What Is Ludwig's Angina?
Ludwig's angina is a rare but serious infection of the space below the jaw and the floor of the mouth, under the tongue. This illness is not to be confused with "angina" which refers to cardiac pain due to coronary artery disease. The infection usually starts in the floor of the mouth then quickly spreads to the area around the jaw on both sides of the face. Ludwig's angina is considered a medical emergency due to risks of impaired breathing .
Symptoms include fever and chills, mouth pain, a swollen tongue, a stiff neck, drooling and trouble swallowing, a muffled voice or trouble speaking and breathing.
Treatments include antibiotics, surgery to remove infection, and the installation of a tube to assist with breathing in severe cases.
You should visit an emergency room immediately. This requires immediate antibiotic treatment and, in some cases, surgery.
How common is Ludwig's Angina?
Ludwig's Angina is also known as
- Submandibular space infection
- Sublingual space infection
Ludwig's Angina Symptoms
Symptoms can be categorized into main symptoms that are more common and other symptoms that only affect some people or people that are experiencing a particularly severe infection.
The following symptoms affect the majority of people with Ludwig's angina due to the body's immune response to the infection, including:
- A high fever
- Chills: This can cause shaking (rigors).
- Mouth pain: This is usually located in the bottom of the mouth where the infection is and may extend to the throat area.
- Swollen tongue: The tongue can swell up to two or three times its normal size. The swelling can cause the tongue to protrude forward out of the mouth, or extend backward into the throat, making it difficult to swallow or breathe.
Other symptoms that affect some people with Ludwig's Angina or people that have a severe infection include:
- Stiff neck: This can occur if the infection spreads to the tissues near the neck, making it painful to fully bend the neck.
- Drooling and trouble swallowing: This can occur because the infection causes swelling of the tissues near the throat as well as the tongue, which prevents normal swallowing.
- Muffled voice or difficulty speaking: This can occur if the infection causes swelling of the tissues near the voice box, which is important for normal production of sound. This is usually a sign of a serious infection.
- Difficulty breathing: This can occur if the infection causes enough swelling that the airway begins to close up. This is a very concerning symptom that requires emergent treatment.
Ludwig's angina may cause the following complications :
- Blockage of the airway
- Septic shock
Ludwig's Angina Causes
The infection associated with Ludwig's angina is usually caused by bacteria normally found inside the mouth. This infection then sometimes spreads to the space below the jaw. Specific causes of Ludwig's angina include:
- Tooth infection: More than two-thirds of cases of Ludwig's angina are caused by a tooth infection, usually an infection of one of the teeth in the back of the mouth . Because the roots of these teeth extend into the space below the jaw, an infection of these teeth can easily spread to that space.
- Infection of tonsils: The tonsils are located in the back of the mouth near the entrance to the throat. An infection of the tonsils can lead to an infected collection of tissue called a peritonsillar abscess. If untreated, the peritonsillar abscess can cause an infection that spreads to the area below the jaw, causing Ludwig's angina .
- Infection of the parotid glands: The parotid glands are one of the main glands that produce saliva. They are located near the cheeks and secrete saliva into the mouth. If they become infected and are not treated, the infection can spread to the area below the jaw and cause Ludwig's angina.
Treatment Options and Prevention for Ludwig's Angina
Ludwig's angina is a medical emergency that should be treated right away, because of the risk of impairing the ability to breathe. Treatment involves a combination of medications to treat the infection and procedures to protect the airway, if necessary . Specific treatments for Ludwig's angina include antibiotics, possible surgery, and a tube to protect the airway.
If you are diagnosed with Ludwig's angina, your physician will give you antibiotic medications to treat the infection. These medications are given through an IV and may be continued for two to three weeks until the infection improves. The specific antibiotic medications chosen will vary based on the organism that is likely causing the infection.
Most cases of Ludwig's angina can be treated with antibiotic medications alone without needing a procedure or surgery to remove the infection. However, if your infection is not getting better with antibiotics, or if imaging shows a collection of fluid in the tissues, a procedure or surgery may be required to remove the infection. Both of these procedures will be done with anesthesia:
- Needle: A needle will be inserted to remove fluid
- Cutting: The area of infection will be cut open and exposed to remove fluid
Tube to protect the airway
If your Ludwig's angina is severe enough to cause difficulty breathing, the physician may decide to place a tube in your nose to protect the airway and prevent swelling from closing the airway. If this cannot be done and you are still having difficulty breathing, the physician may have to do a procedure known as a "tracheostomy." This is only needed in severe cases of Ludwig's angina .
When to Seek Further Consultation for Ludwig's Angina
You should seek medical attention if you develop any symptoms of a severe infection, experience difficulty breathing, or have chest pain.
If you develop any symptoms Ludwig's angina
You should go see your physician right away if you experience a fever, mouth pain, trouble swallowing, or trouble breathing or consider going straight to the emergency department if you are having trouble swallowing or breathing. This is especially important if you recently had a mouth or tooth infection, as this increases the chance that you may have Ludwig's angina. Your physician can do an examination and order imaging to determine if you have Ludwig's angina, and start you on the proper treatment.
If you are already being treated for Ludwig's angina but develop trouble breathing or pain in your chest
You should go back to see your physician right away if you have pain in your chest or difficulty breathing. These could be symptoms of a complication of Ludwig's angina, and your physician may need to change your treatment plan.
Questions Your Doctor May Ask to Determine Ludwig's Angina
To diagnose this condition, your doctor would likely ask about the following symptoms and risk factors.
- Are you sick enough to consider going to the emergency room right now?
- How severe is your fever?
- How long has your fever been going on?
- Is your fever constant or come-and-go?
- Has your fever gotten better or worse?
The above questions are also covered by our A.I. Health Assistant.
- Candamourty R, Venkatachalam S, Ramesh Babu MR, Suresh Kumar G. Ludwig's Angina - An Emergency: A Case Report with Literature Review. Journal of Natural Science, Biology and Medicine. 2012;3(2):206-208. NCBI Link
- Shargorodsky J. Ludwig Angina. U.S. National Library of Medicine: MedlinePlus. Published February 23, 2017. MedlinePlus Link.
- An J, Gossman WG. Ludwig Angina. StatPearls [Internet]. Published January 14, 2018. StatPearls Internet Link
- Bertolai R, Acocella A, Sacco R, Agostini T. Submandibular Cellulitis (Ludwig's Angina) Associated to a Complex Odontoma Erupted into the Oral Cavity. Case Report and Literature Review. Minerva Stomatologica. 2007;56(11-12):639-647. NCBI Link
- Pak S, Cha D, Meyer C, Dee C, Fershko A. Ludwig's Angina. Cureus. 2017;9(8):e1588. Cureus Link
- Kulkarni AH, Pai SD, Bhattarai B, Rao ST, Ambareesha M. Ludwig's Angina and Airway Considerations: A Case Report. 2008;1:19. NCBI Link