Ludwig’s angina


A type of severe cellulitis involving the floor of the mouth.

The floor of the mouth is raised and there is difficulty swallowing saliva.

It is a form of severe diffuse cellulitis with bilateral involvement, primarily of the submandibular space with the sublingual and submental spaces also being involved.

Ludwig angina is associated  with brawny swelling from a rapidly spreading cellulitis of the sublingual, submental, and submandibular spaces with elevation and edema of the tongue, drooling, and airway obstruction. 


Ludwig angina is odontogenic in 90% of cases and arises from the second and third mandibular molars in 75% of cases. 

The airway may be compromised subsequently.

It presents with an acute onset and spreads very rapidly.

Early diagnosis and immediate treatment is key to saving lives.

The condition may have a rapid onset over hours.

Fever, pain, a raised tongue, trouble swallowing, neck swelling are present.

Complications include airway compromise.

Risk factors: primarily dental infection.

The majority of cases follow a dental infection, but causes include a parapharyngeal abscess, mandibular fracture, cut or piercing inside the mouth, or submandibular salivary stones.

The process is a spreading infection of connective tissue through tissue spaces, normally with virulent and invasive organisms.

It specifically involves the submandibular, submental, and sublingual spaces.

If infection spreads through the buccopharyngeal gap, adjacent retropharyngeal and mediastinal infection is possible.

Diagnosis is based on symptoms and examination, and CT scan.

Initial treatment is generally with broad-spectrum antibiotics and corticosteroids.

In severe disease endotracheal intubation or tracheostomy may be required.

Prevention: appropriate dental care including management of dental infections.

Clinical findings may include bilateral lower facial swelling around the mandible and upper neck.

Oral findings may include elevation of the floor of mouth due to sublingual space involvement and posterior displacement of the tongue, creating the potential for a compromised airway.

Additional symptoms that may be present include: painful neck swelling, tooth pain, dysphagia, shortness of breath, fever, and general malaise, while

stridor, trismus, and cyanosis may also be seen when an impending airway crisis is nearing.

The most prevalent cause is a dental infection, accounting for approximately 75% to 90% of cases.

Dental infections of the lower second and third molars are usually implicated, because their roots extend inferiorly below the mylohyoid muscle.

Periapical abscesses of the lower second and third molars result in lingual cortical penetration, leading to submandibular infection.

In addition oral ulcerations, infections of oral malignancy, mandible fracture, bilateral sialolithiasis-related submandibular gland infection,and penetrating injuries of the mouth floor have also been reported as potential causes of Ludwig’s angina.

Predisposition is seen with

diabetes mellitus, malnutrition, compromised immune system, and organ transplantation.

About one third of the cases of Ludwig’s angina are associated with systemic illness: 18% of cases involved diabetes mellitus, 9% involved acquired immune deficiency syndrome, and another 5% were human immunodeficiency virus (HIV) positive.

Dental x-rays can identify infections in the roots of teeth and a neck CT scan can identify deep neck space infection.

Differential diagnosis includes: angioneurotic edema, lingual carcinoma and sublingual hematoma.

Microbiology is commonly polymicrobial and anaerobic in Ludwig’s angina.

Commonly found microbes are Viridans Streptococci, Staphylococci, Peptostreptococci, Prevotella, Porphyromonas and Fusobacterium.

Management principles:

Airway management

Early and aggressive antibiotic therapy

Incision and drainage for any who fail medical management or form localized abscesses.

Adequate nutrition and hydration support.

Airway management is the most important factor in treating patients with Ludwig’s Angina, as it is the leading cause of death.

Airway management ranges from close observation and intravenous antibiotics, to airway intervention with endotracheal intubation or tracheostomy.

Only 10% of children require airway control.

Tracheostomy was performed on 52% of those affected with Ludwig’s Angina over 15 years old.

If nasotracheal intubation is not possible, cricothyrotomy and tracheostomy can be done on patients with advanced stage of Ludwig’s Angina.

Elective tracheostomy is described as a safer method of airway management in patients with fully developed Ludwig’s Angina.

Initial antibiotic coverage is empirical, until culture and sensitivity results are obtained.

Antibiotic therapy should be effective against both aerobic and anaerobic bacteria species commonly involved in Ludwig’s Angina.

Empirical antibiotic coverage should consist of either a penicillin with a B-lactamase inhibitor such as amoxicillin/ticarcillin with clavulanic acid or a Beta-lactamase resistant antibiotic such as cefoxitin, cefuroxime, imipenem or meropenem, and should be given in combination with a drug effective against anaerobes such as clindamycin or metronidazole.

Surgical incision and drainage are employed in managing severe and complicated deep neck infections that fail to respond to medical management within 48 hours.

Surgical I and D for:

Airway compromise


Deteriorating condition

Descending infection

Diabetes mellitus

Palpable or radiographic evidence of abscess formation

Penrose drains are recommended.

The incision and drainage includes debridement of necrotic tissue and thorough irrigation.

Patients must be well-nourished and hydrated to promote wound healing and to fight off infection.

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