Background. Angina Ludovici (Ludwig’s angina) is a severe infection of the connective tissue from the floor of the mouth, usually occurring. rare disorder, Ludwig’s angina is a serious, potentially life-threatening infection of the neck and the floor of the mouth (Table 1). Originally described by Wilhelm. Abstract: Ludwigs angina is a disease which is characterised by the infection in the floor of the oral cavity. Ludwig’s angina is also otherwise commonly known.

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Ludwig’s angina is a potentially life-threatening, rapidly expanding, diffuse inflammation of the submandibular and sublingual spaces that occurs most often in young adults anyina dental infections.

However, this disorder can develop in children, in whom it can cause serious airway compromise. Symptoms include severe neck pain and swelling, fever, malaise and dysphagia. Stridor suggests an impending airway crisis.

Causative bacteria include many gram-negative and anaerobic organisms, streptococci and staphylococci. Initial treatment consists of high doses of penicillin G given intravenously, angiba in combination with other drugs. Patients usually recover without complications.

Ludwig’s angina was described initially by Wilhelm Frederick von Ludwig xngina Five patients had marked swelling of the neck that progressed to involve the tissues covering the muscles between the larynx and the floor of the mouth.

Ludwig described indurated edema of the submandibular and sublingual areas with minimal throat inflammation but without lymph luxwig involvement or suppuration. At that time, the condition was almost always fatal.

A month-old girl was admitted to the hospital because of swelling below the chin that had increased during the previous two days. Fever developed on the day of admission, and she had reduced fluid intake and urine output.

Ludwig’s Angina: The Original Angina

On physical examination, a tender, indurated, warm swelling that spread laterally was seen in the submental area Figure 1. An excoriated oval lesion was present on the chin. The child was uncomfortable and preferred to keep her mouth open. She had no respiratory distress or cyanosis.

Her temperature taken rectally was The oxygen saturation, in room air, was 95 percent. Marked submental swelling in the patient in illustrative case 1; note open mouth. Neck radiographs revealed marked submandibular soft tissue prominence that was characteristic of Ludwig’s angina. Luvwig abscess was seen on ultrasonogram. The white blood cell count was elevated, with a shift to the left.

Blood culture was sterile. The illness resolved following initial treatment with intravenous anginx followed by oral dicloxacillin. A boy aged 33 months presented to the emergency department adalzh of progressive enlargement under the chin for one day and inability to swallow. Three weeks earlier, he had fallen and injured his nose.


On examination, the patient had swelling, erythema and tenderness in the submandibular area. Pain prevented him from opening his mouth Figures 2 and 3. His temperature was Tender swelling in patient in illustrative case 2. Patient is unable to open mouth. Note spread of swelling laterally and abrasion on nose in same patient as shown in Figure 2.

The white blood cell count was 14, cells per mL Radiographs of the neck showed marked soft tissue prominence; no foreign body was present.

Ludwig’s angina was diagnosed clinically, and treatment with intravenous nafcillin was started. By the third day of treatment, the submental tenderness, erythema and induration began to resolve. Incision and drainage produced approximately 10 mL of purulent material. Culture was sterile, as was the initial blood culture. Improvement was obvious within 24 hours of the surgical treatment.

The boy was discharged after seven days of treatment with intravenous nafcillin and was continued on a course of oral penicillin for an additional 10 days.

A knowledge of neck spaces and fascial relationships is important in diagnosing and treating neck infections. Spaces created by various fasciae of the neck are potential areas of infection. Invasion by bacteria produces cellulitis or abscess, and spread occurs by continuity along these paths of least resistance, rather than by lymphatic channels.

The submandibular space is composed of two spaces separated anteriorly by the mylohyoid muscle: The spread of infection is halted anteriorly by the mandible and inferiorly by the mylohyoid muscle 5 Figure 4.

The infectious process expands superiorly and posteriorly, elevating the floor of the mouth and the tongue. This then evolves to an infectious compartment syndrome of the submandibular and sublingual spaces. Sublingual space, superior to mylohyoid muscle.

Ludwig’s Angina

The submandibular space is inferior to the mylohyoid muscle. Spread of process superiorly and posteriorly elevates floor of mouth and tongue. In a study spanning a year period, 7 Ludwig’s angina was diagnosed in 41 patients, of whom 10 24 percent were children. Another study, 8 involving patients who had deep neck abscesses, included 21 children aged 10 years and younger.

Ludwig’s angina has been reported in infants as young as 12 days. Predisposing factors include dental caries, recent dental angkna, sickle cell disease, a compromised immune system, trauma and tongue piercing. The signs and symptoms of Ludwig’s angina are the result of a rapidly expanding cellulitis. Severe pain and neck swelling occur in virtually all patients. Trismus also occurs, as experienced by the child in the second illustrative case.

A child may sit leaning forward to maximize the airway.


Examination may reveal carious molar teeth, neck rigidity or drooling. The presence of stridor, dyspnea, decreased air movement or cyanosis requires prompt attention because it may indicate an impending airway crisis. The bacterial isolates vary and are often mixed. Other anaerobes such as peptostreptococci, peptococci, Fusobacterium nucleatumVeillonella species and spirochetes are also seen. A foul breath odor usually indicates the presence of an anaerobe. Gram-negative organisms such as Neisseria catarrhalis, Escherichia coli, Pseudomonas aeruginosa and Haemophilus influenzae have also been reported.

Treatment includes assessment and protection of the airway, use of intravenous antibiotics, surgical evaluation and, if necessary, operative decompression. Recommended initial antibiotics are high-dose penicillin G, sometimes used in combination with an anti-staphylococcal drug or metronidazole Flagyl I. In penicillin-allergic patients, clindamycin hydrochloride Cleocin HCl is a good choice.

Alternative choices include cefoxitin sodium Cefoxil daalah combination drugs such as ticarcillin-clavulanate Timentinpiperacillin-tazobactam Zosyn or amoxicillin-clavulanate Augmentin.

Surgical drainage may be indicated if no clinical improvement is seen within 24 hours. In one series of 41 patients, including 10 children, seven were treated successfully with conservative medical management.

Incision and drainage were necessary in three patients. Tracheostomy was necessary in adalag one child. One of the 10 children died. Ludwig’s angina can be fatal. Failure to diagnose deep neck infections promptly may be caused by a clinical picture that is altered by previous antibiotic use. With avalah diagnosis, aggressive intravenous antibiotic therapy and management in an intensive care unit, the process should resolve without complications.

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Address correspondence to Richard W. BoxDaytona Beach, FL Reprints are not available from the author. Nelson Textbook of pediatrics. The anatomy of the fasciae of the face and neck with particular reference to the spread and treatment of intraoral infections Ludwig’s that have progressed into adjacent fascial spaces. Management of deep neck infection. Pediatr Clin North Am. Busch RF, Shah D. Otolaryngol Head Neck Surg. Changing trends in deep neck abscess. A retrospective study of patients. Ludwig angina in children.

Ludwig’s angina following dental treatment of a five-year-old male patient: J Clin Pediatr Dent. A complication of tongue piercing.

Deep neck abscesses—changing trends. Schulman NJ, Owens B. Medical complications following successful pediatric dental treatment. This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference.