Introduction

Ludwig’s angina is a potentially fatal cellulitis that originates from odontogenic infections and spreads to involve the submandibular and sublingual spaces, as well as the submental region. While modern improvements in diagnosis, airway management, and antibiotic therapy have significantly reduced its mortality, survivors can face a variety of long-term complications.¹ The quality of life of patients can be profoundly affected by these complications, which are frequently neglected. This article highlights risk factors, addresses the long-term physical, functional, and psychological effects on Ludwig’s angina survivors, and proposes recommendations for comprehensive follow-up care.

Understanding Ludwig’s Angina

In 1836, German physician Wilhelm Frederick von Ludwig was the first to describe Ludwig’s angina as an aggressive form of cellulitis affecting the neck and floor of the mouth. It typically develops from an infected or recently extracted mandibular molar tooth and spreads rapidly through fascial planes, resulting in serious conditions such as mediastinitis, septicaemia, and airway obstruction if left untreated.² Mortality has dropped significantly, from around 50% in the pre-antibiotic era to less than 10% today, owing to the development of broad-spectrum antibiotics, sophisticated imaging, and improved surgical procedures. Significant morbidity remains, however, especially among patients who require invasive treatment, experience a delayed diagnosis, or have a widespread infection.³

The chronic aftermath frequently receives less attention than the acute phase, which concentrates primarily on survival and airway management. This article aims to provide a framework for follow-up and rehabilitation while thoroughly exploring the long-term effects on Ludwig’s angina survivors.

Figure 1: Where does Ludwig’s angina occur? The image above shows that the fascial infection spreads and potentially fills the submandibular, sublingual and submental spaces. Created in BioRender.com

Causes of Ludwig’s Angina

Ludwig’s angina is primarily caused by rapidly spreading bacterial infections that originate in the submandibular, sublingual, and submental regions. The most common cause is dental infection, particularly dental abscesses involving the second and third mandibular molars; these often result from advanced caries, pulpitis, or complications following a tooth extraction.

Other primary sources of infection include:

• Trauma: Pathogens may be introduced by oral lacerations, jaw fractures, or iatrogenic trauma such as tongue piercings
• Sialadenitis: Adjacent fascial spaces may become infected when the submandibular salivary glands become infected
• Upper respiratory tract infections: Infections of the tonsils, pharynx, or parotid glands can spread inferiorly, although this is less frequent
• Poor oral hygiene: Chronic dental infections and problems are more likely to occur in those who practise poor oral hygiene and neglect their teeth
• Immunocompromised states: Steroid consumption, HIV/AIDS, diabetes mellitus, and cancers make individuals more prone to serious infections and delayed recovery²

Bacterial Involvement

Pathogenic bacteria commonly involved are listed in the table below.

Table 1: The table above lists the pathogenic bacteria (aerobic and anaerobic) that could potentially be the root cause of the infection spreading into the fascial space.⁴

Figure 2: Potential causes of Ludwig’s angina. This image highlights the potential causes of Ludwig’s angina, including immunocompromised conditions, poor oral hygiene, dental infections, dental abscess, tooth extraction, salivary gland-related infections, tonsillitis, pharyngitis, and jaw fractures. Created in BioRender.com

Pathophysiology

Ludwig’s angina infection typically originates from an infection in the second or third mandibular molar, owing to the close proximity of their roots to the lingual cortex and the sublingual and submandibular spaces. From there, the infection spreads bilaterally and inferiorly, involving the sublingual, submandibular, and submental spaces.

As the infection spreads into deeper fascial spaces and pus accumulates, firmness can be felt in the floor of the mouth, and the tongue may be pushed upwards and backwards.⁵ As the infection spreads further, the airway can become obstructed, resulting in dyspnoea, dysphagia and dysphonia. The phases of infection are explained in detail in Figure 3.

Figure 3: The flow diagram above displays the phases of infection spread in Ludwig’s angina. Refer to Appendix.

Risk Factors of Chronic Infection

Ludwig’s angina patients generally have a good recovery rate. However, individuals may experience long-term complications as a result of the chronic nature of their condition and invasive treatment procedures. Risk factors include:

• Delayed diagnosis and neglected treatment
• Bacterial invasion
• Comorbid conditions such as immunocompromised conditions, diabetes mellitus, and malnutrition
• Prolonged hospital stay, particularly in the intensive care unit under mechanical ventilation
• Extensive surgical debridement and tracheostomy
• Recurrent persistent infection⁶

Long-Term Management

Although most patients with Ludwig’s angina recover fully, a subset experiences long-term complications due to the aggressive nature of the initial infection and the invasiveness of its treatment. The following measures could enhance long-term outcomes:

• Regular dental and maxillofacial treatment, including prosthodontic rehabilitation and jaw physiotherapy, can enhance oral function and physical appearance
• Survivors should have regular ENT exams to monitor airway patency, vocal cord function, and swallowing
• Speech and swallow care are particularly important for patients with vocal cord or tongue issues
• Breathing exercises and pulmonary function monitoring are crucial for patients with ongoing respiratory difficulties during pulmonary rehabilitation
• Physical therapy exercises for the neck and jaw can prevent fibrosis, restore range of motion, and enhance quality of life
• Psychological support options include cognitive behavioural therapy, support groups, and psychiatric evaluations for individuals with mental health challenges
• Nutritional challenges may arise due to the prolonged disease course and oral dysfunction⁶

Complications

Airway and Respiratory Sequelae

Airway compromise remains the most serious acute concern in Ludwig’s angina, often necessitating emergency management via intubation or tracheostomy. Long-term tracheostomy patients may develop subglottic stenosis, tracheomalacia, or granulation tissue. Long-term tracheal constriction can cause persistent dyspnoea or stridor. Instrumentation or surgical trauma can cause laryngeal and vocal cord dysfunction, including paralysis or dysphonia. These patients frequently require speech therapy and ENT evaluations. Aspiration pneumonia or Acute Respiratory Distress Syndrome (ARDS) can lead to pulmonary problems such as persistent fibrosis or restrictive lung disease. Symptomatic individuals should undergo pulmonary function testing and imaging.⁷

Orofacial and Dental Sequelae

Ludwig’s angina is typically caused by an odontogenic infection, and dental extractions or debridement are often required for treatment. Extraction of several teeth, particularly in the posterior mandible, can lead to tooth loss and malocclusion, affecting mastication, speech, and appearance.⁵ Malocclusion may also result from asymmetrical tooth loss or chronic trismus. Inflammation and fibrosis of the masticatory muscles or temporomandibular joint (TMJ) can cause restricted mouth opening, which affects oral hygiene maintenance, complicates dental rehabilitation, and restricts nutrition. During the acute phase, fibrosis or infection of the submandibular and sublingual glands can cause chronic xerostomia (dry mouth), increasing the risk of secondary dental caries and oral infections.⁸

Neurological Sequelae

Involvement of the mandibular branch of the trigeminal nerve (cranial nerve V) can result in paraesthesia or numbness in the lower lip and chin. In rare cases, injury to the hypoglossal nerve (cranial nerve XII) can cause tongue paralysis or deviation. Infection spreading to the brain through the venous system can cause cavernous sinus thrombosis or brain abscesses, resulting in long-term neurological damage. Survivors may experience cognitive or movement impairments necessitating neurorehabilitation.⁹

Musculoskeletal and Soft Tissue Sequelae

Extensive neck dissection and drainage procedures might cause fibrosis and limited neck movement. Patients may develop noticeable scarring, keloids, or contractures that impair posture and range of motion. Common symptoms of chronic pain and myofascial dysfunction include persistent pain, muscle stiffness, and headaches. Chronic inflammation and nerve sensitisation may contribute to long-term orofacial pain disorders.¹⁰

Quality of Life

Intensive care unit patients, particularly those who underwent emergency airway interventions or experienced septic shock, may develop post-traumatic stress disorder (PTSD). They may experience nightmares, flashbacks, or a fear of choking. Facial disfigurement, speech difficulty, and chronic fatigue may lead to depression, social anxiety, and isolation. Psychological support and counselling should be included in long-term care. Prolonged rehabilitation and time off work might lead to economic hardship. In severe cases, permanent impairment may occur.¹¹

Post-Treatment Care

To minimise long-term effects and ensure a complete functional recovery after Ludwig’s angina, effective post-treatment care is crucial. The patient’s concerns, comorbidities, and psychosocial needs should all be taken into consideration when planning care.

Follow-Up

• Airway and respiratory monitoring: Routine evaluations by pulmonologists and ENT specialists to check for chronic respiratory problems, vocal cord dysfunction, or tracheal stenosis
• Glycaemic control: Recurrent infections are less likely to occur in diabetes patients whose blood sugar levels are regulated
• Infection surveillance: Use routine imaging and clinical examinations to regularly monitor for signs of recurrence or progression

Oral and Dental Rehabilitation

• Oral rehabilitation: After an infection has been treated and the body has healed, dentures or implants can be used to replace missing teeth
• Education on oral hygiene: To avoid recurrent infectionss, emphasise the use of antimicrobial mouthwashes, brushing, and flossing
• Salivary gland care: Use sialogogues (such as pilocarpine), artificial saliva, and plenty of water to treat xerostomia

Speech and Physical Therapy

• Jaw physiotherapy: Exercises that improve mouth opening in trismus or TMJ stiffness
• Neck mobility rehabilitation: Soft-tissue activation and stretching for patients with scarring or cervical fibrosis
• Speech and swallow therapy: For people with articulation-related nerve deficits, dysphagia, or dysphonia

Nutrition Management

• Referral to a dietitian: To ensure adequate intake of calories and nutrients, especially for individuals who have difficulty swallowing or chewing
• Dietary changes: In the early phases of recovery, soft or pureed foods could be advised

Support for Psychosocial and Mental Health

• Psychological counselling: Treat social stigma brought on by facial deformities or intensive care unit experiences, as well as anxiety, sadness, and PTSD
• Support communities: Emotional healing and coping mechanisms may be promoted by peer interaction with other survivors

Aesthetics

• Topical therapy: To treat hypertrophic scars, use steroid creams or silicone sheets
• Surgical options: Take into account reconstructive or scar revision surgeries for severe ruptures or aesthetic issues¹²

FAQs

What is Ludwig’s angina?

Ludwig’s angina is a serious, rapidly spreading bacterial infection of the submandibular, sublingual, and submental areas of the floor of the mouth. Given that it can restrict the airway, it is considered a medical emergency.

What is Ludwig’s angina caused by?

A dental infection, particularly from the lower second or third molars, is the most frequent cause. Salivary gland infections, mandibular fractures, and trauma are other causes.

What makes Ludwig’s angina a potentially fatal medical condition?

If left untreated, the infection can cause rapid swelling of the floor of the mouth and throat, which can result in sepsis, mediastinitis, or airway obstruction.

What are Ludwig’s angina’s typical symptoms?

• Excruciating pain and swelling beneath the jaw
• Breathing, swallowing, or speaking difficulties
• Chills and fever
• Drooling
• Strong neck oedema or an elevated, posteriorly displaced tongue that is “woody”

Does Ludwig’s angina spread?

No, it is not contagious. Bacteria from the mouth or other structures spread to cause this deep tissue infection.

How is the diagnosis of Ludwig’s angina made?

Although the diagnosis is clinical, it is confirmed by:

• Neck CT scan (to evaluate the spread)
• Blood tests (CRP, WBC count)
• Blood or pus cultures (to identify bacteria)

What is the treatment for Ludwig’s angina?

• Timely airway control (may require tracheostomy or intubation)
• Broad-spectrum intravenous antibiotics that target both aerobic and anaerobic bacteria
• Surgical drainage, if there is pus or swelling that obstructs the airway
• Dental extraction of the affected tooth, if necessary

What is included in post-treatment care?

• Regular wound dressing
• Monitoring signs of reinfection
• Taking antibiotics as prescribed
• Maintaining proper oral hygiene
• Management of underlying diseases, such as diabetes
• Dental assessment to prevent recurrence

Who is most susceptible to Ludwig’s angina?

• Individuals with poor oral hygiene
• Immunocompromised individuals with underlying comorbidities
• Individuals who have recently experienced oral trauma or infections

Summary

Although Ludwig’s angina is rare in today’s world, it continues to pose a high risk of long-term complications. A wide range of complications pertaining to the respiratory system, orofacial anatomy, neurological processes, and mental health can impact survivors. Self-esteem, daily activities, and overall quality of life can all be significantly affected by these challenges. A patient-centred, multidisciplinary follow-up plan, adequate rehabilitation, and prompt recognition are essential for enhancing outcomes and allowing survivors to resume a normal and fulfilling life. To ensure that survival from Ludwig’s angina is more than just the absence of death, but rather a return to health and well-being, there should be more emphasis on holistic care and regular follow-up.