What is ludwig’s angina?

Ludwig's angina is a serious and life-threatening illness that affects soft tissues below the mouth and neck. It mostly moves through three spots below the mouth: under the tongue (sublingual), under the chin(submental), and under the jaw(submandibular).¹ As the infection gets worse, the soft tissues get more swollen. This swelling can push the tongue up and back. When this goes on, it can block the airway, making it hard to breathe, which is the most dangerous and deadly complication of the disease.²

Dental infections, mainly in the lower back teeth (often the second and third molars), are the most common cause of Ludwig's angina. These infections make up more than 90% of cases.¹ Other risk factors are systemic diseases like diabetes, alcoholism, poor nutrition, and diseases that hit the body's immune system, like AIDS.³

Before the advancement of antibiotics, the death rate was over 50%.⁴ With prompt airway management and antibiotic therapy, as well as improved imaging and surgical procedures, the death rate has fallen to about 8%.⁵ Therefore, early diagnosis and treatment of Ludwig's angina are crucial.

Aetiology and path of spread

To understand the rapid progression and eventual airway blockage that can occur due to Ludwig's angina, let's review the anatomy of the neck and mouth. The mylohyoid muscle (muscle in the neck region extending from the lower jaw to the hyoid bone) divides the submandibular space into two spaces, the sublingual space and the submylohyoid space. The roots of the back teeth of the lower jaw lie beneath these muscular attachments, allowing infection to enter the submylohyoid space. The infection then spreads forward and backwards, reaching the sublingual and submandibular spaces. Involvement of these spaces can cause the tongue to enlarge 2-3 times and elevate into the lower throat, eventually leading to airway blockage if not treated soon. Swelling of the airway parts can progress fast, occurring within 30-45 minutes of infection onset.⁶

Other causes include inflammation around the throat and tonsils, lower jaw fractures, mouth tissue tears/piercings, salivary gland inflammation and oral cancers.⁷

The presence of tooth decay, recent dental treatments, systemic diseases such as diabetes, malnutrition, alcohol abuse, suppression of the immune system, such as AIDS, and organ transplantation may cause Ludwig's angina.²

Microbial profile

The infection is caused by several types of microorganisms, primarily including oral cavity flora. Viridans group streptococci (more than 40%), Staphylococcus aureus (27%) and Staphylococcus epidermidis (23%) are the bacteria most responsible for Ludwig's angina, respectively. Klebsiella bacteria ( Gram-negative, non-motile, encapsulated bacteria) may be found in more than half of diabetic patients with Ludwig's angina.⁸

Clinical presentation

Patients may report a recent toothache. Fever, fatigue, chills, and weakness are among the most commonly reported symptoms. Trismus (limitation of jaw movement) is one of the main complaints of Ludwig's angina. The presence of trismus indicates that the infection has spread to the parapharyngeal space (deep in the neck). Signs of respiratory involvement include tripod position, drooling (saliva flowing out of your mouth unintentionally), and dysphagia (difficulty swallowing).⁸  Mouth pain, hoarseness, swollen tongue, and stiff neck may also be present.⁵

Diagnostic approach

Although Ludwig's angina typically begins as an infection in the mouth, patients usually have fever, malaise, chills, and general weakness. Symptoms such as trismus, meningismus, drooling, difficult swallowing and tripod position indicate that it is in the later stages of the clinical course.

If there is airway involvement, it suggests a risk of airway loss. As symptoms worsen, patients may lean forward in the tripod position (the person sits or stands leaning forward and supports their upper body by placing their hands on their knees or another surface) and thus attempt to maximise their airway diameter.⁹

If the patient's airway is compromised and urgent intervention is required, the decision to intubate (insert a tube) is based on clinical symptoms and criteria. Making an intubation decision based on a  CT scan may delay treatment. When the patient's airway is properly established, neck CT with intravenous contrast medication is the most accurate method used to assess the severity and status of the infection.¹⁰

Findings on CT scan, such as soft tissue gas, fluid accumulation, muscle oedema, attenuated subcutaneous fat, loss of fat planes in the submyloid space, and soft tissue thickening, may suggest Ludwig's angina.⁹

CT shows 95% sensitivity and 53% specificity for Ludwig’s angina. According to one study, when CT findings are combined with clinical examination, specificity increases to 80%.¹¹

Management strategies

The first step in treating Ludwig's angina is to ensure airway patency and make it easier for the patient to breathe because asphyxia (suffocation resulting from lack of oxygen), resulting from airway obstruction, is the main cause of death. Once the patient's airway is clear, broad-spectrum antibiotics are prescribed to control the infection, and, in some cases, surgical drainage may be used to treat the infection. Intravenous steroids and inhaled adrenaline are adjunctive treatments used to reduce facial and airway oedema and increase antibiotic utilisation.¹²

• Airway management: Patients with hypoxia should be given supplemental oxygen. Swelling in the neck area often makes mask ventilation (the delivery of pressurised air from the upper airways to the patient's lungs) difficult, so it is vital that patients are given oxygen beforehand.¹ Flexible nasotracheal intubation is generally preferred for intubation, but surgical airway adjustments such as cricothyrotomy should be implemented before any airway intervention is performed.¹³  Flexible nasotracheal intubation should be performed by an experienced operator. In cases where an operator is not available for intubation, cricothyrotomy (inserting a tube through an incision in the cricothyroid membrane into the trachea) or tracheostomy (to help air and oxygen reach the lungs by creating an opening into the trachea from outside the neck) is performed in emergency intervention of advanced-stage infections²
• Medical treatment: After airway security is ensured, broad-spectrum intravenous antibiotics are used as first-line treatment.⁴ Antibiotics should affect aerobic, anaerobic, and oral microflora bacteria. The most commonly prescribed antibiotics are ampicillin-sulbactam or clindamycin.¹ Intravenous steroids and inhaled adrenaline (epinephrine) can be used as adjunctive therapy. These drugs make intubation easier by reducing swelling and cellulitis. They also increase the effectiveness of antibiotics by allowing them to pass into the tissues more easily¹³
• Surgical treatment: It is performed to open the airway and allow the patient to breathe. As a result of this procedure, the tongue is moved forward and down, thus re-opening the airway at the back of the throat. In the early stage, surgical decompression (pressure reduction) of the submandibular space can be applied to relieve the airway. This surgical intervention aims to reopen the airway located at the back of the throat by allowing the tongue to move to a lower and more anterior position. Subsequently, the submandibular gland is appropriately relocated, and the mylohyoid muscles are divided to decompress the infected areas. As a result of these surgical interventions, the need for long-term airway intubation can be reduced, and the length of hospital stay can be decreased. In addition, it is a very safe procedure and has no direct complications¹
• Dental management: If Ludwig's angina is determined to be of dental origin, which 90% of cases are - the affected tooth or teeth must be extracted, or other necessary dental treatments must be performed to eliminate the source of infection¹⁴

Prevention and dental role

Although Ludwig's angina is not a common condition, it should be considered in the differential diagnosis of neck swelling, especially in patients with poor oral hygiene and those who have recently undergone various dental treatments. Healthcare providers should not ignore even the slightest complaints about toothache, and life-threatening emergencies like Ludwig's angina should be considered.

FAQs

What is the most common cause of ludwig's angina?

More than 90% of Ludwig's angina cases are caused by a dental infection of the second and third lower molars. Other risk factors include injuries to the lower jaw, diabetes, excessive alcohol consumption, malnutrition and diseases that affect the immune system, such as AIDS.

Can a dentist treat ludwig's angina?

Dentists should identify patients with signs or symptoms of Ludwig's angina and ensure that appropriate antibiotics are prescribed to treat the infection. Dentists should also ensure that the patient is followed up by a medical doctor and that prompt treatment is administered at the first sign of airway obstruction.

Is ludwig's angina an emergency?

Ludwig's angina is a severe infection that starts suddenly and spreads rapidly, affecting the submandibular spaces bilaterally and can result in an emergency situation such as respiratory tract obstruction. With early diagnosis and urgent treatment, this life-threatening disease can be treated.

How quickly does ludwig's angina develop?

The onset and progression of this disease can occur in as little as a few hours. A person with Ludwig's angina may experience swelling in the submandibular area and airway obstruction. In most cases, a tooth infection is the cause.

Summary

Ludwig’s angina is a serious and potentially fatal condition that often begins with a simple dental infection, most commonly from lower molars. Understanding the anatomical, microbial, and clinical aspects is essential for early detection and life-saving management. Dentists play a critical role in preventing such complications through prompt care, education, and interdisciplinary communication.