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Ludwig’s Angina
Ludwig’s Angina

Ludwig’s Angina


This is a serious life threatening generalized septic cellulitis of the fascia spaces found on the floor of the mouth and tongue. It is an extension of infection from mandibular molar teeth into the floor of the mouth covering the submandibular, sublingual and submental spaces bilaterally.



Signs and symptoms

• Pain or tenderness in the mouth floor
• Difficulty swallowing
• Problems with speech
• Neck pain and swelling
• Redness on the neck
• Weakness and fatigue
• An earache
• Tongue swelling
• A fever
• Chills
• Drooling

Diagnostic criteria

• Brawny induration
• Tissues are swollen, board like, not pitted and no fluctuance
• Respiratory distress
• Dysphagia
• Tissues may become gangrenous with a peculiar lifeless appearance on cutting
• Three fascia spaces are involved bilaterally (submandibular, submental and sublingual)


Diagnosis is done by physical examination
CT scan or MRI may be done
Culture and sensitivity may be indicated for patient who do not respond to treatment



    • Quick assessment of airway
    • Incision and drainage is done (even in absence of pus) to relieve the pressure and allow irrigation.
    • Only when the airway distress is significant and there is evidence that it is not relieved by incision and drainage then tracheostomy is needed
    • Supportive care includes high protein diet and fluids for rehydration and detoxification
    • During incision and drainage pus should be taken for culture and sensitivity. Offending tooth should be removed at the same sitting if the patient can open the mouth.


    • Ampicillin 500 mg IV 6 hourly for 5 days
    • Amoxicillin + clavulanic acid 625mg (PO) 8 hourly for 5 days
    • Metronidazole 500mg IV 8 hourly for 5 days

    If allergic to penicillin use

    • Erythromycin (PO) 500mg 6 hourly for 5 days
    • Ceftriaxone 1gm IV once a day for 5 days in case of severe infection.

    Once the patient is able to swallow replace IV medicines with oral treatment.

    Note: For this condition and other life-threatening oral conditions consultation of available specialists (especially oral and maxillofacial surgeons) should go parallel with life saving measures.


Updated on,

4 Novemba 2020 07:34:38


2.Uptodate. Submandibular space infection. Accessed 04.11.2020
3. Medical news today. Dental abscess. Accessed 04.11.2020

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