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EMGuidewire's Podcast

Jan 30, 2020

Join the EMGuideWire Crew from CMC EM Residency Program as they discuss Ludwig's Angina and the management Priorities!!!


  • Angina = “Strangling”
  • Bilateral infection of submental, submandibular, and sublingual spaces
  • 70-85% of cases arise from odontogenic source
    • Periapical abscesses of mandibular molars
    • Piercings (frenulum)
    • URI more common cause in children
  • Source of infection often polymicrobial
    • Most commonly viridans; also Staphylococcus and Bacteroides species
  • Patients usually 20-60 years-old; more common in males1
  • Mortality in treated Ludwig’s Angina = 8%7
  • ***Airway compromise = leading cause of death8

Who Is At Risk?

  • Diabetes mellitus
  • Chronic alcohol abuse
  • IVDA
  • Malnutrition
  • Poor oral hygiene
  • Smokers

Anatomy & Pathophysiology

  • Mylohyoid subdivides submandibular space:
    • Sublingual space
    • Submaxillary (submylohyoid) space
  • Infection extends posteriorly and superiorly, elevating tongue against hypopharynx
  • If left untreated, can extend inferiorly to retropharyngeal space and into superior mediastinum3

Clinical Signs & Symptoms

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

Late Findings

  • Drooling
  • Tongue protrusion
  • Trismus
  • Dysphonia
  • Cyanosis
  • Acute laryngospasm
  • Stridor
  • Patients may demonstrate signs of systemic toxicity → fever, tachycardia, and hypotension

How Do I Make the Diagnosis?

  • Clinically!
  • Consider CT head/neck
    • Can help evaluate extent of infection if clinical situation persists
  • CBC
  • Chemistry
  • Lactate
  • Blood Cultures


  • Emergent ENT/OMFS consult for I&D in OR and extraction of dentition if source is dental abscess
  • Airway Management
    • Intubation will be VERY difficult due to trismus and posterior pharyngeal extension
    • Ideal situation = awake fiberoptic intubation in OR
  • ALWAYS have a surgical airway ready as your back up plan
  • Blind insertion devices (e.g. intubating LMA) are NOT recommended

Management - Antibiotics

  • Must cover typical polymicrobial oral flora
  • Immunocompetent
    • 3rd-generation Cephalosporin + (Clindamycin or Metronidazole)
    • Ampicillin/Sulbactam
    • Penicillin G + Metronidazole
    • Clindamycin (allergic to penicillin)
  • Immunocompromised → *Need MRSA and GNR coverage!3
    • Cefepime + Metronidazole
    • Meropenem
    • Piperacillin-tazobactam
    • Add Vancomycin if concern for MRSA risk factors
  • Steroids
    • Dexamethasone 10 mg IV
      • Thought to chemically decompress for airway protection and increase antibiotic penetration6
    • Nebulized epinephrine
    • Resuscitation and pain control


  • Intracranial infections (e.g. CST, brain abscess)
  • IJ thrombophlebitis (Lemirre’s Syndrome)
  • Mediastinitis
  • Mandibular osteomyelitis
  • Empyema


Three characteristics of Ludwig’s angina can be remembered as the 3 Fs:

  • Feared
  • Often Fatal
  • Rarely Fluctuant
  • ABCs—Sit upright
  • Early notification of ENT/OMFS and anesthesia to facilitate definitive airway management
  • Arrange for the patient to be admitted to ICU


  • Secure the airway EARLY!
    • Prepare and be ready for a difficult airway — expect that the patient will require a surgical airway
  • Prevent the development of septic shock and multi-organ failure — give antibiotics early


  1. Lin HW, O’Neil A, Cunningham MJ. Ludwig’s Angina in the Pediatric Population. Clin Pediatr (Phila) 2009;48:583-7.
  2. Baez-Pravia, Orville V. et al. “Should We Consider IgG Hypogammaglobulinemia a Risk Factor for Severe Complications of Ludwig Angina?: A Case Report and Review of the Literature.” Medicine. 2017;96(47):e8708.
  3. Pandey M, Kaur M, Sanwal M, Jain A, Sinha SK. Ludwig’s Angina in children anesthesiologist’s nightmare: Case series and review of literature. J Anaesthesiol Clin Pharmacol. 2017 Jul-Sep;33(3):406-409.
  4. Botha A, Jacobs F, Postma C. Retrospective analysis of etiology and comorbid diseases associated with Ludwig’s Angina Ann Maxillofac Surg. 2015 Jul-Dec;5(2):168-73.
  5. Parhiscar A, Har-El G. Deep neck abscess: a retrospective review of 210 cases. Ann Otol Rhinol Laryngol 110: 1051, 2001.
  6. Saifeldeen K, R Evans. Ludwig’s Angina. Emerg Med J 2004; 21: 242-243
  7. Nanda N, Zalzal HG, Borah Gl. Negative-Pressure Wound Therapy for Ludwig’s Angina: A Case Series.Plast Reconstr Surg Glob Open2017 Nov 7;5(11):e1561.
  8. Pak S, Cha D, Meyer C, Dee C, Fershko A.Ludwig’s Angina. Cureus. 2017 Aug 21;9(8):e1588.