Ludwig angina is more formally known as septic cellulitis of the submandibular, submental, or sublingual spaces. Ludwig angina is most often the result of a dental abscess of the second or third mandibular molar, before or after tooth extraction, and presents as diffuse swelling of the floor of the mouth and airway. Symptoms can arise quickly and may consist of neck swelling, redness and pain, fever, chills, fatigue, earache, drooling, confusion, and eventually, airway collapse. Prompt treatment is compulsory to prevent the spread of infection and asphyxiation associated with subsequent airway edema.

Ludwig angina is typically caused by hemolytic streptococci from normal oral flora, but it may be caused by a combination of both aerobic and anaerobic bacteria resulting in the infectious process. The swelling in the floor of the mouth may be so extensive that the tongue is displaced upward and posterior, occluding the mouth and oropharynx, and if left untreated, the infection may spread caudally into the thoracic cavity and result in an abscess of the pericardium and lungs or throughout the body as septic shock. Patients may present with extreme lethargy, dehydration, and shortness of breath, and require immediate medical attention.

Treatment of the Ludwig angina patient depends on the extent of airway involvement. A less extensive case may simply require incision and drainage, surgical decompression, and a full course of broad-spectrum antibiotics. However, to determine the degree of inflammation, a computerized tomographic (CT) scan of the head and neck may be warranted as the first step to treatment. A thorough history and physical should also be obtained, and the patient’s anesthesia team should work in conjunction with the surgeons to devise a comprehensive treatment plan. Managing the Ludwig patient may be complex, as he or she may be unable to talk or open his or her mouth adequately for incision and drainage of the affected area. Difficulty opening the mouth in combination with airway edema and displacement of the tongue presents the potential for serious anesthetic risk and complication. A definitive anesthetic strategy, along with backup preparations, is highly recommended for any Ludwig patient.

The anesthesia provider(s) should carefully examine the airway, evaluating all the usual components including Mallampati class, oral opening, cervical range of motion, thyromental distance, and presence/absence of teeth. Additionally, in the Ludwig angina patient, the degree of airway edema, both clinically and radiographically, ability to swallow, amount of secretions, and mobility of the tongue need to be assessed. Tongue mobility is a fairly unique consideration in the Ludwig patient, as the disease process itself involves the submandibular space, which may become edematous and hardened. This is important with respect to airway management because during routine laryngoscopy the tongue is displaced into the submandibular space. In the Ludwig patient, if that space is diminished or unavailable, it can make visualization of the vocal cords and subsequent intubation quite difficult. The anesthesiologist and surgeon may proceed only after this checklist has been carefully evaluated and a clear plan has been devised.

The airway of a Ludwig patient may be deceiving in that it may appear to be unobstructed when the patient is awake and breathing spontaneously, but that may change dramatically after induction and paralyzation. Topically anesthetizing a patient’s larynx and trachea in order to take an “awake look” may not be beneficial, as visualization of laryngeal anatomy postinduction may be greatly reduced compared to that of the awake patient, because of decreased laryngeal muscle tone. Muscle relaxants may allow the edematous tissues adjacent to the trachea to relax after induction and occlude an airway that was patent in an awake Ludwig patient, possibly resulting in difficult, if not impossible, ventilation and/or intubation. Multiple intubation attempts or manipulations of a Ludwig patient’s airway can be especially harmful, as it may cause the accumulation of blood and secretions in the pharynx and can potentiate further complications in already dire circumstances. For these reasons, direct laryngoscopy after topicalization of the airway is not advised in the Ludwig angina patient.