Ludwig's Angina - The Emergency Medical Minute

Ludwig's Angina

Chief Complaint:

Neck and jaw pain


32-year-old female with a history of IV drug use, last injected methamphetamine 2 days ago, presents for 1 day of right-sided neck and jaw pain with associated swelling. She denies trauma, dental pain and sore throat. She states the pain started around lunchtime yesterday and that she is now having trouble swallowing, talking and breathing. She also has a chronic cough, which she attributes to her asthma. She denies a measured fever but has had chills and subjective warmth. She states the right side of her neck and jaw swelled up a few weeks ago but resolved on its own and is not similar to her presentation today. She states she is worried she may have thyroid cancer as her underlying cause of symptoms.

Pertinent Exam Findings:

General Appearance: Acutely ill appearing
ENT: Two finger trismus, hoarse voice Indurated submandibular and sublingual space
Cardiac: Tachycardic without any murmurs. She does not have any Janewy lesions or Osler nodes
Respiratory: Tachypneic

ED Course:

Anesthesia paged to assist with airway.

Spoke with ENT. Discussed full facts of the case and that CT scan was pending as we needed to intubate the patient prior. Patient is unable to lay flat secondary to respiratory distress. ENT agreed with IV antibiotics and stated they would see the patient in the morning.

Patient had glycopyrrolate, ketamine, benzocaine, nebulized lidocaine and an awake intubation was performed. The patient was orotracheally intubated with 6.5 mm ET tube using glidescope blade with partial identification of the airway anatomy which was obstructed by edema.

She was given IV vancomycin and Zosyn. She was admitted to the intensive care unit, intubated for airway protection and ENT consulted.

Hospital Course:

ENT drained a right submandibular gland abscess and right submental abscess. There was a large amount of purulent debris. A penrose drain was placed. Vancomycin and Zosyn were continued, and infectious disease followed.

A persistent right submandibular gland abscess was noted and the patient was taken to the operating room again on day 6. The patient was discharged from the hospital on day 10 on Augmentin with ENT follow-up.

Data Interpretation:

SALIVARY GLANDS: Asymmetric enlargement and edema associated with the right parotid and right submandibular glands. There is also extensive skin thickening throughout the right face and right preauricular regions, with associated subcutaneous stranding/edema extending along the platysm muscle, caudally along the sternocleidomastoid muscle nearly to the sternal notch. In addition, there is a relatively discrete focus of fluid attenuation in the right submandibular space, anterior to the gland, which measures 1.3 x 1.2 x 1.6 cm (transverse X AP X CC). No definitive rim enhancement is seen. Inflammatory stranding and edema is seen throughout the sublingual spaces right greater than left, and throughout both submandibular spaces right greater than left. Both of the anterior belly digastric muscles appear enlarged and hypodense suggestive of edema.
Submucosal edema along the posterior wall of the oropharynx and hypopharynx. Scattered mild prevertebral edema is also present. No discrete rim-enhancing retropharyngeal fluid collection identified.



Ludwig’s Angina (LA) is a rare infection of the submandibular space, which is a potential space consisting of the sublingual and submylohyoid space. One study reviewed cases of LA between 2006 and 2014 and identified 68,770 cases presenting to emergency departments in the United States. The most common etiology for LA is odontogenic infection, most often associated with the mandibular molars, which accounts for close to 70% of all cases. Other causes and risk factors include recent oral or dental trauma, peritonsillar abscess, oral piercings, sialadenitis, diabetes mellitus, and an immunocompromised state. The infection is often polymicrobial with V. streptococci being the most common (40% of cases) followed by S. aureus, S. epidermidis, and a variety of anaerobes.

First described by Karl Friedrich Wilhelm von Ludwig in 1836, LA was a diagnosis with a high mortality rate as it is rapidly spreading and can occlude the airway if left untreated. Mortality has significantly decreased with the discovery of antibiotics, but LA still remains a potentially life-threatening infection. Prompt recognition and treatment of Ludwig’s Angina is necessary in the emergency department due to the high mortality and rapid progression of the infection if left untreated.


The diagnosis of Ludwig’s Angina is predominantly a clinical diagnosis. Initially patients may present with fever, malaise, chills, and mouth pain. Later on in the course the patient may present with drooling, dysphagia, trismus, neck stiffness, stridor, and/or tripoding. On exam the patient may have a tender “woody” indurated submandibular area as well as lingual swelling. There is some utility in imaging, but it’s not necessary to make the diagnosis. Furthermore, imaging should never delay treatment or interfere with airway management.

Computed Tomography (CT) of the neck with intravenous (IV) contrast is the preferred imaging modality with findings that may include soft tissue thickening, increased attenuation of subcutaneous fat, loss of fat planes in submandibular space, gas in the soft tissues, fluid collections, and muscle edema. The sensitivity and specificity of CT in diagnosing LA is 95% and 53% respectively with the specificity increasing to 80% when combined with clinical examination. Magnetic Resonance Imaging (MRI) can be done but is time consuming and difficult to obtain in the emergency setting. Point of care ultrasound is a reliable and readily available diagnostic tool that can assess the extent of airway involvement.

Management in ED:

Once the diagnosis of Ludwig’s Angina has been established, it is imperative that timely assessment of the airway and initiation of empiric broad-spectrum antibiotics occurs. Most cases will be adequately managed by antibiotics and observation, but ENT should be emergently consulted if airway compromise is suspected and OMFS should be consulted if dental abscess is the suspected source of infection. If the airway is compromised, it is recommended that fiberoptic nasal intubation be attempted. This is due to the difficulty and risk associated with blind oral or nasal intubation as an effect of posterior pharyngeal extension and trismus preventing visualization of the epiglottis. Be prepared to perform emergency cricothyrotomy in the event that intubation is unsuccessful or unable to be done. Antibiotic treatment should be tailored based on suspicion of typical offending agents or as data becomes available regarding bacterial cultures. For most immunocompetent patients, acceptable treatment regimens include ampicillin-sulbactam with ceftriaxone and metronidazole as well as clindamycin plus levofloxacin. Immunocompromised patients should have their treatment broadened to antibiotics such as imipenem, meropenem, or piperacillin-tazobactam. If risk of MRSA is suspected, vancomycin or linezolid should also be considered. Patients with Ludwig’s Angina and potential airway involvement not requiring surgery are typically admitted to the ICU for airway monitoring.


Ludwig’s Angina historically carried an approximately 50% mortality rate until the discovery of antibiotics and CT imaging allowed for enhanced detection of these infections and airway compromise. These advances dropped the mortality rate to as low as around 1% according to some sources. As prognosis is dependent on the prompt recognition of the infection, initiation of appropriate antibiotics, and proper airway management, emergency physicians need to be familiar with Ludwig’s Angina.

Differential Diagnoses:

    • Retropharyngeal abscess
    • Angioedema
    • Peritonsillar abscess
    • Strep pharyngitis
    • Bacterial tracheitis
    • Lemierre’s syndrome
    • Upper respiratory infection
    • Herpangina
    • Infectious mononucleosis
    • Stevens-Johnson syndrome
    • Epiglottitis
    • Parotitis
    • Vincent’s angina
    • Acute necrotizing ulcerative gingivitis

Clinical Pearls:

    • Ludwig’s Angina is a can’t miss diagnosis usually presenting with trismus and a tender, indurated submandibular space
    • CT imaging or bedside ultrasound can help characterize the infection, but the diagnosis is predominantly clinical
    • Prompt initiation of antibiotics and airway management are life saving for these patients
    • Fiberoptic nasal intubation or emergent cricothyrotomy may be needed to establish an airway in severe infection
    • Consultation with ENT or OMFS is indicated


  1. Barakate MS, Jensen MJ, Hemli JM, Graham AR. Ludwig’s angina: report of a case and review of management issues. Ann Otol Rhinol Laryngol. 2001;110(5 Pt 1):453-456. doi:10.1177/000348940111000511
  2. Barton ED, Bair AE. Ludwig’s angina. J Emerg Med. 2008;34(2):163-169. doi:10.1016/j.jemermed.2007.08.053
  3. Boscolo-Rizzo P, Da Mosto MC. Submandibular space infection: a potentially lethal infection. Int J Infect Dis. 2009;13(3):327-333. doi:10.1016/j.ijid.2008.07.007
  4. Bridwell R, Gottlieb M, Koyfman A, Long B. Diagnosis and management of Ludwig’s angina: An evidence-based review. Am J Emerg Med. 2021;41:1-5. doi:10.1016/j.ajem.2020.12.030
  5. Furst IM, Ersil P, Caminiti M. A rare complication of tooth abscess–Ludwig’s angina and mediastinitis. J Can Dent Assoc. 2001;67(6):324-327.
  6. McDonnough JA, Ladzekpo DA, Yi I, Bond WR Jr.,, Ortega G, Kalejaiye AO. Epidemiology and resource utilization of ludwig’s angina ED visits in the United States 2006-2014. Laryngoscope. 2019;129(9):2041-2044. doi:10.1002/lary.27734
  7. Miller WD, Furst IM, Sàndor GK, Keller MA. A prospective, blinded comparison of clinical examination and computed tomography in deep neck infections. Laryngoscope. 1999;109(11):1873-1879. doi:10.1097/00005537-199911000-00029
  8. Parhiscar A, Har-El G. Deep neck abscess: a retrospective review of 210 cases. Ann Otol Rhinol Laryngol. 2001;110(11):1051-1054. doi:10.1177/000348940111001111
  9. Reynolds SC, Chow AW. Life-threatening infections of the peripharyngeal and deep fascial spaces of the head and neck. Infect Dis Clin North Am. 2007;21(2):557-viii. doi:10.1016/j.idc.2007.03.002
  10. Zawiślak E, Nowak R. Odontogenic Head and Neck Region Infections Requiring Hospitalization: An 18-Month Retrospective Analysis. Biomed Res Int. 2021;2021:7086763. Published 2021 Jan 18. doi:10.1155/2021/7086763


Aaron Wolfe, DO, FACEP, Director of Education for Emergency Medical Minute and Clinical Associate Faculty for Rocky Vista University College of Osteopathic Medicine

Jack Spartz MSIV

Peter Haskins MSIV

Josh Wahba MSIV


Stay up to date by
joining our mailing list!