Ludwig Angina: Cellulitis, Not Abscess
Ludwig angina is a rapidly spreading bilateral cellulitis of the submandibular, sublingual, and submental spaces—not a true abscess—though abscesses may develop secondarily within the affected tissue planes. 1
Pathophysiologic Classification
Ludwig angina represents diffuse cellulitis characterized by brawny, board-like ("woody") induration of the floor of mouth and neck without discrete pus collection at presentation. 2, 3, 4 This distinguishes it fundamentally from a well-circumscribed abscess requiring primary drainage.
Key Distinguishing Features from True Abscess
- Cellulitis involves diffuse inflammation spreading along fascial planes bilaterally and simultaneously, whereas abscesses are localized purulent collections with defined borders. 5, 6
- The infection spreads rapidly through tissue spaces rather than forming a walled-off cavity, creating the characteristic "bull neck" appearance with firm, non-fluctuant swelling. 2, 4
- While secondary abscess formation can occur as the infection progresses, the initial pathology is cellulitis with severe tissue edema and inflammation. 3, 6
Clinical Implications of This Distinction
The cellulitic nature of Ludwig angina means the primary treatment is aggressive IV antibiotics and airway management, not incision and drainage as would be appropriate for a simple abscess. 2, 3, 4 Surgical intervention in Ludwig angina serves to decompress tissue spaces and drain any secondary purulent collections, but is not the definitive treatment as it would be for a primary abscess.
Treatment Algorithm Based on Pathology
- Immediate airway assessment and securing (tracheostomy in 20% of cases) takes absolute priority because the cellulitic swelling can rapidly compromise the airway. 4, 6
- Broad-spectrum IV antibiotics covering oral flora (streptococci, anaerobes, and staphylococci) must be initiated emergently—the cellulitic spread requires systemic antimicrobial therapy, not just drainage. 2, 5
- Surgical decompression with incision and drainage is performed to release tissue pressure and evacuate any purulent material that has accumulated, but this is adjunctive to medical management. 3, 4
- All offending teeth must be extracted as the odontogenic source drives the cellulitic process in nearly 100% of cases. 3, 4
Common Pitfall to Avoid
Do not approach Ludwig angina as you would a simple cutaneous abscess—attempting incision and drainage alone without securing the airway and initiating IV antibiotics can be fatal. 2, 6 The mortality rate remains 10% even with modern management, primarily from airway obstruction or septic complications. 4
The cellulitic inflammation causes tongue displacement and floor-of-mouth elevation that can progress to complete airway obstruction within hours, making this a true surgical emergency requiring multidisciplinary management. 2, 6