Ludwig’s Angina

Also knows as 

• Angina Ludovici 
• Ludwig's disease
• Cellulitis of the submandibular space
• Submandibular cellulitis
• Submaxillary space infection

Ludwig’s angina is a serious and potentially life-threatening bacterial infection that affects the floor of the mouth, the tongue, and the neck. It spreads rapidly and can cause severe swelling, leading to breathing difficulties. Because of the risk of airway obstruction, Ludwig’s angina is considered a medical emergency and requires immediate treatment.

Causes of Ludwig’s Angina

Ludwig’s angina is caused by a bacterial infection, usually following an untreated dental infection or oral trauma. The infection spreads through the soft tissues and spaces of the neck, causing rapid swelling and inflammation.

a. Bacterial Infections

The most common bacteria involved in Ludwig’s angina include:

• Streptococcus species (such as Streptococcus viridans)
• Staphylococcus species
• Anaerobic bacteria (Bacteroides and Fusobacterium)

These bacteria normally exist in the mouth but can invade deeper tissues when the oral barrier is broken due to injury or infection.

b. Dental Infections (Most Common Cause)

• Tooth abscess (infected lower molars)
• Periodontitis (severe gum infection)
• Impacted wisdom teeth infections
• Recent tooth extractions that become infected

c. Other Causes and Risk Factors

• Poor oral hygiene – Increases bacterial buildup in the mouth.
• Mouth injuries or trauma – Cuts, bites, or puncture wounds can introduce bacteria.
• Tonsillitis or throat infections – Bacteria can spread from the tonsils to deeper tissues.
• Salivary gland infections – Blocked or infected salivary glands can contribute.
• Weakened immune system – Conditions like diabetes, HIV, or cancer increase the risk of severe infections.

Symptoms of Ludwig’s Angina

Symptoms usually appear suddenly and worsen rapidly, requiring urgent medical attention.

a. Swelling and Pain in the Lower Jaw and Neck

• Begins under the tongue and chin, then spreads to the neck.
• The area becomes hard, red, swollen, and painful.
• Skin over the swollen area may feel tight and warm.

b. Difficulty Breathing (Airway Obstruction)

• Swelling pushes the tongue upwards and backwards, blocking airflow.
• Patients may struggle to inhale and exhale, leading to breathing distress.
• Stridor – A high-pitched noise while breathing, indicating airway blockage.

c. Difficulty Swallowing (Dysphagia) and Drooling

• Patients find it hard to swallow food, liquids, or even saliva.
• Drooling occurs because swallowing is too painful or impossible.

d. Fever and Chills (Signs of Infection)

• High fever (above 100.4°F or 38°C) signals a bacterial infection.
• Patients may experience shivering, sweating, and general weakness.

e. Speech Changes and Tongue Swelling (Macroglossia)

• The tongue may become enlarged and push against the roof of the mouth.
• Patients may have difficulty speaking clearly or sound muffled.

f. Difficulty Opening the Mouth (Trismus)

• Jaw stiffness prevents full mouth opening due to tissue inflammation.

g. Increased Heart Rate and Weakness

• The body responds to infection by increasing the heart rate (tachycardia).
• Fatigue and weakness are common as the body fights the infection.

Diagnosis of Ludwig’s Angina

Early diagnosis is crucial to prevent airway obstruction and severe complications. A doctor will diagnose Ludwig’s angina based on clinical symptoms and medical imaging.

a. Physical Examination

• Inspection of the mouth, tongue, and neck for swelling and redness.
• Checking for breathing difficulties or muffled speech.

b. Imaging Tests (To Determine Infection Spread)

• CT Scan (Computed Tomography) – Shows the extent of swelling and fluid accumulation.
• MRI (Magnetic Resonance Imaging) – Detects deep tissue infections.
• X-ray (Dental or Neck X-ray) – Identifies tooth infections or abscesses.

c. Blood Tests

• Complete Blood Count (CBC) – Detects high white blood cell count (sign of infection).
• Blood Cultures – Identifies bacteria in the bloodstream (used to select antibiotics).

Treatment of Ludwig’s Angina

Ludwig’s angina is a medical emergency requiring immediate hospitalization. The main goals of treatment are:

1. Securing the airway to prevent breathing failure.
2. Stopping bacterial infection with IV antibiotics.
3. Draining pus or infected fluid if an abscess forms.

a. Airway Management (Most Critical Step)

• Oxygen therapy – If breathing is slightly affected.
• Endotracheal intubation – A breathing tube is inserted to keep the airway open.
• Tracheostomy (Emergency Surgery) – If swelling completely blocks breathing, a small incision is made in the windpipe (trachea) to insert a breathing tube.

b. Intravenous (IV) Antibiotics

• High-dose IV antibiotics are given immediately to stop the infection.
• Commonly used antibiotics:
  • Penicillin + Metronidazole (for anaerobic bacteria)
  • Clindamycin (for penicillin-allergic patients)
  • Ceftriaxone or Piperacillin-Tazobactam (for severe cases)

c. Surgical Drainage (If Abscess is Present)

• If pus accumulates, a surgeon may drain the infection through an incision.
• This prevents sepsis (a life-threatening blood infection).

d. Dental Treatment (If the Infection Originates from a Tooth)

• Tooth extraction or root canal may be needed for infected molars.
• Antiseptic mouth rinses to reduce bacterial growth.

Complications of Ludwig’s Angina

Without immediate treatment, Ludwig’s angina can lead to serious and fatal complications, including:

• Complete Airway Obstruction – Swelling can fully block breathing, leading to suffocation.
• Sepsis (Blood Infection) – Bacteria can spread into the bloodstream, causing organ failure.
• Mediastinitis – Infection can spread to the chest, affecting the heart and lungs.
• Necrotizing Fasciitis – A severe, flesh-eating bacterial infection of the neck.
• Brain Abscess – Infection can travel to the brain, causing life-threatening swelling.

Prevention of Ludwig’s Angina

Since Ludwig’s angina often results from dental infections, prevention focuses on oral hygiene and early dental care.

a. Maintain Good Oral Hygiene

• Brush teeth twice daily with fluoride toothpaste.
• Floss daily to remove food particles and bacteria.
• Use antiseptic mouthwash to reduce bacterial buildup.

b. Regular Dental Checkups

• Visit a dentist every 6 months to detect and treat dental issues early.
• Seek immediate dental care for tooth pain, swelling, or abscesses.

c. Treat Oral Infections Promptly

• Do not ignore tooth infections, cavities, or gum disease.
• If an abscess develops, see a dentist or doctor immediately.

d. Avoid Oral Trauma

• Protect your mouth from injuries, cuts, or burns that may introduce bacteria.

Conclusion

Ludwig’s angina is a life-threatening bacterial infection that requires immediate medical attention. Without prompt treatment, it can cause airway obstruction, sepsis, and death. Early diagnosis, IV antibiotics, airway management, and possible surgery are critical for survival. If you experience severe mouth or neck swelling, difficulty breathing, or swallowing, seek emergency medical care immediately.