Ludwig's angina is a severe condition, can cause airway obstruction due to swelling of the sublingual and submandibular. Thus the treatment focuses on four important points: maintaining airway patency, surgical measures as indicated (incision and drainage), adequate intravenous antibiotic therapy, and elimination of focal infections.

The protection of airway patency is a top priority in the initial management of Ludwig's Angina. After establishing Ludwig's angina diagnosis, the next step is to ensure a stable airway. Do immediately monitoring for patients who do not require airway control. Meanwhile, patients who urgently need breathing assistance, do the airway control in the operating room by performing a cricothyroidotomy or tracheostomy if necessary. Perform a tracheostomy without waiting for dyspnea or cyanosis. Immediately consult an anesthesiologist and otolaryngologist.

Compared to other infections that occur in the neck, Angina Ludwig needs a tracheostomy more. Nasotracheal intubation of a conscious patient may produce acute airway obstruction. Always prepare for a tracheostomy, even when a skilled anesthetist is performing intubation.

Avoid using narcotics because they cause respiratory depression and exacerbate the ventilation; some authors recommend using inhalational anesthetics. More than 65% of patients with Ludwig's angina develop suppurative infections that can cause narrowing, even obstruction of the airway, requiring drainage.

Recently, a conservative approach is an option in patients with Angina Ludwig. A retrospective study by Wolfe et al. found that only 42% of patients required airway assistance. This study found that of all these patients, none required surgery.

Intubation in a patient with Ludwig's Angina is not easy because of anatomical changes, especially due to pushing. Additionally, intubation also carries a high risk of bleeding and can lead to further tissue edema.

The nasal intubation technique with flexible fiber optics is the recommended option. This technique has a high success rate because it can visualize the vocal cords well. The limitation of this technique is the limited visualization when there are secretions in the oral cavity.

Once the airway is secured, initiate an aggressive intravenous antibiotic administration with initial target therapy for gram-positive and anaerobic bacteria in the oral cavity.

Several antibiotics must be administered, namely: high doses of penicillin and metronidazole, clindamycin, cefixime, piperacillin-tazobactam, clavulanate amoxicillin, and clavulanate ticarcillin.
 
Although controversy remains, giving dexamethasone, which aims to reduce edema and increase antibiotic penetration, may help. Administration of intravenous dexamethasone and nebular adrenaline has been used to reduce upper airway edema in Ludwig's Angina cases.

Surgery by an incision through the midline aims to stop the tension building upon the mouth floor. However, pus is rarely obtained because Angina Ludwig's is cellulitis. Before performing incision and drainage, prepare a possible tracheostomy. It is due to the difficulty of intubating the patient, such as blocking of the larynx's view by the tongue, cannot be compressed by the laryngoscope.

Drainage is placed in the mylohyoid musculus into the sublingual space. Removing the infected tooth is also essential for a complete drainage process.

The following are indications for the performance of surgical drainage:
  • suppurative infection,
  • radiological evidence of fluid buildup in soft-tissue, crepitus,
  • purulent needle aspiration.
  • And there is no improvement after antibiotic therapy. 
  • Removing the infected tooth is also essential for a complete drainage process.


Antibiotics
The most important management of Angina Ludwig is the administration of broad-spectrum antibiotics.
Some of the antibiotic options that can be given are:
  • Benzylpenicillin 1.2 grams four times a day
  • Metronidazole 400 mg intravenously three times a day
  • clindamycin 1.2 grams four times a day.
Antibiotics are generally given for seven days. Add antibiotics for Pseudomonas in treating Ludwig's angina with immunocompromised. Antibiotics for Pseudomonas can be added, such as cefepime, meropenem, or piperacillin-tazobactam. Carry out clinical monitoring of the patient and, if necessary, perform serial blood tests.


COMPLICATIONS
The most severe complication of Ludwig's angina is asphyxia caused by edema of the soft-tissue neck.
In advanced infection, cavernous sinus thrombosis and a cerebral abscess may occur. Other complications that have been reported are:
  • carotid wall infection and arterial rupture, 
  • suppurative thrombophlebitis of the jugular vein, 
  • mediastinitis, 
  • empyema, 
  • pericardial or pleural effusion, 
  • mandibular osteomyelitis, 
  • abscess subphrenic
  • and aspiration pneumonia.

PROGNOSIS
The prognosis for Ludwig's angina depends mainly on the airway's immediate protection and on administering antibiotics to treat the infection. The pre-antibiotic era's mortality rate was 50%, but in the presence of antibiotics, the mortality rate was reduced to 5%.