Ludwig angina

Ludwig angina

Description, Causes and Risk Factors:

Ludwig's angina is a rapidly progressing polymicrobial cellulites of the sublingual and submandibular spaces that can result in life-threatening airway compromise. The Bacteriology of Ludwig's angina is polymicrobial and predominantly involves the oral flora. The organisms most often isolated in patients with the disorder are Streptococcus viridans and Staphylococcus aureus. Anaerobes also are frequently involved, including bacteroides, peptostreptococci, and peptococci.

Other gram-positive bacteria that have been isolated include Fusobacterium nucleatum, spirochetes, and Veillonella, Candida, Eubacteria, and Clostridium species. Gram-negative organisms that have been isolated include Neisseria species, Escherichia coli, Pseudomonas species, Haemophilus influenzae, and Klebsiella species.

Ludwig's angina usually originates from an odontogenic infection, especially from the second or third lower molars. These teeth have roots that lie at the level of the mylohyoid muscle, and abscesses here can spread to the submandibular space. Other less commonly reported causes of Ludwig's angina include sialadenitis, peritonsillar abscess, open mandibular fracture, infected thyroglossal duct cyst, epiglottitis, intravenous injections of drugs into the neck, traumatic bronchoscopy, endotracheal intubation, oral lacerations, tongue piercing, upper respiratory infections, and trauma to the floor of the mouth.

Risk Factors:

    Diabetes mellitus.

  • Neutropenia.

  • Aplastic anemia.

  • Glomerulonephritis.

  • Dermatomyositis.

  • Systemic lupus erythematous (SLE).

  • Alcoholism may also be a contributory factor.

The prognosis in Ludwig's angina depends primarily on immediate protection of the airway and then on prompt antibiotic — and possibly surgical — treatment of the infection. Mortality in the pre-antibiotic era was 50% but, with the advent of current therapies, has declined to less than 5%.


Patients with Ludwig's angina typically have a historyof recent dental extraction or of poor oral hygiene anddental pain. Clinical findings are consistent with sepsisand include fever, tachypnea, and tachycardia. Patientsmay be anxious, agitated, and confused. Their symptomscan include swelling and pain in the floor of the mouthand anterior neck, fever, dysphagia, odynophagia, drooling, trismus, toothache, and fetid breath. Hoarseness,stridor, respiratory distress, decreased air movement,cyanosis, and a “sniffing” position (i.e., the characteristicposture assumed by patients with impending upper airway compromise consisting of an upright posture withthe neck thrust forward and the chin elevated) are allsigns of impending airway catastrophe. Patients mayexhibit dysphonia. More specifically, they may have amuffled tone at higher registers (i.e., a “hot potato” voice)caused by edema of the vocal apparatus; this findingshould be a warning to clinicians of potentially severe airway compromise.

There are 4 cardinal signs of Ludwig's angina:

(1) bilateral involvement of more than a single deeptissue space; (2) gangrene with serosanguineous, putridinfiltration but little or no frank pus; (3) involvementof connective tissue, fasciae, and muscles but not glandular structures; and (4) spread via fascial space continuity rather than by the lymphatic system.


Plain radiographs of the neck and chest often showsoft-tissue swelling, the presence of gas, and the extent ofairway narrowing. Sonography has been used to identifyfluid collections in the soft tissues, as has gallium citrateGa-67 scanning. Panoramic radiographic views of the jawmay show a dental focus of infection. After the airwaypatency is assured, CT scanning is a valuable modality toshow the extent of soft-tissue swelling, the presence ofgas, fluid collection, and airway compromise. MRI is another elegant modality that canbe considered in some patients.


Treatment options:

    If the swelling blocks the airway, you need to get emergency medical help right away. A breathing tube through your mouth or nose and into the lungs to restore breathing. You may need to have surgery called a tracheostomy that creates an opening through the neck into the windpipe. Antibiotics are given to fight the infection. They are usually given through a vein until symptoms go away. Antibiotics taken by mouth may be continued until tests show that the bacteria have gone away. Administration of several antibiotic agents has been proposed, including high-dose penicillin G plus metronidazole, clindamycin, cefoxitin, Tazocin/Zosyn, Augmentin ES-600, and Timentin. Side effects of the medications positive.

  • For those patients who are in more immediate jeopardy, airway control is ideally achieved in the operating room, with surgical backup available, for performance of cricothyroidotomy or formal tracheostomy, if necessary. Endotracheal intubation of these patients can be difficult, and direct laryngoscopy may even precipitate the loss of the airway. Awake fiberoptic intubation is an attractive alternative and should be considered when the degree of airway narrowing is severe. Blind nasotracheal intubation should be avoided because of the degree of airway distortion and because resulting trauma may further narrow an already tenuous airway or cause bleeding or rupture of an abscess.

  • Dental treatment may be needed for tooth infections that cause Ludwig's angina.

  • Surgical drainage is indicated when there is suppurative infection, radiologic evidence of fluid collection or soft-tissue air, clinical fluctuance, crepitus, or a purulent needle aspirate.

NOTE: The above information is educational purpose. The information provided herein should not be used during any medical emergency or for the diagnosis or treatment of any medical condition.

DISCLAIMER: This information should not substitute for seeking responsible, professional medical care.


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