0:01

This is a class example of a patient that presents

0:04

with pain, fever, difficulty swallowing, and a

0:11

lot of jaw pain, and has a rip-roaring infection.

0:15

And when we look at the contrast-enhanced CT

0:17

scan, what we see is diffuse edema and phlegmon

0:22

involving the right side of the floor of the mouth

0:24

that's extending into the submandibular space

0:28

with thickening of this muscle, which is a platysma

0:30

muscle, and also reticulation of the subcutaneous fat.

0:34

Now, the majority of this phlegmon and inflammatory

0:38

process is located within the floor of the mouth.

0:42

So we talked early about the floor

0:43

of the mouth being a compartment.

0:45

The lateral aspect of the floor of

0:47

the mouth is formed by the mandible.

0:48

You have this muscle right here,

0:50

which is the mylohyoid muscle.

0:52

That eventually connects with the hyoid bone,

0:54

and then we have the mylohyoid muscle going

0:56

to the opposite side. When we have a diffuse

1:00

inflammation involving the floor of the mouth,

1:03

this is what's referred to as Ludwig's angina.

1:05

So we call this a diffuse inflammation.

1:08

But Ludwig's angina was initially described

1:11

back in 1836 by a German physician by

1:14

the name of Wilhelm Frederick Von Ludwig.

1:17

So number one, Ludwig's angina was around long before

1:21

CTs and MR was, and it is a clinical diagnosis.

1:25

When we think of Ludwig's angina, we

1:27

think of abscesses in the floor of

1:29

the mouth that need to be drained.

1:31

But the true Ludwig's angina is a diffuse cellulitis

1:34

and phlegmon involving the floor of the mouth,

1:37

that essentially result in a compartment

1:39

syndrome because the mandible is solid.

1:41

The mylohyoid is a very tough and firm

1:44

muscle, and the hyoid bone is solid.

1:46

So if we have a large infection

1:49

that's involving the floor of the mouth,

1:51

then this can result in elevation of the tongue base.

1:54

And what's behind the tongue base?

1:55

Well, the airway is behind the tongue

1:57

base, and this narrows the airway.

2:00

The infection can extend down inferiorly to involve

2:03

the pre-epiglottic space and the epiglottis.

2:06

This is diffuse edema involving the epiglottis,

2:08

and we can see it's narrowing the airway.

2:12

So the term angina was initially described

2:15

years ago, and I think initially by

2:17

Dr. Ludwig, and it means strangulation.

2:20

And the reason that patients with Ludwig's

2:22

angina would present with strangulation

2:25

is because they would have this diffuse

2:26

inflammation involving the floor of the mouth.

2:29

It would elevate the tongue base because the

2:31

firm floor of mouth soft tissues, it would

2:34

narrow the airway, and that would give the

2:36

patient the sensation of difficulty breathing.

2:40

So in actuality, angina

2:42

was initially described by us, the head and

2:44

neck radiologists, and like many of the things in

2:47

radiology, the term was stolen by the cardiologists.