Ludwig's Angina: Higher Incidence and Worse Outcomes Associated With the Onset of the Coronavirus Disease 2019 Pandemic

Melissa Canas, Ricardo Fonseca, Alejandro De Filippis, Leonardo Diaz, Hussain Afzal, Aaron Day, Jennifer Leonard, Kelly Bochicchio, Grant V. Bochicchio, Mark Hoofnagle

Research output: Contribution to journalArticlepeer-review

2 Scopus citations


Background: Ludwig's angina (LA) is a diffuse cellulitis of the submandibular space and adjacent tissues. During the coronavirus disease 2019 (COVID-19) pandemic, odontogenic treatments were often delayed because of the implementation of safety measures to avoid the spread of the virus. We hypothesized that delayed odontogenic treatments associated with the onset of the COVID-19 pandemic would be associated with an increase in the incidence of LA and worse outcomes related to these infections. Patients and Methods: Patients from June 2018 to June 2022 with computed tomography images suggestive of LA and confirmed by ear, nose, throat (ENT) consult were included. We abstracted demographics, outcomes, clinical management, and microbiology. Patients were stratified into pre-COVID and COVID-onset. Our primary outcome, incidence of LA, was defined as: (new LA cases) O (ED evaluations of oral or dental infections 1.5 years). Results: In the pre-COVID group, we identified 32 of 1,301 patients with LA for an incidence of 0.02 per year. The COVID-onset group consisted of 41 of 641 patients, with an incidence of 0.04 per year. In the COVIDonset group, progression to necrotizing fasciitis was more likely (0% vs. 15%; p < 0.024), and they returned to the operating room for repeated debridement (3% vs. 22%; p < 0.020). Likewise, hospital length of stay, intensive care unit (ICU) length of stay, and ventilator days were higher (4.3 - 3.5 vs. 9.5 - 11.3; 1.1 - 1.2 vs. 9.5 - 7.1; 0.3 - 1 vs. 3.6 - 7.1; p < 0.001). Conclusions: Although the prognosis for dental infections diagnosed early is generally favorable, we observed a notable increase in the incidence of LAafter the onset of theCOVID-19 pandemic. Moreover, complications stemming from these infections became more severe in the COVID-onset era. Specifically, the likelihood of necrotizing fasciitis showed a substantial increase, accompanied by an increased risk of respiratory failure and mediastinitis.

Original languageEnglish
Pages (from-to)782-787
Number of pages6
JournalSurgical infections
Issue number9
StatePublished - Nov 1 2023


  • COVID-19
  • Ludwig's angina
  • incidence
  • outcomes


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