Ludwig's angina is an acute, potentially life-threatening infection of the submandibular space that causes severe swelling and difficulty opening the mouth or swallowing. It usually stems from dental infections. Clinical features include bilateral swelling of the submandibular region, elevated tongue, and difficulty speaking or swallowing. Management involves securing the airway through tracheostomy or intubation, administering IV antibiotics, and incising and draining any abscesses through bilateral submandibular and submental incisions. Early diagnosis, antibiotic treatment, and surgical drainage are crucial for successful treatment.

1. Ludwig's angina
Presented by / Mostafa Heeba

2. Regional anatomy
Ludwig's angina
Etiology
Clinical features
Investigation
Management
conclusion

3. Regional anatomy

4. Boundaries-
 Roof: mylohyoid muscle.
 Inferior: deep cervical fascia, platysma,
superficial fascia & skin.
 Laterally: anterior belly of digastric.
 Posteriorly: submandibular space.
Contents-
 Lymph nodes, anterior jugular vein.
Etiology of infection-
 Infected mandibular incisors.
 Anterior extension of submandibular space.

5. Boundaries-
 Superiorly: mucosa of floor of mouth.
 Inferior: mylohyoid muscle.
 Posteriorly: body of hyoid bone.
 Anteriorly & laterally: inner aspect of
mandibular body.
 Medially: geniohyoid, styloglossus,
genioglossus muscle.
Etiology of infection-
 Infected mandibular premolar & 1st molar

6. Submandibular Space
Boundaries-
 Superiorly: mylohyoid muscle, inferior border of
mandible.
 Inferior: anterior & posterior belly of digastric.
 Laterally: deep cervical fascia, platysma,
superficial fascia & skin.
 Medially: hyoglossus,styloglossus,mylohyoid
muscle.
 Posteriorly: to hyoid bone.
 Anteriorly: submental space.
Etiology of infection-
Infected mandibular 2nd & 3rd molars.
From submental,sublingual spaces.

7. S Ludwig's angina’What
 An acute spreading , potentially life-threatening form of cellulitis in
the region of the submandibular glands, causing severe swelling and
tenderness, with fever, pain and difficulty in opening the mouth and in
swallowing. There is some danger that the swelling might extend to
the voice box (LARYNX) and cause ASPHYXIA. The usual source of
infection is grossly neglected teeth. Antibiotics are necessary.
(Wilhelm Friedrich von Ludwig, 1790–1865, German surgeon).

8. Etiology
 Dental caries, recent dental treatment, poor dental hygiene (accounts for
75-90% of cases)
 Oral soft tissue lacerations.
 Puncture wounds of the floor of the mouth.
 Secondary Infections of oral malignancy
 Submandibular sialadenitis
 Systemic compromise such as AIDS, glomerulonephritis, diabetes mellitus,
aplastic anemia, transplant recipients, chemotherapy etc…..

9. Clinical features
 Bilateral ‘wood like’ swelling in the submandibular, sublingual and
submental spaces (rapid onset )
 Skin is tense and tends to pit and blanch on pressure
 Rapidly spreading edema
 Double chin appearance

10. Clinical features
 Elevation and protrusion of tongue, drooling of saliva
 Elevation of the tongue is associated with dysphagia, odynophagia, dysphonia and
cyanosis
 Patients may exhibit muffled voice due to edema of vocal apparatus (hot potato voice)
 Septicemia, High grade fever, Malaise, Body aches, Leukocytosis
 Infection can spread to involve the masticator space and Para pharyngeal space
in the latter stages of the disease

11. Clinical features
Thumb sign on epiglottis indicating
laryngeal edema

12. INVESTIGATIONS
 Panoramic x-ray – to identify possible odontogenic sources
 Cervical, profile and posterior-anterior radiographs – to observe the volume
increasing in the soft tissues and any deviation of the trachea
 Ultra sound has been recommended to differentiate between cellulitis,
abscess and adenopathy in head and neck infection

13. CT scan
 CT scan is most widely used modality

14. Ultrasound
 Ultrasonography is very sensitive in detecting fluid collection
 Quick, widely available, relatively inexpensive, painless
 Involves no radiation
 An effective diagnostic tool to confirm abscess formation in the superficial
facial spaces and is highly predictable in detecting the stage of infection

15. Differential diagnosis
 Angioneuretic edema
 Cellulitis
 Lingual carcinoma
 Lynmphadenitis
 Peritonsillar abscess
 Salivary gland abscess
 sublingual haematoma

16. Treatment goals
Sufficient airway management
Early and aggressive antibiotic therapy
Incision and drainage for any who fail medical
management or form localized abscesses
Adequate nutrition and hydration support

17. MANAGEMENT
Airway
management

18. Airway management
 tracheostomy
 Cricothyroidotomy
 BNI
 fiber-optic nasotracheal intubation

19. Tracheostomy using local anaesthesia was considered as the gold
standard in the past , but
Risk of the spread of infection to the mediastinum,
aspiration of pus, rupture of the innominate artery,
spread of infection to the thorax,
airway loss and tracheal stenosis
Blind nasal intubation (BNI) is questionable because of infrequent
success on first pass and increased trauma with repeated attempts
might necessitate emergency cricothyrotomy

20. cricothyroidotomy
 sometimes performed instead of tracheostomy
 perceived lower risk of spreading infection to mediastinum
Fibreoptic intubation is a sophisticated and less invasive method of
securing airway in patients with deep neck infection

22. Medical management
 Intravenous access, fluid resuscitation, and administration of IV antibiotics
 Antibiotic therapy should be administered empirically and tailored to culture and
sensitivity results
 Antibiotic therapy should be administered empirically and tailored to culture and
sensitivity results
Other regimens –
 Penicillins with β-lactamase inhibitor,
 Second, third, or fourth generation Cephalosporins and Metranidazole

23. SURGICAL MANAGEMENT
INCISION & DRAINAGE
Bilateral submandibular incisions as well as a midline submental incision
Incision approximately 3 to 4 cm below the angle of the mandible and below
the inferior extent of swelling roughly parallel to the inferior border of
mandible

24. Principles (Topazian & Goldberg)
 Incise in healthy skin and mucosa when possible, not at the site of
maximum fluctuance, because these wounds tend to heal with an
unsightly scar;
 Place the incision in a natural skin fold;
 Place the incision in a dependent position;
 Dissect bluntly;
 Place a drain; and
 Remove drains when drainage becomes minimal

25. Tracheostomy and drainage

26. CONCLUSION
 Ludwig’s angina is a life-threatening infection
 Early diagnosis and immediate treatment is the key for successful
management
 Antibiotic therapy should be administered empirically and tailored to culture
and sensitivity results
 Prompt and early surgical intervention is required to provide a higher control
of the patient’s health.

27. Thank you