Ludwig Angina



  • 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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