Ludwig's angina is a severe bacterial infection that simultaneously involves the submandibular, sublingual, and submental spaces bilaterally. It was first described in 1836 and can be caused by odontogenic infections or injuries to the oral cavity. Patients experience fever, difficulty swallowing and breathing, and swelling of the floor of the mouth and tongue. Treatment requires securing the airway, long-term antibiotics, extracting any infected teeth, and surgically draining the infected facial spaces. Without prompt treatment, complications can include sepsis, airway obstruction, and even death.

1. DR DAVIS
NADAKKAVUKARAN
READER
MALABAR DENTAL COLLEGE
LUDWIG’S
ANGINA

2. DEFINITION:
 It is the name given to massive, firm, brawny cellulitis or
induration, and acute, toxic stage, involving
simultaneously, the submandibular, sublingual and
submental spaces bilaterally

3. HISTORICAL BACKGROUND
 It was first described by Wilhelm Friedreich
Von Ludwig (1836)
 The term “ludwig’s angina” was coined by
camerer in 1837
 Many terminologies were used for this
condition which include
1. Marbus strangulatorius
2. Angina malignae
3. Garotillo

4.  Unique identity in general medical
personnel with three “F”s as :
It was to be feared
It rarely become fluctuant
It was often fatal

5. AETIOLOGY:
1. Odontogenic
2. Iatrogenic
3. Traumatic injuries to orofacial region
4. Osteomyelitis
5. Submandibular and sublingual sialadenitis
6. Secondary infections of oral malignancies
7. Miscellaneous causes
8. Cervical lymphoid tissues

6. PATHOLOGY:
 The condition is a cellulitis – a diffuse
inflammation of soft tissues which is not
circumscribed or confined to one area, but in
contrast to the abscess, tends to spread
through tissue spaces and along facial planes

7. MICROBIOLOGY:
 Streptococci , staphylococci, gram negative enteric
micro-organisms such as E.coli and pseudomonas;
and anaerobes including bacteroides , anaerobic
streptococci, peptostreptococcus and
fusospirochaetes

8. INVOLVEMENT:
 Most cases originate in
association with mandibular
second and third molars
 Infection tends to spread
primarily to submandibular
space

9. Periapical infection or pericoronitis
around mandibular 3rd molar
Submandibular space
sublingual space
Submental space (lymphatic spread)

12. SPREAD
SUBLINGUAL SPACES TONGUE
EPIGLOTTIS
SUBMANDIBULAR SPACES SUBMASSETERIC
SPACE
PTERYGOMANDIBULAR
PARAPHARYNGEAL
SPACE
PARATONSILLAR
SPACE
INVESTING LAYER OF
DEEP CERVICAL
FASCIA

14. CLINICAL FEATURES:
a) General examination :
 General constitutional symptoms: Pyrexia, anorexia
chills and malaise
 Marked pyrexia
 Difficulty in swallowing
 Impaired speech and hoarseness of voice
b) Regional examination
1. Extra oral
 Firm/hard brawny swelling in the bilateral
submandibular and submental regions
 Trismus
 Airway obstruction
 Respiratory rate raised
 Cyanosis

15. 2. Intra oral
 Edema of the floor of the mouth and the tongue
 Tongue may be raised against palate
 Increased salivation, stiffness of tongue
movements, difficulty in swallowing
 Backward spread of infection leads to edema
of glottis

16. COMPLICATIONS
 Septicemia
 Obstruct upper
respiratory airway
 Edema of epiglottis
 Thoracic empyma
 Aspiration pneumonia
 Meningitis
 mediastinitis
 Death

17. PRINCIPLES OF TREATMENT
 Early diagnosis
 Maintenance of patent airway
 Intense and prolonged antibiotic therapy
 Extraction of offending teeth
 Surgical drainage or decompression of facial
spaces

18. 1. DIAGNOSIS
 CLINICAL FINDINGS
 CT STUDIES

19. AIRWAY
MAINTENANCE
The need for immediate artificial airway:
 Stridor
 Cyanosis
 difficulty managing secretions.
 Rapid progression of edema

20. AIRWAY MAINTENANCE
 1)intubation of the patient
a)naso endotracheal intubation
 2)surgical airway
a)laryngotomy
b)cricothyroidectomy(tracheotomy)

21. ANTIBIOTIC THERAPY
 Peniciilin G-2 -4 million units IV 4 to 6 hrly.
500mg 6 hrly orally
 amoxicillin 500mg 8th hrly orally
 Cloxacillin 500mg orally 8th hrly
 Allergy to penicillin,erythromycin 600mg 6-8
hrly
 Gentamycin 80mg IM bd(resist Staph. And
Pseudomonas)
 Clindamycin IV 300-600mg 8th hrly
 Metronidazole 400mg 8th hrly(anaeroibc flora)
 Cephalosporins

22.  For aggressive management penicillin or its
derivatives along with metronidazole
 The therapy should also be changed if
favourable results are not observed after 48-
72hrs of therapy
 With the introduction of newer antibiotics the
mortality rate has been significantly dropped from
almost 75%-4%

23. SURGICAL INTERVENTION
It has two aims
 Remove the cause
 Surgical decompression

25. INCISION AND DRAINAGE
 Surgical intervention must be attempted to drain
all the abscessed spaces.
 Bilateral submandibular incisions and if required a
midline submental incision 1cm below the inferior
border of mandible are sufficient to drain the
involved spaces.
 intraoraly parallel to the ducts of the
submandibular glands.

26.  Exploration and an attempt to communicate with
the spaces of infection, by breaking the septa
dividing them and drainage of the contents, are
achieved with these incisions.
 Rubber drains are placed in order to keep the
drainage sites open for at least 3 days, until the
clinical symptoms of the infection have resolved

30. Postoperative clinical photograph 20 days
later
Clinical photograph showing extensive
swelling at submental and
. submandibular spaces
Third postoperative day after drainage of
the purulent accumulation

31. REFERENCE:
 Text book of oral and maxillofacial surgery
-Neelima Anil Malik
 Textbook of oral and maxillofacial surgery
-S M Balaji

32. THANK YOU