Ludwig angina
Ludwig angina is a rapidly progressive, usually odontogenic cellulitis of the submandibular, sublingual, and submental spaces that can cause airway obstruction from posterior tongue displacement. Airway assessment and securing take priority over every other step, followed by broad-spectrum IV antibiotics and drainage of any organized abscess.
- Topic reviewThe full article, organized the way the exam asks it.
- ABIM-format MCQsVignettes with an explanation for every wrong answer.
- Key factsThe numbers and thresholds worth memorizing, up front.
- AI tutorMedBrain answers the question you're stuck on.
What this article covers
- Overview
A rapidly progressive cellulitis of the floor of the mouth: a life-threatening bilateral cellulitis of the submandibular, sublingual, and submental spaces that spreads along fascial planes rather…
- Epidemiology
Associated with poor oral hygiene and dental disease: most cases arise in patients with untreated dental caries, periodontal disease, or a recent dental infection or extraction.
- Risk factors
Untreated dental caries or periodontal disease: the dominant risk factor, particularly disease involving the second or third mandibular molars, the usual source of the infection.
- Pathophysiology
Infection originates from a lower molar and spreads by contiguous extension, not hematogenously: an infected second or third lower molar tooth seeds the adjacent floor of the mouth directly, and the…
- Clinical features
Bilateral submandibular and sublingual swelling with "woody," brawny induration: firm, non-fluctuant, tender swelling under the jaw and floor of the mouth is the hallmark finding and distinguishes this from a simple fluctuant abscess.
- Differential diagnosis
Epiglottitis: drooling, muffled voice, and airway compromise like Ludwig angina, but lacks bilateral submandibular brawny induration; a "thumb sign" on lateral neck radiograph or a cherry-red…
- Diagnosis
Ludwig angina is a clinical diagnosis: bilateral submandibular/sublingual brawny induration, tongue elevation and posterior displacement, trismus, drooling, and an identifiable odontogenic source…
- Management
First, assess and secure the airway; this precedes every other step.
- Complications
Airway obstruction and asphyxiation: the feared and historically most common cause of death, from posterior tongue displacement and floor-of-mouth swelling.
- Prognosis
Outcome is determined primarily by how quickly the airway is secured: early recognition of impending obstruction and a controlled airway plan are the single most decision-relevant factors in outcome.
- Prevention
Treat dental caries and periodontal disease before they progress to abscess: routine dental care and prompt treatment of an infected or abscessed molar prevent the odontogenic seeding that leads to Ludwig angina.
Read the whole article
Subscribing to Internal Medicine opens every article, the full question bank and MedBrain, on the web, iPhone and Android.
Related articles
- Epiglottitis
Epiglottitis is a rapidly progressive supraglottic infection that can obstruct the airway within hours; the exam is limited to inspection only, and airway control precedes any diagnostic confirmation in an unstable patient.
- Peritonsillar abscess
Peritonsillar abscess is the most common deep-space neck infection, presenting with unilateral sore throat, trismus, a muffled hot potato voice, and uvula deviation away from the affected side, treated with prompt drainage plus antibiotics covering group A streptococcus, Staphylococcus aureus, and oral anaerobes.
- Retropharyngeal abscess
Retropharyngeal abscess is a suppurative infection of the retropharyngeal space that follows antecedent pharyngitis, classically in children 6 months to 6 years, and threatens the airway. Diagnosis begins with lateral neck radiography and is confirmed by contrast CT, and treatment is airway assessment, IV antibiotics against oral flora, and surgical drainage for frank abscess or antibiotic failure.
- Necrotizing fasciitis
Necrotizing fasciitis is a rapidly progressive, life-threatening infection of the subcutaneous tissue and superficial fascia driven by vessel thrombosis and bacterial exotoxin production. The hallmark is pain out of proportion to visible skin findings, with crepitus, bullae, and woody induration in advanced disease. Diagnosis is confirmed by direct surgical exploration; the LRINEC score aids risk stratification. Treatment is emergent surgical debridement combined with broad-spectrum empiric antibiotics.
- Suppurative parotitis
Acute suppurative parotitis is a bacterial infection of the parotid gland, most commonly caused by Staphylococcus aureus in a dehydrated or postoperative patient with reduced salivary flow, presenting with unilateral gland swelling and purulent ductal discharge, and treated with hydration, sialagogues, empiric antibiotics, and drainage of any abscess.
- Sialadenitis and Sialolithiasis
Sialolithiasis is a calcified stone in a salivary duct, most often the submandibular (Wharton) duct, causing postprandial colicky gland swelling; sialadenitis is gland inflammation or infection that can follow an obstructing stone or arise independently, treated with hydration, sialagogues, and amoxicillin-clavulanate 875/125 mg PO every 12 hours for infection, escalating to sialendoscopy or drainage when conservative measures fail.
- Cellulitis
Cellulitis is a nonpurulent, spreading infection of the deep dermis and subcutaneous fat, usually caused by beta-hemolytic streptococci, diagnosed clinically and treated with antibiotics alone since there is no collection to drain.