Neck infections and Ludwig’s angina!

Today Jess and Eric presented the fascinating case of a 60 yo gentleman who presented with acute onset neck pain, swelling, and erythema. He was eventually found to have cellulitis and myositis of the SCM muscle and treated with broad spectrum antibiotics, but early on in the case there was high concern for submandibular space infection AKA Ludwig’s angina!

What is it? Ludwig’s angina (named after the German physician who 1st described it in the 19th century: Wilhelm Frederick von Ludwig) is a bilateral infection of the submandibular space in the floor of the mouth. The submandibular space itself is made up of both the submylohyoid and sublingual spaces.

submandibular space

What causes it? Infection is usually due to an infected mandibular molar tooth. It can less commonly be caused by a peri-tonsilar abscess or from suppurative parotitis. Most infections are polymicrobial and reflect oral flora. In immunocompromised patients or IVDU patients aerobic GNRs and MRSA also should be considered.

How does it present? Usually presents as a rapidly expanding bilateral “brawny” or “woody” cellulitis without LAN that usually does not involve abscess formation. It can expand rapidly leading to airway compromise. It can also present with neck or mouth pain, stiff neck, drooling, and dysphagia. Trismus (difficulty opening the mouth) is less common as this is more often seen with parapharyngeal infections.

How is the diagnosis made? Usually clinical history, physical, and CT of the head and neck is good enough. Because there is usually no abscess formation in Ludwig’s angina, bacterial culture is usually not possible.

How is it treated? Broad spectrum abx w/ coverage of staph, strep, anerobes. Pseudomonas coverage for immunocompromised.  If a drainable pocket is seen on CT, surgery may be indicated, but this is rarely the case. Repeated assessments of airway patency is the most important part of anticipatory guidance and a fiber-optic guided nasal approach may be the safest method for intubation as patients with Ludwig’s angina have a higher risk for laryngospasm.









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