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 skin 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 of Ludwig’s angina was coined after William Fredrich Von Ludwig, who was the first to describe the condition in the 1800s. Historically, 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. Before the discovery of antibiotics, a very high mortality (death) rate was linked with Ludwig’s angina.

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 a condition involving chest pain due to lack of oxygenation to the heart.

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. It’s more common in adults than in children. Today, with the use of antibiotics and other treatment, Ludwig’s angina is curable; those who get prompt treatment can expect a full recovery.


Common symptoms of Ludwig’s angina include:

  • Fever, weakness, and fatigue (due to the immune system response to bacterial infection)
  • Swelling of the tongue
  • 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). The inflammatory response leads to edema (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.

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 may require immediate medical attention because as the condition progresses, the swelling of the tongue could obstruct the airway, causing it to be difficult or even impossible to breathe.

Ludwig's Angina
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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)
  • Airway obstruction (according to a 2012 study, “The most feared complication is airway obstruction due to elevation and posterior displacement of the tongue”)
  • Osteomyelitis (infection that has spread to the bone)
  • Death

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

What is Gas Gangrene?
Gas gangrene is commonly 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.


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%)

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, which, when left untreated, could progress to Ludwig’s angina. Although dental infections are the most common cause of Ludwig's angina, there are other causes which may include:

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

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


The primary diagnostic measures used to detect the presence of Ludwig’s angina include:

  • A physical or dental exam to check for swelling of the jaw, neck, and other areas, checking for visible swelling or palpable (those that can be felt) symptoms
  • A patient history to gather information on symptoms as well as any recent dental problems
  • A fluid sample will be taken from the affected area below the tongue and cultured. This is a lab test which examines samples under a microscope and then grows them in culture media to discover the type of bacterium (causative organism) 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 will be taken to check for enlargement of the submandibular (jaw) area, pus, or gas formation that may lead to compression of the airway.


The most important immediate treatment for Ludwig’s angina (whether or not the condition is in the advanced stages) is to secure the airway. This is done either by inserting a breathing tube into the nose or mouth or performing a tracheotomy (making an opening in the windpipe through the neck to insert 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.“ A tracheotomy is only performed for those in advanced stages of Ludwig's angina, with symptoms such as deep neck infection.

Airway compromise is so commonly linked with Ludwig’s angina that the condition warrants hospitalization (or close observation in an outpatient setting) to prepare for the possibility of impending airway obstruction. in fact, airway obstruction is the number one cause of death from the condition.

Early Stage Treatment

During the early stages of the disease, treatment may involve the administration of antibiotics and close observation to ensure that the tongue does not swell and cause obstruction of the airway. Because of the high risk for this, a person with Ludwig's angina is treated under very close observation by the healthcare provider; treatment is never administered at home. Maintaining the airway is the primary concern for any person diagnosed with Ludwig’s angina.

Antibiotics are administered intravenously. Oral (by mouth) antibiotics will be given to take after the IV is discontinued and the patient is discharged to home.

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 includes a dental consultation. Dental treatment may be necessary to treat any tooth abscesses or dental infections. This may require the treatment from 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.


Before antibiotics were available, over half of all people with Ludwig’s angina died from the condition. Today there is only around an 8% mortality (death) rate for people diagnosed with Ludwig’s angina. This is a result of antibiotic therapy, techniques to help drain the edema (fluid build-up) and help prevent spreading of the infection to other tissues, as well as emergency medical techniques to establish and maintain an open airway (such as a tracheotomy).

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:

  • Seek out regular dental care (exams and cleanings as well as restorative dental care to keep tooth decay at bay).
  • Practice good oral hygiene (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.
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Article Sources
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