Ludwig’s Angina: Causes, Clinical Features, and Treatment

Ludwig’s angina is massive and firm cellulitis of the submandibular, sublingual and submental spaces bilaterally. Meaning, it occurs in the floor of the mouth under the tongue area and spreads downwards.

Ludwig’s Angina Name and Significance

This is an emergency condition and needs immediate medical intervention. ‘Ludwig’ is the name of the person who described this deadly condition for the very first time and ‘angina’ means angere in Latin, which means suffocation or a sensation of choking.

This condition can be also described as brawny cellulitis or induration. Ludwig’s angina was first described by Wilhelm Friedrich Von Ludwig in the year 1836, hence the name. It was Camerer who coined the name ‘Ludwig’s angina’ in the year 1837.

Ludwig’s Angina is also called as Marbus strangulatorius, because of the choking or suffocating experience the affected individual goes through. It is also sometimes called as Angina maligna or Garrotillo.

An important thing to be noted here is that when the cellulitis affects bilateral spaces (both sides), it is considered Ludwig’s angina. If the cellulitis affects only one side, no matter how massive the swelling is, it isn’t considered as Ludwig’s.

Among the medical practitioners this particular condition is described as a combination of three ‘F’s, which means to be Feared, rarely becomes fluctuant, and often fatal.

Ludwig’s Angina Causes

Ludwig’s Angina can be caused due to a number of reasons but in about 90% of the cases, the reason is Odontogenic (originating from the tooth and/or related tissues).

Below, we have listed the most common causes of Ludwig’s angina.

Odontogenic Causes

As mentioned earlier, the term ‘odontogenic’ means originating from dental and/or related tissues. Among these, the tooth abscesses are the most common cause of Angina of Ludwig’s.

Most common teeth abscesses that may turn into Ludwig’s are the lower second and third molar tooth abscess.

The other odontogenic abscesses that may cause Ludwig’s are the acute periodontal abscess and acute pericoronal abscess.


Traumatic injuries to the face, especially under the tongue area may result in Ludwig’s angina. The common injuries that may result in Ludwig’s are the mandibular or lower jaw fractures and deep wounds or lacerations of the floor of the mouth region.


Osteomyelitis of the mandible, which may be a result of lower jaw fracture or an acute exacerbation of a chronic condition, has a higher chance of developing into Ludwig’s angina.

Iatrogenic Causes

Iatrogenic means illness caused by medical examination or treatment. Use of contaminated instruments especially the contaminated needle used when administering local anesthesia, may cause Ludwig’s Angina.

Oral Malignancies

Secondary infections resulting from oral malignancies may develop into Ludwig’s angina.


Acute and chronic infections of the Submandibular and sublingual salivary glands or sialadenitis may also result in Ludwig’s cellulitis.

Miscellaneous Reasons

Following are some of the miscellaneous reasons that may result in Ludwig’s angina.

  • Tonsillar infections
  • Infections in the Pharynx region
  • Injuries caused by foreign bodies
  • Injuries caused inside the mouth

Signs and Symptoms

Depending on the severity of the case, the affected person may experience one or more of the following.

  • The individual may feel very ill and dehydrated.
  • Pyrexia – Raised body temperature or fever associated with chills.
  • Anorexia – Condition associated with low weight. It is an eating disorder.
  • Dysphagia or difficulty in swallowing
  • Difficulty in breathing
  • Difficulty in speaking
  • Increased saliva secretion
  • Raised tongue
  • Stiffness of the tongue
  • Hoarseness of voice
  • Massive swelling in the floor of the mouth or under the tongue.
  • Severe tenderness in the cellulitis area
  • Restricted mouth opening or trismus
  • Cyanosis may happen in severe cases. Cyanosis is a condition where the skin and mucous membranes turn blue due to low oxygen levels.
  • In very severe cases, death.

Complications of Ludwig’s Angina and Death

Death in Ludwig’s Angina is not uncommon. In untreated cases, the fatality rate is quite high, especially in the first 12 to 24 hours. However, recent advancements in the field of antibiotics have significantly lowered the death rate in Ludwig’s Angina patients.

Death in cases of Ludwig’s angina is usually a result of asphyxia. Asphyxia is a condition that results from a deprived Oxygen supply.

The other complications of Ludwig’s that may result in death are septicemia, mediastinitis, and aspiration pneumonia.

Carotid sheath involvement is another serious complication of Ludwig’s. The carotid sheath is a fascial layer that surrounds the internal jugular vein, the vagus nerve, the common and internal carotid arteries.

Ludwig’s Angina Treatment

As it is a life-threatening condition, emergency medical intervention is required.

The Treatment Plan

The recovery time of the patient depends on the early diagnosis of the condition. The earlier the diagnosis the faster the recovery and more chances of survival.

The most important thing the doctors may try to do when patients come to the hospital is to establish and maintain a patent airway to help the individual breath easily.

This will then be followed by the elimination of the cause of the disease. Once the cause is eliminated, surgical drainage and decompression of the abscess may be done which is then followed by intense and prolonged antibiotic therapy.

Establishing the Airway

This may be done using an endotracheal tube. As asphyxia is the main cause of death in Ludwig’s cellulitis, maintaining a patent airway is very important for the patient’s survival.

If endotracheal tube insertion isn’t possible due to the upper respiratory obstruction, the airway can be created surgically using procedures like Laryngotomy, and cricothyroidotomy (tracheotomy).

Surgical Intervention

Surgery may be done to remove the cause of Ludwig’s angina in the patient. As most causes are the odontogenic or dental origin, the removal of the offending tooth may be mandatory.

If the odontogenic infection isn’t the reason for the Ludwig’s, the treatment will depend on the nature of the causative agent.

Surgery may also be required for decompression purposes, which is done to relieve the pressure on the underlying structures that are created by cellulitis.

Antibiotic Prophylaxis

Aggressive and prolonged antibiotic prophylaxis may be required while managing a patient of Ludwig’s angina. IV antibiotics will be administered initially.

Penicillin is the drug of choice. If a person is allergic to Penicillin, Erythromycin may be used. Other drugs of choice while treating Ludwig’s may involve Cloxacillin, Gentamicin, Metronidazole, Cephalosporins, etc.

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This content is strictly the opinion of the author and is for informational and educational purposes only. It is not intended to provide medical/dental advice or to take the place of medical advice or treatment from a personal physician or a dentist. All readers/viewers of this content are advised to consult their doctors or qualified health professionals regarding specific health questions.

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