ITS DENTAL COLLEGE

HOSPITAL & RESEARCH CENTRE,

47, KNOWLEDGE PARK III
GREATER NOIDA
DEPARTMENT OF ORAL & MAXILLOFACIAL PATHOLOGY & MICROBIOLOGY

LUDWIGS ANGINA
PRESENTED BY

AISHWARYA SINGH (2013-2017)

INTRODUCTION
Ludwigs Angina is a life threatening
condition which involves toxic cellulitis
in the submandibular space and
secondarily involving the submental
and sublingual spaces as well.
Morbidity and mortality primarily
result from airway compromise from
swelling.
Etiology usually involves an
odontogenic infection

HISTORY
Ludwigs Angina has been named after
the German physician Wilhelm
Friedrich von Ludwig, who first knew
about the disease in 1836.

Other names include "angina Maligna"

and "Morbus Strangularis".

Angina has been taken from the word

angere which means to strangle Ludwig's angina refers to the feeling of

strangling.

ETIOLOGY
Usually originates from an odontogenic
infection, especially from the second or third lower
molars
BACTERIAL CAUSES :

Streptococcus {most commonly}

Staphylococcus

Other microorganisms include

Klebsiella, Clostridium.

MICROBIOLOGY
Common organisms
Streptococcus viridans
Streptococcus milleri group species
Should be considered but
B-hemolytic streptococci
uncommon
Neisseria species
Mycobacterium tuberculosis
Peptostreptococcus
Coagulase-negative staphylococci
Bacteroides

Anaerobic bacteria
are

Prevotella and Porphyromonas

species
Actinomyces species
Bacteroides species
Propionobacterium
Hemophilus

OTHER CAUSES : Periodontal Infections such as Abscess

Trauma
Tongue piercing
Mandibular Fracture

Figure A, Ludwig angina may

initially appear benign.

Figure B, In Ludwig angina,

rapid progression may
compromise the airway in a
few hours.
Roberts and Hedges, p. 1339

PATHOPHYSIOLOGY
Abscess
Spread of bacteria
Reach Submandibular area

Inflammation
Infection spreads to pharynx and other areas

CLINICAL FEATURES
Bilateral wood like
swelling

Airway obstruction

Elevation and protrusion of

Double chin
appearance

tongue

CLINICAL FEATURES
Dyspnea in supine position impending laryngeal
edema
Dysphagia and drooling of saliva
Septicemia
High grade fever
Malaise
Body aches
Leukocytosis

Thumb sign on epiglottis indicating laryngeal

edema

CLINICAL FEATURES

INVESTIGATIONS
Panoramic x-ray to identify possible odontogenic sources
Posterior-anterior radiographs to observe the volume increasing
in the soft tissues and any deviation of the trachea
Ultra sound has been recommended to differentiate between
cellulitis, abscess and adenopathy in head and neck infection
USG has a sensitivity of 95% and specificity of 75%

INVESTIGATIONS
Measure the distance from the
anterior aspect of the vertebral
body to the air column of the
posterior pharyngeal wall.
In patients of Ludwig Angina, you
will observe an increased distance
indicative of a soft tissue swelling

TREATMENT
Maintenance of airway

Deterioration may be rapid

Cricothyrotomy or tracheostomy
may be necessary

Prolonged Antibiotic therapy

Surgical Drainage

Oral maxillofacial surgeon

or ENT
Definitive surgical drainage
and debridement

ANTIBIOTICS

STEROIDS

Extended spectrum
penicillins

Reduce edema
Used routinely when
airway compromise
suspected
Dexamethasone 10-20
mg IV

Ampicillin/Sulbactam
(Unasyn)
Ticarcillin/Clauvulate
(Timentin)
Clindamycin + Cipro

INCISION & DRAINAGE

Bilateral submandibular incisions as well as a midline submental
incision
Incision approximately 3 to 4 cm below the angle of the mandible
and below the inferior extent of swelling roughly parallel to the
inferior border of mandible

TREATMENT GOALS

Sufficient airway
management

Early and aggressive

antibiotic therapy

Incision and drainage

for any who fail medical
management or form
localized abscesses

Adequate nutrition and

hydration support

COMPLICATIONS
If the infection and
inflammation spread to the
pharynx, there may be
asphyxiation due to difficulty
in breathing
If lungs and mediastinum are
involved, there is chest pain
and chest heaviness
Severe case leads to sepsis
and shock

CONCLUSION

Ludwigs Angina is a cellulitis of the submandibular space

most commonly due to abscess spreading from the mandibular
2nd or 3rd molars. If untreated, it may prove to be fatal.
Treatment is medicinal or surgical.

SUMMARY
Serious deep space infection
Potentially fatal
Aggressive manage airway as indicated
Surgical consultation
Antibiotics and steroids
ICU