Ludwig’s Angina

Abdum Muneeb 202020

Iqra Mehmood 202018
Learning Objectives

Applied Anatomy
Aetiology of Ludwig’s Angina
Clinical Picture of Ludwig’s Click icon to add picture
Angina
Differential Diagnosis
Complications of Ludwig’s
Angina
Management of Ludwig’s
Angina
 Applied Anatomy
• Submandibular space lies between the mucous
membrane of the floor of the mouth and tongue on
one side and a superficial layer of deep cervical
fascia extending between the hyoid bone and Click icon to add picture
mandible on the other
• It is divided into 2 compartments
• Sublingual compartment
• Submaxillary and submental compartment

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 Ludwig’s Angina
• Ludwig's angina is life-threatening diffuse cellulitis of the
soft tissue of the floor of the mouth and neck.
• It is infection of submandibular space.
• The condition was named after a German physician, Click icon to add picture
Wilhelm Friedrich von Ludwig
• It rapidly progresses to the surrounding tissues, leading to
various potentially lethal complications

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 Aetiology
• Dental infections
• Roots of premolars often lie above the attachment of mylohyoid and cause
sublingual space infection
• roots of the molar teeth extend up to or below the mylohyoid line and primarily
cause submaxillary space infection

• Submandibular sialadenitis, injuries of oral mucosa and fractures of the

mandible account for other cases

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 Bacteriology
• Streptococcus
• Staphylococcus
• Bacteroides
• H. influenzae
• E.coli
• Pseudomonas

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 Pathophysiology

As the roots of
The infection
Ludwig's angina It progresses the second and
The infection spreads It initially
usually originates below the third
begins in the lingually spreads to the
as a dental mylohyoid mandibular
subgingival rather than sublingual
infection of the line, molars lie
pocket and buccally space and
second or third indicating that below this line,
spreads to the because the progresses to
mandibular it has moved infection of
musculature lingual aspect the
molars, including to the these teeth will
of the floor of of the tooth submandibula
partially erupted sublingual predispose to
the mouth. socket is r space.
third molars. space. Ludwig's
thinner.
angina.

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 Clinical Features
• Odynophagia with varying degrees of trismus.
• Structures in the floor of the mouth are swollen and the tongue seems to be pushed up
and back (localized to sublingual space)
• Submental and submandibular regions become swollen and tender and impart a
woody-hard feel (submaxillary space spread)
• Cellulitis is present
• Tongue is progressively pushed upwards and backward threatening the airway.
• Laryngeal edema may appear

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 Complications
• Infection spreads to parapharyngeal and retropharyngeal
spaces and hence to the mediastinum
• Airway obstruction due to laryngeal edema, or swelling
and pushing back of the tongue Click icon to add picture
• Septicemia
• Aspiration pneumonia

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 History & Physical Exam
• Patients will report a history of recent dental extraction or dental pain.
• Frequent symptoms are neck swelling, neck pain, swallowing, and speaking difficulty.
• Trismus
• It is often described as "bull neck," with increased fullness of the submental area and a
loss of the mandibular angle definition.
• Other symptoms are mouth pain, hoarse voice, drooling, tongue swelling, stiff neck,
and sore throat.
• Stridor indicates impending airway obstruction while speaking difficulty and increased
tongue prominence signals sublingual space involvement.
• On examination, patients will usually have a fever with submental and submandibular
swelling and tenderness.
• Swelling of the floor of the mouth, the elevation of the tongue, and tenderness of the
involved teeth are oral signs of infection.
• The induration of the submental neck and edema in the upper part of the neck are
common extraoral findings

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 Evaluation
• Patient should be intubated immediately
• Once the airway is secured, a CT scan of the neck with intravenous (IV) contrast can
then be used to evaluate the severity of the infection and assess for any abscess
• MRI can be used to identify mediastinal fluid
• Neck and chest x-rays may demonstrate gas in the tissues in the case of infections
caused by anaerobic microflora.
• Metastatic abscesses and pus may be seen with ultrasonography

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 Treatment
• Systemic antibiotics.
• Incision and drainage of the abscess.
• Intraoral—if the infection is still localized to
sublingual space. Click icon to add picture
• External—if the infection involves submaxillary space.
• A transverse incision extending from one angle of
Mandible to the other is made with a vertical opening f
midline musculature of the tongue with a blunt hemostat.
Very often it is serous fluid rather than frank Pus that is
encountered.
• Tracheostomy, if the airway is endangered.

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 Differential Diagnosis
• Cellulitis
• Lingual carcinoma
• Lymphadenitis
• Salivary gland abscess
• Sublingual hematoma
• Peritonsillar abscess

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 CBL 16
A 48 years old female presented to the ER with complaints of progressive, diffuse neck
swelling over the submental area and high grade fever for the past 4 to 5 days. As an ENT
doctor:

• What specific questions you would ask in history to aid and elicit the diagnosis?
• Give differential diagnosis.
• Give management plan of most probable diagnosis.
• Differentiate between neck swellings of various causes.
• What impending emergencies do you need to e aware of and how to manage them?
• Write the labs and prescription for above issue.