Ludwig's Angina in a Centenarian Patient

INTRODUCTION Ludwig’s angina was described first by physician Wilhem Friedrich von Ludwig in 1836 as a rapidly progressive, potentially fatal spread of bilateral cellulitis of the submandibular space associated with elevation and posterior displacement of the tongue.1 The most frequent source of infection are the molars, particularly the second and third mandibular molars.2,3 It is important for medical providers to recognize this condition promptly and initiate proper treatment before the cellulitis progresses to airway obstruction. Before the era of antibiotics, especially penicillin, this disease had a mortality rate greater than 50%. Following the advent of antibiotics, improved dental care, and aggressive surgical treatment, the mortality rate was estimated to be approximately 8%.1,4 Ludwig’s angina is most seen between ages 20 and 60 years, but has been reported in patients as young as 12 days and as old as 84 years.5,6 The incidence in males is three to four times that in females.3 This case study presents a novel report of a centenarian who presented for surgical drainage of Ludwig’s angina. Older patients with peritonsillar and parapharyngeal abscesses present in a subtle fashion with few of the classic symptoms such as fever, in addition to a delayed presentation.7 This tendency made diagnosis challenging. Whether these results can be extrapolated to a patient with Ludwig’s angina remains to be seen. Managing older patients can be difficult due to multiple comorbidities, as seen in our patient, and because of poorer functional status and frailty. A multi-disciplinary team approach was necessary for this complex case, as it presented the dual challenges of an anticipated difficult airway and perioperative considerations of a centenarian.