What Is Ludwig’s Angina?

Do you know that a dental abscess can be very dangerous and cause life-threatening consequences? There is a condition for that in medical literature and it is called Ludwig’s angina.

Ludwig’s angina or Ludwig angina is an infection in your neck and your mouth floor and it is caused by bacteria. Despite being not contagious, this infection is an emergency and has the potential to be fatal.

You can increase your knowledge about this potentially deadly condition by reading our article, where you can find information about important aspects of Ludwig’s angina.

Overview

Ludwig’s angina was first described in 1836 by a German physician, Wilhelm Friedrich von Ludwig. He made a description of rapidly expanding, potentially fatal gangrenous cellulitis and swelling of the soft tissues of the neck and mouth floor.¹ Previously known as “angina maligna” and “morbus strangularis”, Ludwig’s Angina is a bacterial infection in the spaces called submandibular (under the jaw), sublingual (under the tongue), and submental (under the chin) spaces underneath the mouth and down to neck.²

Bacteria consist of a mixture of different types, commonly involving the microorganisms that normally present in the oral cavity.³ 

The word angina comes from the Latin word “angere” which means to strangle.⁴ Due to the location of the infection, progressive swelling may cause displacement of the tongue resulting in disruption of airflow and thus giving the patient the feeling of strangling. That is the most feared and fatal complication of Ludwig’s angina.¹

Causes of Ludwig’s angina

Most of the cases of Ludwig’s angina result from odontogenic infections, which originate in a tooth or the tissues surrounding it. Second and third molars (wisdom teeth) are the most affected teeth. The roots of these teeth are in close proximity to the spaces underneath the mouth. Therefore, a tooth infection or a tooth abscess spreads rapidly to the spaces under the mouth and in the neck.¹

Other reasons which might result in Ludwig’s angina include peritonsillar or parapharyngeal abscesses (throat abscesses or deep neck infections), mandibular fracture (jaw bone fracture), oral cavity cancer, tongue piercing, oral cavity injury, submandibular sialadenitis (inflammation of the submandibular salivary glands), sialolithiasis (salivary gland stones), otitis media (middle ear infection), and osteomyelitis (bone infection).^1,5

Signs and symptoms of Ludwig’s angina

Signs and symptoms of Ludwig’s angina vary depending on the patient and the severity of the infection.⁶

Patients with Ludwig’s angina may present with the following symptoms:⁶

• Neck swelling
• Hardening and swelling of the mouth floor
• Pain on tongue movement
• Feeling unwell
• Weakness and fatigue
• Fever
• Difficulty swallowing
• Drooling of saliva
• Difficulty breathing
• Noisy breathing called stridor
• Shortness of breath
• Ear pain
• Impairment of voice
• Difficulty speaking
• Confusion or mental changes

Audible stridor, impairment of voice, severe dehydration along with lumps and bumps around the neck indicate a progressive disease and airway compromise.⁶ 

Diagnosis

Ludwig’s angina is diagnosed based on the clinical presentation. That means, your doctor can make a diagnosis of Ludwig’s angina following a detailed history taking and a physical examination. A computed tomography (CT) or magnetic resonance imaging (MRI) scans might also be required to detect the extent and location of infection.⁶ 

In case of serious symptoms such as difficulty breathing or respiratory distress, an X-ray may be helpful to identify the severity of soft tissue swelling and airway obstruction. 

A sample of fluid from the affected tissues might also be taken through aspiration to identify bacteria and the sensitivity to the antimicrobial agents in the lab.⁷ 

Management and treatment for Ludwig’s angina

The management of Ludwig’s angina depends on the individual's health condition, the severity of the disease, experience of the healthcare team, and resources available. In the early stages, close monitoring and treatment with antibiotics through veins may be sufficient for the management; however, advanced cases may require surgical management to secure the airway.¹

The most crucial component of the management for Ludwig’s angina is to monitor and protect the airway. In case of airway compromise, endotracheal intubation or a surgical airway with tracheostomy may be required to keep the airway open.⁶ In endotracheal intubation, a breathing tube is inserted into the windpipe (trachea) through the mouth or nose; whereas, in tracheostomy, a tube is inserted into the windpipe through an opening created surgically at the front of the neck. 

An immediate ear, nose, and throat (ENT) specialist consultation should be arranged for a possible surgical drainage of the infection.⁶ Early surgical management improves the outcome in Ludwig’s angina.⁸ 

Another important aspect of the management is antimicrobial treatment with broad-spectrum antibiotics. Antibiotics should be administered before receiving the lab results. 

According to the number of case reports in the literature, steroid use through veins has a potential to decrease the need for airway intervention. However, this remains controversial, as there is no sufficient clinical evidence yet.¹

Risk factors

Despite the fact that most of the cases of Ludwig’s angina have no significant additional condition, individuals with certain conditions have an increased risk of developing it. These conditions include systemic illnesses such as diabetes mellitus, poor nutrition, alcoholism, compromised immune system such as acquired immunodeficiency syndrome (AIDS) and organ transplantation.^{1, 6} 

Poor dental hygiene and smoking are other risk factors shown to increase the risk of having Ludwig's angina. Furthermore, self-medication with NSAIDs are reported to play a role as a determining factor in oral cavity and throat infections. Another hypothesis suggests that masking of clinical signs due to NSAID use results in a delay in consultation and treatment.⁸

Complications

The most dangerous complication of Ludwig’s angina and deep neck infections is the obstruction of the airway as a result of swelling and distortion. Inability to swallow saliva and noisy breathing may be the signs of airway compromise. Ludwig’s angina is always identified with airway compromise as it is the leading cause of death in this condition. Therefore, an immediate intervention to open the airway is life-saving in Ludwig’s angina.¹

Several other serious and potentially life-threatening complications that are associated with Ludwig’s angina include the following:²

• Upper respiratory airway infection: Infections of the body parts that play role in breathing
• Acute respiratory distress syndrome: A life-threatening condition in which the lungs are unable to function properly 
• Descending mediastinitis: Inflammation of the chest cavity caused by spread of infections from mouth and throat
• Necrotising fasciitis: A rare life-threatening infection that develops quickly
• Pleural empyema: Collection of pus between the layers of the lung
• Pericarditis: Inflammation in the lining around the heart
• Epidural abscess: A collection of pus inside the space between the bones and the lining membrane of your brain or spine
• Jugular vein thrombosis: Presence of a blood clot inside major neck vein called jugular vein
• Carotid artery rupture: A tear or break in carotid artery
• Septic emboli: Infected blood clots detached from infection sites 
• Sepsis: Life-threatening reaction of the body to an infection
• Disseminated intravascular coagulopathy: A clotting disorder that can also cause bleeding

FAQs

How can I prevent Ludwig’s angina?

Maintenance of good oral and dental hygiene plays a substantial role in preventing Ludwig’s angina. Therefore, it is very important to attend regular dental check-ups at your dentist. 

In case of oral problems such as mouth sores or toothaches, seek help from a healthcare professional without a delay for the treatment of any infection.⁹

Identifying underlying risk factors and addressing them along with adopting a healthy lifestyle are other steps you can take to prevent Ludwig’s angina.

How common is Ludwig’s angina?

Improvements in oral hygiene and increased availability of antibiotics has decreased the incidence and mortality of Ludwig’s angina significantly.¹⁰ Before the advancements in antibiotic therapy, the number of deaths due to Ludwig’s angina was over 50%. However, this rate has dropped to approximately 8% as a result of antibiotics along with developed imaging and surgical techniques.¹

Most of the cases of Ludwig’s angina are diagnosed in young adults with dental infections. However, it can develop at any age. Approximately a quarter to a third of Ludwig’s angina cases occur in children.

Although it is a rare emergency nowadays, it remains a dangerous condition that needs immediate management.¹⁰

What can I expect if I have Ludwig’s angina?

Ludwig’s angina typically starts as an infection in your teeth and it spreads rapidly to the floor of your mouth and the neck. Initial symptoms might be infection symptoms such as swelling, pain, fever, and malaise. As the condition rapidly progresses, you might experience symptoms related to airway compromise, which include difficulty breathing and swallowing, difficulty speaking, and drooling.

When should I see a doctor?

As the leading cause of Ludwig’s angina is dental infections, it is very important to get help from a healthcare provider in case of a sign of dental infection.

If you think you have a risk factor associated with Ludwig’s angina, contacting a healthcare professional might decrease your risk of having Ludwig’s angina in the future. 

Ludwig’s angina requires prompt treatment to prevent life-threatening complications. It is crucial and life-saving to seek immediate medical attention if you have any suspicion that you might have Ludwig’s angina. 

In case of difficulty breathing, swallowing or drooling, call an ambulance right away.

Summary

Ludwig’s angina is a potentially life-threatening bacterial infection in the mouth floor and neck. The most common cause of Ludwig’s angina is dental infections. The infection spreads rapidly causing symptoms such as swelling, pain, difficulty swallowing and breathing. The most feared complication is airway compromise, which needs immediate medical attention. Diagnosis is done clinically and treatment involves antibiotic therapy, airway protection along with the removal of the infection surgically. 

Poor dental hygiene is a risk factor for Ludwig’s angina. Therefore, having good oral and dental hygiene is an effective method of prevention for Ludwig’s angina.

Although Ludwig’s angina is not a common infection nowadays, it can lead to serious complications and even death. For that reason, it is crucial to seek medical help immediately if you suspect you or someone else may have Ludwig’s angina.