II. Pathophysiology
- Dental Infection spreads to bilateral submandibular space with rapid progression
- Infection displaces the Tongue posteriorly, resulting in airway compromise
- Infection is typically polymicrobial
- Streptococcus Pyogenes and Streptococcus viridans
- Anaerobic Bacteria (e.g. Fusobacteria)
- Immunocompromised patients are a risk of Staphylococcus aureus and Gram Negative Bacteria
III. Causes
-
Dental Infection (Odontogenic Infection)
- Typically involves a mandibular tooth with periapical infection
- Mandibular Fracture Complication
- Tongue or frenulum piercing
IV. Symptoms
- Choking sensation (Ludwig's Angina)
- Dental Infection or lesion
- Facial pain, swelling, redness
V. Signs
- Fever
- Cellulitis of lower face and neck
- Stridor
- Trismus
- Firm, indurated floor of mouth
- Not Ludwig's Angina if this space is soft
VI. Management
- Emergent orofacial surgery or otolaryngology Consultation
- Surgical debridement if abscess seen on imaging
- Surgical debridement reduces airway compromise risk by 10 fold
- Airway management
- Intubation is typically required to secure the airway
- Consider intravenous Dexamethasone to reduce airway impingement
- Consider nebulized Epinephrine
- Antibiotics: Immunocompetent (2-3 agent protocol)
- Metronidazole 500 mg IV every 6 hours AND
- Penicillin G 3 MUIV q6 hours
- If severe, replace Penicillin with Zosyn or Meropenem
- Piperacillin-Tazobactam (Zosyn) 4.5 g IV every 6 hours OR
- Meropenem 1 g IV q8 hours
- Add Vancomycin 1 g IV every 6 hours if Staphylococcus aureus infection (presumed MRSA)
- Indicated if Gram Stain with Gram Positive Cocci in clusters
- Antibiotics: Immunocompromised
- Piperacillin-Tazobactam (Zosyn) 4.5 g IV every 6 hours (or Meropenem 1 g IV q8 hours) AND
- Vancomycin 1 g IV every 6 hours
- Antibiotics: Less Severe Infections
- Amoxicillin-Clavulanate 875-125 mg orally twice daily every 12 hours
- Antibiotics: Penicillin Allergy
- Clindamycin 600 mg IV every 6-8 hours
VII. Complications
- Airway obstruction
- Mediastinal spread via the parapharyngeal space
VIII. References
- (2019) Sanford Guide, accessed 11/23/2019
- Costain (2010) Am J Med 124(2): 115-7 +PMID:20961522 [PubMed]
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| 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, ﾙｰﾄﾞｳｨｯﾋｺｳｷｮｳｴﾝ |
| Swedish | Ludwigs angina |
| Czech | Ludwigova angína, angina Ludovici |
| Finnish | Ludwigin angiina |
| Russian | LIUDVIGA ANGINA, ANGINA LIUDVIGA, АНГИНА ЛЮДВИГА, ЛЮДВИГА АНГИНА |
| Croatian | LUDWIGOVA ANGINA |
| 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 |
