Introduction

Ludwig’s angina is a cellulitis (infection of the skin) that affects the soft tissues in the floor of the mouth and neck. This rare but life-threatening infection affects various areas of the floor of the mouth, specifically the sublingual, submental, and submandibular regions. It can rapidly spread to the tongue and throat.¹

Oftentimes, Ludwig’s angina is caused by a dental infection in the lower molars (tooth abscess), mainly the second and third. Other causes include mouth injury, oral surgery complications, and pericoronitis. Risk factors include poor oral hygiene, diabetes, oral cancer, a compromised immune system, dental caries/cavities, alcohol misuse, and malnutrition. Streptococcus, Staphylococcus and Bacteroides are the types of bacteria that are commonly linked to Ludwig’s angina.¹

Ludwig’s angina is considered a medical emergency as it can lead to serious complications like airway obstruction, asphyxiation, aspiration pneumonia, sepsis, sheath abscess, and carotid arterial rupture. That being said, early recognition and immediate treatment are critical to prevent serious complications. Being pregnant can predispose someone to oral disorders due to the physiological changes that take place in the body. Notably, Ludwig’s angina during pregnancy has been linked to severe illness, mainly septicemia and asphyxia for both the birth parent and the foetus, which leads to mortality.^1,2

Healthcare providers must pay keen attention to any reports of dental pain and issues by pregnant patients. Routine dental care should be emphasised to birth parents, especially those with diagnosed problems, to prevent worsening conditions.³

Initial assessment

History, symptoms and physical exam

Persons affected by Ludwig’s may report the following signs and symptoms:¹

• Recent dental pain
• Fever 
• Weakness/fatigue
• Body chills
• Drooling
• Hoarse voice
• Swelling of the tongue, jaw and mouth floor
• Difficulty breathing and swallowing
• Neck pain, swelling, and/or discolouration
• Slurred speech 
• Trismus

A physical exam may find a prominent swelling of the submental area and a loss of mandibular angle definition due to submandibular swelling, often classified as a “bull neck”. The areas may also be tender to the touch and showcase induration (hardening of the skin) with oedema. Fever, elevation of the tongue and teeth tenderness are possible infection signs.

Treatment and management

Airway management 

The immediate goal in treatment is to secure the airway early to prevent asphyxiation, which is the greatest cause of death. Stridor (noisy breathing) and cyanosis (blue/grey skin or lips) are signs of the late disease stage. Hypoxic patients are supplied with oxygen, but as swelling in the neck can complicate mask ventilation, pre-oxygenating patients in whichever way is crucial. Flexible nasotracheal intubation is the preferred approach to intubation so patients can breathe more easily. A cricothyrotomy or a tracheostomy may be performed under emergency circumstances, especially if intubation is not possible. It's best to avoid using supraglottic airway devices as they can be displaced by swelling or a blind nasotracheal intubation, which can cause bleeding, abscess rupture, aggravate oedema and cause laryngospasm.¹

Imaging

Imaging tests, although not entirely necessary, may be requested to assess a patient’s condition once the airway has been secured. A neck CT with contrast is the gold standard for evaluating the severity/stage of Ludwig’s angina and for identifying abscesses. Additionally, ultrasonography, including point-of-care ultrasound, can be used to confirm Ludwig’s angina and assess the airways.¹

Antibiotic therapy

Once the airway is secured and open, broad-spectrum antibiotics (first-line treatment) are given intravenously, with ampicillin-sulbactam and clindamycin being the most prescribed. Importantly, antibiotics should target aerobic and anaerobic oral microflora. For immunocompromised patients, the coverage should include anaerobes, gram-negative rods, and beta-lactamase-producing aerobes. Here, options are cefepime, meropenem, or piperacillin-tazobactam. Methicillin-resistant Staphylococcus aureus (MRSA) coverage should be considered for those at increased MRSA risk, those previously infected with MRSA and immunocompromised patients. MRSA coverage is accounted for by adding vancomycin IV or linezolid IV to the antibiotic regimen.¹

Corticosteroid therapy

Intravenous corticosteroids (commonly, dexamethasone) and nebulised adrenaline can be used in conjunction with other therapies to reduce swelling, oedema, and cellulitis as well as facilitate intubation and improve the penetration of antibiotics into the fascial spaces. Several studies reported a decrease in the need for airway management with the use of steroids, but their use is not standard and is at a physician’s discretion.¹

Surgical management

Surgery is indicated in some patients, mainly in severe cases, including abscess formation, fluctuance presence, and ineffectiveness of antibiotics. Surgical decompression involves making incisions and draining the infection. This procedure can prevent the need for lengthy airway intubation and reduce hospital stay time. If an infected tooth is the root cause, extraction may be necessary.¹

Obstetric considerations

Delivery timing

Studies show a positive link between periodontal diseases, preterm delivery, and low birth weight. Currently, the majority of reported cases of Ludwig’s angina in pregnancy include birth parents carrying their babies to full term. Induced preterm delivery or a caesarean is indicated in severe cases where the maternal and/or foetal health is at risk.^2,4,6

Analgesia (pain relief) 

Importantly, opioid analgesics and other agents with sedative effects are contraindicated or avoided as they pose a potential risk to foetuses. Therefore, local anaesthesia is recommended.²

Prognosis

The mortality rate of Ludwig’s angina has decreased from around 50% to 8%, thanks to the progress made in diagnosis, antibiotic therapy, and surgical techniques. Early identification and prompt treatment increase the chances of good outcomes.¹

Prevention and follow-up

Dental hygiene

It may not always be possible to prevent Ludwig’s angina, but by practising good oral hygiene regularly and having routine dental checkups and cleanings, the risk can be reduced. During antenatal visits, physicians should educate birth parents on oral health. 

Follow-up

It is crucial to follow up with birth parents affected by Ludwig’s angina after any treatment, surgeries, and/or deliveries. Studies have shown mortality in both birth parents and babies during or after delivery.^2,5

Summary 

Ludwig’s angina is a rare but potentially fatal cellulitis affecting the soft tissues of the mouth and neck, most commonly originating from dental infections in the lower molars. In pregnancy, physiological changes increase susceptibility to oral infections, and Ludwig’s angina poses severe risks to both maternal and foetal health, including airway obstruction, sepsis, and even mortality. Prompt recognition and immediate management are vital. Patients typically present with symptoms such as fever, swelling, difficulty swallowing, and airway compromise. On examination, features like submental swelling, tongue elevation, and trismus are common.

The foremost priority in treatment is airway management, often requiring flexible nasotracheal intubation or, in critical cases, surgical airways like tracheostomy. Imaging, particularly contrast-enhanced CT scans, aids in assessing disease extent and identifying abscesses. Intravenous broad-spectrum antibiotics—such as ampicillin-sulbactam and clindamycin—are first-line treatments, with MRSA coverage added for high-risk individuals. Corticosteroids may be used to reduce oedema and support airway stability, though their use is discretionary. Surgical intervention is necessary when abscesses form or antibiotic therapy fails, and extraction of an infected tooth may also be required.

Pregnant patients require careful monitoring. Although many carry to term, delivery may be expedited in cases where maternal or foetal health is compromised. Opioid analgesics are generally avoided due to foetal risk, making local anaesthetics preferable. Preventive measures, including good oral hygiene and regular dental checkups during pregnancy, are essential. While advances in medical and surgical care have reduced the mortality rate significantly, close follow-up remains crucial to ensure favourable outcomes for both pregnant patient and child.