Ludwig's Angina

Aka: Ludwig's Angina, Ludwig Angina, Cellulitis of Floor of Mouth, Submandibular Space Infection

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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. Imaging

  1. CT Soft Tissue Neck with IV Contrast
    1. Definitive study
    2. Initial management is often based on bedside clinical diagnosis before imaging
    3. As with all imaging, patient must be stable to perform (no signs of impending airway compromise)
      1. Patient must be able to lie supine for CT without worsening dynamic airway compromise
      2. Obtain definitive airway (e.g. Endotracheal Intubation) as needed before imaging

VII. 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. Airway management is typically challenging
      1. See Difficult Airway Assessment
      2. Submandibular and deep space swelling distort anatomy
      3. Trismus reduces mouth opening
    2. Intubation is typically required to secure the airway
    3. In stable patients, consider emergent Consultation with otolaryngology and Anesthesia (for double set-up in OR)
    4. Consider Fiberoptic Nasal Intubation (awake or under Ketamine sedation)
    5. Be prepared for emergent Cricothyrotomy (double set-up) in case of failed airway
  3. Measures to reduce airway edema
    1. Nebulized Epinephrine
    2. Corticosteroids (effect may be delayed up to 6 hours)
      1. Dexamethasone 0.6 mg/kg (up to 10 mg) IV or
      2. Methylprednisolone (Solumedrol) 2.3 mg/kg IV
  4. 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
  5. 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
  6. Antibiotics: Less Severe Infections
    1. No allergy to Penicillin
      1. Ampicillin/Sulbactam (Unasyn) OR
      2. Amoxicillin-Clavulanate 875-125 mg orally twice daily every 12 hours
    2. Penicillin Allergy
      1. Clindamycin 600 mg IV every 6-8 hours

VIII. Complications

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

IX. References

  1. (2019) Sanford Guide, accessed 11/23/2019
  2. Swaminathan and Shoenberger in Swadron (2023) EM:Rap 23(3): 1-2
  3. Costain (2010) Am J Med 124(2): 115-7 +PMID:20961522 [PubMed]
    1. https://www.amjmed.com/article/S0002-9343(10)00742-4/fulltext

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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
Derived from the NIH UMLS (Unified Medical Language System)

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