Ludwig’s angina is a serious and rapidly spreading bacterial infection in the soft tissues on the floor of the mouth, beneath the tongue. This condition is a medical emergency because the swelling it causes can progress quickly, potentially blocking the airway. It is a form of cellulitis, an infection of the deeper layers of the skin and underlying tissues. Immediate medical care is necessary to manage the infection and prevent life-threatening consequences.
Identifying the Symptoms
The signs of Ludwig’s angina can appear suddenly and escalate quickly. Externally, a prominent symptom is significant swelling of the neck and the area beneath the chin. This swelling is often accompanied by redness and tenderness, and the neck may feel hard and board-like to the touch, a texture described as “woody.”
Internally, the infection causes marked swelling on the floor of the mouth and of the tongue itself. This can force the tongue upward and backward toward the throat, which can obstruct the airway. As a result, individuals often experience trouble swallowing, which can lead to drooling, and difficulty speaking, causing speech to become slurred.
Pain is a common feature, often felt in the neck, jaw, and under the tongue, and may be accompanied by a toothache if the infection originated from a dental source. Systemic signs of infection, such as fever and chills, are also frequently present. As the swelling worsens, breathing can become increasingly difficult, sometimes leading to a high-pitched vibrating sound during inhalation known as stridor, signaling a dangerously narrowed airway.
Underlying Causes and Risk Factors
The vast majority of Ludwig’s angina cases originate from a dental infection. Bacteria from an abscessed tooth, most commonly a lower second or third molar, are responsible for over 90% of cases. The roots of these teeth are positioned near the floor of the mouth, allowing bacteria to spread into the surrounding soft tissues. Common bacteria implicated include Streptococcus, Staphylococcus, and Bacteroides species.
While dental problems are the primary trigger, other less frequent causes can introduce bacteria to this area. These include:
- Penetrating injuries to the floor of the mouth
- Fractures of the jawbone
- Complications from oral surgeries
- Oral piercings, particularly of the tongue
Certain underlying health conditions can increase a person’s susceptibility to developing Ludwig’s angina. A compromised immune system, from a condition like diabetes or from certain medications, can hinder the body’s ability to fight off the initial bacterial invasion. Poor oral hygiene, malnutrition, and alcohol use disorder are also recognized risk factors.
The Diagnostic Process
Diagnosis begins with a physical examination by a healthcare provider. The doctor will look for the characteristic signs, such as the firm, bilateral swelling of the submandibular area and the elevation of the tongue. The patient’s report of a rapid onset of pain, difficulty swallowing, and changes in their voice further supports the diagnosis.
To confirm the diagnosis and assess the extent of the infection, imaging studies are performed. A computed tomography (CT) scan with contrast dye is the preferred method. This imaging allows doctors to visualize the soft tissues of the neck and floor of the mouth, showing the spread of the inflammation. It can also identify any distinct collections of pus, known as abscesses, that may require surgical drainage.
In addition to the physical exam and imaging, blood tests are conducted. These tests can reveal signs of a significant infection, such as an elevated white blood cell count. Blood cultures may also be taken to identify the specific type of bacteria causing the infection, which can help in tailoring antibiotic treatment, though therapy is usually started before these results are available.
Medical Treatment Approaches
Treatment for Ludwig’s angina is urgent, and the first priority is securing the patient’s airway to prevent obstruction from swelling. In many cases, this involves endotracheal intubation, where a tube is placed through the mouth or nose into the trachea to keep the airway open. If swelling is too severe to allow for intubation, an emergency surgical procedure called a tracheostomy may be necessary, creating a direct opening into the trachea from the neck.
Simultaneously, aggressive antibiotic therapy is initiated. Patients are given high doses of broad-spectrum antibiotics directly into the bloodstream through an intravenous (IV) line. This approach is started immediately to combat the infection as quickly as possible, even before the specific bacteria are identified.
A third component of treatment is often surgical intervention to drain the source of the infection. If a CT scan reveals one or more abscesses, a surgeon will make incisions to drain the collected pus. This procedure relieves pressure and removes a large amount of infectious material, helping to control the inflammation and allowing antibiotics to work effectively.
Potential Complications and Recovery
If not treated promptly, Ludwig’s angina can lead to severe complications. The most immediate danger is airway obstruction from the swelling, which can lead to asphyxiation. Other potential complications include:
- The infection spreading downward into the chest cavity (mediastinitis)
- The infection entering the bloodstream, causing a widespread reaction called sepsis
- Sepsis progressing to septic shock, characterized by low blood pressure and organ failure
- The formation of a blood clot in the neck’s jugular vein
- The development of an aneurysm in the carotid artery
Despite the serious nature of the condition, the prognosis for patients who receive prompt and aggressive medical care is very good. Most people who are treated early make a full recovery with few, if any, lasting effects. The recovery process involves a hospital stay for monitoring and continued antibiotic therapy.