Ludwig's angina is life-threatening cellulitis of the soft tissue involving the floor of the mouth and neck. It involves three compartments of the floor of the mouth, the sublingual, submental, and submandibular. The infection is rapidly progressive, leading to potential airway obstruction. The most common etiology is a dental infection in the lower molars, mainly second and third, accounting for over 90% of cases. Any recent infection or injury to the area may predispose the patient to develop Ludwig's angina. Predisposing factors include diabetes, oral malignancy, dental caries, alcoholism, malnutrition, and immunocompromised status. This review addresses the management and acute treatment of this possibly lethal condition.
Objectives:Summarize the recommended treatment of Ludwig's angina.Outline the typical presentation of a patient with Ludwig's angina.Review the pathophysiology of Ludwig's angina.Explain the interprofessional team strategies for improving care coordination and communication regarding the management of patients with Ludwig's angina.Access free multiple choice questions on this topic.
In most cases, Ludwig's angina develops in previously healthy patients; however, some predisposing factors have been suggested, including diabetes mellitus, oral malignancy, alcoholism, malnutrition, and immunocompromised status.
There is no significant gender predilection for Ludwig's angina. Approximately 1/3 of cases are associated with other systemic illnesses (i.e., HIV and diabetes mellitus), and poor dentition and dental hygiene are independent risk factors. Before the development of antibiotics, mortality exceeded 50%. With rapid airway management and antibiotic therapy, along with advanced imaging and surgical procedures, mortality has decreased to around 8%.
Ludwig's angina usually originates as a dental infection of the second or third mandibular molars, including partially erupted third molars. The infection begins in the subgingival pocket and spreads to the musculature of the floor of the mouth. It progresses below the mylohyoid line, indicating that it has moved to the sublingual space. As the roots of the second and third mandibular molars lie below this line, infection of these teeth will predispose to Ludwig's angina. The infection spreads lingually rather than buccally because the lingual aspect of the tooth socket is thinner. It initially spreads to the sublingual space and progresses to the submandibular space.
The disease is usually polymicrobial, involving oral flora, both aerobes, and anaerobes. The most common organisms are Staphylococcus, Streptococcus, Peptostreptococcus, Fusobacterium, Bacteroides, and Actinomyces. Immunocompromised patients are at higher risk of Ludwig's angina.
The most critical aspect of evaluation is the airway. If Ludwig's angina is diagnosed, the patient should be intubated immediately. Imaging has no role in the immediate assessment of the patient - the decision to intubate is made solely on clinical parameters, as sending a patient with an impending airway to the CT scanner will delay treatment and may be lethal.
The treatment of Ludwig's angina is aimed principally at protecting the airways - the most common cause of death is asphyxiation from airway obstruction - controlling the infection with antibiotic therapy, and in some cases of well-established infections surgical draining.
Although Ludwig's angina is a clinical diagnosis, it may be hard to differentiate from other diseases initially. Imaging may be helpful in this situation to rule out other causes of the patient's symptoms. Still, the clinician must only order an imaging test once the airway is secured or in the case of patients who can breathe comfortably and handle their secretions while supine.
Due to the life-threatening complication of airway obstruction from Ludwig's angina, mortality exceeded 50% before the development of antibiotics. Thanks to antibiotic therapy, improved imaging modalities, and surgical techniques, mortality decreased to approximately 8%.
As mentioned, Ludwig's angina is rapidly progressive cellulitis which can cause airway obstruction requiring immediate intervention. Any airway symptoms or the inability to handle oral secretions are indications for elective intubation to prevent mortality. In addition, close monitoring is needed to avoid the extension of the cellulitis to the adjacent areas, which may cause mediastinitis or cellulitis of the neck. It may also evolve to aspiration pneumonia.
Ludwig's angina is a rapidly progressive cellulitis that can quickly cause airway obstruction. It requires immediate intervention and close monitoring to prevent death from asphyxiation. It can also result in mediastinitis, necrotizing cellulitis of the neck, and aspiration pneumonia. The safest way to deal with these patients is a coordinated interprofessional approach involving the provider, nurse, and, if needed, a consultant such as an otolaryngologist or anesthesiologist. This will provide the best outcome and highest patient safety. [Level V]
Ludwig's angina (lat.: Angina ludovici) is a type of severe cellulitis involving the floor of the mouth and is often caused by bacterial sources. Early in the infection, floor of the mouth raises due to swelling, leading to difficulty swallowing saliva. As a result, patients may present with difficulty speaking and drooling. As the condition worsens, the airway may be compromised and hardening of the spaces on both sides of the tongue may develop. Overall, this condition has a rapid onset over a few hours.
With the advent of antibiotics in 1940s, improved oral and dental hygiene, and more aggressive surgical approaches for treatment, the risk of death due to Ludwig's angina has significantly reduced. It is named after a German physician, Wilhelm Frederick von Ludwig, who first described this condition in 1836.
Ludwig's angina is a form of severe, widespread cellulitis of the floor of the mouth, usually with bilateral involvement. Infection is usually primarily within the submandibular space, and the sublingual and submental spaces can also be involved. It presents with an acute onset and spreads very rapidly, therefor early diagnosis and immediate treatment planning is vital and lifesaving. The external signs may include bilateral lower facial swelling around the jaw and upper neck. Signs inside the mouth may include elevation of the floor of mouth due to sublingual space involvement and posterior displacement of the tongue, creating the potential for a compromised airway. Additional symptoms may include painful neck swelling, drooling, tooth pain, dysphagia, shortness of breath, fever, and general malaise. Stridor, trismus, and cyanosis may also be seen when an impending airway crisis is nearing.
The most prevalent cause of Ludwig's angina is dental related, accounting for approximately 75% to 90% of cases. Infections of the lower second and third molars are usually implicated due to their roots extending below the mylohyoid muscle. Periapical abscesses of these teeth also result in lingual cortical penetration, leading to submandibular infection.
Other causes such as oral ulcerations, infections secondary to oral malignancy, mandible fractures, sialolithiasis-related submandibular gland infections, and penetrating injuries of the mouth floor have also been documented as potential causes of Ludwig's angina. Patients with systemic illness, such as diabetes mellitus, malnutrition, compromised immune system, and organ transplantation are also commonly predisposed to Ludwig's angina. A review reporting the incidence of illnesses associated with Ludwig angina found that 18% of cases involved diabetes mellitus, 9% involved acquired immune deficiency syndrome, and another 5% were human immunodeficiency virus (HIV) positive.
There are a few methods that can be used for determining the microbiology of Ludwig's angina. Traditionally, a culture sample is collected although it has some limitations, primarily being the time-consuming and sometimes unreliable results if the culture is not processed correctly. Ludwig's angina is most often found to be polymicrobial and anaerobic. Some of the commonly found microbes are Viridans Streptococci, Staphylococci, Peptostreptococci, Prevotella, Porphyromonas and Fusobacterium.
Ludwig's angina (LA) is an odontogenic infection, a pathological condition that represents an emergency in Oral and Maxillofacial Surgery as it threatens the life of the patient, as it progressively obstructs the airway, due to the advance of the infection in the submandi-bular, sublingual and submental spaces. An updated review of the literature is presented here, including the management, treatment, origin, its transmission routes, the possible complications, as well as a report of two cases seen in the West General Hospital "Dr. José Gregorio Hernández" (HGO) in Los Magallanes de Catia (Caracas, Venezuela). The diagnosis of LA, clinical handling, and the relevance of the role played by the oral and maxillofacial surgeon in the diagnosis, in order to save the life of the patient, is also discussed.
Se desconocía la causa bacteriana de la enfermedad, por lo tanto, Ludwig nunca la relacionó con una infección y menos odontogénica. Dos años después de describir la enfermedad Ludwig muere, aparentemente por una enfermedad inflamatoria en el cuello1'2'4,5. En el año 2000 Thomas Flynn define la angina de Ludwig (AL) como una celulitis que involucra los espacios sublingual y submandibular bilateralmente, así como también el espacio submental. Esta infección tiene el potencial de obstruir las vías aéreas a nivel cervical poniendo en peligro la vida del paciente. Debido a esto, tratarla lo más pronto posible es asegurar su supervivencia4,6,7.
Se indica tomografía computarizada en la que se evidencia una imagen isodensa en el espacio parafaríngeo compatible con un aumento del volumen, mostrando una disminución de la luz de las vías aéreas de la región cervical (fig. 2) y corroborando el diagnóstico de angina de Ludwig. 2b1af7f3a8