Ludwig Angina

Basics

Named for German physician Wilhelm Friedrich von Ludwig, who 1st described this in 1836 as a rapidly progressive, gangrenous cellulitis and edema of soft tissues of the neck, floor of the mouth
Gangrene is serosanguineous infiltration with little or no frank pus or primary abscesses
- Contiguous spread may encircle the airway or involve the mediastinum
- Emergent interventions rarely include surgical or aspiration techniques
Most deaths are due to airway compromise, occlusion, and resultant asphyxia
- Mortality exceeded 50% in preantibiotic era, currently <8%

Odontogenic in 90% of adult cases, usually from 2nd, and 3rd mandibular molars
Less commonly: Mandibular fractures, oral lacerations, contiguous infections, sialadenitis, errant drug injections, tongue piercings
Polymicrobial: β-hemolytic strep commonly associated with anaerobes such as peptostreptococcus, pigmented bacteroides
- Microbiologic analyses may guide therapy

Factors Increasing Morbidity and Mortality

Comorbid illness
Diabetes mellitus – specifically shown to independently increase life-threatening complications above other comorbidities
Pregnancy
Large body habitus
Involvement of more than one neck space
Anterior visceral space involvement (hyoid bone → superior mediastinal space)

Pediatric Considerations

Frequently no clear etiology or site of origin
Ideally, a destination facility will have specialty expertise available (surgery and subspecialties, anesthesia) and be properly equipped to provide emergent intervention

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