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Year : 2014  |  Volume : 5  |  Issue : 3  |  Page : 211-214

Ludwig's angina: A case report and review of management

Department of Oral and Maxillofacial Surgery, SRM Dental College and Hospital, Ramapuram, Chennai, Tamil Nadu, India

Date of Web Publication14-Aug-2014

Correspondence Address:
Sasikala Balasubramanian
Senior Lecturer, Department of OMFS, SRM Dental College and Hospital, Ramapuram, Chennai-89, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0976-433X.138778

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Space infection in the Oral and Maxillofacial region is common from odontogenic origin especially in the immunocompromised patients. Ludwig's angina which is relatively uncommon remains a potentially life-threatening condition due to the risk of impending airway obstruction. Thus, because of its invasive nature, early identification and management of Ludwig's angina is extremely important.

Keywords: Airway obstruction, Ludwig′s angina, life-threatening, space infection

How to cite this article:
Balasubramanian S, Elavenil P, Shanmugasundaram S, Himarani J, Krishnakumar Raja V B. Ludwig's angina: A case report and review of management. SRM J Res Dent Sci 2014;5:211-4

How to cite this URL:
Balasubramanian S, Elavenil P, Shanmugasundaram S, Himarani J, Krishnakumar Raja V B. Ludwig's angina: A case report and review of management. SRM J Res Dent Sci [serial online] 2014 [cited 2023 Feb 8];5:211-4. Available from:

  Introduction Top

Ludwig's angina was first described by the German surgeon Wilhelm Friedrich von Ludwig in 1836as a rapidly and frequently fatal progressive gangrenous cellulitis and edema of the soft tissues of the neck and floor of the mouth. [1]

Ludwig's angina is a severe diffuse cellulitis that presents an acute onset and spreads rapidly, affecting the submandibular, sublingual, and submental spaces bilaterally resulting in a state of emergency because of impending airway obstruction.

Ludwig's angina usually starts with submandibular space infection from second or third lower molar then it spreads to the sublingual space of the same side. From there it crosses to the opposite side sublingual space and thence to the contralateral submandibular space. The involvement of submental space is by lymphatic spread. It can also start from sublingual space and progress to the submandibular space.Infection from the sublingual space spreads posteriorly in the substance of the tongue in the cleft between the hypoglossus and genioglossus muscles and reaches epiglottis which causes edema of the glottis and respiratory obstruction. [2]

Causes of Ludwig's angina includes odontogenic infection, penetrating injury of the floor of the mouth,osteomyelitis, compound fracture of the jaw, otitis media, submandibular gland sialidenitis, sialolithiasis, and tongue piercing. Of all these, the major cause is of odontogenic infection, mainly from the second and third lower molar teeth. [3]

Predisposing factors are dentalcaries, recent dental treatment like dental extraction, systemic illness such as diabetes mellitus (DM), malnutrition, alcoholism, compromised immune system like AIDS, organ transplantation, and trauma. In children, it can occur de novo, without any apparent cause. [4]

In Ludwig's angina, patients demonstrate swelling in the floor of the mouth and neck, pain, malaise, fever, and dysphagia. In these patients, inability to swallow saliva and stridor indicate imminent airway compromise. The most feared complication is airway obstruction due to elevation and posterior displacement of the tongue and edema of the glottis. [5]

The presence of swelling in the neck and floor of the mouth, edema of the glottis, makes it difficult to anaesthetize the patient. Aggressive use of intravenous antibiotics and surgical decompression with removal of source of infection and airway management is mandatory to prevent mortality. [6]

  Case report Top

A 65-year-old patient reported to the Department of Oral and Maxillofacial Surgery with chief complaints of inability to open the mouth, pain and difficulty in swallowing with a swelling in relation to the lower jaw and neck for the past 4 days [Figure 1],[Figure 2] and [Figure 3]. On physical examination, he was toxic in appearance and his vital signs were monitored immediately. Thetemperature was 100°F with a pulse rate of 80 beats per minute (BPM), blood pressure (BP) of 100/70 mmHg, and a respiratory rate of 22 breaths per minute. Mouth opening was limited to 1.5 cm (interincisal distance). Extra-oral swelling was indurated and non-fluctuant with bilateral involvement of the submandibular and sublingual region. An infected third molar had been extracted 3 days earlier. An immediate diagnosis of Ludwig's angina was made, and the patient was posted for surgical decompression under local anesthesia with monitoring of oxygen saturation and vital signs by anesthesiologist. The blood report was normal except for rise in erythrocyte sedimentation rate (ESR), total white blood cell (WBC) count, and neutrophils. In the operating theater, electrocardiography, noninvasive BP, and pulse oximetry were used for monitoring vitals. Intravenous access was obtained and an infusion of normal saline started. Separate stab incisions was made in relation to the submandibular space bilaterally and submental space. A sinus forceps was introduced to open up the tissue spaces and pus was drained [Figure 4]. The wound was irrigated with normal saline, and corrugated rubber drain was placed and secured to the skin with silk sutures [Figure 5]. Intra-operatively, the vitals were stable. Intravenous administration of Cefotaxime 1 g bd (two times), Gentamycin 80 mg bd, Metronidazole 500 mg, tid (three times a day) were given for 5 days. Postoperative irrigation was done through the drain which was removed after 36 hr. Patient recovery was satisfactory. The following morning the patient was comfortable, with a pulse rate of 68 BPM, BP of 110/70 mmHg and oxyhemoglobin saturation of 97%. The neck swelling had regressed [Figure 6],[Figure 7],[Figure 8] and [Figure 9].
Figure 1: Pre operative- frontal view

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Figure 2: Pre operative- neck view

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Figure 3: Pre operative- mouth opening

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Figure 4: Draining pus

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Figure 5: Drain fixed

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Figure 6: Immediate post operative - neck view

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Figure 7: Late post operative- frontal view

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Figure 8: Late post operative- neck view

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Figure 9: Late post operative- mouth opening

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  Discussion Top

Ludwig's angina in the preantibiotic era which carried a very high mortality rate of around 50%has dropped down to around 8-10% today. The bacterial organisms generally isolated include Streptococci viridans, Staphylococcus aureus, and Staphylococcus epidermidis. Only 7% of Ludwig's angina cases are due to group A β-hemolytic streptococcus. Initial antibiotic treatment should be broad spectrum to cover gram-positive and gram-negative bacteria as well as anaerobes. Penicillin, metronidazole, clindamycin, and ciprofloxacin are commonly the antibiotics of choice. [7]

The treatment plan for each patient should bebased on the phase ofthe infection and associated conditions at the time of presentation. The surgeon's experience, existing resources, and personnelare all essential factors forassessment.

Tracheal intubation with a flexible bronchoscope by using topical anesthesia is highly successful in adult patients with deep neck infections. Tracheostomy using local anesthesia is recommended if fiberoptic intubation is not feasible, the clinician is not skillful in the use of awake -fiberoptic intubation, or when intubation attempts have failed. [8]

Larry W. Moreland et al., from their clinical experience and literature review concluded that conservative management of Ludwig's angina is acceptable in selective cases, provided that early antibiotic therapy is commenced and any collectable abscess is drained. They proposed an airway management protocol for these cases. Patients are then categorized as having either a severe airway compromise or a stable airway based on respiratory rate, oxygen saturation, and findings on fiberoptic laryngoscopy. In the severely compromised group (patients unable to maintain saturation on room air above 95%, respiratory rate >25, or a significant airway compromise on fiberoptic laryngoscopy) a definitive airway is required. They suggested awake, fiberoptic-assisted intubation should be attempted first; if this fails then a surgical tracheostomy is performed under local anesthesia. [9]

In some patients intravenous dexamethasone and nebulized adrenaline have been used to reduce upper airway edema to defer or avoid airway instrumentation altogether. Oro-tracheal intubation by direct laryngoscopy may be difficult due to distorted airway anatomy, trismus and tissue immobility. Blind nasal intubation is to be avoided as it could cause catastrophic bleeding, laryngospasm, airway edema, rupture of pus into the oral cavity, and aspiration. In skilled and experienced hands, flexible fiberoptic nasal intubation is the preferred method of airway management and has a high rate of success. When fiberoptic bronchoscopy is not feasible, not available, or has failed, cricothyrotomy and tracheostomy are the options. [10]

  Conclusion Top

Management of Ludwig's angina should be based on patient's clinical condition. It is essential to identify Ludwig's angina in the earlier stages of the disease, when it is easier to manage. In advanced cases, airway management and surgical drainage with organism specific antibiotic therapy are important in avoiding complications.

  References Top

1.Candamourty R, Venkatachalam S, Babu MR, Kumar GS. Ludwig′s Angina - An emergency: A case report with literature review. J Nat Sci Biol Med 2012;3:206-8.  Back to cited text no. 1
2.Seward GR, Malcolm H, David AM. Killey and Kay′s Outline of Oral Surgery. Part 1. 2 nd ed. Bristol: Wright; 1987. p. 139-40.  Back to cited text no. 2
3.Gbolahan OO, Olowookere S, Aboderin A, Omopariola O. Ludwig′s angina following self application of an acidic chemical. Ann Ibadan Postgrad Med 2012;10:34-7.  Back to cited text no. 3
4.Saifeldeen K, Evans R. Ludwig′s angina. Emerg Med J 2004;21:242-3.  Back to cited text no. 4
5.Duprey K, Rose J, Fromm C. Ludwig′s angina. Int J Emerg Med 2010;3:201-2.  Back to cited text no. 5
6.Kaluskar S, Bajaj P, Bane P. Deep space infections of neck, Indian J Otolaryngol Head Neck Surg 2007;59:45-8.  Back to cited text no. 6
7.Kassam K, Messiha A, Heliotis M. Ludwig′s Angina: The Original Angina. Case Rep Surg 2013 Article I 0974269, 4 Pages.  Back to cited text no. 7
8.Ovassapian A, Tuncbilek M, Weitzel EK, Joshi CW. Airway management in adult patients with deep neck infections: A case series and review of the literature. Anesth Analg 2005;100:585-9.  Back to cited text no. 8
9.Moreland LW, Corey J, McKenzie R. Ludwig′s angina. Report of a case and review of the Literature. Arch Intern Med 1988;148:461-6.  Back to cited text no. 9
10.Kulkarni AH, Pai SD, Bhattarai B, Rao ST, Ambareesha M. Ludwig′s angina and airway considerations: A case report. Cases J 2008;1:19.  Back to cited text no. 10


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]

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