Ludwig's angina


  • Bilateral infection of submental, submandibular, and sublingual spaces
  • Cellulitis without clear fluctuance/abscess
  • 85% of cases arise from an odontogenic source, usually mandibular molars
    • Strep, staphylococcus, bacteroides
  • Patients usually 20-60yr; male predominance
  • Intubation may be very difficult
    • Consider awake endoscopic NP or OP intubation
    • Anesthesia or ENT back-up if possible

Clinical Features

  • Dysphagia
  • Odynophagia
  • Trismus
  • Edema of upper midline neck and floor of mouth
  • Late signs
    • Stridor, drooling, cyanosis


  • Classical definition
    • Infection of sublingual AND submylohyoid/submaxillary spaces
  1. Begins in floor of mouth
  2. Aggressive "woody" or brawny cellulitis in submandibular space
  3. No lymphatic involvement
  4. Generally no abscess formation
  5. Bilateral infection
  • CT face with contrast
    • Only obtain if diagnosis is question
    • Pt may lose airway in scanner if lies flat


Airway Managment

  • Airway management
  • Preference for an awake Intubation
  • Emergent ENT consult for operative I&D and extraction of dentition if source is dental abscess


    • Must cover typical polymicrobial oral flora and tailored based on patient's immune status
    • Most commonly a 3rd generation cehpalosporin + (clindamycin or metronidazole)
  • If the patient is immuncompromised, the antibiotics need to also cover MRSA and gram-negative rods[1]

Immunocompetent Host

Antibiotics Options:[2]

  1. Ampicillin/Sulbactam 3 g IV q6 hrs
  2. Penicillin G 2-4 MU IV q6 hrs + metronidazole 500 mg IV q6 hrs
  3. Clindamycin 600 mg IV q6 hrs (option for those allergic to penicillin)


  1. Cefepime 2 g IV q12 hrs + Metronidazole 500 mg IV q6 hrs
  2. Meropenem 1 g IV q8 hrs
  3. [[Piperacillin-tazobactam 4.5 g IV q6 hrs
  4. Add Vancomycin 15-20 mg/kg q8 hrs (max 2 g per dose) if concern for MRSA risk factors


  • Admit, usually ICU for airway monitoring

See Also

  1. PTA
  2. Retropharyngeal Abscess
  3. Pharyngitis


  • Tintinalli
  • ER Atlas
  • Rosen's
  • Uptodate
  1. Costain N, Marrie T. Ludwig’s Angina. American Journal of Medicine. Feb 2011. 124(2): 115-117
  2. Barton E, Blair A. Ludwig’s Angina. J Emerg Med. 2008. 34(2): 163-169.