Ludwig’s angina

Ludwig’s angina, otherwise known as angina
ludovici, is a serious, potentially life-threatening cellulitis, or connective tissue infection,
of the floor of the mouth, usually occurring in adults with concomitant dental infections
and if left untreated, may obstruct the airways, necessitating tracheotomy. It is named after the German physician, Wilhelm
Friedrich von Ludwig who first described this condition in 1836. Other names include “angina Maligna” and “Morbus
Strangularis”. Ludwig’s angina should not be confused with
angina pectoris, which is also otherwise commonly known as “angina”. The word “angina” comes from the Greek word
ankhon, meaning “strangling”, so in this case, Ludwig’s angina refers to the feeling of strangling,
not the feeling of chest pain, though there may be chest pain in Ludwig’s angina if the
infection spreads into the retrosternal space. The life-threatening nature of this condition
generally necessitates surgical management with involvement of critical care physicians
such as those found in an intensive care unit. Causes
Dental infections account for approximately 80% of cases of Ludwig’s angina. Mixed infections, due to both aerobes and
anaerobes, are of the cellulitis associated with Ludwig’s angina. Typically, these include alpha-hemolytic streptococci,
staphylococci and bacteroides groups. The route of infection in most cases is from
infected lower molars or from pericoronitis, which is an infection of the gums surrounding
the partially erupted lower molars. Although the widespread involvement seen in
Ludwig’s usually develops in immunocompromised persons, it can also develop in otherwise
healthy individuals. Thus, it is very important to obtain dental
consultation for lower-third molars at the first sign of any pain, bleeding from the
gums, sensitivity to heat/cold or swelling at the angle of the jaw. There has been a single case reported where
Ludwig’s angina was thought to be caused by a recent tongue piercing. Symptoms and signs
True Ludwig’s Angina is a cellulitic facial infection. The signs are bilateral lower facial swelling
around the lower jaw and upper neck. This is because the infection has spread to
involve the Submandibular, Sublingual and Submental spaces of the face. Swelling of the Submandibular space, while
externally is concerning the true danger lies in the fact that the swelling has also spread
inwardly – compromising, or in effect narrowing the airway. Dysphagia, Odynophagia are symptoms that are
typically seen and demand immediate attention. The Sublingual and Submental spaces are anterior
to the Submandibular space. Swelling in these areas can often push the
floor of the mouth, including the tongue upwards and backwards – further compromising the airway. Localisation of infection to the sublingual
space is accompanied by swelling of structures in the floor of the mouth as well as the tongue
being pushed upwards and backwards. Spread of infection to the submaxillary spaces
is usually accompanied by signs of cellulitis rather than those of an abscess. Submental and submandibular regions are swollen
and tender. Additional symptoms include malaise, fever,
dysphagia, odynophagia and, in severe cases, stridor or difficulty breathing. There may also be varying degrees of trismus. Swelling of the submandibular and/or sublingual
space is imminent. Treatment
Treatment involves appropriate antibiotic medications, monitoring and protection of
the airway in severe cases, and, where appropriate, urgent maxillo-facial surgery and/or dental
consultation to incise and drain the collections. The antibiotic of choice is from the penicillin
group. Incision and drainage of the abscess may be
either intraoral or external. An intraoral incision and drainage procedure
is indicated if the infection is localized to the sublingual space. External incision and drainage is performed
if infection involves the perimandibular spaces. A nasotracheal tube is sometimes warranted
for ventilation if the tissues of the mouth make insertion of an oral airway difficult
or impossible. In cases where the patency of the airway is
compromised, skilled airway management is mandatory. Fiberoptic intubation is common. Ludwig’s angina is a life-threatening condition,
and carries a fatality rate of about 5%. References

Leave a Reply

Your email address will not be published. Required fields are marked *