Ludwig’s Angina

Epidemiology

The term Ludwig’s angina refers to cellulitis involving the SLS. In 1939 Grodinsky put forward the diagnostic criteria for this clinical entity: (1) involvement of both submandibular and sublingual spaces either unilaterally or bilaterally; (2) the formation of serosanguinous phlegmon or gangrene but without the formation of abscess; (3) involvement of connective tissues, fascia, and muscles but not the submandibular or sublingual glands; and (4) disease propagation by direct extension (without the involvement of lymphatics). The presence of an odontogenic infection is common and should be evaluated in all cases. Because the SLS is an enclosed space, one can consider the progressive inflammation and phlegman a “compartment syndrome” of the SLS. Advanced cases will result in airway obstruction.

Clinical Findings

Patients usually present with pain, tenderness, and swelling of the floor of mouth. Progression of disease will result in laryngeal edema and resultant airway obstruction. In neglected cases, Ludwig’s angina may spread inferiorly through fascial planes into the mediastinum. Hence, some patients may present with chest pain.

Pathology

Cellulitis of the floor of mouth is usually secondary to infection of the mandibular molars in as high as 90% of the cases. This infection is usually due to Streptococcus or Staphylococcus.