Introduction

Ludwig’s angina is a polymicrobial bacterial infection of the tongue and the floor of the mouth. It is a potentially fatal condition that causes swelling in the floor of the mouth, under the jaw and in the neck. This leads to a rapid airway obstruction and is hence characterised as a life-threatening condition.¹

Ludwig’s angina is caused by various strains of aerobic and anaerobic bacteria, including those of the genus Streptococcus, Staphylococcus, Peptostreptococcus, Bacteroides, and Actinomyces. In diabetic patients, Ludwig’s angina is primarily caused by a strain of bacteria known as Klebsiella pneumoniae.³

Ludwig’s angina was named after a German physician Karl Friedrich Wilhelm von Ludwig in 1836, who first described the fatal and rapidly progressive infection in his patients. Obstruction of airway due to swelling in the neck and elevation of tongue and trismus developed at a later stage is the leading cause of death in these patients.²

Signs and Symptoms of Ludwig’s Angina

Ludwig’s angina is characterised by a distinct set of symptoms, including:

• Severe toothache, due to infection of the lower second or third molar as well as the wisdom teeth
• Firm swelling of the submental, sublingual and submandibular regions under the jaw
• Bull’s neck(classical sign)

Treatment and Management of Ludwig’s Angina 

Ludwig’s angina is a serious condition that requires immediate attention from a multidisciplinary team of medical specialists. This may include an Ear, Nose, and Throat (ENT) specialist, an anaesthesiologist, and an oral surgeon. Four crucial interventions are required for proper treatment and management of Ludwig’s angina, including:

• Airway management
• Intravenous antibiotics
• Intravenous corticosteroids
• Surgical drainage

In patients with Ludwig’s angina, surgery is typically required if an abscess (e.g., a buildup of pus) or soft swelling is present, or if antibiotics fail.

Why is Ludwig’s Angina dangerous to a diabetic patient?

In most cases, Ludwig’s angina usually starts from a dental infection. Other causes include infections in the throat or tonsils, foreign objects, or secondary infections from cancers at the base of the tongue or the floor of the mouth.

In people with poorly controlled diabetes, infections are more common and severe due to weakened immunity caused by long-term high blood sugar levels.⁴ Ludwig’s angina is a fast-spreading, fatal infection that causes tissue death in the soft tissues of the neck and the floor of the mouth, which aggravates in immunocompromised patients.⁵

FAQs

What are the “red flag” symptoms that you should be aware of in Ludwig’s angina cases?³

Ludwig’s angina is marked by a unique set of “red flag” symptoms, including:

• Restrictions in opening the mouth
• Bilateral submandibular swelling(under the jaw)
• A muffled, thick, and indistinct quality of speech, also known as a “hot potato” voice
• Fever
• Firm or swollen floor of the mouth
• Restricted tongue mobility
• Difficulty swallowing
• Drooling
• Bad breath, also known as halitosis

Is Ludwig’s angina preventable?

Yes, Ludwig’s angina can be prevented as follows:

• Maintenance of good oral hygiene
• Visit your dentist for regular check-ups and get dental caries treated on priority basis 
• Special attention to be paid to your health condition if you are an immunocompromised patient
• If you are having uncontrolled diabetes, defer dental treatment until your blood sugar is controlled
• Be under care and regular checkups for your blood sugar management by your attending physician.
• Staying hydrated and maintaining a balanced, healthy diet

What are the risk factors for developing Ludwig’s angina?⁶

There are various risk factors associated with the onset of Ludwig’s angina, including:

• A compromised immune system
• Alcohol use disorder
• Cavities
• Diabetes
• Malnutrition
• Oral cancer
• Poor oral hygiene

What are the complications of Ludwig’s angina?⁶

Ludwig’s angina may cause various complications, including:

• Asphyxiation, also known as a lack of oxygen
• Aspiration pneumonia, a type of lung infection attributed to the inhalation of foreign materials
• Blocked airway
• Mediastinitis, an infection of the area in the chest between the lungs (i.e. the mediastinum)
• Blood clot in the neck vein
• Empyema, a condition that causes pus in the chest
• Necrotizing fasciitis, a rare but acute complication of Ludwig’s angina characterized by tissue death
• Osteomyelitis, a severe infection of the bone
• Sepsis, a life-threatening reaction to infection
• Septic shock (the last stage of sepsis, marked by dangerously low blood pressure)

How are LA cases diagnosed?

Diagnosis of Ludwig’s angina is executed via a physical examination by your healthcare provider. Doctors look out for the characteristic symptoms of the disease, including a swelling under the jaw, an enlarged tongue, or the presence of trismus. In addition, your healthcare provider may run additional tests to confirm the presence of pus and the extent of the infection.⁶ The main methods of diagnosis include:

• Bacteria culture test
• Computer tomography (CT) scan
• Ultrasound

What is the prognosis of LA cases?

Today, most people recover from Ludwig’s angina if there is prompt intervention by medical specialists and emergency doctors. Availability of antibiotics and corticosteroids have also aided in the better prognosis of Ludwig’s angina. However, early diagnosis and prompt treatment are crucial for recovery. The earlier the treatment begins, the better are the chances of recovery. Although rare, fatalities can still occur—approximately 8% of affected individuals die due to airway swelling and oxygen deprivation.⁶

Summary

Ludwig’s angina is a polymicrobial bacterial infection of the mouth and the neck. It is mainly caused by a combination of aerobic and anaerobic bacteria of the genus Streptococcus, Staphylococcus, Peptostreptococcus, Bacteroides, and Actinomyces. Odontogenic (e.g., dental) origin of infection comprises the majority (73.1%) of cases, while non-odontogenic causes makes up the minority (14.0%) of cases. Ludwig’s angina of unknown origin is present in a high percentage of pediatric cases worldwide.⁷

Patients with additional conditions (e.g., diabetes) require special consideration. Approximately a third of cases are linked to systemic illnesses such as chronic kidney disease, lupus, aplastic anemia, lymphopenia (e.g., low white blood cell count in the blood), a weakened immune system, and diabetes.⁴

Uncontrolled diabetes and delayed treatment of dental infections is a medical emergency and can be fatal in case of  Ludwig’s angina. Early drainage of pus is needed, and a tracheostomy for the airway management may be performed to facilitate breathing if the airway is blocked.⁵