An Overview of Ludwig's Angina

An Infection of the Soft Tissue of the Mouth, Jaw, and Neck

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Ludwig’s angina is a rare infection of the soft tissues of the mouth that can become serious. It causes severe pain, tenderness, and swelling underneath the tongue and in other areas (such as the neck and jaw). In some instances, the swelling can be so severe that the airway becomes obstructed and breathing is difficult, resulting in an emergency situation.

The name Ludwig’s angina was coined after William Fredrich Von Ludwig, who was the first to describe the condition in the 1800s. Historically, before the discovery of antibiotics, Ludwig’s angina was a common cause of death from gangrenous cellulitis and edema (swelling) of the soft tissues of the neck and floor of the mouth.

In severe instances, Ludwig’s angina can spread from the neck into the mediastinum (the area located between the lungs, where the heart lies), causing some people to experience chest pain. Thus, part of the name of the condition is “angina," which is chest pain that's usually due to a lack of oxygenation to the heart.

Ludwig’s angina is more common in adults than in children. Today, with the use of antibiotics and other treatments, Ludwig’s angina is curable. Getting prompt treatment usually leads to a full recovery.

Symptoms

The infection caused by Ludwig’s angina often starts as a tooth abscess, causing pus to accumulate in the center of the tooth. The infection then spreads to other areas of the mouth, jaw, neck, and more.

The inflammatory response leads to swelling of the neck and tissues of the submandibular (facial space of the head and neck), submaxillary (lower jawbone area), and sublingual (under the tongue) spaces.

Common symptoms of Ludwig’s angina include:

  • Fever, weakness, and fatigue
  • Drooling
  • Problems with speech due to tongue swelling
  • Trouble swallowing
  • Pain in the floor of the mouth, particularly with tongue movement
  • Ear pain
  • Redness, swelling, and pain in the neck due to inflammation

As the condition progresses, symptoms may include:

  • Confusion or other mental changes from prolonged hypoxia (lack of oxygen)
  • Difficulty breathing, fast breathing, or other breathing problems (such as stridor—a harsh vibrating noise when breathing caused by obstruction)
  • Chest pain, resulting from inflammation that has spread to the mediastinum area

Symptoms of Ludwig’s angina require immediate medical attention. As the condition progresses, tongue swelling could obstruct the airway, causing it to be difficult or even impossible to breathe.

Ludwig's Angina
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Complications

As Ludwig’s angina progresses, there are some dangerous complications that could develop if the condition is left untreated, such as:

  • Severe infection (leading to gas gangrene)
  • Trouble breathing
  • Sepsis (bacterial infection in the bloodstream)
  • Osteomyelitis (infection that has spread to the bone)

According to a 2012 study, “The most feared complication is airway obstruction due to elevation and posterior displacement of the tongue.” This can lead to death.

If you are experiencing breathing problems, call 911 or seek immediate emergency medical attention.

What is Gas Gangrene?
Gas gangrene is usually caused by group A streptococcus and Staphylococcus aureus. As the bacteria grow in the affected area (the floor of the mouth, jaw, and neck) they create toxins and gas, which can damage tissues, cells. and blood vessels.

Causes

The underlying cause of Ludwig’s angina is a bacterial infection. The common culprits are group A beta-hemolytic Streptococcus associated with anaerobic germs (those that do not require oxygen to live) such as pigmented Bacteroides.

According to medical research studies, other causative organisms that were isolated from deep neck infections include:

  • Streptococcus viridans (40.9%)
  • Staphylococcus aureus (27.3%)
  • Staphylococcus epidermis (22.7%)

Dental infections are the most common cause of Ludwig's angina. The bacteria that cause Ludwig's angina often originate from a tooth infection. In fact, according to a 2011 study published in the American Medical Journal, “Infections account for 70% of cases. The second mandibular molar is the most common site of origin for Ludwig's angina, but the third mandibular molar is also commonly involved.”

Poor dental hygiene is often the cause of a tooth infection.

Other causes may include:

  • Trauma, leading to an infection of the mouth
  • A tooth extraction (which developed infection)
  • Chronic conditions that compromise the immune system

Seek prompt treatment for a dental infection or abscess to prevent complications such as Ludwig's angina.

Diagnosis

If you have any symptoms of a tooth or mouth infection, see a healthcare provider. They will take your medical history and ask about your symptoms, as well as any recent dental problems. They will examine you to check for visible swelling of the jaw, neck, and other areas, as well as palpable (those that can be felt) areas of swelling.

The primary diagnostic measures used in the diagnosis of Ludwig’s angina include:

  • A fluid sample will be taken from the affected area below the tongue. The samples will be examined with a microscope. The sample will also be placed in culture media to identify the type of bacterium that may be producing the infection.
  • Imaging tests such as contrast-enhanced computed tomography (CT) or magnetic resonance imaging (MRI) scans of the mouth, jaw, and neck can visualize edema, pus, or gas formation that may lead to compression of the airway.

Treatment

Airway compromise is so commonly linked with Ludwig’s angina that the condition warrants close observation to prepare for the possibility of impending airway obstruction. In fact, airway obstruction is the number one cause of death from the condition.

The most important immediate treatment for Ludwig’s angina is to secure the airway. This is done either with a breathing tube that's inserted into the nose or mouth or with a tracheostomy procedure (a surgical opening in the windpipe through the neck for insertion of a breathing tube). 

According to a 2012 study, “tracheotomy using local anesthesia has been considered the gold standard of airway management in patients with deep neck infections, but it may be difficult or impossible in advanced cases of infection because of the position needed for tracheotomy or because of anatomical distortion of the anterior neck.“

Early Stage Treatment

During the early stages of the disease, treatment may involve the administration of antibiotics and close observation. Because of the high risk for tongue swelling and airway obstruction, a person with Ludwig's angina is treated under very close observation by the healthcare provider.

Treatment is never administered at home.

Antibiotics are administered intravenously. Oral (by mouth) antibiotics will be given after the IV is discontinued.

Treatment for Advanced Stage Ludwig's Angina

Surgical drainage may be necessary to remove fluid from secondary abscesses. Needle drainage is often performed to lower the risk of the infection spreading.

Discharge Instructions

Follow-up/discharge instructions often include a dental consultation.

Dental treatment may be necessary to treat any tooth abscesses or dental infections. This may require a dental specialist, called an endodontist, to do a root canal on the affected tooth. A root canal is a procedure involving the removal of the infected tissue in the tooth that has formed an abscess.

Prognosis

Before antibiotics were available, over half of all people with Ludwig’s angina died from the condition. Today there is around an 8% mortality (death) rate for people diagnosed with Ludwig’s angina.

A Word From Verywell

Ludwig’s angina is a rare, yet preventable condition in most cases. You can decrease your risk by implementing these interventions:

  • Get regular dental care, including exams and cleanings, as well as restorative dental care to keep tooth decay at bay.
  • Practice good oral hygiene, including brushing and flossing teeth daily.
  • If you have any type of infection or unexplained pain in your mouth, seek medical attention right away.
  • Avoid unnecessary risks, such as tongue piercing, which increases the risk of infection in the mouth.
  • See a dentist anytime a tooth is causing pain, a filling falls out, you notice a foul smell in your mouth, or your gums or teeth are bleeding.
  • If you injure your mouth and it doesn’t heal promptly, have it checked out right away by a healthcare provider.
7 Sources
Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.
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  2. McKellop J, Mukherji K. Emergency head and neck radiology, Neck infections. Applied Radiology: Journal of Practical Medical Imaging and Management.

  3. Costain N, Marrie TJ. Ludwig's angina. Am J Med. 124(2):115-7. doi:10.1016/j.amjmed.2010.08.004

  4. Candamourty R, Venkatachalam S, Babu MR, Kumar GS. Ludwig's angina—an emergency: A case report with literature review. J Nat Sci Biol Med. 3(2):206-8. doi:10.4103/0976-9668.101932

  5. Penn Medicine. Gas gangrene.

  6. Parker E, Mortimore G. Ludwig's angina: a multidisciplinary concern. Br J Nurs. 28(9):547-551. doi:10.12968/bjon.2019.28.9.547

  7. Yu CH, Minnema BJ, Gold WL. Bacterial infections complicating tongue piercingCan J Infect Dis Med Microbiol. 21(1):e70–e74. doi:10.1155/2010/987059

By Sherry Christiansen
Sherry Christiansen is a medical writer with a healthcare background. She has worked in the hospital setting and collaborated on Alzheimer's research.