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Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 3,
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Vol. 2, Issue 3, May-July 2012Indian Journal of Multidisciplinary
Dentistry, Vol. 2, Issue 3, May-July 2012518 519Indian Journal of
Multidisciplinary Dentistry, Vol. 2, Issue 3, May-July 2012Indian
Journal of Multidisciplinary Dentistry, Vol. 2, Issue 3, May-July
2012518 519Indian Journal of Multidisciplinary Dentistry, Vol. 2,
Issue 3, May-July 2012
*Senior Lecturer, Dept. of Oral and Maxillofacial
Surgery**Professor, Dept. of Oral and Maxillofacial
PathologyReader, Dept. of Oral and Maxillofacial SurgeryReader,
Dept. of Oral and Maxillofacial PathologyChettinad Dental College
and Research Institute, ChennaiAddress for correspondenceDr S Vijay
ParthibanE-mail: [email protected]
AbstrAct
Ludwigs angina is a rapidly progressing cellulitis characterized
by the bilateral involvement of the submandibular, sublingual and
submental spaces. It typically originates from an infected or
recently extracted tooth, commonly the lower second and third
molars. We present a case of Ludwigs angina in a 50-year-old
man.
Key words: Induration, airway obstruction, incision and
drainage
Ludwigs angina is a potentially life-threatening infection of
the neck and floor of the mouth. It is a rapidly progressing
cellulitis of the floor of the mouth characterized by firm
induration and elevation of the tongue leading to severe airway
obstruction. This was described by William Frederick Von Ludwig in
1836,1 when he presented a clinical observation and necropsy
finding of a patient with the same clinical condition. He described
a firm connective tissue tumefaction that extends uniformly about
the periphery of the neck, under the chin region of the jaw and
beyond to involve the tissues between larynx and floor of the
mouth.
Criteria for accurate diagnosis of Ludwigs angina have been
described by Ludwig and Grodinsky. They describe Ludwigs angina as
cellulitic infection of submandibular space, usually involving more
than one neck space, producing firm induration of floor of mouth
and posterior displacement of tongue. It spreads by continuity
along the fascial planes, then by lymphatics and rarely involves
the glandular structures. The condition is known for its aggressive
course, airway compromise and high mortality when not treated
promptly.2-6 We report a case of Ludwigs
angina in a 50-year-old and review the presentation and
management of this disease.
Case Presentation
A 50-year-old man weighing 60 kg and 165 cm in height, presented
with complaints of swelling of lower- half of face and neck with
difficulty in breathing and swallowing and inability to open the
mouth for the past three days, and had been spitting out saliva. He
had pain in the right back tooth region one week before swelling
appeared. He was nil by mouth for more than eight hours. On
physical examination, he had no respiratory distress, but was
uncomfortable because of pain and intraoral drainage of pus.
Patient was febrile (38.80 C) with the pulse rate of 106
beats/minute, blood pressure of 140/90 mmHg and a respiratory rate
of 25 breaths/minute. The mouth opening was restricted with
inter-incisal gap of 1 cm. There was a diffuse, tender and
indurated neck swelling, warm on palpation particularly in
submandibular and submental space. Neck extension was painful and
limited. On intraoral examination, floor of the mouth was
erythematous and indurated. Tongue was elevated from the floor of
the mouth and he was not able to protrude the tongue beyond the
corner of mouth, which is characteristics of Ludwigs angina.
A diagnosis of Ludwigs angina was made and he was scheduled for
emergency drainage of abscess. He was admitted and observed for 10
days in the ward. Submental and sublingual incision and drainage
was done and the pus was sent for culture and antibiotic
sensitivity. Corrugated rubber drain was placed through
Ludwigs Angina: A Rare Case Report
S Vijay Parthiban*, R Sathish Muthukumar**, M Alagappan, M
KarthiM KarthiKarthi
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Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 3,
May-July 2012518 519Indian Journal of Multidisciplinary Dentistry,
Vol. 2, Issue 3, May-July 2012Indian Journal of Multidisciplinary
Dentistry, Vol. 2, Issue 3, May-July 2012518 519Indian Journal of
Multidisciplinary Dentistry, Vol. 2, Issue 3, May-July 2012Indian
Journal of Multidisciplinary Dentistry, Vol. 2, Issue 3, May-July
2012518 519Indian Journal of Multidisciplinary Dentistry, Vol. 2,
Issue 3, May-July 2012
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Figure 1. Photograph showing submandibular, submental
swelling.
Figure 2. Restricted mouth opening, tongue protrusion.
Figure 3 and 4. Photograph showing submental incision and drain
in place.
Figure 5 and 6. Photograph showing improved tongue protrusion
and mouth openi ng, respectively.
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Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 3,
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a submental incision. Periodontally affected 44, 47 and 48 were
extracted. Empirical antibiotic regimen IV cefotaxime 1 g b.i.d.,
metronidazole 500 mg b.i.d, IV dexamethasone 8 mg was started
immediately. The culture and antibiotic sensitivity test reported a
predominant growth of Staphylococcus aureus that was sensitive to
amikacin and ofloxacin. Based on the antibiotic sensitivity test,
the drug regimen was altered. The patient was kept under
observation for 10 days and discharged following complete
recovery.
Discussion
While described as far back as the writings of Hippocrates and
Galen, necrotizing fasciitis Ludwigs angina was first detailed by
Wilhelm Frederick Von Ludwig in 1836.7 Ludwigs angina is a rapidly
progressing cellulitis involving the submandibular, sublingual and
submental space.8 Ludwigs angina is odontogenic in origin in 90% of
cases. Various other causes are oral lacerations, mandible fracture
and infection of oral malignant tumor. Recent infection or
extraction of lower 2nd or 3rd molar are the most common cause for
Ludwigs angina as their roots extend below the mylohyoid line of
the mandible. To understand the pathophysiology of Ludwigs angina
requires the knowledge of anatomy of submandibular space. This
space is bounded superiorly by the mucosa of floor of the mouth and
inferiorly by superficial layer of deep cervical fascia as it
extends from hyoid bone to mandible. This space is subdivided by
mylohyoid
Figure 7. Photograph of the patient on the day of discharge.
muscle into to submaxillary space below and sublingual space
above. The infection spreads among both the spaces via the
posterior edge of mylohyoid muscle. Further progression occurs
superiorly from submaxillary space to the sublingual space
producing firm induration of floor of the mouth, elevation and
posterior displacement of tongue leading to airway compromise. If
untreated, it can spread posteriorly along the intrinsic tongue
muscles to parapharyngeal and retropharyngeal spaces, which may
progress to the mediastinum.
Ludwigs angina originates from infected or recently extracted
tooth, most commonly mandibular second and third molars.8 Various
other causes reported are mandible fracture, submandibular
sialadenitis, peritonsillar abscess, epiglottitis and oral
malignancy. It begins as a moderate infection and can progress
rapidly to brawny bilateral swelling of upper neck with pain,
trismus and tongue elevation accompanied with dysphagia and fever.
The most serious complication of Ludwigs angina is asphyxia due to
expanding edema of soft tissues of neck.9 Another common cause of
death is acute loss of airway during intervention to control the
condition.10 Stridors, anxiety, cyanosis, sitting posture are late
signs of impending airway obstruction and indicate the need for
immediate airway management.3 Spread of infection to mediastinum,
carotid sheath, skull base and meninges are other complications.
Ludwigs angina was formerly fatal, but now with adequate medical
and surgical treatment, has a reduced rate of mortality.11 Even
after the advent of newer antibiotics Ludwigs still remains a
potentially life-threatening infection because of the impending
airway crisis.5 So, the early recognition, diagnosis and treatment
of Ludwigs angina is very important. The cornerstone of medical
management is the use of antibiotics active against streptococci,
staphylococci and anaerobic species. Steroid therapy has been
suggested as an adjunct to halt the progression of edema and
prevent the need for artificial airway.
ConclusionLudwigs angina is a life-threatening infection of
floor of the mouth and neck. Early diagnosis and immediate
treatment is the key for successful management of Ludwigs angina.
In advanced cases, securing the airway, surgical drainage and
antibiotics following culture and sensitivity test are
important.
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Vol. 2, Issue 3, May-July 2012Indian Journal of Multidisciplinary
Dentistry, Vol. 2, Issue 3, May-July 2012520 521Indian Journal of
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