Page 12 - GP fall 2023

Ludwig’s Angina: A Case Report

Author: Joseph DiDonato, III, DDS, MBA, FAGD

History of Ludwig’s Angina penicillin to combat lactamase-producing consult when she presented for a limited
Ludwig’s angina is a potentially life-threat- Bacteroides species. In patients sensitive dental exam to address the chip on tooth
5
ening infection that can arise from the man- to penicillin, clindamycin is the recom- #31 distal. The patient could not remember
dibular teeth or the floor of the mouth and mended substitute. In all patients, bacte- if a restoration had been accomplished for
move into the mediastinum causing airway riological investigations to determine cul- #31 and the first visual exam revealed a full
obstruction, cardiac decompensation, and ture and sensitivities should be done when adult dentition, with minimal plaque and a
death. The infection is a progressive nec- possible. In the event that mandibular teeth very small chip on the distal ridge of #31,
1
rotizing cellulitis of the floor of the mouth, are demonstrated as the cause, immediate perhaps in a composite filling (Figure 1).
the throat, and the neck that, in advanced surgical removal with debridement of the
stages, can cause swelling of the neck, air- surgical site can be the fastest step toward
way obstruction, and septic shock. Diagno- definitive treatment.
sis requires a critical clinical examination,
radiographic survey, and clinical history. Among the list of risks for Ludwig’s, clini-
Definitive treatment may include antibiotic cians should consider recent oral (tongue)
therapy, debridement of the infected areas, piercings, along with dental infection, im-
excision of the necrotic tissue, and drain- munosuppression, malnutrition, diabetes 31
age of purulent material. mellitus, oral or dental trauma, injection
drug use, and chronic alcohol use.
Ludwig’s angina was first described in 31
1836 by Wilhelm Friedrich von Ludwig, In recent years the advent of cone beam
a German physician. Ludwig was a medi- computerized tomography (CBCT) has 31
cal prodigy achieving his doctorate at age given dentistry a new tool for radiographic
21 and rising to become recognized as an survey and diagnosis of odontogenic infec-
astute diagnostician. His characterization tions that have perforated the lingual plate
of the disease, at a time when radiograph- in the area of the mandibular molars. Per- Figure 1. Photo showing #31.
ic survey was not available, included a foration, as seen on the CBCT, is a critical Figure 1. Photo showing #31.
detailed account of the oral manifesta- finding and should trigger immediate an-
tion, usually unilateral, the progression to tibiotic and, if possible, surgical interven- As part of the exam, a bitewing x-ray was
the posterior throat, and the swelling that tion. If the airway is compromised, there initially attempted (Figure 2). The patient
Figure 1. Photo showing #31.
displaces the tongue into the pharyngeal must be an immediate referral for urgent Figure 1. Photo showing #31.
space. care, airway observation, and support.
“The tongue rests upon a red, indurated Case Presentation
mass which feels like a hard ring adjacent The patient is a 28-year-old female who
to the inner surface of the jaw bone. Open- presented upon the advice of her physician. #31
ing the mouth becomes difficult and pain- She had not been to see a dentist in over
ful; speech is impaired, hoarse, and has a four years and had no dental complaints
throaty quality. This is because the tongue other than a small ‘chip’ on the distal of
is pressed upwards and backwards, there is #31. The patient was asymptomatic. Clin-
pressure upon the larynx, and the smaller ical and radiographic examination revealed #31
throat muscles are involved. Swallowing is no temperature sensitivity, lymphadenop-
#31
definitely difficult and requires great effort athy, or pericementitis. She had been fol- Figure 2. Initial bitewing radiograph.
on the part of all the neck muscles.” 2 lowed for six months with a series of vague had a difficult time with the x-ray and could
Figure 2. Initial bitewing radiograph.
complaints that was currently under inves-

Ludwig described the condition as ‘a pe- tigation. not open wide enough to accommodate the
culiar hardness of the involved tissue; hard standard sensor. However, enough of tooth
swelling beneath the tongue; well defined, Initially, the patient presented to her phy- #31 could be seen that a larger-than-ex-
pected restoration was present. A second
firm edema of the neck; and (interesting- sician complaining of neck crepitus and a
Figure 2. Initial bitewing radiograph.
ly) absence of glandular involvement.’ He slight burning sensation on the right side attempt proved equally as difficult but did
3

reported that death usually occurred within of the neck in the carotid triangle. Some reveal a much larger restoration with sec-
10 to 12 days. In the era before antibiot- two months later, she reported the burning ondary caries (Figure 3).
Figure 2. Initial bitewing radiograph.
ics, Ludwig’s angina may have had a 50% sensation had decreased but that she felt a
mortality rate. A year later, a colleague nodule at the base of her tongue. During the
4

penned the name ‘angina Ludovici’ (Lud- next month, she reported an altered sensa-
wig’s angina), derived from the Latin ‘an- tion in the posterior pharynx followed by a
gere’, meaning ‘to strangle’. In the original slight discomfort in the center of her chest.
paper, there is no mention of the etiology She did not report any airway obstruction
or of an identification of the dentition as a but did have anxiety taking deep breaths.
source. This was described as a feeling of “height-
ened anxiety|”, which the patient had dif-
Currently, penicillin is the antibiotic of ficulty localizing and characterizing. In an Figure 3. Next attempt of a bitewing radiograph.

choice to target gram-positive cocci, while attempt to support the anxiety complaint,
metronidazole should be combined with the patient was in line for a psychological
www.nysagd.org l Fall 2023 l GP 12 Figure 3. Next attempt of a bitewing radiograph.
Figure 3. Next attempt of a bitewing radiograph.

Figure 3. Next attempt of a bitewing radiograph.