Ahluwalia A, Crossman T, Smith H. Current training provision and training needs in oral health for UK general practice trainees: survey of General Practitioner Training Programme Directors. BMC Med Educ. 2016; 16

Boscolo-Rizzo P, Da Mosto MC. Submandibular space infection: a potentially lethal infection. Int J Infect Dis. 2009; 13:(3)327-33

Botha A, Jacobs F, Postma C. Retrospective analysis of etiology and comorbid diseases associated with Ludwig's Angina. Ann Maxillofac Surg. 2015; 5:(2)168-73

British Dental Association. Commissioning more urgent care slots for dental patients could reduce A&E pressure. 2017. (accessed 26 March 2019)

Candamourty R, Venkatachalam S, Ramesh Babu MR, Kumar GS. Ludwig's angina—an emergency: a case report with literature review. J Nat Sci Biol Med. 2012; 3:(2)206-208

Celakovsky P, Kalfert D, Tucek L Deep neck infections: risk factors for mediastinal extension. Eur Arch Otorhinolaryngol. 2014; 271:(6)1679-1683

Dental emergencies: basic science. 2017. (accessed 26 March 2019)

Crouch R, Patel A, Williams S, Dale J. An analysis of telephone calls to an inner city accident and emergency department. J R Soc Med. 1996; 89:(6)324-328

Compassion in practice: nursing, midwifery and care staff. Our vision and strategy. 2012. (accessed 26 March 2019)

Edetanlen BE, Saheeb BD. Comparison of outcomes in conservative versus surgical treatments for Ludwig's angina. Med Princ Pract. 2018; 27:(4)362-366

Eftekharian A, Roozbahany NA, Vaezeafshar R, Narimani N. Deep neck infections: a retrospective review of 112 cases. Eur Arch Otorhinolaryngol. 2009; 266:(2)273-7

Fallon L, Fleming MD Inflammation, 7th edn. In: Auday B, Buratovich MA, Marrocco GF, Moglia P (eds). : Salem Press; 2014

Diagnosis: Ludwig's angina. 2004.

A rare complication of tooth abscess—Ludwig's angina and mediastinitis. 2001.

Hasan W, Leonard D, Russell J. Ludwig's angina—a controversial surgical emergency: how we do it. Int J Otolaryngol. 2011; 2011

Health Education England, NHS Improvement, NHS England. Multi-professional framework for advanced clinical practice in England. 2017. (accessed 26 March 2019)

MacLeod's clinical examination, 14th edn. In: Innes JA, Dover AR, Fairhurst K (eds). Edinburgh: Elsevier; 2018

Kataria G, Saxena A, Bhagat S, Singh B, Kaur M, Kaur G. Deep neck space infections: a study of 76 cases. Iran J Otorhinolaryngol. 2015; 27:(81)293-299

Kurien M, Mathew J, Job A, Zachariah N. Ludwig's angina. Clin Otolaryngol Allied Sci. 1997; 22:(3)263-265

An adolescent with sore throat and odynphagia: a case report of Ludwig's angina. 2018.

Ludwig's angina: diagnosis and treatment. 2002.

Martini F, Nath JL, Bartholomew E. Fundamentals of anatomy and physiology, 10th edn. England: Pearson Education; 2015

McDonnough JA, Ladzekpo DA, Yi I, Bond WR, Ortega G, Kalejaiye AO. Epidemiology and resource utilization of Ludwig angina ED visits in the United States: 2006-2014.: The Laryngoscope; 2019

Ludwig's angina. GP Notebook. 2019. (accessed 27 March 2019)

Nasr IH, Papineni McIntosh A, Mustafa S, Cronin A. Professional knowledge of accident and emergency doctors on the management of dental injuries. Community Dent Health. 2013; 30:(4)234-240

National Institute for Health and Care Excellence. Algorithm for managing suspected sepsis in adults and young people aged 18 years and over in an acute hospital setting (tool to accompany NICE guideline 51). 2017. (accessed 16 April 2019)

Neff SP, Merry AF, Anderson B. Airway management in Ludwig's angina. Anaesth Intensive Care. 1999; 27:(6)659-661

Newcastle University Press Office. Study reveals multi-million pound price tag of toothache at A&E. 2017. (accessed 26 March 2019)

Pak S, Cha D, Meyer C, Dee C, Fershko A. Ludwig's angina. Cureus. 2017; 9:(8)

Samaei H, Weiland T, Dilley S, Jelinek G. Knowledge and confidence of a convenience sample of Australasian emergency doctors in managing dental emergencies: results of a survey'. Emerg Med Int. 2015; 2015

Shemesh A, Yitzhak A, Ben Itzhak J, Azizi H, Solomonov M. Ludwig angina after first aid treatment: possible aetiologies and prevention: case report. J Endod. 2019; 45:(1)79-82

Srirompotong S, Art-Smart T. Ludwig's angina: a clinical review. Eur Arch Otorhinolaryngol. 2003; 260:(7)401-403

Wingfield T. Promoting dental health among high risk groups. BMJ. 2015; 350

Winters S. A review of Ludwig's angina for nurse practitioners. J Am Acad Nurse Pract. 2003; 15:(12)546-549

Evidence-based diagnosis and management of ENT emergencies. 2007. (accessed 27 March 2019)

Ludwig's angina: a multidisciplinary concern

09 May 2019
Volume 28 · Issue 9


Although relatively uncommon, Ludwig's angina is a potentially life-threatening infection of the floor of the mouth and neck. There is a danger of airway obstruction by swelling in the area and displacement of the tongue, and patients are at risk of deterioration. There are many factors thought to place patients at an increased risk of developing the condition. These include recent dental treatment, dental caries or generally poor dentition, chronic disease such as diabetes, alcoholism and malnutrition, and patients with compromised immune systems (eg AIDS, organ transplantation). This article examines the aetiology of Ludwig's angina and considers the presentation, diagnosis and treatment of a patient who presented to an out-of-hours streaming area of a local emergency department, with an emphasis on the importance of a multidisciplinary approach. It also considers the need for ongoing education and awareness of health professionals to ensure the successful diagnosis, management and treatment of this condition, particularly in the context of patients with poor access to dental care presenting first to the emergency department.

Ludwig's angina is a potentially life-threatening infection of the submandibular, sublingual and submental spaces. It was first described by Wilhelm Friedrich von Ludwig, a German physician, in 1836, as a gangrenous induration of the soft tissues of the floor of the mouth and neck, with a ‘woody’ cellulitis (Winters, 2003). Peak incidence of the disease occurs between the ages of 20 and 40 years, predominantly in men (McMorran et al, 2019). There are many predisposing factors that are thought to place patients at an increased risk of developing the condition. These include recent dental treatment, dental caries or generally poor dentition, chronic disease such as diabetes, alcoholism, malnutrition, and a compromised immune system such as people with AIDS or following organ transplantation (Candamourty et al, 2012).

Since the introduction of antibiotics in the 1940s, with advances in surgical approaches and improved oral and dental hygiene, the mortality rate for Ludwig's angina, which once exceeded 50%, has reduced significantly (Saifeldeen and Evans, 2004; Lai and Pancer, 2018). By the 1990s, mortality rates were down to 10% or lower (Kurien et al, 1997; Neff et al, 1999). However, although they are now rare, deep neck infections are still potentially fatal (Furst et al, 2001; Boscolo-Rizzo and Da Mosto, 2009). Reviews of deep space neck infections have estimated the incidence of Ludwig's angina at between 4% (Srirompotong and Art-Smart, 2003) and 8% (Eftekharian et al, 2009). This drop in mortality and incidence is due to advances in both preventive and curative health care but it has now left many health professionals with increasingly limited experience of Ludwig's angina (Saifeldeen and Evans, 2004). Because it can rapidly deteriorate without immediate and adequate treatment, this now limited experience could increase the risk to patients, if a timely diagnosis is not given.

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