Introduction

What is Ludwig’s angina?

Ludwig’s angina is a rapidly spreading bacterial cellulitis that develops in the areas beneath the tongue, chin, and lower jaw, as well as in the neck. Ludwig’s angina is characterised by considerable swelling and inflammation in the area and can cause airway obstruction with limited access to the airway without fast medical attention.^1,2

Causes

• Dental (odontogenic) infections: the most common cause of Ludwig’s angina is a dental (odontogenic) infection, which is usually due to untreated dental decay or some complication of dental treatment
• Poor oral hygiene: is a significant risk factor for Ludwig’s angina, especially in people with immunosuppressed states or other existing health complications, as it favours bacterial growth and infection
• Immunosuppression: several conditions can lead to a decrease in immune response (such as chemotherapy or HIV), which can lead to a predisposition to Ludwig’s angina
• Trauma: trauma to the mouth or neck can lead to the introduction of bacteria that can cause infection
• Systemic infections: infrequently, systemic infections such as dengue fever in pregnancy can result in Ludwig’s angina^1,2,3

Common symptoms

Early symptoms

• Swelling and pain: swelling and pain are usually at the base of the mouth and in the neck
• Bilateral neck swelling: swelling usually occurs on both sides of the neck
• Elevated tongue: the swelling makes the tongue look elevated in the oral cavity
• Dysphagia: patients may present with complaints of dysphagia because of an inability to swallow food or liquids due to the swelling from the abscess
• Dysarthria: swelling may make it hard for patients to speak with clear articulation
• Fever and malaise: some systemic symptoms could include isolated or low-grade fever and malaise^1,2,3

Late symptoms

• Dyspnea: unprovided abscess treatment will progressively worsen shortness of breath in patients
• Stridor: patients may exhibit classic signs of airway obstruction, such as noisy breathing
• Trismus: swelling in the jaw or neck may present as an inability to open the mouth completely
• Toxicity: patient symptoms may include tachycardia, hypotension, and malaise, these symptoms may suggest sepsis or shock
• Airway obstruction: if abscess swelling occurs within the time frame of airway obstruction without adequate treatment, patients may experience respiratory collapse, which could be life-threatening^1,2,3

Rapid progression and potential severity

It is a rapidly advancing, life-threatening infection that leads to airway blockage as well as septic shock. Therefore, early identification and rapid intervention, along with appropriate treatment, are essential to prevent progression or death.⁴

Importance of recognising airway compromise early

Recognising signs of airway compromise in Ludwig’s angina early on is critical because it can progress rapidly, and swelling can cause airway obstruction, leading to a potentially fatal situation of asphyxiation. 

Important clinical findings, such as swelling in the floor of the mouth and challenges with jaw mobility, necessitate a thorough assessment of the airway, as prompt action is essential to avoid total airway obstruction and potential fatality.^1,5

Early warning signs of airway compromise

Early signs of airway compromise in Ludwig's angina can be subtle but are vital for recognising the need for intervention. These include voice muffling, trouble swallowing, drooling, and swelling of the mouth or neck. Stridor, trismus, and respiratory distress are late signs of an imminent risk of airway obstruction. It is essential to recognise these early signs, particularly when the clinical history suggests possible airway compromise (e.g. dental infections, oral procedures). Diagnostic imaging, like contrast-enhanced CT, may be helpful, but only if the patient is stable. Stabilise the airway as quickly as possible, while initiating appropriate antibiotics and surgical drainage. Proactive airway management and monitoring in a level IV facility (ICU) can prevent disastrous outcomes.¹

When to seek emergency care

Seek immediate medical care if you experience: 

• Swelling in the neck or mouth
• Difficulty breathing or swallowing
• Excessive drooling
• Hoarse voice
• Fever
• Worsening pain and swelling
• Stridor or breathing difficulties
• Trismus and "woody" swelling beneath the jaw

Prompt diagnosis and treatment for airway management and the use of antibiotics are crucial for a favourable outcome.²

Diagnosis and management

Reduced oral hygiene and/or states of immunosuppression, such as diabetes, are commonly seen in this condition. Initial signs may consist of swelling in both submandibular areas, pain when elevating the tongue on both sides, difficulty swallowing, and occasionally trismus. Loss of airway is the most serious potential complication of Ludwig's angina.

Diagnosis is often clinical but can include imaging to evaluate the extent of the infection, which may be assessed with some diagnostic imaging using a CT scan with contrast or ultrasound. 

First-line management emphasises the importance of securing the airway through endotracheal intubation performed as an emergency or urgent intervention, or through surgical tracheostomy, along with the administration of early, broad-spectrum intravenous antibiotics. Once the airway is secured and antibiotics have been started, controlling the source of infection may necessitate surgical drainage, which includes interventions to facilitate such drainage.

Prompt recognition and management mitigate serious life-altering consequences. Delay opens pathways for a greater burden of serious complications like necrotising fasciitis and septicemia.^1,2,3,6,7

Prevention and risk reduction

The primary way to prevent Ludwig's angina is by maintaining proper oral hygiene, promptly addressing and treating dental issues, and raising public awareness about untreated oral infections. Early recognition of swelling, pain, and voice changes will help facilitate early medical care. The use of intravenous antibiotics in combination with surgical drainage of the submandibular space will prevent airway obstruction and greatly reduce mortality. 

Patients should have regular dental check-ups, particularly those in the at-risk categories, such as the elderly, children, pregnant women, and those who are immunocompromised. Early identification of oral infections that may lead to Ludwig's angina is much less dangerous than waiting until there are complications. 

In the past 100 years, with aggressive management, mortality has decreased from more than 50% to <10% at present. Lastly, public education on maintaining good oral hygiene and awareness about treatment delay for dental problems can assist in further decreasing the rates of Ludwig's angina.^1,8

Summary

Ludwig’s angina is a serious bacterial infection that spreads quickly in the areas beneath the tongue, chin, and lower jaw, leading to significant swelling and the risk of airway blockage. The most common cause is dental infections, often due to untreated decay or dental treatments. Poor oral hygiene and conditions that weaken the immune system can increase the risk, as well as trauma to the mouth or neck. Early symptoms include swelling and pain at the base of the mouth, swelling in both sides of the neck, an elevated tongue, difficulty swallowing (dysphagia), and trouble speaking (dysarthria). Patients may also experience fever and general discomfort. If untreated, the condition can worsen, leading to shortness of breath, noisy breathing (stridor), inability to open the mouth (trismus), and signs of severe illness like rapid heart rate and low blood pressure.

Airway obstruction can occur, which is life-threatening. Recognising early signs of airway compromise is crucial since the condition can decline rapidly. Signs to watch for include a muffled voice, difficulty swallowing, drooling, and swelling. Stridor and respiratory distress are late signs indicating a serious risk. If symptoms arise, immediate medical attention is necessary. Diagnosis is typically clinical but may involve imaging to assess the infection's extent. Treatment focuses on securing the airway, often requiring urgent medical procedures, along with administering antibiotics. Preventing Ludwig's angina is mainly about maintaining good oral hygiene, addressing dental issues promptly, and ensuring regular check-ups, especially for high-risk individuals. Public awareness is key to reducing the incidence of this condition.