What is Ludwig's Angina?

What is Ludwig's Angina?

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

Clinical Definition and Pathophysiology

Ludwig's angina represents a severe diffuse cellulitis with acute onset that spreads rapidly and bilaterally, creating an emergency situation due to the risk of airway compromise. 1 This is a rapidly spreading infection specifically involving the floor of the mouth, distinguishing it from other neck infections. 2

The condition can progress to necrotizing fasciitis of the neck and floor of the mouth, making it a frequently fatal gangrenous cellulitis if not managed promptly. 3

Key Clinical Features

Physical examination findings include:

• Woody or indurated floor of the mouth with submandibular swelling 2
• Tongue protrusion and elevation of the floor of the mouth 1, 4
• Diffuse swelling and induration in the submandibular area with tenderness 4
• Trismus (limited mouth opening), which is a late finding indicating advanced disease 2
• Dysphonia, dysphagia, and drooling 4
• Limited neck range of motion 4

Risk Factors and Etiology

Patients at increased risk include those with:

• Poor dentition or dental caries (most common source) 2, 5
• Recent dental procedures or oral infections 5
• Immunosuppression (AIDS, organ transplantation, malignancy) 4, 5
• Diabetes mellitus or pre-diabetes 4, 5
• Alcoholism and malnutrition 4, 5
• Use of non-steroidal anti-inflammatory drugs for self-medication 3

The infection most commonly arises from Streptococcal and Staphylococcal organisms, with dental sources being the primary origin. 4

Critical Management Principles

The American Academy of Pediatrics emphasizes that Ludwig's angina requires systemic antibiotics and surgical drainage of abscesses, with early surgical decompression under antibiotic coverage being essential. 6

Immediate Priorities:

1. Airway management - Due to threat of rapid airway compromise, emergent consultation to anesthesia and otolaryngology is critical if definitive airway is required 2
2. First-line airway approach - Flexible intubating endoscopy with preparation for surgical airway (tracheostomy may be necessary) 1, 2
3. Source control - Examination of oral cavity for dental source and removal of ill-fitting dentures 6
4. Broad-spectrum parenteral antibiotics - Must be initiated immediately 1, 3
5. Surgical drainage - Formal surgical decompression of involved spaces and drainage of any abscesses or fluid collections 1, 3

Diagnostic Imaging:

• CT of neck soft tissue with contrast is preferred if patient can safely leave the ED and tolerate lying supine 2
• Point-of-care ultrasound can be useful adjunct, particularly for patients unable to tolerate supine positioning 2

Clinical Course and Complications

A critical pitfall is that the infection can spread beyond the initial site. Cases demonstrate spread to the mediastinum, pleura, mastoid, and even central nervous system, requiring repeated drainage procedures and prolonged treatment. 4, 3 Optimal surgery must drain all collections and excise all necrotic tissues for antibiotic efficacy and healing. 3

All patients require ICU admission for close airway observation after initial stabilization. 2