Ludwig Angina

Fig 1: Axial contrast-enhanced CT image shows extensive subcutaneous inflammatory change, fluid (yellow stars) in the left submandibular space. There are enlarged and inflamed left sternocleidomastoid (arrow) and left mylohyoid muscles (green star). Several drains (arrowheads) are present. The patient is intubated.
Fig 2: Coronal-reformatted CT image shows similar findings in the left submandibular region (arrow and yellow stars). There are several fluid collection in the superior mediastinum (red stars).

Facts:

• Ludwig is a name of a German surgeon who first described this condition in 1836; angina in Latin means "to strangle"
• Infection of the submandibular space usually preceded by odontogenic infection (particularly when the 2nd or third molar involved). The infection extends inferiorly to mandibular insertion of the mylohyoid muscle, then spreads into the submandibular space and then along neck fascial planes.
• Common cause: mixed aerobic and anaerobic bacteria (normal oral flora)
• Male, 20-40 years old
• Preceding odontogenic infection, peritonsillar abscess, mandible fracture or other facial trauma
• Currently, mortality is about 10%

How to Diagnose

Suggested diagnostic criteria: cellulitis (not need to be abscess), submandibular space (bilateral or unilateral), gangrene with foul serosanguinous fluid on incision, fascia-muscle-connective tissue involvement and sparing of glands, direct spread rather than by lymphatics

How Infection Gets to Other Spaces

Submandibular space connects with other spaces, including parapharyngeal, retropharyngeal spaces. These spaces also connect with other deep spaces of the neck. These are also interconnected with the mediastinum (therefore Ludwig angina can cause acute mediastinitis, empyema and pericarditis).

Our case: Ludwig angina causing acute mediastinitis and empyema.

References:

1. Rosen EJ, Bailey BJ. Deep neck spaces and infections. University of Texas Medical Branch at Galveston Website.

2. Marcus BJ, et al. A case of Ludwig angina. Am J Forensic Med Pathol 2008;23:255-259.