Ludwig’s Angina

ludwigs angina picture

What is Ludwig’s Angina

Ludwig’s angina is defined as an infection occurring at the floor of the mouth. The exact location of this condition is beneath the tongue and is mainly due to bacterial infection. In other words, it is basically a severe inflammatory condition of the glands located under the jaw. Some experts call it a severe cellulitis of submaxillary space that later involves the sublingual and submental structures. The condition is rare in children.

It is a rare condition but potentially serious and life-threatening disorder. Also, the condition is worst known for its aggressiveness, quick progress and airway blockage. Wilhelm Frederick von Ludwig first coined the term in 1836. Nevertheless, the term should not be confused with Angina pectoris wherein the patient suffers from severe chest pain. In Ludwig’s angina, there is the feeling of choking, and not the feeling of any pain in the chest or thorax. However, there may be chest pain in Ludwig’s angina in case the infection has spread into the retrosternal space.

Synonyms of Ludwig’s Angina

Alternative names of Ludwig’s Angina include Submandibular space infection, angina ludovici and Sublingual space infection.

Other two synonyms found for this condition include:

  1. Angina Maligna, and
  2. Morbus Strangularis

Causes of Ludwig’s Angina

Below mentioned are the ca usative factors of Ludwig’s Angina.

  1. Dental infections contribute about 80% of the causes of Ludwig’s angina. If often happens after teeth’s infection (like tooth abscess) or direct injury in the mouth.
  2. Mixed infection (because of both anaerobes and aerobes)
  3. Alpha-hemolytic streptococci, bacterioides group and staphylococci

Generally, the infection in the root of the teeth is found at lower molars or pericoronitis (an infection of the gums surrounding the molars (usually third). Nevertheless, individuals with less immunity are likely to develop Ludwig’s Angina. There has been a single case reported stating tongue piercing resulting into Ludwig’s angina.

Ludwig’s Angina Symptoms

Soon after infection, the swelling of the tissues is observed. The inflammation may block the airway resulting into breathlessness and difficulty in swallowing. Other symptoms are mentioned below:

  • Dyspnea (difficulty in breathing)
  • Mood change or confusion
  • Fever
  • Pain in neck
  • Swollen neck
  • Redness of the neck
  • Weakness
  • Fatigue
  • Lethargy

Ludwig’s Angina Picture

ludwigs angina picture

Picture : Submandibular area swelling in the Ludwig’s angina patient

Image source :

Other symptoms that may occur with Ludwig’s Angina include

  • Dysphagia (difficulty in swallowing)
  • Dribbling
  • Pain in ear
  • Hoarseness
  • Cyanosis
  • Unusually sounding speech (experts compare this sound as if spoken with a hot potato in mouth)

Diagnosis and Tests

Above mentioned symptoms are observed or noticed during physical examination and interrogation with the patient with Ludwig’s Angina. The neck and head is carefully examined that shows swelling and redness on upper neck and under the chin. The swelling may extend up to the floor of the mouth. The patient’s tongue protrudes out because of the swelling.

Upon examining the oral cavity, elevation of the tongue and woody and brawny induration of the floor of the mouth is noticed. In addition, nonfluctuant suprahyoid swelling typically indicate the condition of Ludwig’s angina. Bilateral submandibular edema featured with severe tenderness on touch and in some cases subcutaneous emphysema further confirm the condition of Ludwig’s angina.

Physicians may prescribe CT scan as further investigation. The CT scan of neck may give clear idea to diagnose Ludwig’s Angina. Body fluid culture or tissue culture may show bacteria responsible for infection.

Clinical manifestation

Patients with Ludwig’s angina typically present some history of dental extraction, injury or poor oral hygiene with pain in teeth. In some cases fever, tachypnea (abnormally rapid breathing) and tachycardia (increased heart rate) are noticed. The patients with Ludwig’s angina could be anxious, confused and agitated.

Treatment of Ludwig’s Angina

The treatment includes proper antibiotic medicines. If the patient is immune compromised, the antibiotics are needed to be broad spectrum to cover MRSA and gram-negative rods.  One important thing to note here is the mortality for Ludwig’s angina was about 50 per cent before the era of broad-spectrum antibiotics and wonderful airway clearing techniques. Today, the mortality is from 0 to 4%.

Apart from medication, it is important to monitor and protect the airway in cases in advanced stage. If the airway blockage is too much, urgent maxilla-facial surgery and/or dental consultation for incision and drainage the collection is highly recommended.

Incision and drainage: the content of the abscess is drained out through incision and drainage. This can be done intraoral or external. Nevertheless, intraoral drainage is preferred in case the infection is present in sublingual area. External incision and drainage is advised in case of infection involving perimandibular area.

In some unfortunate case, the tissues of the mouth enter an oral airway and obstruct it. Such cases are treated by putting nasotracheal tube for open up the ventilation. In some severe cases wherein the patency of the airway is highly compromised, a careful airway management is sought. This means management of the airway should be as per the American Society of Anesthesiologists’ Difficult Airway Algorithm and requires fiberoptic intubation.


If left untreated, Ludwig’s angina is a life-threatening condition with a fatality rate of about 5 per cent. However, the disease can be treated with proper protection of airway and prescription of antibiotics.

Possible Complications

Below mentioned are possible complications of Ludwig’s angina

  • Septic shock
  • Sepsis (generalized infection)
  • Complete airway blockage

When to seek emergency medical help

The patient must seek emergency medical help in case of severe airway blocking making difficult to breath.


The prevention of this disease is possible with good oral hygiene. Brushing the teeth twice a day is advised. Also, regular mouthwash with antiseptic liquid help preventing this ailment. An individual must not ignore any pain in gums or teeth, foul smell coming from the mouth or bleeding from tongue, gums or teeth and consult dentist.


Introduction and definition additional source: (From Dorland, 27th edition); Source: MeSH 2007

Murphy SC. The person behind the eponym: Wilhelm Frederick von Ludwig (1790-1865). J Oral Pathol Med 1996;25:513–5.

Dhingra, PL; Dhingra, Shruti (2010) [1992]. In Nasim, Shabina. Diseases of Ear, Nose and Throat. Dhingra, Deeksha (5 ed.). New Delhi: Elsevier. pp. 277–278. ISBN 978-81-312-2364-2.

University of Maryland Medical Center:

Clinical Research Paper (Whitepaper):


Koenig, Laura M.; Carnes, Molly (1999). “Body Piercing: Medical Concerns with Cutting Edge-Fashion”. Journal of General Internal Medicine 14 (6): 379–385. doi:10.1046/j.1525-1497.1999.00357



New York Times Health:


  1. I’m interested in finding info on my case of Ludwig’s angina at northbay hospital in fairfield ca 2009 it was severe and I was in icu for weeks


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