Ludwig’s angina is a rapidly progressive, life-threatening deep neck infection that primarily involves the submandibular, sublingual, and submental spaces.
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✅ Characteristics of Ludwig’s Angina
Ludwig’s angina is characterized by:
▪️ Bilateral involvement of submandibular spaces
▪️ Diffuse cellulitis rather than localized abscess formation
▪️ Rapid spread along fascial planes
▪️ High risk of airway obstruction
In children, the disease may progress more quickly due to looser connective tissue planes and smaller airway diameter, increasing morbidity if diagnosis or treatment is delayed.
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The condition most commonly originates from:
▪️ Untreated dental caries
▪️ Periapical infections of mandibular molars
▪️ Failed dental extractions
▪️ Periodontal infections
The infection spreads inferiorly and medially from the mandibular molars into the submandibular and sublingual spaces, potentially extending to the parapharyngeal and mediastinal regions.
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➤ Local Signs
▪️ Bilateral submandibular swelling
▪️ Firm, indurated floor of the mouth
▪️ Elevation and posterior displacement of the tongue
▪️ Trismus
▪️ Dysphagia
➤ Systemic Signs
▪️ Fever
▪️ Tachycardia
▪️ Toxic appearance
▪️ Malaise
➤ Airway Warning Signs
▪️ Drooling
▪️ Muffled or “hot potato” voice
▪️ Stridor
▪️ Respiratory distress
These findings indicate imminent airway compromise and require immediate intervention.
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Diagnosis is primarily clinical, supported by:
▪️ Contrast-enhanced CT scan to evaluate extension
▪️ Laboratory findings: leukocytosis, elevated CRP
▪️ Identification of odontogenic source
Imaging should never delay airway management.
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Surgical intervention is indicated when:
▪️ Airway compromise is present
▪️ There is lack of response to antibiotics
▪️ Abscess formation is suspected
Key surgical principles include:
▪️ Early airway protection (endotracheal intubation or tracheostomy)
▪️ Wide surgical drainage of involved spaces
▪️ Removal of the odontogenic source (extraction of the infected tooth)
▪️ Placement of surgical drains
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Empirical intravenous antibiotic therapy should cover aerobic and anaerobic bacteria, including streptococci and oral anaerobes.
Common regimens include:
▪️ Ampicillin–sulbactam
▪️ Clindamycin (especially in penicillin-allergic patients)
▪️ Piperacillin–tazobactam in severe cases
Antibiotic therapy should be adjusted based on culture results when available.
📊 Comparative Table: Hospital Admission Criteria in Pediatric Odontogenic Infections
| Clinical Finding | Clinical Significance | Risk if Untreated |
|---|---|---|
| Airway compromise | Indicates imminent respiratory obstruction | Asphyxia, cardiac arrest |
| Rapidly spreading facial or neck swelling | Suggests deep fascial space involvement | Mediastinal extension, sepsis |
| Systemic toxicity | Indicates severe infection | Septic shock |
| Inability to tolerate oral intake | Risk of dehydration and aspiration | Clinical deterioration |
Ludwig’s angina remains a medical and surgical emergency, particularly in pediatric patients. Delayed recognition of odontogenic infections significantly increases the risk of airway obstruction, sepsis, and mortality. A multidisciplinary approach involving pediatric dentistry, maxillofacial surgery, pediatrics, and anesthesiology is essential for optimal outcomes.
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Ludwig’s angina in children is a rare but potentially fatal odontogenic infection. Early identification, prompt airway management, aggressive antibiotic therapy, and timely surgical intervention are fundamental to reducing complications and mortality.
🎯 Clinical Recommendations
▪️ Treat dental infections aggressively in pediatric patients
▪️ Educate caregivers about warning signs of deep neck infections
▪️ Do not delay hospital referral when airway symptoms appear
▪️ Ensure close postoperative and dental follow-up
📚 References
✔ Brook, I. (2018). Microbiology and management of deep facial infections and Ludwig’s angina. Journal of Oral and Maxillofacial Surgery, 76(8), 1683–1691. https://doi.org/10.1016/j.joms.2018.02.014
✔ Moreland, L. W., Corey, J., & McKenzie, R. (2019). Ludwig’s angina: Report of a case and review of the literature. Archives of Internal Medicine, 149(2), 461–466.
✔ Saifeldeen, K., & Evans, R. (2004). Ludwig’s angina. Emergency Medicine Journal, 21(2), 242–243. https://doi.org/10.1136/emj.2003.012336
✔ American Academy of Pediatric Dentistry. (2023). Management of acute dental infections. Pediatric Dentistry, 45(6), 389–398.
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