Ludwig Angina

Clinical History

The patient presents with fever and malaise, as well as mouth pain and dysphagia after right third molar extraction because of ongoing infection. On physical examination the patient has limited mouth opening and tender induration of the right submandibular region. As a predisposing factor, the patient had poor dental hygiene.

Imaging Findings

Contrast-enhanced CT shows a hypodense collection of fluid in the sublingual space near the third right molar tooth that represents an odontogenic abscess. There is loss of fat planes within the right submandibular space and oedema of the oropharynx.

Discussion

BACKGROUND: Ludwig's angina is an infection of the floor of the mouth (sub mandibular and sublingual space) [1]. It is an aggressive, rapidly spreading cellulitis with potential airway obstruction. The infection arises commonly from an infected second or third mandibular molar tooth, because these tooth apices extend inferiorly to the mandibular insertion of the mylohyoid muscle, allowing extension of infection into the submandibular space. Infection may spread into other fascial spaces of the neck and may lead to airway compromise and mediastinitis [2]. Predisposing factors include diabetes, poor dental hygiene, compromised immune status, and intravenous drug abuse [3].

CLINICAL PERSPECTIVE: The disease is usually precipitated by an odontogenic infection [4] but can be due to a penetrating trauma as well. Patients typically present with malaise, fever, chills, as well as mouth pain, stiff neck and dysphagia [5]. As the illness progresses, breathing difficulties can appear.
On physical examination, the patient usually has an open mouth because of lingual swelling and the floor of the oropharynx is usually elevated and erythematous. There may be tender induration in the submandibular area, and there can be lymphadenopathy [6].

IMAGING PERSPECTIVE: The imaging modality of choice is computed tomography (CT) [7] because of the availability in the urgent care, to evaluate for mass effect on the airway or drainable abscesses, as well as complications like mandibular osteomyelitis, spread of infection into the deep fascial spaces of the neck [2]. Infrequently, Ludwig’s angina has been documented to extend deeper into the soft tissues and progress to craniocervical necrotizing fasciitis (8). Key findings are swelling of the floor of the mouth with loss of fat planes within the submandibular space, and there can be focal fluid collections within the fascial spaces of the neck. Enlargement of the submandibular lymph nodes may also be seen. In a patient with Ludwig´s angina blood cultures should be obtained.

OUTCOME: Timely assessment and management of the airway is essential, as well as treatment with broad-spectrum antibiotics [5, 9]. Surgical drainage is important if a fluid collection is identified on imaging.

TAKE HOME MESSAGE: Ludwig´s angina is an aggressive, rapidly spreading cellulitis of the floor of the mouth. CT imaging is essential to support clinical suspicion, to describe spread inferiorly through fascial planes into the mediastinum and to indentify drainable fluid collections, as well as to rule out other complications, like craniocervical necrotizing fasciitis.

Differential Diagnosis List

Final Diagnosis

Ludwig's angina

URL:	https://www.eurorad.org/case/10202
DOI:	10.1594/EURORAD/CASE.10202
ISSN:	1563-4086