Ludwig Angina (Floor of the Mouth Infections)

23 Apr


Bilateral infection of the submandibular space that involves both of the two main compartments in the floor of the mouth- the sublingual and the submylohyoid spaces

-Commonly caused from an infection of either the second or third mandibular molar tooth since their roots are located below the level where the mylohyloid muscle attaches to the mandible

Rapidly spreadingaggressive infection with SEVERE potential for airway compromise

-Abscess formation is not usually present



-Typically polymicrobial involving normal oral flora



-Fever, mouth pain, stiff neck, drooling, dysphagia, and may tripod in order to maximize airway size

-Voice changes and stridor are particularly late findings


Physical Exam:

-Tender symmetric induration/swelling in the submandibular area

Floor of the oropharynx is extremely tender, elevated (look under the tongue), and erythematous



-your eyes/hands/brain

CT is not necessary for diagnosis but can help demonstrate extent of infection 



Airway protection is the primary issue with these infections; definitive airway should be established prior to stridor/cyanosis

            -nasotrachial intubation, or cric, if the OP approach is toast


Clindamycin, Unasyn, PCN G plus Metronidazole are all suitable choices.

-For immunocompromised patients, Cefepime plus metronidazole, a Carbapenam, or Zosyn

-If MRSA is a high risk factor, Vancomycin should be ADDED to the above regimen


            -Some studies have shown improved outcomes with dexamethasone administration

-When a tooth is suspected as the culprit for the infection, prompt tooth removal is ESSENTIAL

-PROMPT ENT consultation is recommended

Submitted by J. Grover.  

Sources: Saifeldeen K and Evans R. “Ludwig’s Angina.”  Emergency Medicine Journal.  2004;21:242-243.; Tintinalli’s Emergency Medicine.  7th Edition.; Uptodate.  Submandibular Space Infections; picture 1 from; picture 2


2 Responses to “Ludwig Angina (Floor of the Mouth Infections)”

  1. Kane Guthrie April 23, 2013 at 20:51 #

    Can you please show credit to for the picture at the top or kindly remove it from the post.



    • dailyem April 23, 2013 at 21:17 #

      References (including credit links for pictures) are always at the bottom with the listed sources/references, but I will edit the link to include the website name. No disrespect intended to LITFL.

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