Did you know that a tooth infection in the lower molars can result in Ludwig’s angina?. This is a serious condition that threatens life. In cases where it affects children, the action to diagnose and manage should be swift, as it spreads rapidly.  In this article, you can find the symptoms of this condition and the challenges faced when it affects children. The article also explains the diagnosis and treatment plan.

What is ludwig’s angina?

Ludwig's angina is a serious bacterial infection of the soft tissue that affects the floor of the mouth and neck. It spreads through three main areas: the sublingual space (under the tongue), the submental space (under the chin), and the submandibular space (under the jaw).

The main defining feature that sets Ludwig’s angina apart from other conditions is the fact that it often begins with a tooth problem. In turn,  the most common cause of Ludwig's angina is an infection that starts in the lower molar teeth. 

The infection progresses rapidly to the adjacent tissues, leading to life-threatening complications like difficulty breathing due to airway obstruction, aspiration pneumonia, and sheath abscess or rupture of the carotid sheath.

When Ludwig’s angina happens in children, it’s harder to treat because they have a higher risk of their airway getting blocked. This is mainly because a child’s larynx (voice box) sits higher in the neck compared to adults, which makes it easier for swelling to block their breathing. Therefore, poses a difficulty in treating them.² Altogether, it's crucial that the diagnosis is made early and treatment is given immediately, which includes protecting the airway, prescribing the antibiotics, and surgical drainage of established infections. 

Causes of ludwig’s angina

Ludwig's angina mainly starts from tooth infections. In about 90% of cases, Ludwig’s angina is caused by infections in the second or third molars—the back teeth in the lower jaw.

The main reason for this condition is periapical abscesses of lower molars. Periapical infections happen because of untreated dental decay of the tooth, fracture, or failed dental root canal treatment.³

The other reasons are laceration or oral piercing, fracture of the mandible, trauma while inserting a breathing tube into the airway of a patient who has undergone traumatic injury, which mainly occurs during emergency care. Infections of the bone, abscesses in the peritonsillar and parapharyngeal region.

Additionally, it is also seen in inflammation of the submandibular salivary glands, infection occurring in the middle ears, and thyroglossal duct cysts.

Risk factors associated with ludwig’s angina

The common risk factors that lead to Ludwig's angina include poor oral hygiene, tooth decay, and a history of recent dental treatment, such as deep fillings, which are closer to the pulp where tooth nerves reside. Additionally, people who have diabetes, malnutrition, drink a high amount of alcohol, have immunosuppressing disorders like AIDS, and people who have received an organ transplant are also included as risk factors.

Risk factors in children

Children with Ludwig’s angina are at higher risk for airway obstruction since the position of the larynx is higher in comparison with adults.

Signs and symptoms 

• Decay and pain in the lower tooth or teeth, fever,  
• Painful swelling in the neck
• Elevation of the tongue
• Mouth opening
• Tenderness in the jaw
• Ain during swallowing
• Rolling of saliva from the mouth
• Normal rapid breathing
• Shortness of breath²

Presentation and challenges in children

Ludwig's angina is a bacterial infection. It involves three spaces of the jaw. It's submandibular(under the jaw), submental(under the chin), and sublingual space(under the tongue). The infection is known to spread rapidly. It is a serious condition in adults and is mainly due to complications of oral infections. Although Ludwig's angina is rare in children,  it is a serious and potentially life-threatening condition in children. This is due to an increase in airway obstruction caused by the higher anatomical position of the larynx (voice box) in children.

Application of local anaesthesia and preserving the airway is also a challenging task. Additionally, selecting the endotracheal tube and deciding on the anaesthesia has been a difficult part.² The position of the larynx in children is higher in the neck. Therefore, they are at higher risk for airway obstruction.  

Diagnosis of ludwig’s angina

Ludwig’s angina is diagnosed mainly through clinical evaluation. We cannot rely on imaging studies for direct diagnosis. When the airway is compromised in patients with Ludwig's angina, intubation has to be done immediately. Sending the patient to a CT scan may delay the treatment, which could be dangerous, as establishing the airway is the most important in this condition. After the airway is secured, CT with intravenous contrast would be the best option to evaluate the severity and assess the infection.

Observations in a CT scan might include gas in soft tissues, accumulation of fluid, oedema of muscles, and increased fat in subcutaneous tissue. We can also observe thickening of soft tissue and loss of fat planes in the submylohyoid space. Ultrasound and point-of-care ultrasound are helpful tools in the emergency department for patients who cannot lie on their backs.⁷

It would not be possible to diagnose early through laboratory tests. Blood cultures are done to determine the spread of infection. Taking a sample with a swab or needle usually doesn’t help much in diagnosing Ludwig’s angina.

Treatment

1. Airway stability and observation are the foremost things to assess and maintain in patients with Ludwig’s angina.
2.  In a retrospective study done with children affected with Ludwig's angina, 10% of children needed control of the airway, and 52 % of children aged above 15 years underwent tracheostomy⁸
3. Antibiotics should be administered immediately to control both aerobic and anaerobic infections. 
4. Intravenous steroids reduce oedema and cellulitis, maintain the airway and improve antibiotic penetration to the affected area, and hasten the recovery
5. Surgical decompression is the treatment of choice for patients who are not responsive to medical therapy. Surgical services are indicated depending on the involvement of the space due to dental infection⁸
6. Necessary nutrition and hydration are recommended to be provided to Ludwig’s angina patients

FAQ’s

What is the main reason for mortality in ludwig's angina?

Failure to establish an airway and compromising it is the leading cause of mortality.

What are the procedures that have reduced the mortality rate in ludwig's angina from 50% to 8%?

Managing and securing the airway rapidly, administering antibiotic therapy to prevent infections, utilising advanced imaging, and employing surgical procedures have been key factors in reducing the mortality rate.

What are the microbial organisms involved in ludwig's angina?

There are many microorganisms involved in Ludwig’s angina. It involves oral flora and includes both aerobic and anaerobic microorganisms, like Streptococcus, Actinomyces.

How is ludwig’s angina diagnosed?

Ludwig’s angina is mainly diagnosed by clinical evaluation. Intubation and securing the compromised airway 

How is point-of-care ultrasound (POCUS) helpful in Ludwig’s angina?

POCUS is a helpful tool used in the emergency department to confirm deep tissue infections and assess their extent. It is used mainly in patients who cannot tolerate lying flat on their backs.

How can we prevent ludwig's angina?

Proper dental care, awareness in recognising the signs and symptoms, and getting early treatment for mouth and throat infections are a few measures to prevent Ludwig's angina.

Conclusion

 All in all, Ludwig's angina in children is a rare but dangerous condition. When we diagnose early, it can save lives. Diagnosis is usually done by clinical evaluation. Establishing the airway is the foremost important in preventing death. We can prevent Ludwig’s angina by taking proper dental care. Routine dental checkups and getting treated for teeth which have caries are very important measures for prevention at all ages.