CASE

An 8-year-old female presented to the Pediatric Emergency Department (PED) for evaluation of left-sided facial swelling, facial erythema, and fever for three days. Patient’s mother noted that the patient was having left-sided mandibular tooth discomfort for several weeks and was scheduled for an upcoming root canal. The patient developed increasing pain and swelling on the affected side and was prescribed oral antibiotics for a presumed odontogenic infection by her dentist. On the day of, she was experiencing increased pain, redness, swelling, and trismus and developed a fever.

She had no past medical or surgical history, no pertinent family history, took no medications and had no known allergies to medications or food.

In the PED, her vital signs showed fever (100.8 °F), tachycardia (126 BPM), and tachypnea (RR 24). Her blood pressure and SpO2 were within normal limits. On physical exam, she appeared uncomfortable, tearful, anxious, and in mild distress secondary to pain. Airway was patent. She had a large area of swelling and erythema to the left lower face that was warm and tender to the touch. The submandibular space on the left was mildly firm and indurated but was soft on the right. There was no fluctuance or lymphadenopathy. One finger trismus was present but the patient was not drooling and was managing her secretions.

Because of the patient’s abnormal vital signs and the above physical exam findings, there was concern for Ludwig’s angina.

Labs were unremarkable. Dental was consulted who recommended CT neck with IV contrast and oral surgical consultation. The patient was started on Ampicillin-Sulbactam and made NPO. Dexamethasone and Ketorolac were administered and she was admitted to the pediatric hospitalist for further management.

DIAGNOSIS

Small periapical abscesses at the left third mandibular space with adjacent facial soft tissue swelling but no drainable collections. Left submandibular sialadenitis.

Discussion

While this case was not Ludwig’s angina, it is important to review the typical findings and management as this is a cannot miss diagnosis. Ludwig’s angina is a potentially life-threatening, diffuse, bilateral, cellulitis of the submandibular and sublingual spaces of the mouth. It is most commonly caused by odontogenic infections in adults; however, in children, upper respiratory infections are the leading cause. Poor dental hygiene, diabetes, obesity, malnutrition, alcoholism, NSAID use, immunosuppression, and trauma are all risk factors for the development of Ludwig’s angina. [1, 2]

The floor of the mouth is made up by the division of the submandibular space into the sublingual and the submylohyoid spaces by the mylohyoid muscle. Infection spreads due to the roots of the mandibular teeth lying below the mylohyoid-mandibular attachments and enters the submylohyoid space where it tracts superiorly and posteriorly into the sublingual and submandibular space. Life-threatening pathology occurs when tongue swelling and elevation begin to obstruct the hypopharynx and edema of the epiglottis, vocal cords, and aryepiglottic folds culminate in airway obstruction. [2]

Figure 1. Anatomy of the floor of the mouth [3]

The infection is most commonly polymicrobial with Viridans streptococci making up the majority of cases (40%). Staphylococcus aureus (27%) and Staphylococcus epidermidis (23%) make up most of the remaining number of cases. Other commonly involved bacteria include Enterococcus species, E. coli, Fusobacterium, Streptococcus species, Klebsiella, Peptostreptococcus, Bacteroides, and Actinomyces species. [1, 2, 4]

History may reveal fever, chills, malaise, and weakness. More advanced symptomatology like trismus, meningismus, tripoding, drooling, and dysphagia indicate progression of disease and worsening pathology. Signs of respiratory distress such as altered mental status, cyanosis, difficulty breathing, and stridor are markers for impending airway compromise. Trismus indicates extension into the parapharyngeal space, while meningismus suggests involvement of the retropharyngeal space. Both can lead to mediastinal involvement. Examination may show a tender, bilateral, tense, and indurated submandibular area with a woody/brawny texture. [2]

Laboratory testing, other than blood cultures, has limited utility in these patients. CT of the neck with intravenous contrast is the imaging modality of choice. Findings on CT include soft tissue thickening, increased attenuation of the subcutaneous fat, loss of fat planes in the submandibular space, soft tissue gas, focal fluid collections, and muscle edema. [2]

Image 1. Representative CT image showing classic signs of Ludwig’s Angina [5]

Airway management, broad-spectrum antibiotics, and surgical debridement are the mainstays of treatment. Blind nasotracheal and oral intubation should be avoided due to the risk of worsening airway edema. Supraglottic devices should also be avoided due to their potential for displacement should airway edema worsen. Early consultation with other airway experts such as pediatric anesthesia and ENT is paramount. A surgical airway should also be considered in time-sensitive circumstances. Broad spectrum antibiotics such as Ampicillin-Sulbactam, Ceftriaxone + Metronidazole, and Clindamycin + Levofloxacin are all appropriate choices in the immunocompetent patient. For immunocompromised hosts, Cefepime, Piperacillin-Tazobactam, Imipenem and Meropenem are acceptable choices. MRSA coverage can include Vancomycin or Linezolid. Adjunctive medications like steroids, analgesics, and nebulized epinephrine are also commonly used. [2, 4]

Surgical intervention typically involves debriding necrotic tissue and draining all pathologic fluid collections. Indications for surgery include patients who fail antibiotic therapy, fluctuance on examination, or evidence of visible abscesses on imaging. Patients should be admitted to the intensive care unit for ongoing airway monitoring. [2]

case resolution

Once her workup was completed, it was determined that the patient did not have Ludwig’s angina due to the lack of bilaterality of her submandibular induration on physical exam and CT findings. The patient was taken to the operating room the next morning and underwent extraction of tooth 19 (K) along with incision and drainage of a sublingual space abscess under general anesthesia. She remained afebrile post-operatively and was discharged home the following day on Augmentin with close dental and primary care follow up.

take-aways

Ludwig’s angina is a potentially life-threatening soft tissue infection of the floor of the mouth that is characterized by its diffuse and bilateral nature.
Airway management and early consultation with other pediatric airway specialists in severe cases can be life-saving interventions.
Broad-spectrum antibiotics +/- surgical debridement are involved in definitive management.

AUTHOR: Dylan Perez, DO, is a second-year emergency medicine resident at Brown Emergency Medicine Residency

FACULTY REVIEWER: Meghan Beucher, MD, is an attending physician at Hasbro Children’s Hospital and an Assistant Professor and Clinician Educator of Emergency Medicine & Pediatrics.

references

1. Benhoummad, Othmane, et al. [Internet] “Ludwig’s Angina in a Child: A Case Report and Literature Review - the Egyptian Journal of Otolaryngology.” SpringerOpen, Springer Berlin Heidelberg, 26 Apr. 2023 [accessed 28 March 2025], Available from: ejo.springeropen.com/articles/10.1186/s43163-023-00431-1.

2. Bridwell, Rachel, et al. [Internet] “Diagnosis and Management of Ludwig’s Angina: An Evidence-Based Review.” The American Journal of Emergency Medicine, U.S. National Library of Medicine, 10 Dec. 2020 [accessed 28 March 2025), Available from: pubmed.ncbi.nlm.nih.gov/33383265/.

3. Hartman, Richard A. [Internet] “Ludwig’s Angina in Children.” American Family Physician, American Academy of Family Physicians, 1 July 1999 [accessed 29 March 2025], Available from: www.aafp.org/pubs/afp/issues/1999/0701/p109.html.

4. Onuchukwu, Chukwuma E., and Nivedita Muraldihar. [Internet] “A Case of Ludwig’s Angina Following Influenza in a 16-Year-Old Male.” Rhode Island Medical Journal (2013), U.S. National Library of Medicine, 7 Sept. 2024 [accessed 29 March 2025], Available from: pubmed.ncbi.nlm.nih.gov/39186393/.

5. Estep, Lauren, and Tammer El-Aini. [Internet] “Imaging - Medical Image of the Month: Ludwig’s Angina.” Southwest Journal of Pulmonary, Critical Care and Sleep, 2 Apr. 2019 [accessed 29 March 2025], Available from: www.swjpcc.com/imaging/2019/4/2/medical-image-of-the-month-ludwigs-angina.html.

Tooth Terrors: When To Be Concerned for Ludwig’s Angina in the Pediatric Patient