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Copyright (c) 2025 Abdulaziz Ali S Alabdali, Yahya Ahmed Madkhali, Khalid Hamoud J Alanazi, Aysha Saeed Zaied Alkhaldi, Walaa Khaled Hassan Soror, Kharifa Hadi Hassan Al Marzoog, Abdu Aboud Mohd Hakamy, Thamer Bandar Alfaqir, Majidah Muaatq Al Jamily, Salha Hassan Ibrahim Muslih, Abeer Ibrahim Ahmed Wasly
This work is licensed under a Creative Commons Attribution 4.0 International License.
Interprofessional Management of Submandibular Space Infections (Ludwig’s Angina): Nursing, Radiology, Pharmacy, Dental, and Emergency Perspectives
Corresponding Author(s) : Abdulaziz Ali S Alabdali
Saudi Journal of Medicine and Public Health, Vol. 2 No. 2 (2025)
Abstract
Background: Ludwig’s angina is a rapidly progressive, bilateral cellulitis of the submandibular, sublingual, and submental spaces, most commonly originating from infections of the mandibular second or third molars. It is characterized by aggressive softtissue edema, airway compromise, and continuity of spread along deep cervical fascial planes rather than lymphatic pathways, making rapid recognition and management essential.
Aim: This article aims to provide a comprehensive, interdisciplinary overview of the clinical presentation, anatomical considerations, diffusion mechanisms, pathophysiology, evaluation strategies, and evidencebased management of Ludwig’s angina.
Methods: A narrative, multidisciplinary review was conducted using current clinical knowledge from nursing, emergency medicine, dentistry, radiology, anesthesia, and surgery. The review synthesizes anatomical descriptions, pathophysiological progression, diagnostic findings, and treatment modalities.
Results: Findings highlight that Ludwig’s angina typically originates from odontogenic infections (over 90% involving second/third molars) and spreads contiguously across fascial planes, often leading to severe airway obstruction. Early airway control—preferably via awake fiberoptic intubation—is critical, while surgical drainage is reserved for cases with abscess formation or failure of medical therapy. Broadspectrum IV antibiotics targeting aerobic and anaerobic organisms remain essential, along with prompt extraction of the causative tooth. Multidisciplinary coordination significantly reduces mortality from historical rates of nearly 50% to less than 5% in modern practice.
Conclusion: Ludwig’s angina remains a medical and surgical emergency requiring rapid recognition, airway protection, early antibiotic therapy, and targeted surgical intervention. A coordinated, interdisciplinary approach is key to improving outcomes and preventing lifethreatening complications.
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- Chow AW. Ludwig angina. In: Durand ML, Bogorodskaya M, editors. UpToDate; 2022. Last updated: Oct 04, 2022.
- Saifeldeen K, Evans R. Ludwig’s angina. Emerg Med J. 2004;21:242–3.
- Bansal A, Miskoff J, Lis RJ. Otolaryngologic critical care. Crit Care Clin. 2003;19:55–72.
- Winters M. Evidence-based diagnosis and management of ENT emergencies. American Academy of Emergency Medicine. Medscape Emerg Med. 2007; https://www.medscape.com/viewarticle/551650_4
- Moreland LW, Corey J, McKenzie R. Ludwig’s angina. Report of a case and review of the literature. Arch Intern Med. 1988;148:461–6.
- Murray AD. Deep neck infections. In: Meyers AD, editor. Medscape; 2023. Updated: April 07, 2022. https://emedicine.medscape.com/article/837048-overview
- Boscolo-Rizzo P, Da Mosto MC. Submandibular space infection: a potentially lethal infection. Int J Infect Dis. 2009;13:327.
- Bridwell R, Gottlieb M, Koyfman A, Long B. Diagnosis and management of Ludwig’s angina: an evidence-based review. Am J Emerg Med. 2021;41:1.
- Kovalev V. A severe case of Ludwig’s angina with a complicated clinical course. Cureus. 2020;12:e7695.
- Mohamad I, Narayanan MS. “Double Tongue” appearance in Ludwig’s angina. N Engl J Med. 2019;381:163.
- Furst IM, Ersil P, Caminiti M. A rare complication of tooth abscess—Ludwig’s angina and mediastinitis. J Can Dent Assoc. 2001;67:324.
- Quinn FB. Ludwig angina. Arch Otolaryngol Head Neck Surg. 1999;125(5):599.
- An J, Madeo J, Singhal M. Ludwig angina (Updated 2022 Oct 10). In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2023. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482354/
- Brook I. Microbiology and principles of antimicrobial therapy for head and neck infections. Infect Dis Clin N Am. 2007;21(2):355–91.
- Spitalnic SJ, Sucov A. Ludwig’s angina: case report and review. J Emerg Med. 1995;13:499–503.
- Saifeldeen K, Evans R. Ludwig’s angina. Emerg Med J. 2004;21(2):242–3.
- Barakate MS, Jensen MJ, Hemli JM, Graham AR. Ludwig’s angina: report of a case and review of management issues. Ann Otol Rhinol Laryngol. 2001;110(5 Pt 1):453–6.
- Marple BF. Ludwig angina: a review of current airway management. Arch Otolaryngol Head Neck Surg. 1999;125:596–9.
- Shockley WW. Ludwig angina: a review of current airway management. Arch Otolaryngol Head Neck Surg. 1999;125:600.
- Vieira F, Allen SM, Stocks RM, Thompson JW. Deep neck infection. Otolaryngol Clin N Am. 2008;41:459.
- Ovassapian A, Tuncbilek M, Weitzel EK, Joshi CW. Airway management in adult patients with deep neck infections: a case series and review of the literature. Anesth Analg. 2005;100:585.
- Barton ED, Bair AE. Ludwig’s angina. J Emerg Med. 2008;34:163.
- Freund B, Timon C. Ludwig’s angina: a place for steroid therapy in its management? Oral Health. 1992;82:23–5.
- Crespo AN, Chone CT, Fonseca AS, Montenegro MC, Pereira R, Milani JA. Clinical versus computed tomography evaluation in the diagnosis and management of deep neck infection. Sao Paulo Med J. 2004;122(6):259–63.
- Wolfe MM, Davis JW, Parks SN. Is surgical airway necessary for airway management in deep neck infections and Ludwig angina? J Crit Care. 2011;26(1):11–4.
- Shi H, Yang Z, Li H, et al. Efficacy of needle aspiration in patients with oral-maxillofacial abscesses: a retrospective study of 15 consecutive patients. Am J Otolaryngol. 2022;43:103216.
References
Chow AW. Ludwig angina. In: Durand ML, Bogorodskaya M, editors. UpToDate; 2022. Last updated: Oct 04, 2022.
Saifeldeen K, Evans R. Ludwig’s angina. Emerg Med J. 2004;21:242–3.
Bansal A, Miskoff J, Lis RJ. Otolaryngologic critical care. Crit Care Clin. 2003;19:55–72.
Winters M. Evidence-based diagnosis and management of ENT emergencies. American Academy of Emergency Medicine. Medscape Emerg Med. 2007; https://www.medscape.com/viewarticle/551650_4
Moreland LW, Corey J, McKenzie R. Ludwig’s angina. Report of a case and review of the literature. Arch Intern Med. 1988;148:461–6.
Murray AD. Deep neck infections. In: Meyers AD, editor. Medscape; 2023. Updated: April 07, 2022. https://emedicine.medscape.com/article/837048-overview
Boscolo-Rizzo P, Da Mosto MC. Submandibular space infection: a potentially lethal infection. Int J Infect Dis. 2009;13:327.
Bridwell R, Gottlieb M, Koyfman A, Long B. Diagnosis and management of Ludwig’s angina: an evidence-based review. Am J Emerg Med. 2021;41:1.
Kovalev V. A severe case of Ludwig’s angina with a complicated clinical course. Cureus. 2020;12:e7695.
Mohamad I, Narayanan MS. “Double Tongue” appearance in Ludwig’s angina. N Engl J Med. 2019;381:163.
Furst IM, Ersil P, Caminiti M. A rare complication of tooth abscess—Ludwig’s angina and mediastinitis. J Can Dent Assoc. 2001;67:324.
Quinn FB. Ludwig angina. Arch Otolaryngol Head Neck Surg. 1999;125(5):599.
An J, Madeo J, Singhal M. Ludwig angina (Updated 2022 Oct 10). In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2023. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482354/
Brook I. Microbiology and principles of antimicrobial therapy for head and neck infections. Infect Dis Clin N Am. 2007;21(2):355–91.
Spitalnic SJ, Sucov A. Ludwig’s angina: case report and review. J Emerg Med. 1995;13:499–503.
Saifeldeen K, Evans R. Ludwig’s angina. Emerg Med J. 2004;21(2):242–3.
Barakate MS, Jensen MJ, Hemli JM, Graham AR. Ludwig’s angina: report of a case and review of management issues. Ann Otol Rhinol Laryngol. 2001;110(5 Pt 1):453–6.
Marple BF. Ludwig angina: a review of current airway management. Arch Otolaryngol Head Neck Surg. 1999;125:596–9.
Shockley WW. Ludwig angina: a review of current airway management. Arch Otolaryngol Head Neck Surg. 1999;125:600.
Vieira F, Allen SM, Stocks RM, Thompson JW. Deep neck infection. Otolaryngol Clin N Am. 2008;41:459.
Ovassapian A, Tuncbilek M, Weitzel EK, Joshi CW. Airway management in adult patients with deep neck infections: a case series and review of the literature. Anesth Analg. 2005;100:585.
Barton ED, Bair AE. Ludwig’s angina. J Emerg Med. 2008;34:163.
Freund B, Timon C. Ludwig’s angina: a place for steroid therapy in its management? Oral Health. 1992;82:23–5.
Crespo AN, Chone CT, Fonseca AS, Montenegro MC, Pereira R, Milani JA. Clinical versus computed tomography evaluation in the diagnosis and management of deep neck infection. Sao Paulo Med J. 2004;122(6):259–63.
Wolfe MM, Davis JW, Parks SN. Is surgical airway necessary for airway management in deep neck infections and Ludwig angina? J Crit Care. 2011;26(1):11–4.
Shi H, Yang Z, Li H, et al. Efficacy of needle aspiration in patients with oral-maxillofacial abscesses: a retrospective study of 15 consecutive patients. Am J Otolaryngol. 2022;43:103216.