The hallmark of Ludwig's angina is the sudden and abrupt appearance of symptoms. Bilateral symmetric neck swelling and pain, fever and dysphagia are seen in initial stages [11]. Toothache, odynophagia, trismus and palpable crepitus may be encountered as well [1] [7]. Airway compromise is manifested by stridor, cyanosis, inability to swallow saliva, laryngeal edema and physical examination can reveal an elevated tongue that prevents air passage [13]. Brawny, bilateral tender induration of the submandibular space is observed during palpation, with absence of lymphadenopathy [6].

• Fever

  Elevation of the tongue, difficulty in eating and swallowing, edema of the glottis, fever, rapid breathing, and moderate leukocytosis are the most common symptoms. [medical-dictionary.thefreedictionary.com]

  A 54-year-old female presented to the emergency department (ED) with right-sided facial pain, subjective fever, and chills for 1 week. [link.springer.com]

  The patient should be examined for swelling below the inferior border of the mandible, fever, excessive trismus, floor of mouth or tongue elevations, and deviation of the pharyngeal walls. [cda-adc.ca]

  The patient soon becomes desperately ill, with fever, respiratory distress, headache and malaise. [exodontia.info]

• Malaise

  Patients have swelling, pain, and elevation of the tongue, malaise, fever, neck swelling, and dysphagia. The submandibular area can be indurated, sometimes with palpable crepitus. [link.springer.com]

  The patient soon becomes desperately ill, with fever, respiratory distress, headache and malaise. [exodontia.info]

  Symptoms include severe neck pain and swelling, fever, malaise and dysphagia. Stridor suggests an impending airway crisis. Causative bacteria include many gram-negative and anaerobic organisms, streptococci and staphylococci. [ncbi.nlm.nih.gov]

  Nonspecific constitutional symptoms: Fever, malaise, anxiety Pain: Tongue, throat, jaw, chest, neck stiffness Dysphagia, dysphonia Dentition, dental care suboptimal Transport in position of comfort Allow adult tripod “sniffing” position, to suction themselves [5minuteconsult.com]

  Patients classically present with fever, malaise, sudden onset of tender swelling of the floor of the mouth, associated with dysphagia, dyspnea, and drooling. [pediatric-infectious-disease.imedpub.com]

• Malnutrition

  Risk factors Diabetes mellitus Chronic alcohol abuse intravenous drug abuse HIV/ AIDS Malnutrition Poor oral hygiene Recent dental procedures 70% of Ludwig’s angina is odontogenic in origin CLINICAL FEATURES Mouth and throat pain Trismus (limited mouth [lifeinthefastlane.com]

  Patient with systemic illness, such as diabetes mellitus, malnutrition, compromised immune system, and organ transplantation are also commonly predisposed to Ludwig's angina.It is found that one third of the cases of Ludwig's angina are associated with [en.wikipedia.org]

  We opined that chronic malnutrition could be a very strong factor in the spread of odontogenic infection to the neck. [saudisurgj.org]

  Malnutrition E. Alcoholism F. Compromised Immune System Such As AIDS G. Organ Transplantation And Trauma 8. [slideshare.net]

  Predisposing factors include diabetes, oral malignancy, dental caries, alcoholism, malnutrition, and immunocompromised status. This review addresses the management and acute treatment of this possibly lethal condition. [ncbi.nlm.nih.gov]

• Pallor

  He had pallor, but icterus was absent. There was a diffuse, tender and indurated neck swelling in submandibular and submental space [Figure 1]. Neck extension was painful and limited. On oral examination, the dental hygiene was normal. [ijmm.org]

• Weight Loss

  As a result, patients suffer from weight loss due to loss of fat, muscle and skin initially, followed by bone and internal organs in the late phase. [en.wikipedia.org]

• Aspiration

  If surgery is necessary, use of perioperative tocolytic agents, aspiration prophylaxis, left uterine displacement perioperatively. [ispub.com]

  It can also result in mediastinitis, necrotizing cellulitis of the neck, and aspiration pneumonia. [ncbi.nlm.nih.gov]

  Complications include aspiration, pneumonia, empyema, mediastinitis, pericarditis, carotid artery or internal jugular vein thrombosis or erosion, and sepsis. © 2004 Lippincott Williams & Wilkins, Inc. [journals.lww.com]

• Diarrhea

  However, she denied chest pain, dyspnea, diarrhea, or pain in the upper face or shoulders. [cureus.com]

  However, a higher rate of adverse gastrointestinal effects and diarrhea has been reported in association with clindamycin treatment ( 214 ), leaving this drug as an effective alternative in patients allergic to penicillin or when treatment with amoxicillin [doi.org]

• Cyanosis

  It is manifested by voice changes, inability to swallow saliva and blue discoloration of the face and skin (cyanosis). [symptoma.com]

  Stridor, trismus, and cyanosis may also be seen when an impending airway crisis is nearing. The most prevalent cause of Ludwig's angina is odontogenic, accounting for approximately 75% to 90% of cases. [en.wikipedia.org]

  The presence of stridor, dyspnea, decreased air movement or cyanosis suggests impending airway compromise. [whonamedit.com]

  […] manifestations  Poor oral hygeine, tooth pain  Tachypnea, and tachycardia and fever  Swelling and pain in the floor of the mouth  Dysphagia, odynophagia, drooling, trismus, and fetid breath  Hoarseness, stridor, respiratory distress, decreased air movement, cyanosis [slideshare.net]

  Stridor, trismus, cyanosis, and tongue displacement suggest an impending airway crisis. Oedema and induration of the anterior neck, often with cellulitis, may be present in advanced cases. Early signs and symptoms of obstruction may be subtle. [emj.bmj.com]

• Dental Abscess

  This is why it’s important to visit an oral surgeon as soon as you suspect you may have a dental abscess. [orasurgery.com]

  Imaging may be performed to assess for airway patency and the presence of an underlying dental abscess. Generally, there is diffuse edema within and between the affected submandibular, sublingual, or submental spaces. [radiopaedia.org]

  Ludwig's angina is an uncommon infection of the deep tissues of the face and neck that usually evolves from more superficial infections such as dental abscesses. [ncbi.nlm.nih.gov]

  This 40 year-old patient reported 5 days of dental pain and was initially referred for treatment of a dental abscess. [nursingtimes.net]

  dental abscess; it can also complicate mandibular fractures, foreign body or laceration of the floor of the mouth, tongue piercings Signs / symptoms : dysphagia, odynophagia, neck pain and swelling, drooling; bilateral submandibular swelling, “wooden [emergucate.com]

• Toothache

  If an infection can progress rapidly from a toothache to a life-threatening infection, then it is critical that dentists be able to recognize the danger signs and identify the patients who are at risk. [ncbi.nlm.nih.gov]

  Images in Clinical Medicine Jon Heavey, M.D., and Naren Gupta, M.D., Ph.D. 2 Citing Articles A 58-year-old healthy man was evaluated for a toothache of 2 days' duration. [nejm.org]

  It can be difficult for patients to tell the difference between a typical toothache and an abscess, so you should become familiar with the signs of abscess. [orasurgery.com]

• Suggestibility

  It is suggested that a combination of penicillin and an antibiotic effective against anaerobes such as metronidazole is the most appropriate initial chemotherapy pending confirmation from the bacteriology laboratory. [ncbi.nlm.nih.gov]

  Suggested algorithm for diagnosis and management of 15. [slideshare.net]

  Stridor, trismus, cyanosis, and tongue displacement suggest an impending airway crisis. Oedema and induration of the anterior neck, often with cellulitis, may be present in advanced cases. Early signs and symptoms of obstruction may be subtle. [emj.bmj.com]

• Anger

  The term “angina”, is derived from the Latin word “angere”, which means “choke”; and the Greek word “ankhone”, which means “strangle”. [en.wikipedia.org]

  […] fast evolution involving the region of the submandibular gland which is disseminated through anatomic contiguity without tendency towards abscess formation 3 Fs It was to be feared Rarely became fluctuant Often was fatal LUDWIG’S ANGINA (LATIN TERM ANGERE [slideshare.net]

  Prior to antibiotics, swelling frequently led to respiratory obstruction and death; thus, the term angina was added to the description which arises from angere meaning “to strangle”. [emblog.mayo.edu]

• Neck Swelling

  Painful neck swelling, tooth pain, dysphagia, dyspnoea, fever, and malaise are the most common complaints. Neck swelling and a protruding or elevated tongue are seen in the vast majority. [emj.bmj.com]

  Cyanotic patients with a superiorly and posteriorly displaced tongue and severe neck swelling observed on physical examination are hallmarks of this infection. [symptoma.com]

  The external signs may include bilateral lower facial swelling around the mandible and upper neck. [en.wikipedia.org]

  Patients have swelling, pain, and elevation of the tongue, malaise, fever, neck swelling, and dysphagia. The submandibular area can be indurated, sometimes with palpable crepitus. [link.springer.com]

• Facial Swelling

  Physical examination revealed right-sided facial swelling, trismus, tongue elevation (Fig. 1 ), submandibular and sublingual swelling, and tenderness with adenopathy. Computed tomography (CT) findings were (Fig. 2 ) consistent with Ludwig’s angina. [link.springer.com]

  No clear cause of the facial swelling was determined, but it was presumably from an ulcerative lesion in the floor of the mouth. [ncbi.nlm.nih.gov]

  The external signs may include bilateral lower facial swelling around the mandible and upper neck. [en.wikipedia.org]

  Seventy-two hours after the pain appeared, the patient returned to the office with massive facial swelling that developed over a 24-hour period. Her past medical history included hypertension, remote thyrotoxicosis and a previous breast biopsy. [cda-adc.ca]

  Case Description A previously healthy 12-year-old Emirati male, presented to the Pediatrics emergency department with a chief complaint of right lower facial swelling of two days’ duration. [pediatric-infectious-disease.imedpub.com]

• Neck Mass

  Male with throat pain and neck swelling. [malacards.org]

  Neck mass: diagnosis and management / Deepak Kademani, Meredith August -- Keratocystic odontogenic tumor / M.A. [worldcat.org]

• Neck Edema

  There is typically a bilateral submandibular edema,  The swelling of the anterior soft tissues of the neck above the hyoid bone sometimes leads to the characteristic “bull’s neck” appearance of affected patients.  Adenopathy and fluctuance are not usually [slideshare.net]

  Similarly, a tracheostomy is extremely difficult because of the inability of the patient to lie supine and the presence of significant neck edema. [pmaksimovich.tripod.com]

• Facial Edema

  Click here to view Figure 2: Axial computed tomography images showing laryngeal inlet edema with airway compromise and subcutaneous emphysema. Click here to view The erythematous rashes and facial edema subsided gradually. [ijccm.org]

The diagnosis can be made by characteristic clinical findings that are highly suggestive of Ludwig's angina. Cyanotic patients with a superiorly and posteriorly displaced tongue and severe neck swelling observed on physical examination are hallmarks of this infection. The diagnostic criteria include bilateral involvement of submandibular and sublingual spaces, rapidly spreading cellulitis without involvement of lymph nodes or abscess formation and onset of the infection in the floor of the mouth [6]. All of these findings can be confirmed by imaging studies such as CT [13]. Additionally, the attempts to determine the causative agent should be made through microscopic evaluation of aspirated samples.

• Staphylococcus Aureus

  Pathological analysis showed polymicrobial flora including Staphylococcus aureus, Eikenella corrodens, Clostridium clostridiforme, and Prevotella buccae. [link.springer.com]

  Other pathogens include Staphylococcus aureus, Staphylococcus epidermidis, Bacteroides sp., Hemophilus influenzae, Klebsiella pneumoniae, and Pseudomonas aeruginosa. [journals.lww.com]

  A greater population of Staphylococcus aureus and black-pigmented bacteroides were isolated from patients with LA. CONCLUSION: Elevated levels of CRP and urea could indicate the severity of infection in patients with LA. [ncbi.nlm.nih.gov]

  aureus infection (presumed MRSA ) Indicated if Gram Stain with Gram Positive Cocci in clusters Antibiotics: Immunocompromised Piperacillin -Tazobactam (Zosyn) 4.5 g IV every 6 hours (or Meropenem 1 g IV q8 hours) and Vancomycin 1 g IV every 6 hours Antibiotics [fpnotebook.com]

To ensure good patient outcomes, it is imperative to establish proper airway passage, as hypoxia and asphyxiation can rapidly develop. Oral, endotracheal or nasal fiberoptic intubation are often necessary, while severe airway compromise may necessitate tracheotomy or cricothyrotomy [3]. Drainage of the floor of the mouth through small incisions has shown positive results in treating patients, which is why it is often considered in practice [14]. In addition to airway management, prompt administration of intravenous antibiotics is equally important. Penicillin G in combination with metronidazole is considered as first-line therapy, while piperacillin-tazobactam or clindamycin (in penicillin-allergic patients) are also recommended in treating Ludwig's angina [5]. Vancomycin is a drugs that can be added to the regimen if gram-positive microogranisms are found on microscopy [5]. The role of corticosteroids has shown to be beneficial in some studies and dexamethasone given for 48h has shown to reduce edema [7].

Before antibiotics were used, mortality rates from Ludwig's angina were more than 50%, but the introduction of antimicrobial therapy has substantially reduced death rates and are now between 0-8% [10]. Due to the abrupt onset and marked progression of airway obstruction, this infection can still be fatal if not recognized on time and complications such as mediastinitis, pericarditis, pleural empyema and endocranial spread may further increase the risk for fatal outcome [11]. For these reasons, an early diagnosis and aggressive management are life-saving steps for the majority of patients [12].

Spread of an odontogenic infection (most commonly of 2nd and 3rd mandibular molars) to the submandibular space is the most common cause of Ludwig's angina and between 50-90% of cases are thought to originate by this pathway [6]. Recent tooth extraction has also been listed as one of the causes [1], while peritonsilar and parapharyngeal abscesses, oral lacerations, submandibular siadenitis and mandibular fractures can also serve as a source [7]. Numerous pathogens have been identified, including β-hemolytic streptococci, Staphylococcus aureus, Staphylococcus epidermidis, Peptostreptococcus, Bacteroides sp., but also Eikenella corrodens, Clostridium sp. and Prevotella [3] [8]. In up to 50% of cases, the infection involves more than one microbial agent [2].

The introduction of antibiotics into medical practice has substantially reduced the appearance of Ludwig's angina, but several risk factors have been identified. Dental caries, recent dental procedures such as tooth extraction, malnutrition, alcohol abuse, systemic illnesses such as diabetes mellitus and immunosuppression due to human immunodeficiency virus (HIV) infection and organ transplantation have all been described as conditions that predispose individuals to Ludwig's angina [3].

The pathogenesis of Ludwig's angina starts with spread of the infection from other sites, most commonly the mandibular teeth. Firstly, the infection is spread to the submandibular, sublingual and submental spaces and the entire floor of the mouth becomes infiltrated. An intense inflammatory reaction leads to rapidly progressive development of bilateral gangrenous cellulitis of the floor of the mouth [9], causing abrupt and severe induration of the neck. More importantly, it displaces the tongue superiorly and posteriorly, thus contributing to airway compromise [4], whereas spread to the retropharyngeal and pharyngomaxillary spaces can fully constrict the trachea and disable air passage [3]. Neither abscess formation nor lymphatic involvement is seen in Ludwig's angina, which are some of the features that may distinguish it from other types of infection [6].

Since poor dental hygiene, dental carries and immunosuppression are shown to be the most significant risk factors for Ludwig's angina, major steps in prevention can be made by maintaining proper dental care and regular check-ups. Management of underlying disease that cause immunosuppression is also important.

Ludwig's angina is a potentially fatal infection of the submandibular and sublingual space that was initially described almost 200 years ago [1]. It is a form of rapidly developing gangrenous cellulitis that involves the soft tissues of the floor of the mouth [2]. It is shown that Ludwig's angina stems from preceding dental infection or tooth extraction, most commonly involving the lower teeth (second and third molars) and the gums [1], and a number of pathogens have been described as causative agents. β-hemolytic streptococci (including Streptococcus viridans), Peptostreptococcus, Bacteroides sp., Staphylococcus aureus, Staphylococcus epidermidis and several other have been mentioned in literature [3], but up to 50% of cases of Ludwig's angina are polymicrobial infections. The pathogenesis starts with local spread of the bacteria from the oral cavity to the sublingual, submandibular and submental spaces, where an intense inflammatory reaction occurs and produces a rapid onset of symptoms [4]. The spaces are infiltrated bilaterally, without the classical formation of an abscess and involvement of lymph nodes and most common symptoms include neck swelling, fever, pain and dysphagia. The most significant and most serious complication of this infection is airway compromise (angina meaning strangling) due to superior and posterior displacement of the tongue as a result of intense swelling of the floor of the mouth. Signs of airway obstruction include cyanosis, stridor and inability to swallow saliva and may call for immediate therapeutic measures [1]. The diagnosis can be made based on clinical criteria, but to confirm Ludwig's angina, computed tomography (CT) is an efficient method. Treatment primarily focuses on ensuring proper ventilation and air passage, which may sometimes require endotracheal intubation or tracheostomy. Intravenous antibiotic should be administered immediately and drugs such as clindamycin, penicillin and metronidazole are recommended [5]. Prior to the introduction of antibiotic therapy, mortality rates of this infection were up to 50%, but numerous advances in both antimicrobial therapy and intensive care management have substantially improved patient outcomes. Although in rare cases complications may ensue, including mediastinal, pleural, pericardial and endocranial spread, which presents as a significant risk for the patient, whereas asphyxiation due to sudden airway compromise may develop if the diagnosis is not made early on.

Ludwig's angina is a rare, but potentially life-threatening bacterial infection of the floor of the mouth. In most cases, an infection of the tooth or adjacent tissues that spreads to this space is the cause, but several other types of infections in the head and neck region may trigger this condition. Streptococci and Staphylococci are bacterial species that are most commonly identified as culprits, but various other species have been identified and in 50% of patients, more than one bacteria is present. Certain risk factors have been established, such as recent dental procedures, poor oral hygiene, diabetes mellitus and immunosuppression due to human immunodeficiency virus (HIV) infection or organ transplantation. As the infection spreads to the spaces below the tongue, an intense inflammatory reaction occurs, which leads to extensive swelling and the appearance of a bulged neck together with symptoms such as fever, neck pain and swallowing difficulties. One of the most feared complications of Ludwig's angina is breathing compromise that can develop because of displacement of the tongue by swelling and spread of the infection to spaces that surround the trachea. It is manifested by voice changes, inability to swallow saliva and blue discoloration of the face and skin (cyanosis). These symptoms appear abruptly and death may ensue rapidly if treatment is not initiated promptly, which is why an early diagnosis can save the patient's life. In addition to findings during physical examination, computed tomography of the neck (CT scan) and identification of bacteria from patient samples are performed to confirm Ludwig's angina and determine the causative agent, respectively. Immediate intravenous administration of antibiotics and ensuring adequate airway passage that may often require intubation are the mainstay of therapy. Before antibiotics were discovered, almost 50% of patients suffering from Ludwig's angina did not survive, but despite the introduction of antibiotic and advanced intensive care management, fatal outcomes are still encountered in up to 8% of cases. For these reasons, an early diagnosis is detrimental.

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