What is Ludwig's angina?

Ludwig's Angina

Ludwig's angina is a rapidly progressive, potentially life-threatening cellulitis of the submandibular, sublingual, and submental spaces characterized by floor of mouth elevation, airway compromise, and high mortality if not promptly treated. 1, 2

Definition and Pathophysiology

Ludwig's angina is a severe diffuse cellulitis with:

• Acute onset and rapid bilateral spread
• Involvement of submandibular, sublingual, and submental spaces
• Elevation of the floor of the mouth
• Potential for airway obstruction

The condition typically originates from odontogenic infections (poor dentition, dental procedures) but can also arise from:

• Oral piercings (particularly tongue piercings)
• Sialadenitis
• Trauma to oral cavity
• Spread from pharyngeal or peritonsillar infections

Clinical Presentation

Key clinical features include:

• Submandibular swelling and induration ("woody" texture)
• Elevation of the floor of the mouth and tongue
• Dysphagia and drooling
• Dysphonia (voice changes)
• Pain in submandibular region
• Limited neck range of motion
• Trismus (limited mouth opening) - a late finding
• Respiratory distress, stridor (signs of airway compromise)
• Fever and systemic signs of infection

Diagnosis

Diagnosis is primarily clinical, based on:

• Characteristic bilateral submandibular swelling
• Elevated floor of mouth
• Signs of impending airway compromise

Imaging studies that may be helpful include:

• CT scan of neck with contrast (preferred if patient can tolerate lying supine)
• Point-of-care ultrasound (useful for patients who cannot tolerate supine positioning)
• Radiographs to identify dental sources of infection

Management

The management of Ludwig's angina requires immediate attention to the airway, followed by antibiotic therapy and surgical drainage, as this condition can rapidly progress to airway obstruction and death. 2, 3

1. Airway management:

   • Early consultation with anesthesia and otolaryngology
   • Flexible intubating endoscopy with preparation for surgical airway
   • Elective tracheostomy may be necessary in advanced cases

2. Antimicrobial therapy:

   • Broad-spectrum antibiotics targeting oral flora
   • Coverage for streptococci, staphylococci, and anaerobes
   • Parenteral administration initially

3. Surgical intervention:

   • Incision and drainage of abscesses
   • Removal of infected teeth if odontogenic source
   • Decompression of involved spaces

4. Supportive care:

   • ICU admission for close airway monitoring
   • Fluid resuscitation
   • Pain management

Complications

Potential complications include:

• Airway obstruction (most life-threatening)
• Spread of infection to mediastinum, pleura, or CNS 4
• Sepsis and septic shock
• Aspiration pneumonia
• Carotid artery rupture or jugular vein thrombosis
• Acute myocardial infarction (rare complication) 5

Prognosis

With early diagnosis and appropriate management, prognosis is generally good. However, delayed treatment can lead to significant morbidity and mortality, primarily due to airway compromise or spread of infection to vital structures.

Key Points for Emergency Management

• Recognize the condition early through clinical examination
• Prioritize airway management above all other interventions
• Initiate broad-spectrum antibiotics promptly
• Obtain early surgical consultation for drainage
• Monitor closely for signs of spreading infection

Ludwig's angina represents a true medical emergency that requires rapid recognition and intervention to prevent life-threatening complications.