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[Conditions](https://durgical.com/en/conditions/) · [Head and neck](https://durgical.com/en/anatomy/region/head-and-neck/)

# Deep neck infection and Ludwig angina

A deep neck infection is a spreading infection or abscess between the layers of the neck; Ludwig angina, in the floor of the mouth, can block breathing.

Updated 2026-10-29

## Structures involved

Tap one to see what it is and open it in 3D.

- [Cervical fascia](https://durgical.com/en/anatomy/superficial-investing-cervical-fascia/)
- [Mylohyoid](https://durgical.com/en/anatomy/mylohyoid-muscle/)
- [Pharynx](https://durgical.com/en/anatomy/pharynx/)
- [Submandibular gland](https://durgical.com/en/anatomy/submandibular-gland/)
- [Carotid sheath](https://durgical.com/en/anatomy/carotid-sheath/)
- [Internal jugular vein](https://durgical.com/en/anatomy/internal-jugular-vein/)
- [Tongue](https://durgical.com/en/anatomy/tongue/)
- [Palatine tonsils](https://durgical.com/en/anatomy/palatine-tonsil/)

## In embryology

- [Thyroglossal duct cyst and ectopic thyroid](https://durgical.com/en/embryology/thyroglossal-duct-cyst-and-ectopic-thyroid/)
- [Branchial cleft cysts, sinuses and fistulas](https://durgical.com/en/embryology/branchial-cleft-cysts-sinuses-and-fistulas/)

## Why it happens

- [Patterns of acute inflammation: serous, fibrinous, purulent, abscess, ulcer](https://durgical.com/en/general-pathology/patterns-of-acute-inflammation-serous-fibrinous-purulent-abscess-ulcer/)
- [Outcomes of acute inflammation: resolution, abscess, scar or chronic inflammation](https://durgical.com/en/general-pathology/outcomes-of-acute-inflammation-resolution-abscess-scar-or-chronic-inflammation/)

## What it is

A bacterial infection, cellulitis or abscess, in the spaces between the deep layers of [cervical fascia](https://durgical.com/en/anatomy/superficial-investing-cervical-fascia/). Ludwig angina is a rapidly spreading cellulitis of the floor of the mouth that can block the airway.

## Who gets it

Odontogenic infections are now the most common source in adults and tonsillar infections in children. Diabetes and poor dental access are common backgrounds.

## Causes

- Odontogenic infection, especially of the second and third mandibular molars (main cause of Ludwig angina)
- Tonsillitis, pharyngitis and peritonsillar abscess
- Salivary gland infection, trauma, foreign bodies and injection drug use
- Usually polymicrobial: streptococci, staphylococci and oral anaerobes

## Risk factors

- Poor dental hygiene and untreated caries
- Diabetes mellitus
- Immunosuppression
- Recent dental procedures

## Pathophysiology

Infection spreads along fascial planes from its source into potential spaces of the neck. In Ludwig angina, infection from lower molars whose roots lie below the [mylohyoid](https://durgical.com/en/anatomy/mylohyoid-muscle/) line enters the submandibular and sublingual spaces on both sides and pushes the [tongue](https://durgical.com/en/anatomy/tongue/) up and back. Spread to the parapharyngeal, retropharyngeal and danger spaces can reach the mediastinum or the [carotid sheath](https://durgical.com/en/anatomy/carotid-sheath/).

## Classification

- By space: submandibular (Ludwig angina), parapharyngeal, retropharyngeal, danger and prevertebral spaces
- Cellulitis versus abscess

## Symptoms and signs

- Fever, neck pain and swelling
- Painful swallowing, drooling and muffled voice
- Trismus
- Firm, tender, woody swelling of the floor of the mouth with a raised tongue in Ludwig angina
- Neck stiffness or reduced neck movement

## Red flags

- Stridor, difficulty breathing or inability to lie flat
- Drooling and inability to swallow saliva
- Chest pain or widening mediastinum (mediastinitis)
- Signs of sepsis
- Unilateral neck swelling with persistent fever ([internal jugular vein](https://durgical.com/en/anatomy/internal-jugular-vein/) thrombosis, Lemierre syndrome)

## Diagnosis

**Clinical**
Airway assessment comes first; examination of teeth, [pharynx](https://durgical.com/en/anatomy/pharynx/), floor of mouth and neck.

**Tests**
Blood count, inflammatory markers, glucose, blood cultures and culture of drained pus.

**Imaging**
Contrast-enhanced CT of the neck (and [chest](https://durgical.com/en/anatomy/region/chest/) if mediastinitis is suspected) once the airway is safe; ultrasound for superficial collections.

## Differential diagnosis

- Peritonsillar abscess
- Epiglottitis
- Angioedema
- Cervical lymphadenitis
- Infected branchial or thyroglossal cyst

## Goal of treatment

Secure the airway, control infection with antibiotics and drainage, and remove the source.

## Treatment

**Acute**
Airway protection is the priority: close monitoring, and awake fibreoptic intubation or surgical airway (tracheostomy) when the airway is threatened.

**Medical**
Intravenous broad-spectrum antibiotics covering streptococci and anaerobes; corticosteroids are sometimes used to reduce swelling.

**Surgical**
Incision and drainage of abscesses and extraction or treatment of the infected tooth.

**Follow-up**
Intensive care monitoring when the airway or circulation is at risk.

## Complications

- Airway obstruction
- Descending mediastinitis
- Sepsis
- Internal jugular vein thrombosis (Lemierre syndrome)
- Carotid artery erosion
- Necrotising fasciitis

## Prognosis

Good with early airway control, antibiotics and drainage. Mortality rises steeply with airway loss, mediastinitis or delayed treatment.

## Prevention

- Timely treatment of dental infections
- Good oral hygiene and control of diabetes

## Test yourself

Think of the answer, then tap the question to see it.

## What is the most common source of Ludwig angina?

An odontogenic infection, usually of the second or third mandibular molars.

## Which spaces are involved in Ludwig angina?

The submandibular and sublingual spaces on both sides (the submandibular space).

## What is the first priority in a patient with suspected deep neck infection?

Assessing and securing the airway.

## Which space connects the neck to the posterior mediastinum?

The danger space (between the alar and prevertebral fascia).

## What is Lemierre syndrome?

Septic thrombophlebitis of the internal jugular vein after oropharyngeal infection, classically from Fusobacterium necrophorum.

[Add to my cards (5)](https://durgical.app/estudiar/?add=/en/conditions/deep-neck-infection-and-ludwig-angina/)

## Related conditions

- [Dental caries](https://durgical.com/en/conditions/dental-caries/)
- [Streptococcal pharyngitis](https://durgical.com/en/conditions/streptococcal-pharyngitis/)
- [Cervical lymphadenopathy](https://durgical.com/en/conditions/cervical-lymphadenopathy/)
- [Sepsis and septic shock](https://durgical.com/en/conditions/sepsis-and-septic-shock/)
- [Type 2 diabetes mellitus](https://durgical.com/en/conditions/type-2-diabetes-mellitus/)
- [Peritonsillar abscess](https://durgical.com/en/conditions/peritonsillar-abscess/)
- [Periodontitis](https://durgical.com/en/conditions/periodontitis/)
- [Sialolithiasis (salivary stones)](https://durgical.com/en/conditions/sialolithiasis/)

Educational information, not medical advice. For any symptom, see a health professional.

Sources: [Deep Neck Infections](https://www.ncbi.nlm.nih.gov/books/NBK513262/) (StatPearls (NCBI Bookshelf), 2024); [Ludwig Angina](https://www.ncbi.nlm.nih.gov/books/NBK482354/) (StatPearls (NCBI Bookshelf), 2025).

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Source: https://durgical.com/en/conditions/deep-neck-infection-and-ludwig-angina/
License: CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). Cite as: DurgiPedia (durgical.com), https://durgical.com/en/conditions/deep-neck-infection-and-ludwig-angina/