Ludwig angina

**Definition:** Ludwig angina is a bilateral, rapidly spreading cellulitis (usually without discrete abscess formation early) of the submandibular space. It involves the sublingual and submental spaces, with potential extension to the parapharyngeal and retropharyngeal spaces. "Angina" here comes from the Latin/Greek for "strangling," not cardiac chest pain.

**Etiology:** - Odontogenic infection in about 80-90% of cases, usually the 2nd or 3rd mandibular molars. The roots of these teeth lie below the mylohyoid line, so infection drains into the submandibular space. - Other causes: peritonsillar abscess, mandible fracture, oral laceration, tongue piercing, and submandibular gland infection. - Risk factors: poor dental hygiene, diabetes, immunocompromise, alcohol use disorder, and malnutrition.

**Microbiology:** Polymicrobial, with mixed aerobes and anaerobes. - Viridans group streptococci (*Streptococcus viridans*) - *Staphylococcus aureus* - Oral anaerobes: *Peptostreptococcus*, *Prevotella*, *Fusobacterium*, *Bacteroides*

**Pathophysiology:** - Infection spreads by contiguity through fascial planes, not by lymphatics. - The sublingual space communicates with the submandibular space around the posterior edge of the mylohyoid muscle. - Swelling pushes the tongue up and back, which compromises the airway. - Tissue is firm and "woody" (brawny induration) rather than fluctuant.

**Clinical features:** - Fever, malaise, and neck pain and swelling - Bilateral submandibular swelling, with an erythematous, tender, "bull neck" appearance - Floor of mouth elevated, with the tongue pushed up and back - Dysphagia, odynophagia, drooling, and trismus - Muffled "hot potato" voice - Airway compromise: stridor, dyspnea, tripod positioning, and inability to lie flat

**Diagnosis:** - Primarily clinical. - CT neck with IV contrast defines the extent and any abscess, but only if the patient is stable and the airway is secure. - Labs: leukocytosis, elevated inflammatory markers, and cultures from blood or drainage.

**Management (airway first):** 1. **Secure the airway.** Options are awake fiberoptic nasotracheal intubation or tracheostomy/cricothyrotomy, which is preferred if intubation is predicted to be difficult or fails. Avoid sedation or paralysis without a secured airway, since loss of muscle tone can cause complete obstruction. 2. **IV antibiotics:** Broad-spectrum with anaerobic coverage, such as ampicillin-sulbactam, or penicillin plus metronidazole, or clindamycin. Add MRSA coverage (e.g., vancomycin) if risk factors are present. 3. **Surgical drainage/debridement** of abscesses, plus removal of the offending tooth. 4. Supportive care: IV fluids and glycemic control.

**Complications:** - Airway obstruction (the leading cause of death) - Spread to the parapharyngeal or retropharyngeal space, leading to descending necrotizing mediastinitis - Sepsis - Jugular vein thrombophlebitis (Lemierre-like picture) - Carotid sheath involvement - Aspiration pneumonia

**High-yield board pearls:** - Bilateral involvement of submandibular, sublingual, and submental spaces is classic. - The classic buzzwords are an elevated, swollen tongue and floor of mouth after a dental infection or extraction. - The most important next step is airway assessment and protection, not imaging or antibiotics alone. - It is a cellulitis rather than a true abscess, so there may be nothing to drain early. - It is often associated with a dental infection of the lower molars.