Clinical Manifestations

Angina Ludwig's patient's main complaint is bilateral swelling of the neck or "bull neck." Swelling may be accompanied by neck pain, fever, and chills. Some patients complain of odynophagia and dysphagia. In some rare cases, patients complain of pain in the mouth.

Hoarseness, hypersalivation, swelling of the tongue, neck stiffness, and sore throat are common complaints. Patients may also complain of non-specific symptoms related to the inflammatory response such as fever, malaise, and weakness. 

The patient can be restless, agitated, and confused. Other symptoms are a painful swelling of the floor of the mouth and anterior neck, fever, dysphagia, odynophagia, drooling, trismus, tooth pain, and halitosis. Hoarseness, stridor, respiratory distress, decreased air movement, cyanosis, and "Sniffing" position.

A study of 38 patients found that 100% submandibular and submental swelling, 65% dysphagia, 55% odynophagia, 42% stridor breath sounds, and 55% experienced voice changes. These results are consistent with studies that found neck swelling, dysphagia, voice changes, and stridor as the most common clinical manifestations.

Patients may develop dysphonia caused by edema of the vocal structures. Halitosis, excessive salivation, dysphagia, odynophagia, and difficulty breathing should be alerted by clinicians as signs of severe airway problems. Stridor, difficulty expelling secretions, anxiety, cyanosis, and sitting position, are the final signs of prolonged airway obstruction and indications of an inhaler's insertion.

Patients usually present with pain, tenderness, and swelling at the floor of the mouth. In untreated Ludwig's angina, the inflammation can spread down the mediastinal area. So that sometimes patients come with complaints of chest pain.

On oral examination, by elevating the tongue, there is a large induration at the base and anterior of the tongue, and suprahyoid swelling. There is usually bilateral submandibular edema. Swelling of the anterior neck tissue above the hyoid bone is often referred to as a bull's neck appearance.


How to diagnose Ludwig's Angina?

The diagnosis of Ludwig's Angina can usually be confirmed using only a clinical approach. A proper history and physical examination are generally sufficient to make a diagnosis. Additional examinations can be performed to determine the severity of the infection or whether an abscess has formed, which requires additional treatment.

Diagnosis Criteria

In 1939, Grodinsky developed the diagnostic criteria used to diagnose Ludwig's Angina. Grodinsky mentioned that in the case of Ludwig's Angina, there must be:

Cellulitis (not abscess) in the submandibular cavity, affecting more than one cavity and usually bilateral
Produces gangrene with serosanguinous infiltration and foul-smelling, but only a small amount of pus.
It involves connective tissue, fascia, and muscles but does not involve glandular structures.
 Spread by continuity than by the lymphatics.

1. History
Patients with Ludwig's angina usually have a history of previous tooth extraction or poor oral hygiene and dental infections. The clinical symptoms that are often found consistent with sepsis include fever, tachypnea, and tachycardia.

The patient may also complain of jaw pain, trismus, and elevation of the tongue. The tongue elevation that occurs in the patient is accompanied by pain. This elevation also causes the patient to have difficulty swallowing. The elevation of the tongue, which occurs as a result of enlarging the cavity underneath, then causes a displacement of the tongue's base and has the potential to close the patient's airway.

2. Physical Examinations
a. Inspection
On inspection: there is a Bull neck, which is a swelling in the neck area below the jaw (submental and submandibular area) and a loss of the mandibular angle.

b. Oral Examination
On oral examination, with elevated tongue, there is a large induration at the mouth floor and anterior to the tongue, and suprahyoid swelling. There is usually bilateral submandibular edema. The presence of brawny induration in the mouth floor is a clinical symptom that the clinician suggests performing airway stabilization measures as soon as possible, followed by further diagnostic confirmation.

3. Supporting Examinations
a. Roentgen
Plain radiographs can show the extent of soft tissue swelling, the presence of air, and the presence of airway narrowing. Chest x-rays can show the extent of the infectious process to the mediastinum and lungs.

b. USG
Ultrasound can show the location and size of the pus, as well as metastases from the abscess. Ultrasound can be helpful in diagnosis in pediatric patients because it is non-invasive and non-radiation. Ultrasound also helps guide the aspiration of the needle to locate the abscess.

c. CT scan
CT scan is the imaging method of choice because it provides the best radiologic evaluation of deep neck abscesses. CT scans can detect fluid accumulation, the spread of infection, and the degree of airway obstruction and help decide when to need artificial respiration.

d. MRI
MRI provides better resolution for soft tissue than a CT scan. However, MRI has a disadvantage, which is the long duration of imaging, making it extremely dangerous for patients who have difficulty breathing.

Ludwig's Angina diagnosis is made based on clinical symptoms: swelling, and thickening of the submandibular, submental, and floor of the mouth, especially on MRI examination. It is important to differentiate between cystic and solid lesions. Ultrasound can provide important information to see if there are complications from an abscess. MRI has certain advantages for detecting soft tissue involvement compared to CT-scan. Both have modalities to make an accurate diagnosis. MRI shows vascular complications such as internal jugular vein thrombosis and carotid artery erosion. It is essential to know the radiological features of Ludwig's angina for early diagnosis and to prevent complications.