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Ludwig angina: airway first

  • Emergency

A rapidly spreading, woody infection of both sides of the floor of the mouth, usually from a lower molar. It can close the airway within hours.

Updated

See it in 3D: Mylohyoid · Submandibular gland · Sublingual gland · Tongue

What it is

Ludwig angina is a bilateral cellulitis of the submandibular, sublingual and submental spaces, most often from an infected lower second or third molar. The floor of the mouth becomes firm (woody) and raised, pushing the tongue up and back; the neck under the jaw is swollen and tender. Patients have fever, drooling, difficulty swallowing and speaking (a «hot potato» voice) and, as swelling progresses, stridor and respiratory distress. It may not form a collectable abscess early. Diabetes, immunosuppression and poor dental health are common backgrounds.

How to recognise it

  • Bilateral swelling under the jaw with a firm, raised floor of mouth and elevated tongue.
  • Drooling, dysphagia, muffled voice, trismus, then stridor.
  • Patients prefer to sit upright and lean forward.
  • Most cases start from lower molars.
  • Death is from airway obstruction or spread to the mediastinum.

What to do at once

  1. Keep the patient sitting upright; do not lay flat; give oxygen; avoid sedation.
  2. Call senior anaesthesia and ENT or maxillofacial surgery at once; prepare for a difficult airway (awake fibreoptic intubation or a surgical airway).
  3. Obtain intravenous access and start broad-spectrum intravenous antibiotics covering streptococci and oral anaerobes.
  4. Image with contrast CT only when the airway is safe.
  5. Arrange surgical drainage and extraction of the source tooth.
  6. Manage glucose and sepsis; admit to a high-dependency or intensive care setting.

Costly mistakes

  • Sending the patient to the CT scanner alone before securing the airway is a classic fatal error.
  • Oxygen saturation can be normal until the airway is almost closed.
  • Attempted intubation by inexperienced staff can turn a partial obstruction into a complete one.

Next step / Initial management

  • Every suspected Ludwig angina is an emergency: refer to the hospital with airway capability immediately, by ambulance if needed.
  • Antibiotics and airway management start before definitive imaging and drainage.
  • After recovery, refer for full dental treatment to remove other sources of infection.

Test yourself

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

Which spaces are involved in Ludwig angina?

The submandibular, sublingual and submental spaces on both sides.

What is the most common source of Ludwig angina?

An infected lower second or third molar.

What is the first priority in managing Ludwig angina?

Securing the airway, with the patient upright and an experienced airway team.

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See it in 3D4

The structures of Durgical's 3D anatomy where it is found.

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Educational content; it does not replace assessment by a dentist or doctor and is not a clinical instruction. For facial or neck swelling with difficulty swallowing or breathing, a knocked-out tooth or bleeding that will not stop, go to an emergency department at once.

Sources: Ludwig Angina (StatPearls Publishing (NCBI Bookshelf), 2025); Deep Neck Infections (StatPearls Publishing (NCBI Bookshelf), 2024); Odontogenic Orofacial Space Infections (StatPearls Publishing (NCBI Bookshelf), 2023).

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