Ludwig’s Angina: Higher Incidence and Worse Outcomes Associated with the Onset of the COVID-19 Pandemic

Author(s):
Melissa Canas; Ricardo Fonseca; Alejandro De Filippis; Leonardo Diaz; Hussain Afzal; Aaron Day; Jennifer Leonard; Kelly Bochicchio; Grant Bochicchio; Mark Hoofnagle

Background:

Ludwig’s Angina (LA) is a diffuse cellulitis of the submandibular space and adjacent tissues, usually originating from dental infections. Early recognition and treatment are of utmost importance to avoid complications. During the COVID-19 pandemic, odontogenic treatments were often delayed due to the implementation of mask mandates, lockdown, and uncertainty of the novel coronavirus.

Hypothesis:

We hypothesized that delayed odontogenic treatments associated with the onset of the COVID-19 pandemic would increase incidence of Ludwig’s Angina and worse outcomes related to these infections.

Methods:

Our prospectively maintained Acute and Critical Care Surgery database spanning Jun-2018 to Jun-2022 was queried for patients admitted with CT images suggestive of Ludwig’s Angina and a diagnosis confirmed by ENT consult. We abstracted demographics, outcomes, clinical care management details, and microbiology results. Patients were stratified into two groups: pre-COVID (Jun-2018 to Dec-2019) and COVID-onset (Jan-2021 to Jun-2022). The incidence of LA for each period was defined as: (new LA cases) ÷ (ED evaluations of oral and/or dental infections x 1.5 years). We subsequently analyzed the groups using chi-squared and student T-test.

Results:

During the pre-COVID timelapse, a total of 1,301 patients were admitted to the ED with oral and/or dental infections. In the COVID-onset group, only 641 patients were admitted with these diagnoses. In the pre-COVID group, we identified 32 patients with the diagnosis of LA for an incidence of 0.02 per year. The COVID-onset group consisted of 41 patients, with an incidence of 0.04 per year. There was no difference in demographics or antibiotic treatment between the two groups. Development of necrotizing fasciitis was significantly more likely in the COVID-onset group (0% vs 15%; p <0.024), and they were also more likely to return to the OR for repeated debridement (3% vs 22%; p <0.020). Hospital length of stay, ICU length of stay, and ventilator days were also increased in this group (4.3±3.5 vs 9.5±11.3; 1.1±1.2 vs 9.5±7.1; 0.3±1 vs 3.6±7.1 respectively; p <0.001). The most common isolated microbe pre-COVID was S. viridans (55.5%) vs polymicrobial with mixed upper respiratory microorganisms (69.2%) with COVID-onset.

Conclusions:

During the onset of the COVID-19 pandemic, non-emergent dental procedures were often deferred because they were considered high risk for the spread of COVID-19. Although most dental infections diagnosed early have an excellent prognosis and low complication rate, delayed treatment was associated with a higher incidence of Ludwig’s Angina and overall worse outcomes in our study population.