What is Ludwig's Angina?

Ludwig's Angina: Definition and Clinical Entity

Ludwig's angina is a rapidly progressive, life-threatening bilateral cellulitis involving the submandibular, sublingual, and submental spaces of the floor of the mouth that can cause acute airway obstruction. 1, 2

Pathophysiology and Anatomic Distribution

• Ludwig's angina represents a severe diffuse cellulitis with acute onset that spreads rapidly and bilaterally, affecting multiple fascial spaces simultaneously 1
• The infection involves the floor of the mouth with characteristic elevation that can displace the tongue posteriorly and superiorly, creating airway compromise 1
• This is a form of necrotizing fasciitis when it progresses, with potential for gangrenous spread into the neck 3

Common Etiologic Factors

• Odontogenic infections are the primary source, with poor dentition being the most common predisposing factor 1, 2
• Risk factors include recent dental procedures, dental caries, diabetes mellitus, alcoholism, malnutrition, and immunocompromised states (AIDS, organ transplantation, malignancy) 4, 5
• Streptococcal and Staphylococcal species are the most common causative organisms 4

Clinical Presentation

• Patients present with submandibular swelling that is characteristically "woody" or indurated on palpation 2
• Associated symptoms include dysphagia, drooling, dysphonia, tongue protrusion, and pain 4
• Trismus is a late finding and indicates advanced disease 2
• Fever, neck tenderness, limited neck range of motion, and erythematous oropharynx are common 4
• The hallmark physical finding is bilateral submandibular induration with elevation of the floor of the mouth 6, 1

Life-Threatening Complications

• Airway obstruction from posterior tongue displacement is the most immediate threat to life 1, 2
• The infection can spread to the mediastinum, pleural space, and even the central nervous system 4
• Patients may develop breathlessness and stridor as the airway becomes compromised 1
• Descending necrotizing mediastinitis represents a severe complication requiring chest tube drainage 4

Critical Diagnostic Approach

• Examination of the oral cavity for dental sources of infection is necessary, with removal of ill-fitting dentures 7
• CT of the neck with IV contrast is the preferred imaging modality if the patient can safely leave the emergency department and tolerate lying supine 2
• Point-of-care ultrasound serves as a useful adjunct, particularly for patients unable to tolerate the supine position 2

Emergency Management Priorities

The treatment triad consists of: (1) airway protection, (2) broad-spectrum antibiotics, and (3) surgical drainage under antibiotic coverage. 7, 1, 2

• Emergent consultation to anesthesia and otolaryngology is essential when airway intervention may be required 2
• Flexible intubating endoscopy is the first-line approach for definitive airway management in the emergency department, with preparation for surgical airway 2
• Early surgical decompression and drainage of abscesses is critical, as prognosis is directly related to early surgical debridement 1, 3
• Multiple surgical procedures may be required to drain all collections and excise necrotic tissue, which is necessary for antibiotic efficacy 3
• Patients require intensive care unit admission for close airway observation 2

Common Pitfall

• Self-medication with non-steroidal anti-inflammatory drugs has been associated with severe necrotizing cervical cellulitis and may mask early symptoms while allowing progression 3