Ludwig angina is defined as rapidly spreading bilateral cellulitis of the submandibular and sublingual spaces with associated tongue elevation. A characteristic painful, brawny induration is present in the involved tissue. The posterior mandibular molars are the usual odontogenic origin for the infection. Streptococcus, Staphylococcus, and Bacteroides species are the most common pathogens. Affected individuals are typically 20 to 60 years old, with a male predominance. Patients are usually febrile and may demonstrate impressive trismus, dysphonia, and odynophagia. Dysphagia and drooling are secondary to tongue displacement and oropharyngeal swelling. Potential airway compromise or spread of infection to the deep cervical layers and the mediastinum is possible.
Management and Disposition
Acute laryngospasm with airway compromise is a potentially life-threatening complication; thorough plans for definitive airway management should be prepared since up to one-third of patients require definitive airway placement. Broad-spectrum aerobic and anaerobic parenteral antibiotic therapy should be initiated. Analgesia should be given as needed. CT or magnetic resonance imaging (MRI) can identify abscess location, but great care should be taken to ensure the patient can protect the airway while tolerating the imaging process. Emergent otolaryngologic or oral surgical consultation is warranted for definitive intraoperative incision and drainage of the abscess. Admission to the intensive care unit is indicated for airway surveillance and management.
Ludwig Angina. Note the diffuse submandibular swelling and fullness. Direct palpation of this area would reveal a characteristic brawny induration. Potential airway compromise is a key concern in all patients with Ludwig angina. (Photo contributor: Jeffrey Finkelstein, MD.)
Brawny submandibular induration and tongue elevation are common and characteristic clinical findings.
The 2nd mandibular molar is the most common site of origin for Ludwig angina.
Acute laryngospasm with sudden total airway obstruction may be precipitated by attempts at oral or nasotracheal intubation.
Ludwig Angina. Sagittal view on CT scan demonstrates fluid collection and abscess formation within the floor of the mouth along with superior displacement of the tongue in this patient with Ludwig angina. (Photo contributor: Jake Block, MD.)