Ludwig's angina: a multidisciplinary concern

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.