Ludwig's angina

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  • Bilateral infection of submental, submandibular, and sublingual spaces
  • Cellulitis without clear fluctuance/abscess should heighten suspicion
  • 85% of cases arise from an odontogenic source, usually mandibular molars
  • Source of infection are polymicrobial most commonly Strep Staphylococcus and Bacteroides species
  • Patients usually 20-60yr; male predominance [1]
  • Often there is noo lymphatic involvement and no abscess formation but infection rapidly spreads bilateraly

Clinical Features

Early Signs

  • Dysphagia
  • Odynophagia
  • Trismus
  • Edema of upper midline neck and floor of mouth
  • "Woody" or brawny texture to floor of mouth with visible swelling and errythema

Late signs


Classical definition

  • Infection of sublingual AND submylohyoid/submaxillary spaces

Imaging Studies

  • CT face with contrast will help delineate area of inifection
    • Only necessary to obtain imaging if diagnosis is question. Imaging should not delay emergent airway managment and as patient lays flat in CT scanner there is a high risk for respiratory failure.


Airway Managment

  • Airway management
  • Preference for an awake Intubation
  • Emergent ENT consult for operative I&D and extraction of dentition if source is dental abscess
  • Intubation may be very difficult due to trismus and posterior pharyngeal extension
    • Consider awake fiberoptic with Anesthesia or ENT back-up with setup for Cricothyrotomy


  • Must cover typical polymicrobial oral flora and tailored based on patient's immune status
  • Most commonly a 3rd generation cehpalosporin + (clindamycin or metronidazole)
  • If the patient is immuncompromised, the antibiotics need to also cover MRSA and gram-negative rods[2]

Immunocompetent Host

Antibiotics Options:[3]

  1. Ampicillin/Sulbactam 3 g IV q6 hrs
  2. Penicillin G 2-4 MU IV q6 hrs + metronidazole 500 mg IV q6 hrs
  3. Clindamycin 600 mg IV q6 hrs (option for those allergic to penicillin)


Antibiotics Options:[3]

  1. Cefepime 2 g IV q12 hrs + Metronidazole 500 mg IV q6 hrs
  2. Meropenem 1 g IV q8 hrs
  3. Piperacillin-tazobactam 4.5 g IV q6 hrs
  4. Add Vancomycin 15-20 mg/kg q8 hrs (max 2 g per dose) if concern for MRSA risk factors


  • Admit, usually ICU for airway monitoring

See Also

  1. PTA
  2. Retropharyngeal Abscess
  3. Pharyngitis


  1. Buckley M, O’Connor K. Ludwig’s angina in a 76-year-old man. Emerg Med J. 2009;26:679-680
  2. Costain N, Marrie T. Ludwig’s Angina. American Journal of Medicine. Feb 2011. 124(2): 115-117
  3. 3.0 3.1 Barton E, Blair A. Ludwig’s Angina. J Emerg Med. 2008. 34(2): 163-169.