Introduction

Ludwig’s angina is a bacterial infection characterized by soft tissue cellulitis affecting the neck and floor of the mouth. The term Ludwig’s angina was introduced by the German physician Friedrich von Ludwig in 1836. The advancement of this condition is rapid. The involvement of spaces such as the submandibular, sublingual and submental compartments can be evident in Ludwig’s angina. The primary cause of this condition is the infection originating from the lower molar teeth. Any injury in the tissues in the lower part of the oral cavity may eventually lead to an infection and can cause Ludwig’s angina. Other factors which can predispose to Ludwig’s angina are dental decay, diabetes, old age and immunosuppressed condition. Ludwig’s angina can cause airway obstruction, which leads to breathlessness, pneumonia, etc. Gender prevalence is not evident in Ludwig’s angina. Airway obstruction leads to death in Ludwig’s angina. 

Pathophysiology

Ludwig’s angina usually originates at the floor of the mouth and spreads to the other compartments. The roots of the lower molars are inferiorly attached, and thus the tooth infection can easily spread to the submandibular space.¹ The infection spreads to the neck through the spaces between the fascial layers and rather than through lymphatic drainage.² The profession of the infection to the neck is seen as a “Bull neck”.² Both aerobic and anaerobic bacteria are involved in Ludwig’s angina. More than 50% of diabetes people with Ludwig’s angina present with Klebsiella pneumoniae.² Individuals with diabetes, haemodialysis and recent hospitalization are at a risk of methicillin-resistant Staphylococcus aureus (MRSA) infection.¹

Causes of Ludwig’s angina

The primary cause of Ludwig’s angina is the decay of lower molars. The dental decay affecting the second and third molar teeth can cause Ludwig’s angina.³ Periapical abscess of the second and third molar teeth can lead to Ludwig’s angina. Other causes include laceration of the oral mucosa, osteomyelitis, fracture of the mandible, peritonsillar abscess, thyroglossal cyst, submandibular sialadenitis and otitis media. Poor oral hygiene and dental caries are the main predisposing factors that leads to Ludwig’s angina.¹

Symptoms of Ludwig’s angina

• Swelling in the mouth and neck
• Fever and chills
• Malaise
• Pain
• Tongue displacement
• Trismus
• Difficulty in swallowing
• Airway obstruction
• Difficulty in breathing

Diagnosis of Ludwig’s angina

The primary parameter to diagnose Ludwig’s angina is the clinical features. In patients with deep neck infection, tracheostomy using local anaesthesia is done to manage airway obstruction. Securing the airway, followed by a neck CT is advised to assess the infection.⁴ A neck CT, using intravenous contrast will help to avoid the delay in treatment and assess the infection.⁴ The findings in the CT scan include the gas in the soft tissues, edema of the muscles, fat stranding in the submylohyoid space and thickening of the soft tissues.¹ Ultrasound scan aids in detecting Ludwig’s angina and assessing the airways. The spread of the infection into the bloodstream can be detected by blood cultures. In elderly people, diagnosis should be promptly done to avoid delay in treatment. 

Management of Ludwig’s angina 

Ludwig’s angina can be managed by medical intervention and by surgical intervention. The primary path of treatment is to manage and secure the airway in case of a compromised airway. Infections can be controlled by intravenous antibiotics. Surgical intervention might be needed in the advanced stage of infection. Intravenous steroids and nebulized adrenaline can be used as adjuvants to improve antibiotic penetration and to reduce edema.² In immunocompromised people, treatment should be given to avoid the spread of the infection.

Airway management

Supplemental oxygen should be provided to hypoxic individuals. Patients should be intubated in a seated position and awake using a flexible intubation endoscope.⁵ in advanced stages of infection, as an emergency procedure, cricothyrotomy or tracheostomy is done. Direct view of the larynx is important in nasotracheal intubation in Ludwig’s angina to avoid bleeding, abscess rupture, and laryngospasm.

Intravenous antibiotics

After managing the airway, broad-spectrum antibiotics serve as the treatment regimen of Ludwig’s angina. Antibiotic coverage should include aerobes, anaerobes and oral microflora. Commonly recommended antibiotics are Ampicillin-sulbactam or clindamycin. The antibiotic coverage for immunocompromised people should include gram-negative rods and beta-lactamase-producing aerobes and anaerobes. Immunocompromised people who are at increased risk of MRSA should include vancomycin IV or linezolid IV in addition to antibiotics as MRSA coverage.⁶

Intravenous corticosteroids

Intravenous steroids and nebulized adrenaline help in reducing edema, facilitate intubation and the penetration of antibiotics. Some studies have shown that the use of steroids can decrease the need for airway management.⁷ The most commonly used steroid for managing Ludwig's angina is Dexamethasone.

Surgical intervention

The main aim of surgical intervention is to reopen the oropharyngeal airway by allowing the tongue to move towards the front, lower position.⁸ Surgical decompression is a safe procedure without any complications, and it avoids the requirement of prolonged airway intubation.

Complications

Ludwig’s angina is a rapidly progressing cellulitis that causes airway obstruction. The delay in treatment can cause the infection to spread to other areas and can lead to complications such as mediastinitis and neck cellulitis. It can also cause aspiration pneumonia. In immunocompromised patients, sepsis can lead to multiple organ failure.⁹

Summary

Ludwig’s angina is an infection caused by bacteria that is characterized by the cellulitis of the soft tissue affecting the neck and floor of the mouth. Ludwig's angina progresses rapidly and is caused by the decay of lower molar teeth. Other risk factors include dental decay, injury to oral tissues, old age, immunocompromised condition, diabetes, alcoholism and malnutrition. The bacteria that cause dental decay, which comprises both aerobic and anaerobic types, are involved in Ludwig’s angina.

The clinical symptoms of Ludwig’s angina are characterized by pain, swelling of the neck and mouth, fever, trismus, difficulty in swallowing and difficulty in breathing. The diagnostic measures of Ludwig’s angina are clinical features, imaging results, and blood cultures. 

The management of Ludwig’s angina involves various measures. Managing and securing the airway should be done in cases of airway obstruction. Antibiotic administration, corticosteroids and surgical intervention are the treatment modalities of Ludwig’s angina. Elderly people and immunocompromised individuals require immediate attention and detailed monitoring to prevent death from asphyxiation.