Ludwig's Angina: Dental Origin and Surgical Management in Somalia

Ludwig's angina: a critical emergency in Mogadishu

Ludwig's angina represents a rapidly progressive form of cellulitis involving the submandibular, sublingual, and submental spaces bilaterally. This life-threatening condition, due to rapid airway obstruction, constitutes a major therapeutic challenge, particularly in healthcare settings where epidemiological data remain scarce, as is the case in Somalia.

This retrospective study aimed to analyze the demographic profile, etiology, clinical presentation, management modalities, complications, and length of hospital stay of a cohort of 90 patients diagnosed with Ludwig's angina, admitted between January 1, 2024, and December 31, 2024, at the Mogadishu Somali–Türkiye Recep Tayyip Erdoğan Training and Research Hospital.

The analysis was based on data extracted from medical records to evaluate the impact of consultation delays on the length of hospital stay, while documenting clinical outcomes in a resource-limited environment. The study seeks to establish, via linear regression, the predictive link between the duration of symptoms before admission and the length of hospital stay, in order to better understand the factors influencing morbidity within this specific population.

Methodology: retrospective analysis

This study was designed as a retrospective review to document the management of Ludwig's angina in a resource-limited hospital setting. The analysis focuses on the medical records of 90 patients admitted to the Mogadishu Somali–Türkiye Recep Tayyip Erdoğan Training and Research Hospital over a one-year period, extending from January 1, 2024, to December 31, 2024.

Protocol and population

The cohort is composed exclusively of patients with a confirmed clinical diagnosis of Ludwig's angina. Variables extracted from the records include demographic data, dental or other etiology, duration of symptoms before admission, referral source, and the therapeutic protocol applied.

Data analysis and treatment modalities

Data processing was performed using descriptive and inferential statistics to correlate clinical management and hospital outcomes. The study segments the population into two main therapeutic approaches:

• A group treated with intravenous antibiotic therapy combined with close airway monitoring (46.7%, n = 42).
• A group that required surgical intervention (53.3%, n = 48), divided between deep surgical decompression (38.9%, n = 35) and superficial drainage (14.4%, n = 13).

To evaluate the temporal impact on morbidity, a linear regression was applied to determine the relationship between the duration of symptoms before admission and the length of hospital stay (LOS).

Results: Clinical profile and management

The retrospective study conducted on 90 patients reveals a marked male predominance (77.8%, n = 70) with a mean age of 39.1 ± 21.4 years. The etiology is predominantly odontogenic (82.2%, n = 74), dominated by periodontal and periapical abscesses (65.5%, n = 59).

Therapeutic management was split into two distinct approaches according to clinical severity:

Regarding hospital complications, 48.9% of patients (n = 44) experienced adverse events, with sepsis being the major complication (36.7%, n = 33). Despite this morbidity, institutional mortality was zero (0.0%).

Statistical analysis highlights a direct correlation between the time to treatment and the length of hospital stay:

• Linear regression model: The duration of symptoms before admission is a significant predictor of prolonged hospitalization (B = 0.500; p < 0.001).

These data highlight the critical impact of the consultation delay on the length of hospital stay, confirming that every day of delay in diagnosis increases the burden of care required to stabilize these deep neck space infections.

Ludwig's angina: focus on Somali data

Ludwig's angina remains a dreaded life-threatening emergency, characterized by fulminant progression. This retrospective study conducted at the Mogadishu Somali–Türkiye Recep Tayyip Erdoğan Training and Research Hospital on 90 patients (2024 cohort) provides valuable clinical insight into management in a resource-limited setting. Odontogenic etiology is largely dominant, accounting for 82.2% of cases, with a marked prevalence of periodontal and periapical abscesses (65.5%).

Clinical analysis of results

The salient point lies in the burden of complications: 48.9% of patients presented with hospital complications, with sepsis remaining the major risk (36.7%). While mortality is zero in this series, the statistical correlation between the duration of symptoms before admission and the length of hospital stay (B = 0.500, p < 0.001) underscores the urgency of early management. In practice, 53.3% of patients required surgical decompression, confirming that drainage remains an essential therapeutic pillar in the face of failure of conservative antibiotic treatment alone.

Limitations and implications

This study is limited by its retrospective design. Although the results are encouraging in terms of survival, they highlight that access to primary dental care is improvable, a factor that inevitably delays initial presentation. For the practitioner, this finding reinforces the idea that an infection of dental origin, if not treated promptly upstream, can rapidly evolve into an extreme emergency.

Summary of results

This retrospective study conducted on 90 patients with Ludwig's angina reveals a male predominance (77.8%) and a predominantly odontogenic origin (82.2%), mainly linked to periodontal and periapical abscesses. Management required surgical drainage in 53.3% of cases, while 46.7% were treated with intravenous antibiotic therapy and monitoring, with an infectious complication rate of 48.9% and zero mortality.

Concretely, for the practitioner:

• Diagnostic alert: The direct correlation between the duration of pre-admission symptoms and the duration of hospitalization requires immediate management from the first clinical signs to limit septic complications.
• Odontogenic management: Dental etiology is the major causal factor here; your systematic radiographic assessments during abscesses are critical to prevent extension into deep cervical spaces.
• Monitoring: In case of suspected Ludwig's angina, rigorous monitoring of the airways is essential, even in the absence of an immediate surgical procedure.

Technical lexicon: Ludwig's angina

Ludwig's angina: Rapidly progressive cellulitis affecting the submandibular, sublingual, and submental spaces bilaterally, presenting a critical risk of airway obstruction.

Deep operative decompression: Major surgical intervention performed in 38.9% of the study patients to treat the extension of the infection into the deep spaces of the neck.

Superficial drainage: Targeted surgical procedure, performed in 14.4% of patients, aimed at evacuating purulent collections limited to superficial areas.

Odontogenic origin: Dominant etiology in this cohort (82.2%), mainly linked to local periapical and periodontal abscesses, identified as the main cause of the infection.

Sepsis: Major systemic complication observed in 36.7% of hospitalized patients, constituting the most frequent complication within the sample.

Length of stay (LOS): Hospital variable significantly correlated with the duration of symptoms before admission (B=0.500, p<0.001), where late management leads to prolonged hospitalization.

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