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Swelling in submandibular area in patient with Ludwig's angina

Ludwig's angina, otherwise known as angina ludovici, is a serious, potentially life-threatening cellulitis, or connective tissue infection, of the floor of the mouth, usually occurring in adults with concomitant dental infections. It is named after the German physician, Wilhelm Friedrich von Ludwig who first described this condition in 1836. Other names include "angina Maligna" and "Morbus Strangularis."

Ludwig's angina should not be confused with angina pectoris, which is also otherwise commonly known as "angina". The word "angina" comes from the Greek word ankhon, meaning "strangling", so in this case, Ludwig's angina refers to the feeling of strangling, not the feeling of chest pain, though there may be chest pain in Ludwig's angina if the infection spreads into the retrosternal space.

The cause is usually an infection with Streptococcus spp, although other bacteria can cause the condition. Since the advent of antibiotics, Ludwig's angina has become a rare disease.Causes

The route of infection in most cases is from infected lower third molars or from pericoronitis, which is an infection of the gums surrounding the partially erupted lower third molars. Although the widespread involvement seen in Ludwig's is usually develops in immunocompromisedpersons, it can also develop in otherwise healthy individuals. Thus, it is very important to obtain dental consultation for lower-third molars at the first sign of any pain, bleeding from the gums, sensitivity to heat/cold or swelling at the angle of the jaw.

Ludwig's angina is also associated with piercings of the lingual frenulum.

Symptoms

The symptoms include swelling, pain and raising of the tongue, swelling of the neck and the tissues of the submandibular and sublingual spaces, malaise, fever, dysphagia (difficulty swallowing) and, in severe cases, stridor or difficulty breathing. Swelling of the submandibular and/or sublingual spaces are distinctive in that they are hard and classically 'boardlike'. Important signs include the patient not being able to swallow his/her own saliva and the presence of audible stridor as these strongly suggest that airway compromise is imminent.

Treatment

Treatment involves appropriate antibiotic medications, monitoring and protection of the airway in severe cases, and, where appropriate, urgent maxillo-facial surgery and/or dental consultation to incise and drain the collections. A nasotracheal tube is sometimes warranted for ventilation if the tissues of the mouth make insertion of an oral airway difficult or impossible. In cases where the patency of the airway is compromised, skilled airway management is mandatory. This entails management of the airway according to the American Society of Anesthesiologists' "Difficult Airway Algorithm" and necessitates fiberoptic intubation.