Ludwig angina

Ludwig angina refers to rapidly progressive inflammation (cellulitis) of the floor of mouth, which is potentially life threatening due to the risk of rapid airway compromise. 

Largely due to the advent of antibiotics the condition is uncommon in present day modern societies. Immunocompromised patients are at higher risk.

Usually, the patient has signs and symptoms of preceding dental infection. Due to the anatomy of the submandibular, sublingual and submental spaces and the mylohyoid muscle, spread of infection can occur between these spaces. Subsequent swelling can displace the tongue superiorly and posteriorly leading to potential airway obstruction and asphyxiation. When severe, the floor of mouth swelling can also cause trismus, odynophagia and dysphagia. The classic signs are a brawny, tender non-fluctuant induration of the submandibular space, with elevation of the tongue.  

Three characteristics of Ludwig's angina can be remembered as 3 Fs: feared, often fatal but rarely fluctuant 4,5.

When left untreated, this infection can spread inferiorly into the neck and mediastinum.

Ludwig angina is a rapidly-spreading life-threatening cellulitis of the floor of mouth, involving the submandibular, sublingual, and submental spaces.

Most cases (85%) are thought to originate from an untreated odontogenic infection, mainly Streptococcus sp., Staphylococcus sp., and Bacteroides sp 4. Of the other 15% of cases, causes include 4:

It is primarily a clinical diagnosis. Generally, there is diffuse oedema within and between the affected submandibular, sublingual, or submental spaces. The presence of an abscess involving any of these spaces may raise concern. Accompanying swelling and elevation of the tongue may also be present.

The most important aspect of treatment is protection of the airway for which tracheostomy may be required. Aggressive intravenous antibiotics are the mainstay of therapy and intravenous steroids may help reduce the swelling and hence risk of airway compromise. Drainable collections are treated urgently with surgical decompression.

It is named after Wilhelm Friedrich von Ludwig: German physician, who first described this condition in 1836 2. Notably he died in December 1865 from 'non-specific neck inflammation' which some believe was Ludwig's angina 4.

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Article information

rID: 9908
System: Head & Neck
Section: Pathology
Synonyms or Alternate Spellings:
  • Ludwig's angina
  • Angina ludovici

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