Diagnosis
Ludwigs angina
Life-threatening rapidly spreading acute cellulitis in the submandibular, sublingual, and submental spaces (floor of the mouth, under the tongue).
Also known as: Angina maligna, Morbus strangularis
Etiology
Cause [gc2]
Oral cavity infection or tooth abscess (70-90%)
Mouth injury
Osteomyelitis
Facture of the jaw
Otitis media
Tongue piercing
Sialadenitis and sialolithiasis
Peritonsillar or parapharyngeal abscess
Infected thyroglossal duct cysts
Microbe [uym][gc2]
Streptococcus viridans
Staphylococcus aureus
Enterococcus, Escherichia coli
Bacteroides
Actinomyces spp
Pseudomonas
Pathophysiology [gc2]
Infection begins in the floor of the mouth
Rapidly extends to the submandibular space
Involvement of the sublingual and submandibular spaces can lead to tongue elevation
May cause edema of epiglottitis, vocal cords, and aryepiglottic folds
May further extend to the parapharyngeal/retropharyngeal space and mediastinum
Risk factors [uym][gc2]
Dental caries
Recent dental treatment
Diabetes mellitus
Malnutrition
Alcoholism
Neutropenia
Glomerulonephritis
Compromised immune system (AIDS, SLE, organ transplant)
Complications [gc2]
Respiratory obstruction due to edema of the glottis
Aspiration pneumonia
Descending necrotizing mediastinitis
Sepsis
Multiple organ failure
Epidemiology
Incidence per 100.000 [uym][6wk][1am][aqu][h9n][at1]
Symptoms & findings
Symptoms
Anorexia, Confusion, Drooling, Dysphagia, Dyspnea, Fatigue, Fever, Halitosis, Hot potato voice, Malaise, Odynophagia, Stridor, Trismus, Weakness
Clinical findings
None listed.
Anamneses
None listed.
Localized findings
Approach
Blood test
CT collum
Treatment
Airway safety: [4ya][uym][7iw][ngr][yur][nmz][gc2]
Intubation or tracheostomy
Antibiotic treatment:
Penicilling G 4-30 million units per day (doses every 4-6 hours)
Metronidazol 500mg x 4
Clindamycin 450-900mg x 3
Surgical drainage:
Extraction of the offending teeth
Incision and drainage of abscess
Important adjuncts:
Dexamethasone
Metabolic control
Fluid replacement
Differential diagnoses
Anaphylaxis, Dental infection, Lymphadenopathy, Peritonsillar abscess, Sepsis, Sialadenitis, Sialolithiasis, Thyroid abscess
References
[1] AL Ghabra Y, Brizuela M, Winters R, et al. Ludwig Angina. [Updated 2025 Jun 22]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482354/
[2] Okoje VN, Ambeke OO, Gbolahan OO. LUDWIG'S ANGINA: AN ANALYSIS OF CASES SEEN AT THE UNIVERSITY COLLEGE HOSPITAL, IBADAN. Ann Ib Postgrad Med. 2018 Jun;16(1):61-68.
[3] Botha A, Jacobs F, Postma C. Retrospective analysis of etiology and comorbid diseases associated with Ludwig's Angina. Ann Maxillofac Surg. 2015 Jul-Dec;5(2):168-73.
[4] Fakir, M. A. Y., Bhuyan, M. A. H., Uddin, M. M., Rahman, H. M., Al-Masum, S. H. I., & Khan, A. M. (2009). Ludwigs Angina: a study of 50 cases. Bangladesh Journal of Otorhinolaryngology, 14(2), 51–56.
[5] Canas M, Fonseca R, De Filippis A, Diaz L, Afzal H, Day A, Leonard J, Bochicchio K, Bochicchio GV, Hoofnagle M. Ludwig's Angina: Higher Incidence and Worse Outcomes Associated With the Onset of the Coronavirus Disease 2019 Pandemic. Surg Infect (Larchmt). 2023 Nov;24(9):782-787.
[6] Anjrini, A.A., Kruger, E., & Tennant, M. (2014). A 10-year retrospective analysis of hospitalisation for oral cellulitis in Australia: the poor suffer at 30 times the rate of the wealthy. Faculty Dental Journal, 5, 8-13.
[7] Lin QL, Du HL, Xiong HY, Li B, Liu J, Xing XH. Characteristics and outcomes of Ludwig's angina in patients admitted to the intensive care unit: A 6-year retrospective study of 29 patients. J Dent Sci. 2020 Dec;15(4):445-450.
[8] Bross-Soriano D, Arrieta-Gómez JR, Prado-Calleros H, Schimelmitz-Idi J, Jorba-Basave S. Management of Ludwig's angina with small neck incisions: 18 years experience. Otolaryngol Head Neck Surg. 2004 Jun;130(6):712-7.
[9] Spitalnic SJ, Sucov A. Ludwig's angina: case report and review. J Emerg Med. 1995 Jul-Aug;13(4):499-503.
[10] Barakate MS, Jensen MJ, Hemli JM, Graham AR. Ludwig's angina: report of a case and review of management issues. Ann Otol Rhinol Laryngol. 2001 May;110(5 Pt 1):453-6.
[11] Bridwell R, Gottlieb M, Koyfman A, Long B. Diagnosis and management of Ludwig's angina: An evidence-based review. Am J Emerg Med. 2021 Mar;41:1-5.
[12] Kumar S, Ambikavathy M. Ludwig's Angina: Report of 40 Cases and Review of Current Concepts in Emergency Management in a Rural Tertiary Facility Teaching Hospital. Int J Head Neck Surg 2017; 8 (1):11-14.
[13] [First Aid for the Surgery Clerkship]
[14] [Primary Surgery, Maurice King]