Ludwig’s Angina: Symptoms, Causes, Treatment, Prognosis, Epidemiology, Complications

Ludwig’s angina is a rare bacterial infection that affects the floor of the mouth. It usually occurs if a tooth infection is left untreated. If the condition is not promptly treated it can lead to serious complications and can be fatal.

What is Ludwig's Angina?

What is Ludwig’s Angina?

Ludwig’s angina (also known as angina Ludovici) is a form of cellulitis or connective tissue disorder that affects the submandibular, sublingual and submental spaces i.e. the area under the tongue and the neck. It is an emergency condition which is characterised by sudden onset and rapid progress. If left untreated it can obstruct the airway and can cause death from breathlessness.

Signs and Symptoms of Ludwig’s Angina

Ludwig’s angina is primarily characterised by swollen tongue, bull neck appearance, and difficulty in breathing. Other signs and symptoms include:

  • Tenderness over floor of the mouth/underneath the tongue is a common symptom of Ludwig’s Angina.
  • Swelling and inflammation of the neck
  • Pain under the chin and over the neck is also a symptom of Ludwig’s Angina
  • Upwards displacement of the tongue caused by swelling in tongue
  • Difficulty swallowing
  • Speech difficulties
  • Uncontrolled drooling
  • Ear pain
  • Generalized weakness and fatigue
  • Fever and chills
  • Mental issues.

In advanced cases, as the swelling of the tongue progresses it may cause airway blockage leading to breathing difficulties. It is a life-threatening situation and can even lead to death.

Epidemiology of Ludwig’s Angina

Ludwig’s angina occurs mostly in healthy individuals. Certain systemic conditions act as predisposing factors. Odontogenic infection or oral cysts accounts for 90% of the cases of Ludwig’s angina. With improvement in imaging techniques and advancement in surgical options, the mortality rate of Ludwig’s angina has reduced from 50% to 8%. This condition is more common in adults than in children; and more common in males than in females. Most of the cases are seen in between the age of 20 to 60 years.

Prognosis of Ludwig’s Angina

Ludwig’s angina progresses rapidly and needs immediate attention. It can be treated completely with appropriate antibiotics. It needs constant monitoring and protection of the airway from blockage. If left untreated, Ludwig’s angina can cause death from sepsis and airway obstruction.

Causes of Ludwig’s Angina

Ludwig’s angina is bacterial in origin commonly caused by Streptococcus, Staphylococcus and Bacteroides species. It is primarily caused by infection of the second and third molars as the roots of these teeth have direct access to the submaxillary space. Other causes of Ludwig’s angina include:

  • Dental abscesses
  • Dental injury or trauma can also cause Ludwig’s Angina
  • Peritonsillar/parapharyngeal abscesses
  • Mandibular fractures
  • Oral lacerations and piercings
  • Oral cancer

Pre-disposing factors include:

  • Poor oral hygiene
  • Dental caries
  • Recent dental treatment or tooth extraction
  • Underlying systemic conditions such as diabetes, alcoholism, poor immunity, malnutrition etc.

Complications Due to Ludwig’s Angina

Ludwig’s angina can lead to the following complications:

Diagnosis of Ludwig’s Angina

The first step in diagnosis of Ludwig’s angina includes physical examination by a qualified physician or an oral surgeon. Once the signs and symptoms are rightly identified, further investigations can be done for confirming the diagnosis. MRI with contrast and CT scan of the head and neck region are done for determining the extent of infection. Fluid cultures are done for identification of the causative organism. Other laboratory tests such as Urea & Electrolytes, Full blood count (FBC), Lactate, C-reactive Protein (CRP) and Liver Function Test (LFT) can also be considered.

Treatment of Ludwig’s Angina

The treatment for ludwig’s angina includes the following:

  • Clearing the Airway to Manage Ludwig’s Angina: It is important to clear the airway to prevent breathlessness and further complications. This is done by a procedure called tracheotomy, where a small opening is created surgically directly into the windpipe through the neck. In some cases, a tube is inserted through the nose or mouth into the lungs for maintaining the airway.
  • Drainage of Excess Fluids for Managing Ludwig’s Angina: Drainage of excess fluids may be necessary to control oedema and excessive swelling. In certain cases, surgical/needle drainage may be considered.
  • Antibiotic Medication to Treat Ludwig’s Angina: Antibiotic medicines are recommended for management of the underlying bacterial infection. The choice of antibiotic should be broad spectrum and cover anaerobic, gram-negative and gram positive organisms. In most of the cases, a combination of penicillin, metronidazole and clindamycin are used.
  • Treatment of Ludwig’s Angina by Administration of Steroids: Steroids such as Dexamethasone is given intravenously for the first 48 hours for management of oedema and cellulitis and for better absorption of antibiotics.

Prevention of Ludwig’s Angina

Preventive measures include maintaining good oral hygiene and regular visits to the dentist. It is also recommended to use mouthwash regularly to prevent dental infections. If a person is planning on getting a piercing done on his tongue, he or she is advised to get it done under sterile conditions. Any oral issues should not be ignored and should be reported to a dentist at the earliest.


Ludwig’s angina is a rapidly progressing, life-threatening infection of the soft tissue of the neck and floor of the mouth. It typically occurs in individuals with poor oral hygiene or post dental treatments. If it is correctly diagnosed by a clinician in the early stages, it can be treated and reversed. Controlling the airway is one of the most important aspects for treating Ludwig’s angina in addition to antibiotic coverage, surgical intervention and advanced intensive care. Early intervention by ENT specialist, oral surgeon and anaesthesiologist assure prompt recovery and control of the situation.

Team PainAssist
Team PainAssist
Written, Edited or Reviewed By: Team PainAssist, Pain Assist Inc. This article does not provide medical advice. See disclaimer
Last Modified On:May 4, 2022

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