What is Ludwig Angina?
Ludwig angina is a rare but serious infection affecting the soft tissues of the mouth and neck’s area. This condition was identified and named in 1836 by a German doctor, Wilhelm Friedrich von Ludwig. The term ‘angina’ comes from the Latin word ‘angere’, which means choking.
Ludwig angina spreads around three areas of the mouth’s floor: under the tongue (sublingual), below the chin (submental), and under the lower jaw (submandibular). It is mainly caused by an infection of the lower molar teeth, however, it is also used to refer to any infection in the same areas of the mouth. The infection can quickly spread to nearby tissues, causing grave issues such as blocking the airway, inflammation of the lungs due to inhaling food or liquid (aspiration pneumonia), and rupturing or forming an abscess (a pocket of pus) around the main artery in the neck (the carotid artery).
Because of the severity of these complications, it is extremely important to quickly recognize and treat Ludwig angina. Treatment includes ensuring the airway remains clear, administering antibiotics, and performing surgery to drain the infection if it is significant.
What Causes Ludwig Angina?
Ludwig angina is mainly caused by infections related to teeth in the lower jaw, specifically the second and third molars. These infections account for about 90% of Ludwig angina cases. Most commonly, abscesses (pockets of pus) around these molars are what leads to the disease.
There are other, less common causes of Ludwig angina as well. These include things like oral piercings or cuts, a fractured lower jaw, complications from putting a tube in the windpipe, bone infections, abscesses around the tonsils or back of the throat, inflammation of a salivary gland under the jaw, middle ear infections, and infected cysts located near the thyroid gland.
Poor oral hygiene, tooth decay, and recent dental treatments are also factors that might contribute to the development of Ludwig angina. While it usually develops in people who were previously healthy, there are some factors which might make a person more likely to get Ludwig angina. These include things like having diabetes, alcohol use disorder, poor nutrition, or a weakened immune system, which might be seen in people with AIDS or those who have had an organ transplant.
Risk Factors and Frequency for Ludwig Angina
Ludwig angina, a type of severe mouth infection, affects both sexes equally. The main reason people die from Ludwig angina is due to difficulties with breathing. In the past, before antibiotics were invented, more than half of the people with the disease didn’t survive. With the help of modern medical practices such as quick management of breathing issues, antibiotic treatment, advanced imaging techniques, and surgical procedures, the death rate has been lowered to approximately 8%.
Signs and Symptoms of Ludwig Angina
If you’ve recently had a toothache, you might want to look out for signs of a possible infection. This type of illness often triggers symptoms like fever, feeling tired, getting chills, and feeling weak. Another common symptom is trismus, a condition where it becomes difficult to open your mouth – this is usually an indication that the infection has spread to the space around your throat.
Frequently, people with this condition might even struggle with problems like difficulty swallowing, drooling, or holding themselves in a tripod position – propping themselves up with their arms – to help with their breathing. Other signs to watch out for include mouth pain, having a hoarse voice, swelling of the tongue, drooling, and having a stiff neck.
On examination, doctors often notice that the patient’s neck seems inflated and the angle of the jaw isn’t sharp, actually seeming to disappear into the neck – this is often called a ‘bull neck’. Usually, these patients also have a fever as well as swelling and tenderness under the jaw and mouth. If you look inside their mouths, you might see swelling of the floor of their mouth and their tongue may also be raised. They would feel tenderness around the teeth where the infection has set in.
Doctors also often find stiffness in the neck under the jaw and swelling in the upper part of the neck. However, despite this condition being an infection, it does not typically involve swelling of the lymph nodes.
- Recent toothache
- Fever
- Tiredness
- Chills
- Weakness
- Difficulty opening the mouth (Trismus)
- Difficulty swallowing, drooling or tripod positioning
- Hoarse voice
- Swelling of the tongue
- Stiff neck
- Mouth pain
- Appearance of a ‘bull neck’
- Tenderness under the jaw and mouth
- Swelling of the floor of the mouth
- Raised tongue
- Stiffness in the neck under the jaw
- Swelling in the upper part of the neck
Testing for Ludwig Angina
Ludwig angina, a type of severe infection, is typically identified by a healthcare professional closely examining your symptoms. Images like X-rays or scans don’t usually play a significant role in diagnosing this condition. Sometimes, if the infection affects your breathing, your doctor might need to create an artificial way to provide oxygen, a process called intubation. They will make this decision based on what they observe during their clinical evaluation. Waiting for any additional tests or scans before starting treatment can lead to unnecessary delays.
Once your airway is secure, then the doctor might conduct a CT scan. This particular scan, often done with an injected dye for greater clarity, helps assess the severity of the infection and check for pockets of pus, known as abscesses. Specific signs of Ludwig angina that the CT scan might show include trapped gas, buildup of fluid, swollen muscles, thinning fat under the skin, loss of fat spaces in a certain neck area, and thickening of the tissue.
Apart from CT scans, another helpful technique could involve the use of ultrasound. An ultrasound can not only help spot signs of Ludwig angina but can also be employed to check the health of the airways.
Lastly, it’s worth noting that while your healthcare provider may order some blood tests, these aren’t essential for diagnosing Ludwig angina. The main role of these tests is to see if the infection has spread into your blood. But, testing the infected area directly by swabbing or using a needle to collect fluid is often of limited help when it comes to Ludwig angina.
Treatment Options for Ludwig Angina
The primary goal when treating Ludwig angina, a type of severe mouth infection, is to secure the patient’s airway due to the risk of breathing difficulties, which can be potentially life-threatening. Once this is done, the next steps include controlling the infection with intravenous antibiotics, and sometimes undertaking surgical drainage for severe infections. Additional treatments can include intravenous steroids and inhaled adrenaline to help reduce facial swelling and increase the effectiveness of the antibiotics.
It’s important to ensure the patient is receiving enough oxygen, particularly if they are showing signs of low oxygen levels in the blood. However, the swelling in the neck often associated with Ludwig angina can make it difficult to use a mask for providing oxygen. So, regardless of the method used, it is important to make sure the patient is fully oxygenated beforehand.
Placing a breathing tube, or intubating the patient, can be complicated by a swollen tongue and difficulty opening the mouth (trismus). The preferred method is flexible nasotracheal intubation, inserting a flexible tube into the nose and down into the windpipe. However, this requires an experienced doctor. If this isn’t possible, an emergency surgical procedure to create an airway, like a cricothyrotomy, may be needed. Managing the breathing passage before signs of airway blockage, like stridor (a harsh sound when breathing) or cyanosis (blueish skin), is critical, as these are late symptoms of the disease.
A procedure known as blind nasotracheal intubation, passing a breathing tube without directly viewing the windpipe, should be avoided as it can potentially cause bleeding, worsen swelling, or even lead to spasms of the voice box (laryngospasm). Similarly, certain airway devices that are placed above the windpipe (supraglottic) could get displaced due to swelling, and therefore should also be avoided.
Once the breathing passage is secured, antibiotics are given intravenously to fight the infection. The antibiotics are typically broad-spectrum, meaning they can kill a wide range of bacteria, including those commonly found in the mouth. The specific antibiotics prescribed may be adjusted based on the patient’s immune status and their risk of drug-resistant bacteria, such as MRSA.
Intravenous steroids and inhaled adrenaline can be used as additional treatments, helping to reduce swelling and potentially facilitating intubation. These treatments can also increase the effectiveness of the antibiotics. In some cases, the use of steroids has been shown to decrease the need for breathing interventions; however, more research is needed to confirm this.
In some cases, a surgical procedure may be used to decompress the space under the jaw, which can help to improve the status of the airway. This surgery involves making an incision below the jaw and releasing pressure in the affected areas. This could potentially reduce the need for prolonged breathing tube use and shorten the overall hospital stay. Surgery is indicated when there is a visible abscess seen on imaging, a palpable swelling on examination, or when antibiotic treatment has not been effective.
What else can Ludwig Angina be?
Ludwig angina is a condition that is usually diagnosed based on the symptoms observed by a doctor. However, it can sometimes be difficult to tell it apart from other illnesses at first. In these cases, using imaging tests like X-rays or CT scans can be useful to rule out any other possible causes. But it’s important to note that this should be done only after ensuring the patient can breathe properly. Especially for patients who are able to breathe comfortably and handle their saliva while lying flat on their backs, these imaging tests can be performed.
What to expect with Ludwig Angina
Before antibiotics were developed, more than half of people with a severe infection of the mouth and throat known as Ludwig angina died, mainly because they couldn’t breathe properly. But thanks to progress in antibiotic treatments, better imaging techniques for diagnosis, and improvements in surgical methods, the death rate for Ludwig angina has now dropped significantly to around 8%.
Possible Complications When Diagnosed with Ludwig Angina
Ludwig angina is a swiftly advancing skin infection that can block the airway, demanding quick treatment. If someone has trouble with their airway functions or struggles to manage saliva, it’s crucial to intubate them proactively to avoid death risks.
People with Ludwig angina need strict monitoring to stop the infection from spreading to neighboring areas. The infection could give rise to complex conditions like mediastinitis (inflammation of the area between the lungs) or neck cellulitis. Moreover, Ludwig angina could evolve into aspiration pneumonia.
What requires immediate attention is a severe complication called descending necrotizing mediastinitis—instances of which majorly occur in the area behind the throat (71%) and alongside the carotid artery (21%). It’s a common occurrence for sepsis, a deadly infection, to cause the failure of multiple organs, particularly in patients with weakened immune systems.
- Swiftness in treatment for Ludwig angina
- Importance of intubation for preventing possible mortality
- Strict monitoring to prevent the spread of infection
- Possible complications: mediastinitis, neck cellulitis, aspiration pneumonia
- Severe complication: descending necrotizing mediastinitis
- Risks of sepsis leading to multiple organ failures, especially in patients with weak immune systems
Preventing Ludwig Angina
An infection originating from the teeth is the most common cause of a serious condition called Ludwig angina. It’s crucial for patients with dental infections to get health and safety information to lessen the chances of serious side effects. There are some warning signs that might mean the swelling is getting worse and you might need to see a doctor urgently:
* Trouble opening your mouth wide
* Swelling on both sides under your jaw
* A voice change that makes you sound like you are talking with a hot potato in your mouth
* Fever
* Hard or swollen area on the bottom of your mouth
* Difficulty moving your tongue
* Trouble swallowing
* Excessive drooling