Ludwig’s angina in children is a rapidly progressive cellulitis of the submandibular, sublingual, and submental spaces, typically originating from odontogenic infections.
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Prompt recognition and multidisciplinary management are critical to reduce morbidity and mortality.
✅ Etiology and Pathophysiology
The condition usually arises from untreated dental caries affecting primary mandibular molars, leading to infection that spreads through fascial planes. The polymicrobial flora typically includes:
▪️ Streptococcus viridans
▪️ Anaerobic streptococci
▪️ Staphylococcus aureus
▪️ Bacteroides species
The infection causes bilateral submandibular swelling, elevation of the tongue, and progressive airway compromise.
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Compared to adults, children may present with more subtle early signs but deteriorate rapidly. Hallmark features include:
▪️ Firm, bilateral submandibular swelling
▪️ Elevated and posteriorly displaced tongue
▪️ Drooling and dysphagia
▪️ Fever and malaise
▪️ Respiratory distress (advanced cases)
Stridor, tachypnea, and cyanosis indicate impending airway obstruction.
Diagnosis
Diagnosis is primarily clinical. However:
▪️ Contrast-enhanced CT scan helps evaluate the extent of deep neck space involvement.
▪️ Laboratory findings often show leukocytosis and elevated inflammatory markers.
Imaging should not delay airway stabilization.
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1. Airway Management (Priority)
Immediate assessment of airway patency
Early involvement of anesthesiology
Consider fiberoptic intubation
Surgical airway (tracheostomy) if intubation fails
2. Intravenous Broad-Spectrum Antibiotics
Empirical therapy should cover aerobic and anaerobic organisms.
Recommended regimens include:
▪️ Ampicillin–sulbactam
▪️ Clindamycin
▪️ Ceftriaxone + metronidazole
Therapy is adjusted based on culture results.
3. Surgical Intervention
▪️ Incision and drainage when abscess formation is identified
▪️ Removal of odontogenic source (e.g., extraction of infected primary tooth)
4. Supportive Care
▪️ Hospital admission
▪️ Intravenous fluids
▪️ Continuous monitoring in severe cases
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Although rare, Ludwig’s angina in children remains a potentially fatal condition. Early antibiotic therapy alone may be insufficient if airway compromise develops. Studies emphasize that airway protection is the cornerstone of management, followed by aggressive antimicrobial therapy and elimination of the infection source.
Preventive dentistry plays a crucial role, as most pediatric cases originate from untreated carious lesions.
🎯 Clinical Recommendations
▪️ Treat odontogenic infections promptly in pediatric patients
▪️ Refer immediately if bilateral submandibular swelling is observed
▪️ Never underestimate early tongue elevation or drooling
▪️ Initiate empirical IV antibiotics without delay in suspected cases
▪️ Manage patients in hospital settings with airway monitoring
✍️ Conclusion
Ludwig’s angina in children is a life-threatening deep neck infection requiring rapid diagnosis and multidisciplinary management. Early airway control, intravenous broad-spectrum antibiotics, and elimination of the infectious source are essential to prevent fatal complications. Preventive dental care remains the most effective strategy to reduce incidence.
📊 Comparative Table: Clinical Signs and Symptoms of Ludwig’s Angina in Children
| Clinical Sign or Symptom | Pathophysiological Significance | Clinical Severity Indicator |
|---|---|---|
| Bilateral submandibular swelling | Spread of cellulitis across fascial planes | Early to moderate stage |
| Elevated and posteriorly displaced tongue | Floor-of-mouth edema causing airway narrowing | Moderate to severe stage |
| Drooling and dysphagia | Impaired swallowing due to sublingual space involvement | Progressive infection |
| Stridor and respiratory distress | Critical airway obstruction | Life-threatening emergency |
✔ Britt, J. C., Josephson, G. D., & Gross, C. W. (2000). Ludwig’s angina in the pediatric population: Report of a case and review of the literature. International Journal of Pediatric Otorhinolaryngology, 52(1), 79–87. https://doi.org/10.1016/S0165-5876(99)00256-1
✔ Boscolo-Rizzo, P., & Da Mosto, M. C. (2009). Submandibular space infection: A potentially lethal infection. International Journal of Infectious Diseases, 13(3), 327–333. https://doi.org/10.1016/j.ijid.2008.06.007
✔ Lin, H. W., O’Neill, A., Cunningham, M. J. (2009). Ludwig’s angina in the pediatric population. Clinical Pediatrics, 48(6), 583–587. https://doi.org/10.1177/0009922809332689
✔ Rosen, T., & Vokes, D. (2018). Deep neck space infections. In: Flint, P. W., et al. (Eds.), Cummings Otolaryngology: Head and Neck Surgery (7th ed.). Elsevier.
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