Ludwig’s Angina

Ludwig’s angina is an uncommon but important diagnosis not to be missed in patients attending the ED.


It is a potentially life threatening complication of untreated dental infection. It is a rapidly progressing submaxillary, submandibular, and sublingual necrotizing cellulitis and can lead to airway obstruction and death. It requires an early diagnosis and treatment which may include an urgent surgical airway if the airway is compromised [13].

Two thirds of cases of Ludwig’s angina are odontogenic, anterior teeth often being the starting site for sublingual infection and, 2nd and 3rd molars are a starting point for submaxillary space infection [14].


The presentation is variable, but symptoms such as dysphagia, neck pain and tooth pain, and signs such as tongue elevation and/or protrusion and neck swelling are all common [15]. Trismus is usually absent unless there is spread to parapharyngeal space. Patients frequently have co-morbidities such as diabetes, or are immunosuppressed.

There may also be signs of airway obstruction such as stridor and dyspnoea.


Swift recognition and aggressive and early intervention is paramount. Airway safety is the primary concern, followed by administration of intravenous antibiotics and consideration of surgical drainage.

It is vital that, in addition to a maxillofacial specialist, an experienced anaesthetist and otolaryngologist are involved. Antibiotic therapy should follow the guidance already outlined for dental abscess.

Learning bite

Ludwig’s angina can rapidly progress to airway compromise. Early recognition is the key to treatment.