Case of Ludwig’s Angina presenting with “Double Tongue” appearance

Dr Irfan Mohamad, at Universiti Sains Malaysia, Kubang Kerian, Malaysia and colleagues have reported a rare case of “Double Tongue” Appearance in Ludwig’s Angina. The case has appeared in the New England Journal of Medicine.

Ludwig’s angina is a rare skin infection that occurs on the floor of the mouth, underneath the tongue. This bacterial infection often occurs after a tooth abscess but can also follow other mouth infections or injuries. It is a form of severe diffuse cellulitis that presents an acute onset and spreads rapidly, bilaterally affecting the submandibular, sublingual and submental spaces resulting in a state of emergency. Early diagnosis and immediate treatment planning could be a life-saving procedure. This infection is more common in adults than children and people who get prompt treatment usually recover fully.

Ludwig's angina was coined after the German physician, Wilhelm Friedrich von Ludwig who first described this condition in 1836 as a rapidly and frequently fatal progressive gangrenous cellulitis and edema of the soft tissues of the neck and floor of the mouth

A 68-year-old man presented to the emergency department with a 2-day history of swelling of the neck. One week before presentation, he had a toothache, followed by fever and progressive difficulty and pain with swallowing both solids and liquids. He had no difficulty opening his mouth and had no voice changes or noisy breathing. Examination showed right submandibular and submental swelling with marked edema of the floor of the mouth, resulting in the superior displacement of the tongue. Dentition was poor, with multiple dental caries.

Flexible nasopharyngolaryngoscopy revealed oedema of the valleculae and epiglottis. The airway was not obstructed. The patient received a diagnosis of Ludwig’s angina, an infection of the submandibular space that can rapidly progress and compromise the airway. He was treated with broad-spectrum intravenous antibiotic agents and closely observed for any sign of airway obstruction. Carious teeth were extracted while the patient was under local anesthesia. The patient completed a course of antibiotics, and at 1 month of follow-up, he was well and had no residual symptoms.