II. Pathophysiology

  1. Dental Infection spreads to bilateral submandibular space with rapid progression
  2. Infection displaces the Tongue posteriorly, resulting in airway compromise
  3. Infection is typically polymicrobial
    1. Streptococcus Pyogenes and Streptococcus viridans
    2. Anaerobic Bacteria (e.g. Fusobacteria)
    3. Immunocompromised patients are a risk of Staphylococcus aureus and Gram Negative Bacteria

III. Causes

  1. Dental Infection (Odontogenic Infection)
    1. Typically involves a mandibular tooth with periapical infection
  2. Mandibular Fracture Complication
  3. Tongue or frenulum piercing

IV. Symptoms

  1. Choking Sensation (Ludwig's Angina)
  2. Dental Infection or lesion
  3. Facial pain, swelling, redness

V. Signs

  1. Fever
  2. Cellulitis of lower face and neck
  3. Stridor
  4. Trismus
  5. Firm, indurated floor of mouth
    1. Not Ludwig's Angina if this space is soft

VI. Management

  1. Emergent orofacial surgery or otolaryngology Consultation
    1. Surgical Debridement if abscess seen on imaging
    2. Surgical Debridement reduces airway compromise risk by 10 fold
      1. Edetanlen (2018) Med Princ Pract 27(4):362-6 +PMID:29886486 [PubMed]
  2. Airway management
    1. Intubation is typically required to secure the airway
    2. Consider intravenous Dexamethasone to reduce airway impingement
    3. Consider nebulized Epinephrine
  3. Antibiotics: Immunocompetent (2-3 agent protocol)
    1. Metronidazole 500 mg IV every 6 hours AND
    2. Penicillin G 3 MUIV q6 hours
      1. If severe, replace Penicillin with Zosyn or Meropenem
      2. Piperacillin-Tazobactam (Zosyn) 4.5 g IV every 6 hours OR
      3. Meropenem 1 g IV q8 hours
    3. Add Vancomycin 1 g IV every 6 hours if Staphylococcus aureus infection (presumed MRSA)
      1. Indicated if Gram Stain with Gram Positive Cocci in clusters
  4. Antibiotics: Immunocompromised
    1. Piperacillin-Tazobactam (Zosyn) 4.5 g IV every 6 hours (or Meropenem 1 g IV q8 hours) AND
    2. Vancomycin 1 g IV every 6 hours
  5. Antibiotics: Less Severe Infections
    1. Amoxicillin-Clavulanate 875-125 mg orally twice daily every 12 hours
  6. Antibiotics: Penicillin Allergy
    1. Clindamycin 600 mg IV every 6-8 hours

VII. Complications

  1. Airway obstruction
  2. Mediastinal spread via the parapharyngeal space

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Related Studies

Ontology: Ludwig's Angina (C0024081)

Definition (MSHCZE) Hnisavý zánět spodiny dutiny ústní charakteru flegmony s nebezpečím dušení a provázený celkově těžkým stavem. (cit. Velký lékařský slovník online, 2013 http://lekarske.slovniky.cz/ )
Definition (MSH) Severe cellulitis of the submaxillary space with secondary involvement of the sublingual and submental space. It usually results from infection in the lower molar area or from a penetrating injury to the mouth floor. (From Dorland, 27th ed)
Concepts Disease or Syndrome (T047)
MSH D008158
SnomedCT 196542004, 54572003
English Ludwig Angina, Ludwig's Angina, Ludwigs Angina, Angina, Ludwig's, Ludwig's angina (diagnosis), Ludwig angina, Ludwig's Angina [Disease/Finding], anginas ludwig, angina ludwig, ludwigs angina, ludwig's angina, ludwig angina, Ludwig's angina, Ludwig's angina (disorder), Ludwig; angina, Ludwig, angina; Ludwig
Japanese ルードウィッヒ口峡炎, ルードウィッヒコウキョウエン
Swedish Ludwigs angina
Czech Ludwigova angína, angina Ludovici
Finnish Ludwigin angiina
Polish Angina Ludwiga, Ropowica Ludwiga
Hungarian angina Ludovici
Norwegian Ludwigs angina
Dutch Ludwig; angina, angina; Ludwig, angina Ludovici, Angina Ludovici, Ludwig-angina
Spanish angina de Ludwig (trastorno), angina de Ludwig, Angina de Ludwig
German Ludwig Angina, Angina Ludovici, Ludwig-Angina
French Angine de Ludwig, Angine de Gensoul-Ludwig, Maladie de Gensoul
Italian Angina di Ludwig
Portuguese Angina de Ludwig