I and Moss TJ. (2005): The effects of intra-amniotic injection of periodontopathic lipopolysaccharides in sheep. Am J Obstet Gynecol 193: 313–321.
Kiss H, Petricevic L and Husslein P (2004) Prospective randomised controlled trial of an infection screening programme to reduce the rate of preterm delivery. BMJ 14; 329 (7462): 371.