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Ludwig’s Angina – Spoon Feed Version

February 26, 2021

Written by Vivian Lei

Spoon Feed
Ludwig’s angina is a life-threatening infection of the floor of the mouth and requires prompt clinical recognition, airway evaluation, and treatment with broad-spectrum antibiotics and surgical source control.

Why does this matter?
This review article on the diagnosis and management of Ludwig’s angina is tailored to the emergency clinician.

This kind of angina gives me chest pain…

Risk factors: Recent dental infection, oral piercings, immunosuppression, malnutrition, diabetes mellitus, oral/dental trauma, injection drug use, chronic alcohol use

Pathophysiology: Polymicrobial infection of the submandibular and sublingual space resulting in tongue enlargement and elevation against the hypopharynx

Presentation: Fever, malaise, chills progressing to trismus, meningismus, drooling, dysphagia, and tripod positioning. Exam reveals tender, symmetric, tense, and indurated submandibular area with possible lingual swelling and elevation of the floor of the mouth.

Diagnosis: While diagnosis is clinical, CT of the neck with IV contrast can assist with diagnosis and extent of infection. The patient must be stable for imaging and able to lie supine. Point-of-care ultrasound may have a role in evaluating for fluid collections and airway involvement.


  • Perform serial assessments of airway and hemodynamics.

  • Immediate airway intervention for patients with significant airway swelling, dyspnea, or rapid progression

    • Emergent otolaryngology and anesthesia consults, if available

    • Preoxygenation

    • Awake nasotracheal intubation in seated position with flexible intubating endoscope and preparation for surgical cricothyrotomy (avoid blind nasotracheal or oral intubation due to risk of airway trauma and worsening edema, supraglottic airway devices are at risk for displacement due to swelling)

  • Broad spectrum antibiotics covering anaerobic, aerobic, and oral flora

  • Consider adjunctive steroids and nebulized epinephrine

  • Early surgical consultation for consideration of source control (otolaryngology or oromaxillofacial surgery)

  • Admission to intensive care

Diagnosis and management of Ludwig’s angina: An evidence-based review. Am J Emerg Med. 2020 Dec 23;41:1-5. doi: 10.1016/j.ajem.2020.12.030. Online ahead of print.

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