Ludwig's Angina

What Ludwig's angina is

Below the tongue and jaw are connected tissue spaces: the sublingual space above a sheet of muscle called the mylohyoid, and the submandibular space below it. The roots of the lower second and third molars extend below the mylohyoid line, so infection from these teeth drains directly into the submandibular space.

In Ludwig's angina, infection spreads through these spaces on both sides. It typically forms a hard, "woody" swelling rather than a single pocket of pus. Because the floor of the mouth is boxed in by the jaw bone, the swelling can only expand upward, lifting the tongue toward the roof of the mouth, and backward, toward the airway. "Angina" here comes from the Latin for choking, not from heart pain.

Symptoms

Symptoms usually develop over 24 to 48 hours after a toothache:

• Painful, firm, board-like swelling under the chin and jaw on both sides.
• Pain and swelling under the tongue; the tongue may be raised or pushed forward.
• Difficulty swallowing and drooling.
• Muffled voice and difficulty speaking.
• Difficulty opening the mouth (trismus).
• Neck pain and swelling.
• Fever, chills and feeling very unwell.
• Late signs: noisy breathing (stridor), sitting forward to breathe, bluish lips.

Causes and risk factors

• Dental infection: responsible for most adult cases, usually from a dental abscess of a lower molar or after a tooth extraction.
• Other sources: infected salivary glands, injuries or piercings of the floor of the mouth, jaw fractures, and in children often no clear cause.
• Bacteria: usually a mix of mouth bacteria, including streptococci, staphylococci and anaerobes.

Risk factors include poor dental health, diabetes, alcohol use disorder, a weakened immune system, malnutrition and recent dental work.

How Ludwig's angina differs from other neck infections

These are all deep neck infections and may overlap.

Diagnosis

The diagnosis is mainly clinical. Securing the airway comes before tests in anyone with breathing difficulty.

• Examination of the mouth, tongue, jaw and neck, and of the teeth for the source.
• Flexible scope through the nose to view the airway, done carefully.
• CT scan of the neck with contrast: shows the extent of infection and any pus collection or gas, once the airway is safe.
• Blood tests: white cell count, inflammatory markers, blood cultures and glucose.
• Dental X-rays to identify the causative tooth.

Treatment

Airway protection

This is the first priority. Patients are kept sitting up and monitored closely, often in intensive care. If the airway is threatened, a breathing tube is placed, usually with a flexible scope while awake, or a surgical airway (tracheostomy) is made under local anesthetic. Standard intubation can be dangerous because of the swollen tongue and tissues.

Antibiotics

High-dose IV antibiotics are started immediately to cover mouth bacteria, including anaerobes. They are continued until swelling settles, then switched to tablets to complete a course, often totaling 2 to 3 weeks.

Surgery

• Removing the infected tooth or treating the dental source.
• Incision and drainage if CT shows pus or the infection is not improving on antibiotics within 24 to 48 hours.

Steroids are sometimes used to reduce airway swelling, but their role is not firmly established.

Complications

• Airway obstruction and death from suffocation.
• Spread of infection into the chest (mediastinitis) or around the heart.
• Sepsis.
• Necrotizing fasciitis of the neck.
• Pneumonia from aspirated pus.
• Blood clot in the jugular vein.

Outlook

Before antibiotics, about half of people with Ludwig's angina died. Today, with early airway management, antibiotics and surgery, mortality is under 10 percent and most people recover without lasting problems. Delay in seeking care is the main risk.

Prevention

• Get toothaches, broken teeth and gum swelling treated promptly.
• Brush twice daily, clean between teeth and see a dentist regularly.
• Seek help quickly for any jaw or face swelling after dental work.
• Keep diabetes well controlled.

Frequently asked questions

What causes Ludwig's angina?

Most cases come from an infected lower molar tooth, especially the second or third molar, whose roots sit below the muscle forming the floor of the mouth. Bacteria spread into the spaces under the tongue and jaw. Less often it follows a tooth extraction, injury, piercing or salivary gland infection.

What are the first signs of Ludwig's angina?

Early signs are a worsening toothache with swelling and tenderness under the jaw or chin, pain under the tongue, fever and difficulty swallowing. Within hours to a day or two, the swelling can become hard, spread to both sides and lift the tongue. This needs emergency care.

Is Ludwig's angina life-threatening?

Yes. The swelling can block the airway within hours. It can also spread into the chest or cause sepsis. With prompt treatment, including airway protection, IV antibiotics and drainage, most people survive and recover fully.

How is Ludwig's angina treated?

Doctors first make sure the airway is safe, sometimes by placing a breathing tube or tracheostomy. IV antibiotics are started immediately, the infected tooth is removed, and any pus collection is drained surgically. Most people need several days in hospital.

Can you get Ludwig's angina without a tooth infection?

Yes, though it is less common. It can follow a tongue piercing, injury to the floor of the mouth, a jaw fracture, a salivary gland infection, or a tonsil infection. In children, a clear source is often not found.