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SCS-18-0285
BRIEF CLINICAL STUDIES
Radiologic Imaging of Ludwig
Angina in a Pediatric Patient
Gökhan Polat, MD and Recep Sade, MD
Abstract: Ludwig angina is an important disease with deadly
consequences. Especially in the pediatric patient group, recognition
of the disease may be difficult due to patient incompatibility. For
this reason, radiologic imaging methods should be carefully
selected. Diffusion-weighted magnetic resonance imaging and
contrast-enhanced examinations are the most important methods
for the diagnosis of the disease.
Key Words: Contrast-enhanced imaging, diffusion-weighted
magnetic resonance imaging, Ludwig angina
L udwig angina is a diffuse bacterial tissue infection in the
sublingual, submandibular, and submental spaces, characterized
by its tendency to spread swiftly to the adjacent tissues.1 Ludwig
angina spreads along the facial structures and can extend into
surrounding nerves, vessels, and muscle tissue.2 In most patients
with Ludwig angina, the original source of the infection is odonto-
genic, generally an untreated or an undiagnosed dental abscess,
otitis media, sialadenitis, tongue piercing, or sialolithiasis of the
submandibular glands.1,2 In our patient, the authors report a pedi-
atric patient with Ludwig angina that evolved from a chronic
multiple dental caries.1
PATIENT
Previously healthy 12-year-old children presented to the hospital
with a sore throat and neck worsened who had progressively
swelling over the previous 2 days. The patient was having trouble
breathing. He reported that multiple dental caries had not been
treated for a year. He also had difficulty with moving his tongue,
opening his mouth, and swallowing. Fiber optic laryngoscopy
showed laryngeal edema. His blood pressure was 115/62 mm
Hg with a heart rate of 100/min, the body temperature of 38.5
8C, a respiration rate of 20/min, and an oxygen saturation percent-
age of 97% on room air. The swelling was nonfluctuant, indurated,
and exquisitely tender. His laboratory examination had leukocy-
tosis of 14,300/mL. A contrast-enhanced computed tomography
(CT) and magnetic resonance imaging (MRI) of her neck revealed
heterogeneous enhancing tongue muscle structures (Fig. 1). Ste-
nosis due to swelling in the oropharyngeal airway was observed
(Fig. 1, arrows). He was also treated with ondansetron, morphine,
ketorolac, and IV methylprednisolone. He reported improvement
in pain after 4 days.
From the Department of Radiology, Faculty of Medicine, Ataturk
University, Erzurum, Turkey.
Received February 7, 2018.
Accepted for publication April 7, 2018.
Address correspondence and reprint requests to Gökhan Polat, MD,
Department of Radiology, Faculty of Medicine, Ataturk University,
25040 Erzurum, Turkey; E-mail: dr.g.polat@gmail.com
The authors report no conflicts of interest.
Copyright # 2018 by Mutaz B. Habal, MD
ISSN: 1049-2275
DOI: 10.1097/SCS.0000000000004646
The Journal of Craniofacial Surgery  Volume 00, Number 00, Month 2018
Copyright © 2018 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
FIGURE 1. Contrast-enhanced computed tomography (A) and magnetic
resonance imaging (B) showed heterogeneous enhancement. Narrowing of
the oropharyngeal airway was observed (arrows). Diffusion restriction was
observed in diffusion-weighted images (C, D).
DISCUSSION
This article illustrates a pediatric patient with Ludwig angina.
Ludwig angina is a bacterial cellulitis at the oral cavity floor that
rapidly extends to the adjacent structures beyond the mylohyoid
muscle.3 Early diagnosis and treatment of this disorder are impor-
tant due to the complications that can occur in association with
Ludwig angina.1 Complications of Ludwig angina are mediastinitis,
empyema, airway obstruction, carotid arterial rupture or sheath
abscess, necrotizing fasciitis, pericardial effusion, thrombophlebitis
of the internal jugular vein, osteomyelitis, aspiration pneumonia
subphrenic abscess, and pleural effusion.1
Imaging modalities can aid in the diagnosis of Ludwig angina if
it is not clinically apparent.2 Certain findings on a CT and MRI
increase the likelihood Ludwig angina such as the inflammation of
the skin, subcutaneous fat, and muscular structures.2,4 Heteroge-
neous contrast enhancement at the base of the mouth is important in
contrast images.2,4 Diffusion-weighted images show significant
diffuse constriction at this level. Diffusion restriction and circum-
ferential contrast enhancement show that abscess formation devel-
ops. The clinician should opt to image with contrast and diffusion-
weighted images in these situations for supporting the diagnosis
of infection.
Consequently, given that the reported child mortality rates from
this disorder remain high, an elevated index of suspicion for Ludwig
angina must be maintained by the clinician when presented with a
pediatric with new-onset neck swelling and oral cavity, even when
no offending pathologies are promptly noted.
REFERENCES
1. Pak S, Cha D, Meyer C, et al. Ludwig’s angina. Cureus 2017;9:e1588
2. Chueng K, Clinkard DJ, Enepekides D, et al. An unusual presentation of
Ludwig’s angina complicated by cervical necrotizing fasciitis: a case
report and review of the literature. Case Rep Otolaryngol
2012;2012:931350
3. Kobayashi M, Watanabe K. Ludwig angina. CMAJ 2017;189:E246
4. Lin HW, O’Neill A, Cunningham MJ. Ludwig’s angina in the pediatric
population. Clin Pediatr (Phila) 2009;48:583–587
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