Ludwig's angina is a type of severe cellulitis involving the floor of the mouth and is often caused by bacterial sources. Early in the infection, the floor of the mouth raises due to swelling, leading to difficulty swallowing saliva. As a result, patients may present with drooling and difficulty speaking. As the condition worsens, the airway may be compromised and hardening of the spaces on both sides of the tongue may develop. Overall, this condition has a rapid onset over a few hours. The majority of cases follow a dental infection. Other causes include a parapharyngeal abscess, mandibular fracture, cut or piercing inside the mouth, or submandibular salivary stones. The infection spreads through the connective tissue of the floor of the mouth and is normally caused by infectious and invasive organisms such as Streptococcus, Staphylococcus, and Bacteroides. Prevention is by appropriate dental care including management of dental infections. Initial treatment is generally with broad-spectrum antibiotics and corticosteroids. In more advanced cases endotracheal intubation or tracheostomy may be required. With the advent of antibiotics in 1940s, improved oral and dental hygiene, and more aggressive surgical approaches for treatment, the risk of death due to Ludwig's angina has significantly reduced. It is named after a German physician, Wilhelm Frederick von Ludwig, who first described this condition in 1836.
Signs and symptoms Ludwig's angina is a form of severe, widespread cellulitis of the floor of the mouth, usually with bilateral involvement. Infection is usually primarily within the submandibular space, and the sublingual and submental spaces can also be involved. It presents with an acute onset and spreads very rapidly, therefore early diagnosis and immediate treatment planning is vital and lifesaving. The external signs may include bilateral lower facial swelling around the jaw and upper neck. Signs inside the mouth may include elevation of the floor of mouth due to sublingual space involvement and posterior displacement of the tongue, creating the potential for a compromised airway. Additional symptoms may include painful neck swelling, drooling, tooth pain, dysphagia, shortness of breath, fever, and general malaise. Stridor, trismus, and cyanosis may also be seen when an impending airway crisis is nearing.
Causes The most prevalent cause of Ludwig's angina is dental related, accounting for approximately 75–90% of cases. Infections of the lower second and third molars are usually implicated due to their roots extending below the mylohyoid muscle. Periapical abscesses of these teeth also result in lingual cortical penetration, leading to submandibular infection. Other causes such as oral ulcerations, infections secondary to oral malignancy, mandible fractures, sialolithiasis-related submandibular gland infections, and penetrating injuries of the mouth floor have also been documented as potential causes of Ludwig's angina. Patients with systemic illness, such as diabetes mellitus, malnutrition, compromised immune system, and organ transplantation are also commonly predisposed to Ludwig's angina. A review reporting the incidence of illnesses associated with Ludwig angina found that 18% of cases involved diabetes mellitus, 9% involved acquired immune deficiency syndrome, and another 5% were human immunodeficiency virus (HIV) positive.
Diagnosis Infections originating in the roots of teeth can be identified with a dental X-ray. A CT scan of the neck with contrast material is used to identify deep neck space infections. If there is suspicion of the infection of the chest cavity, a chest scan is sometimes done. Angioneurotic oedema, lingual carcinoma and sublingual hematoma formation following anticoagulation should be ruled out as possible diagnoses.
Microbiology There are a few methods that can be used for determining the microbiology of Ludwig's angina. Traditionally, a culture sample is collected although it has some limitations, primarily being the time-consuming and sometimes unreliable results if the culture is not processed correctly. Ludwig's angina is most often found to be polymicrobial and anaerobic. Some of the commonly found microbes are Viridans streptococci, Staphylococci, Peptostreptococci, Prevotella, Porphyromonas and Fusobacterium.
Treatment For each patient, the treatment plan should be consider the patient's stage of infection, airway control, and comorbidities. Other things to consider include physician experience, available resources, and personnel are critical factors in formulation of a treatment plan. There are four principles that guide the treatment of Ludwig's angina: sufficient airway management, early and aggressive antibiotic therapy, incision and drainage for any who fail medical management or form localized abscesses, and adequate nutrition and hydration support.
Airway management
Airway management has been found to be the most important factor in treating patients with Ludwig's angina, i.e. it is the "primary therapeutic concern". Airway compromise is known to be the leading cause of death from Ludwig's angina.
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