Ludwig's angina

Ludwig's angina, otherwise known as angina ludovici, is a serious, potentially life-threatening infection of the tissues of the floor of the mouth, usually occurring in adults with concomitant dental infections. It is named after the German physician, Wilhelm Frederick von Ludwig who first described this condition in 1836.

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.

Causes
The cause is usually a bacterial infection, most often streptococci or staphylococci, although other bacteria can also cause this. Since the advent of antibiotics, Ludwig's angina has become a rare disease.

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 wide-spread involvement seen in Ludwig's is usually seen to develop in persons with a state of lowered immunity, it can develop in otherwise healthy individuals also. 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.

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.

Trivia
It is believed that Elizabeth I of England died of Ludwig's angina in 1603. This conclusion is speculative but is based on ex-post facto analysis of contemporary accounts of her symptoms in the last weeks of her life.