Deep neck infections (Ludwig angina)

Deep neck infections (Ludwig angina)

Deep neck infections (Ludwig angina)

Ludwig angina is the most commonly encountered neck space infection. It is a cellulitis of the sublingual and submaxillary spaces, often arising from infection of the mandibular dentition. Deep neck abscesses most commonly originate from odontogenic infections.

Other causes include suppurative lymphadenitis, direct spread of pharyngeal infection, penetrating trauma, pharyngoesophageal foreign bodies, cervical osteomyelitis, and intravenous injection of the internal jugular vein, especially in drug abusers.

Recurrent deep neck infection may suggest an underlying congenital lesion, such as a branchial cleft cyst. Suppurative lymphadenopathy in middle-aged persons who smoke and drink alcohol regularly should be considered a manifestation of malignancy (typically metastatic squamous cell carcinoma) until proven otherwise.

Symptoms of Ludwig’s angina

The symptoms include swelling of the tongue, neck pain, and breathing problems.

Ludwig’s angina often follows a tooth infection or other infection or injury in the mouth. The symptoms include:

  • pain or tenderness in the floor of your mouth, which is underneath your tongue
  • difficulty swallowing
  • drooling
  • problems with speech
  • neck pain
  • swelling of the neck
  • redness on the neck
  • weakness
  • fatigue
  • an earache
  • tongue swelling that causes your tongue to push against your palate
  • a fever
  • chills
  • confusion

Call your doctor if you have symptoms of Ludwig’s angina. As the infection progresses, you may also experience trouble breathing and chest pain. It may cause serious complications, such as airway blockage or sepsis, which is a severe inflammatory response to bacteria. These complications can be life-threatening.

You need immediate medical attention if you have a blocked airway. You should go to the emergency room or call 911 if this occurs.

Clinical Disease

Patients with Ludwig angina have edema and erythema of the upper neck under the chin and often of the floor of the mouth. The tongue may be displaced upward and backward by the posterior spread of cellulitis, and coalescence of pus is often present in the floor of mouth. This may lead to occlusion of the airway. Microbiologic isolates include streptococci, staphylococci, Bacteroides, and Fusobacterium. Patients with diabetes may have different flora, including Klebsiella, and a more aggressive clinical course.

Patients with deep neck abscesses usually present with marked neck pain and swelling. Fever is common but not always present. Deep neck abscesses are emergencies because they may rapidly compromise the airway. Untreated or inadequately treated, they may spread to the mediastinum or cause sepsis.

Contrast-enhanced CT usually augments the clinical examination in defining the extent of the infection. It often will distinguish inflammation and phlegmon (requiring antibiotics) from abscess (requiring drainage) and define for the surgeon the extent of an abscess. CT with MRI may also identify thrombophlebitis of the internal jugular vein secondary to oropharyngeal inflammation. This condition, known as Lemierre syndrome, is rare and usually associated with severe headache. The presence of pulmonary infiltrates consistent with septic emboli in the setting of a neck abscess should lead one to suspect Lemierre syndrome or injection drug use, or both.


Usual doses of penicillin plus metronidazole, ampicillinsulbactam, clindamycin, or selective cephalosporins are good initial choices for treatment of Ludwig angina. Culture and sensitivity data are then used to refine the choice. Dental consultation is advisable to address the offending tooth or teeth. External drainage via bilateral submental incisions is required if the airway is threatened or when medical therapy has not reversed the process.

Treatment of deep neck abscesses includes securing the airway, intravenous antibiotics, and incision and drainage. When the infection involves the floor of the mouth, base of the tongue, or the supraglottic or paraglottic space, the airway may be secured either by intubation or tracheotomy.


Tracheotomy is preferable in the patients with substantial pharyngeal edema, since attempts at intubation may precipitate acute airway obstruction. Bleeding in association with a deep neck abscess is very rare but suggests carotid artery or internal jugular vein involvement and requires prompt neck exploration both for drainage of pus and for vascular control.

Patients with Lemierre syndrome require prompt institution of antibiotics appropriate for Fusobacterium necrophorum as well as the more usual upper airway pathogens. The use of anticoagulation in treatment is of no proven benefit.


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