Description

• 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%

Etiology

• 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

• 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)

• 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