Ludwig's angina

Ludwig's angina, otherwise known as angina ludovici, is a serious, potentially life-threatening cellulitis infection of the tissues of the floor of the mouth, usually occurring in adults with concomitant dental infections. It is named after the German physician, Wilhelm Frederick von Ludwig who first described this condition in 1836. Other names include "angina Maligna" and "Morbus Strangularis."

Ludwig's angina should not be confused with angina pectoris, which is also otherwise commonly known as "angina". The word "angina" comes from the Greek word ankhon, meaning "strangling", so in this case, Ludwig's angina refers to the feeling of strangling, not the feeling of chest pain, though there may be chest pain in Ludwig's angina if the infection spreads into the retrosternal space.


The cause is usually a bacterial infection, most often Actinomyces israelii and other actinomyces spp, although other bacteria can also cause this (occurring mainly in the submandibular space which is followed by infection entering into the submaxillary space and further). Since the advent of antibiotics, Ludwig's angina has become a rare disease.

The route of infection in most cases is from infected lower third molars or from pericoronitis, which is an infection of the gums surrounding the partially erupted lower third molars. Although the wide-spread involvement seen in Ludwig's is usually seen to develop in persons with a state of lowered immunity, it can develop in otherwise healthy individuals also. Thus, it is very important to obtain dental consultation for lower third molars at the first sign of any pain, bleeding from the gums, sensitivity to heat/cold or swelling at the angle of the jaw. Post-procedural infection of tongue frenulum (mouth floor) piercing can lead to the life-threatening Ludwig's angina.


The symptoms include swelling, pain and raising of the tongue, swelling of the neck and the tissues of the submandibular and sublingual spaces, malaise, fever, dysphagia (difficulty swallowing) and, in severe cases, stridor or difficulty breathing. Swelling of the submandibular and/or sublingual spaces are distinctive in that they are hard and classically 'boardlike'. Important signs include the patient not being able to swallow his/her own saliva and the presence of audible stridor as these strongly suggest that airway compromise is imminent.


Treatment involves appropriate antibiotic medications, monitoring and protection of the airway in severe cases, and, where appropriate, urgent maxillo-facial surgery and/or dental consultation to incise and drain the collections. A nasotracheal tube is sometimes warranted for ventilation if the tissues of the mouth make insertion of an oral airway difficult or impossible. In cases where the patency of the airway is compromised, skilled airway management is mandatory. This entails management of the airway according to the American Society of Anesthesiologists' "Difficult Airway Algorithm" and necessitates fiberoptic intubation.


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