Overview
Ludwig's Angina
Topic Overview
Summary
Ludwig's angina is a rapidly progressive, potentially life-threatening cellulitis of the submandibular, sublingual, and submental spaces. It typically originates from dental infection (lower molars). The hallmark is bilateral, brawny induration of the floor of mouth with tongue elevation. Airway compromise is the main cause of death. Treatment is urgent airway management, IV antibiotics, and surgical drainage if abscess present. Named after Wilhelm Friedrich von Ludwig (1836).
Key Facts
- Origin: Usually dental (2nd/3rd lower molars)
- Spaces involved: Submandibular, sublingual, submental (bilateral)
- Key feature: Elevated, "woody" floor of mouth; tongue pushed up and back
- Main risk: Airway obstruction — can be fatal
- Treatment: Secure airway + IV antibiotics + surgical drainage
Clinical Pearls
"Angina" = choking sensation (Latin) — refers to airway compromise, not cardiac
Ludwig's is cellulitis, NOT abscess — may not have fluctuance early
Awake fibreoptic intubation is preferred if airway needed — avoid paralysis
Why This Matters Clinically
Ludwig's angina kills by airway obstruction. Early recognition, airway preparation, and aggressive treatment are life-saving. Every patient needs urgent senior anaesthetic and surgical input.
Visual Summary
Visual assets to be added:
- Submandibular space anatomy diagram
- Clinical photo of Ludwig's angina
- Airway management algorithm
- CT showing floor of mouth infection
Epidemiology
Incidence
- Rare but serious
- Decreasing due to antibiotics and dental care
- Still common in developing countries
Demographics
- Adults (20-60 years)
- Male predominance
- Associated with poor dental hygiene
Risk Factors
| Factor | Notes |
|---|---|
| Dental infection | Lower 2nd/3rd molars (roots below mylohyoid) |
| Poor dental hygiene | |
| Diabetes | Higher risk, worse outcomes |
| Immunocompromise | |
| IV drug use | |
| Recent dental procedure |
Pathophysiology
Anatomy
- Submandibular space: Below mylohyoid
- Sublingual space: Above mylohyoid
- Submental space: Midline, below chin
- Spaces communicate — infection spreads rapidly
Mechanism
- Dental infection (usually lower molars)
- Roots of lower 2nd/3rd molars extend below mylohyoid
- Infection enters submandibular space
- Spreads to sublingual and submental spaces
- Bilateral brawny edema → tongue elevation
- Airway compromise
Why Airway is at Risk
- Tongue pushed posteriorly and superiorly
- Cannot lay flat (worsens obstruction)
- Trismus limits oral access
- Swelling may extend to larynx
Organisms
- Polymicrobial (oral flora)
- Streptococci (viridans group)
- Staphylococcus aureus
- Anaerobes (Bacteroides, Fusobacterium, Peptostreptococcus)
Clinical Presentation
Symptoms
Signs
Red Flags
| Finding | Significance |
|---|---|
| Stridor | Impending airway loss |
| Drooling | Cannot swallow |
| Elevated tongue | Posterior displacement |
| Rapidly progressive | Needs urgent intervention |
Rapidly progressive neck swelling
Common presentation.
Mouth/floor of mouth pain
Common presentation.
Difficulty swallowing (odynophagia)
Common presentation.
Drooling
Common presentation.
Fever
Common presentation.
Difficulty speaking ("hot potato" voice)
Common presentation.
Difficulty breathing
Common presentation.
Clinical Examination
General
- Toxic appearance
- Sitting forward
- Drooling
- Fever
Neck
- Bilateral submandibular swelling
- Brawny induration ("woody")
- Tender
- May extend to anterior neck
Oral
- Elevated floor of mouth
- Tongue pushed up
- Trismus (limited mouth opening)
- May see dental source
Airway Assessment
- Voice changes
- Stridor
- Oxygen saturation
Investigations
Clinical Diagnosis
- Often clinical — do NOT delay treatment for imaging if airway compromised
Blood Tests
| Test | Purpose |
|---|---|
| FBC | WCC elevated |
| CRP | Elevated |
| U&E, glucose | Baseline; diabetes screen |
| Blood cultures | If septic |
Imaging
| Modality | Indication |
|---|---|
| CT neck with contrast | Gold standard if stable; shows extent, abscess, airway |
| Plain X-ray | May show gas (necrotising infection) |
Do NOT
- Delay airway management for imaging
- Use sedation without airway plan
- Lay patient flat
Classification & Staging
By Stage
- Early: Cellulitis, no abscess
- Late: Abscess formation
By Severity
- Mild: Localised, no airway compromise
- Severe: Airway compromise, systemic sepsis
Management
Airway — PRIORITY
| Situation | Approach |
|---|---|
| Stable airway | Close monitoring; prepare for deterioration |
| Impending obstruction | Awake fibreoptic intubation (preferred) |
| Cannot intubate | Surgical airway (tracheostomy/cricothyroidotomy) |
Key points:
- Do NOT sedate or paralyse without airway plan
- Have surgical airway equipment ready
- Senior anaesthetist essential
IV Antibiotics — High-Dose, Broad-Spectrum
| Regimen | Notes |
|---|---|
| Co-amoxiclav | 1.2g IV TDS |
| + Metronidazole | 500mg IV TDS (anaerobic cover) |
| Alternative | Clindamycin if penicillin allergic |
| Add vancomycin | If MRSA risk |
Surgical Management
| Indication | Procedure |
|---|---|
| Abscess | Incision and drainage |
| No improvement | Surgical exploration |
| Dental source | Extraction (once stable) |
Supportive Care
- IV fluids
- Analgesia
- Steroids (controversial; may reduce oedema — discuss with team)
- ICU if airway concerns
Complications
Local
- Airway obstruction (main cause of death)
- Abscess formation
- Spread to parapharyngeal space
- Necrotising fasciitis
Distant
- Mediastinitis (descending infection)
- Aspiration pneumonia
- Sepsis
- Jugular vein thrombosis (Lemierre's)
Mortality
- 8-10% with treatment
- Higher if airway not secured
Prognosis & Outcomes
Prognosis
- Good if airway secured and treated early
- Poor if delayed or complicated by mediastinitis
Factors Affecting Outcome
- Time to airway management
- Time to antibiotics
- Presence of abscess/necrotising infection
- Comorbidities (diabetes)
Evidence & Guidelines
Key Guidelines
- No specific national guideline
- Management based on case series and expert consensus
Key Evidence
- Early airway intervention reduces mortality
- Polymicrobial antibiotics essential
Patient & Family Information
What is Ludwig's Angina?
Ludwig's angina is a serious infection of the floor of the mouth, usually from a tooth infection. It causes severe swelling that can block your airway.
Symptoms
- Swelling under the jaw and chin
- Difficulty swallowing or breathing
- Fever
- Drooling
Treatment
- Hospital admission
- Antibiotics through a drip
- Sometimes surgery to drain the infection
- May need a breathing tube
Prevention
- Good dental hygiene
- See a dentist regularly
- Treat tooth infections early
Resources
References
Key Studies
- Bansal A, et al. Ludwig's angina: a review of management. Br J Oral Maxillofac Surg. 2017;55(2):126-132. PMID: 27993440
- Candamourty R, et al. Ludwig's angina – an emergency: a case report with literature review. J Nat Sci Biol Med. 2012;3(2):206-208. PMID: 23225990
Reviews
- Costain N, Marrie TJ. Ludwig's angina. Am J Med. 2011;124(2):115-117. PMID: 21295190