Ludwig’s Angina

What is Ludwig’s angina?

Ludwig’s angina is an acute, serious and potentially life-threatening condition characterized by massive, firm indurations involving the submandibular, sublingual and submental spaces on both the sides below the floor of the mouth. The condition is cellulitis of the connective tissue in the region of jaws. It is also known as angina maligna, morbus strangularis and angina ludovici. It is generally follows untreated dental infections and it could be life threatening if it obstructs the airway.

What are the symptoms?

The condition generally follows a progressed dental abscess or other infections in the region of jaws and face. The initial symptoms include a firm, brawny swelling below the chin. The swelling involves the floor of the mouth and can be seen in the mouth as the swelling pushes the tongue upwards and backwards within the oral cavity.

The swelling can also involve the neck region just below the angle of the jaws and ears. The swelling is severely tender and its consistency is described as woody hard. The swelling in this region leads to spasm of the muscles located surrounding the jaws. Muscle spasms lead to restricted jaw movements and limited mouth opening. Typically the mouth remains open due to the swelling – also referred to as a locked jaw. Swallowing and eating becomes difficult.

The lymph nodes in the neck region are enlarged and tender. Fever, body ache, chills and nausea may be present. In progressed cases, the rate of breathing is increased and airway obstruction may be present. Bluish discoloration of skin and mucosa may occur due to lack of oxygen. Death may occur in untreated cases of Ludwig’s angina within 10-24 hours due to airway obstruction and choking.

What causes Ludwig’s angina?

The causative organism of Ludwig’s angina include bacterium belonging to streptococcus, staphylococcus and bacteroid groups. In majority of cases with Ludwig’s angina, untreated dental infection is a chief causes. The commonly involved conditions are acute periapical or periodontal abscess affecting lower second or third molars. Abscesses associated with an erupting wisdom tooth (pericoronal abscess) can also lead to formation of Ludwig’s’ angina.

The other causes are as follows :

  • Use of contaminated needles in dental anesthesia.
  • Trauma to the orofacial structures(mandibular fractures, deep penetrating injuries to the skin).
  • Osteomyelitis of jaws.
  • Acute salivary gland infections.
  • Infected tonsils.
  • Secondary infection of oral malignant lesions.
  • Tongue piercings.

How is it treated?

Ludwig’s angina should be treated as a life threatening emergency condition. The treatment plan is generally aggressive with antibiotics and surgical procedures. Choice of antibiotics includes penicillins, gentamycin, metronidazole and cephalosporin. The patient should be given IV fluids to avoid dehydration. Potential complications should be treated accordingly.

The offending tooth is extracted and surgical drainage and decompression of the infected space is carried out. The surgical incisions are carried out both intra and extra orally depending on the involved spaces. Incision and drainage is performed followed by placement of a drain to relieve the intense pressure.

In all phases of treatment airway should be monitored to avoid airway obstruction. In airway compromised cases naso-endotracheal intubation should be done. In cases with severe airway obstruction surgical procedures such as laryngotomy and tracheotomy can be carried out.

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