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 angina can be remembered as the 3 Fs: feared, often fatal but rarely fluctuant 4,5.
When left untreated, this infection can spread inferiorly into the neck and mediastinum.
Most cases (85%) are thought to originate from an untreated odontogenic infection, mainly Streptococcus spp., Staphylococcus spp., and Bacteroides spp. 4. Of the other 15% of cases, causes include 4:
- peritonsillar or parapharyngeal abscess
- penetrating injuries to the floor of the mouth
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.
Treatment and prognosis
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.
History and etymology
It is named after Wilhelm Frederick von Ludwig (1790-1865) 6, a 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 angina 4.
Angina in this context is being used in its more general sense of an intense localised pain, rather than the specific pain of cardiac ischaemia.
- 1. W. F. Von Ludwig. Über eine in neuerer Zeit wiederholt hier vorgekommene Form von Halsentzündung. Medicinisches Correspondenzblatt des Württembergischen ärztlichen Vereins, Stuttgart, 1836, 6: 21-25.
- 2. Silverman PM, Zeiberg AS, Sessions RB et-al. Helical CT of the upper airway: normal and abnormal findings on three-dimensional reconstructed images. AJR Am J Roentgenol. 1995;165 (3): 541-6. AJR Am J Roentgenol (abstract) - Pubmed citation
- 3. Ludwig BJ, Foster BR, Saito N, Nadgir RN, Castro-Aragon I, Sakai O. Diagnostic imaging in nontraumatic pediatric head and neck emergencies. Radiographics : a review publication of the Radiological Society of North America, Inc. 30 (3): 781-99. doi:10.1148/rg.303095156 - Pubmed
- 4. Wasson J, Hopkins C, Bowdler D. Did Ludwig's angina kill Ludwig?. J Laryngol Otol. 2006;120 (05): 363-5. doi:10.1017/S0022215106000806 - Pubmed citation
- 5. Nguyen VD, Potter JL, Hersh-Schick MR. Ludwig angina: an uncommon and potentially lethal neck infection. AJNR. American journal of neuroradiology. 13 (1): 215-9. Pubmed
- 6. Murphy SC. The person behind the eponym: Wilhelm Frederick von Ludwig (1790-1865). (1996) Journal of oral pathology & medicine : official publication of the International Association of Oral Pathologists and the American Academy of Oral Pathology. 25 (9): 513-5. Pubmed