Ludwig’s Angina: Serious Infection of the Mouth and Neck

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Ludwig’s angina sounds scary, but it’s a bad infection in your mouth and neck that causes swelling. This swelling can be dangerous because it might make it hard to breathe. If your mouth or neck feels swollen and you have trouble breathing, talking, or swallowing, see a doctor right away! They can help you get better fast. 

In this blog, we’ll discuss these topics:

What is Ludwig’s angina?

Ludwig’s angina is a serious bacterial infection that occurs in the floor of the mouth, under the tongue. It usually starts from an infection in the roots of the teeth, like a tooth abscess, or from an injury to the mouth. The infection causes swelling and fluid buildup in the neck and jaw area, which can lead to difficulty breathing and swallowing. It requires immediate medical treatment to drain the fluid and administer antibiotics to fight the infection.

What parts of your body does Ludwig’s angina affect?

Ludwig’s angina primarily affects the submandibular space of the neck. It is a severe, rapidly progressing cellulitis that involves the floor of the mouth. The specific areas affected by Ludwig’s angina include

  1. Submandibular space: The area under the lower jaw.
  2. Sublingual space: The area underneath the tongue.
  3. Submental space: The area under the chin.

These infections can cause swelling and can potentially obstruct the airways, making it a medical emergency. It often results from dental infections, particularly those involving the lower molars.

What causes Ludwig’s angina?

Ludwig’s angina is typically caused by bacterial infections, most commonly originating from dental sources. The main causes include

  1. Dental Infections: Infections in the lower molars, particularly the second and third molars, are the most frequent sources. Tooth abscesses and untreated dental caries can lead to the spread of infection to the submandibular space.
  1. Trauma or Injury: Trauma to the mouth or neck, including lacerations, fractures, or puncture wounds, can introduce bacteria that lead to infection.
  1. Infections of the Oral Cavity: Other infections within the mouth, such as peritonsillar abscesses or mandibular osteomyelitis, can also spread to the submandibular space.
  1. Systemic Conditions: Immunocompromised individuals, those with diabetes, or patients with poor oral hygiene are at a higher risk of developing Ludwig’s angina due to a decreased ability to fight infections.
  1. Postoperative Infections: Complications from oral or dental surgeries can sometimes lead to Ludwig’s angina.

What are the symptoms of Ludwig’s angina?

The symptoms of Ludwig’s angina can develop rapidly and are typically severe due to the potential for airway obstruction. Key symptoms include

Swelling and Pain

  • Submandibular swelling: Noticeable swelling under the jaw and on the floor of the mouth.
  • Firm and tender swelling: The swelling is often firm and tender to the touch.
  • Pain: Severe pain in the neck and floor of the mouth.

Mouth and Throat Issues

  • Elevation of the tongue: The tongue may be pushed upwards and backward due to swelling.
  • Difficulty swallowing (dysphagia): Trouble swallowing food or liquids.
  • Difficulty speaking: Speech may be slurred or difficult.
  • Drooling: Excessive saliva and difficulty managing oral secretions.

Breathing Problems

  • Stridor: A high-pitched wheezing sound caused by disrupted airflow.
  • Difficulty breathing (dyspnea): Shortness of breath or labored breathing.
  • Airway obstruction: Potentially life-threatening blockage of the airway.

Systemic Symptoms

  • Fever and chills: Indicative of a systemic infection.
  • Malaise: General feeling of illness or discomfort.
  • Tachycardia: Increased heart rate.

Other Signs

  • Redness of the neck: Erythema and warmth over the affected area.
  • Firm, woody consistency: The swollen area may feel hard and “woody” due to the cellulitis.

How is Ludwig’s angina diagnosed?

Diagnosing Ludwig’s angina involves a combination of clinical evaluation, imaging studies, and sometimes laboratory tests. Here are the steps typically involved in the diagnosis

Clinical Evaluation

  • Medical History: Assessing the patient’s symptoms, recent dental procedures, oral hygiene, and medical history.
  • Physical Examination: Checking for signs of swelling, firmness, tenderness in the submandibular and sublingual spaces, elevation of the tongue, difficulty swallowing, and airway obstruction. The physical exam may reveal a “woody” or firm consistency of the affected area.

Imaging Studies

  • CT Scan (Computed Tomography): A CT scan of the neck is often used to assess the extent of the infection, identify abscess formation, and evaluate airway compromise. It provides detailed images of the soft tissues.
  • MRI (Magnetic Resonance Imaging): Although less commonly used, an MRI can provide detailed images of the soft tissues and help in assessing the spread of infection.
  • Ultrasound: Can be useful in identifying fluid collections and guiding drainage if needed.

Laboratory Tests

  • Blood Tests: Complete blood count (CBC) to check for elevated white blood cell count (indicative of infection) and other markers of inflammation.
  • Blood Cultures: To identify the causative organism and guide antibiotic therapy.
  1. Aspiration and Culture
  • Needle Aspiration: In some cases, needle aspiration of the swollen area may be performed to obtain pus for culture and sensitivity testing. This helps in identifying the specific bacteria involved and tailoring antibiotic treatment.
  1. Airway Assessment
  • Laryngoscopy: In cases where airway obstruction is a concern, direct visualization of the airway using a laryngoscope may be necessary to assess the degree of obstruction and plan for potential intubation or tracheostomy.

How to Treat Ludwig’s angina?

Treating Ludwig’s angina involves prompt and aggressive management to prevent complications, particularly airway obstruction. The main components of treatment include

Airway Management

  • Monitoring: Continuous monitoring of the airway for signs of obstruction.
  • Intubation: If there is any indication of airway compromise, early intubation may be necessary to secure the airway.
  • Tracheostomy: In severe cases where intubation is not possible due to swelling, a tracheostomy (surgical creation of an opening in the neck to insert a tube into the windpipe) may be required.

Antibiotic Therapy

  • Broad-Spectrum Antibiotics: Empirical treatment with broad-spectrum antibiotics covering both aerobic and anaerobic bacteria. Common choices include a combination of penicillin, metronidazole, or clindamycin.
  • Tailored Antibiotics: Once culture and sensitivity results are available, antibiotic therapy can be adjusted to target the specific pathogens identified.

Surgical Intervention

  • Incision and Drainage: Surgical drainage of abscesses or infected spaces is often necessary to control the infection. This can be performed through intraoral or external incisions depending on the location and extent of the infection.
  • Debridement: Removal of necrotic or infected tissue may be required in some cases.

Supportive Care

  • Hydration and Nutrition: Intravenous fluids and nutritional support may be needed, especially if the patient is unable to eat or drink due to swelling and pain.
  • Pain Management: Appropriate analgesics to manage pain and ensure patient comfort.
  • Monitoring and ICU Care: Severe cases may require intensive care unit (ICU) monitoring and support.

Addressing the Source of Infection

  • Dental Treatment: Identifying and treating the primary source of infection, such as an infected tooth, is crucial. This may involve dental extraction or other dental procedures to eliminate the source of the infection.

Follow-Up Care

  • Regular Monitoring: Continuous monitoring for signs of improvement or complications.
  • Reevaluation: Regular reevaluation by healthcare professionals to adjust treatment as necessary.

Can you prevent Ludwig’s angina?

Preventing Ludwig’s angina primarily involves maintaining good oral hygiene and addressing dental issues promptly. Here are some key measures to help prevent this serious infection:

Good Oral Hygiene

  • Regular Brushing and Flossing: Brush your teeth at least twice a day and floss daily to remove food particles and plaque.
  • Mouthwash: Use an antiseptic mouthwash to reduce bacteria in the mouth.

Regular Dental Check-Ups

  • Routine Dental Visits: See your dentist regularly for check-ups and cleanings, typically every six months.
  • Early Treatment of Dental Issues: Address cavities, tooth abscesses, and gum disease promptly to prevent the spread of infection.

Prompt Treatment of Oral Infections

  • Seek Immediate Care: If you experience tooth pain, swelling, or other signs of oral infection, seek dental care immediately.
  • Follow-Up on Treatments: Complete any prescribed courses of antibiotics and follow your dentist’s instructions for care after dental procedures.

Avoiding Oral Trauma

  • Protective Gear: Use mouthguards during contact sports to prevent injuries to the mouth and teeth.
  • Caution with Foods: Be cautious with hard foods that can cause tooth fractures.

Managing Underlying Health Conditions

  • Control Diabetes: If you have diabetes, keep your blood sugar levels under control, as high blood sugar can increase the risk of infections.
  • Boost Immune Health: Maintain a healthy diet, get regular exercise, and manage stress to support your immune system.

Avoid Tobacco and Alcohol

  • Quit Smoking: Smoking can increase the risk of oral infections and slow the healing process.
  • Limit Alcohol Consumption: Excessive alcohol use can also contribute to poor oral health and increase the risk of infections.


Q1. What causes Ludwig’s angina? 

A1. Most cases are caused by dental infections, especially in the second and third molars. These teeth have roots that go deep into the jaw, so infections can easily spread to the spaces under the jaw.

Q2. What does Ludwig’s angina feel like?

  • A2. Pain and swelling in the neck.
  • A swollen or protruding tongue.
  • Swollen cheeks and jaw.
  • Pain or tenderness under the tongue.

Q3. What’s the difference between cellulitis and Ludwig’s angina? 

A3. Cervical cellulitis is a localized infection in the back of one side of the neck. In contrast, Ludwig’s angina usually affects both sides of the neck and is more widespread. It causes severe pain when swallowing or talking.

Q4. What is the triad of Ludwig’s angina? 

Q4. Ludwig’s angina affects three areas in the floor of the mouth: the sublingual, submental, and submandibular spaces. The infection spreads quickly and can block the airway. Most cases are linked to dental infections in the lower molars, especially the second and third ones, which cause over 90% of the cases.

Q5. What is the first treatment for Ludwig’s angina? 

A5. Ludwig’s angina causes a lot of swelling and fluid buildup in the neck and jaw area. To relieve this, doctors cut to drain the fluid and help you breathe better. You’ll also get IV antibiotics to fight the bacteria causing the infection.

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