Ludwig’s Angina in Somalia: Clinical Characteristics, Management, and Outcomes from a Tertiary Emergency Department Retrospective Study. First report of Ludwig’s angina in Somalia

Ludwig’s Angina in Somalia: Clinical Characteristics, Management, and Outcomes from a Tertiary Emergency Department Retrospective Study. First report of Ludwig’s angina in Somalia | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Ludwig’s Angina in Somalia: Clinical Characteristics, Management, and Outcomes from a Tertiary Emergency Department Retrospective Study. First report of Ludwig’s angina in Somalia Abdullahi Ahmed Ahmed, Ismail Mohamoud Abdullahi, Hussein Hassan Mohamud, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8062782/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 11 You are reading this latest preprint version Abstract Background and Objectives Ludwig’s angina is a life-threatening cellulitis of the submandibular space that can rapidly compromise the airway. Despite its clinical importance, data from Somalia are lacking. This study aims to document the demographic distribution of Ludwig’s angina, evaluate patients who presented at Mogadishu Somali Turkey Training and Research Hospital over one year, and analyze the causes, complications, length of hospital stay, treatment, outcomes, and management approaches used. Materials and Methods A retrospective analysis was conducted on 90 patients diagnosed with Ludwig’s angina. Demographic and clinical data, including age, sex, cause, referral source, duration of symptoms, length of hospital stay, clinical presentation, and treatment modality, were recorded and analyzed. Results Ludwig’s angina was more prevalent in males (77.8%), with a mean patient age of 39.1 years. The leading cause was odontogenic infection (65.5%), most commonly periodontal abscesses (34.4%). Surgical decompression was performed in 38.9% of patients, whereas targeted antibiotic therapy was administered in 46.7%. Complications were observed in 48.9% of cases, with septicemia being the most frequent (36.7%). A statistically significant correlation was found between prolonged hospital stays and the severity of clinical manifestations (B = 0.500, p < 0.001). Importantly, no mortality was recorded. Conclusion This study highlights a high complication rate and frequent delayed presentation among Somali patients with Ludwig’s angina, although no deaths were reported. Early recognition, timely airway management, and surgical drainage remain crucial to prevent morbidity. Improved access to dental care and early referral could help reduce the burden of this potentially fatal condition in resource-limited settings. Ludwig angina surgical drainage submental swelling odontogenic infection antibiotics Introduction Ludwig’s angina, also known as Angina Ludovici, is a potentially life-threatening infection characterized by rapidly progressive cellulitis involving the floor of the mouth and submandibular spaces bilaterally, which can lead to airway obstruction (1) . Although multiple etiologies such as tonsillitis, mandibular fractures, and penetrating injuries of the oral cavity have been reported, the most common cause remains odontogenic infections, particularly periapical and periodontal disease of the mandibular molars (2) . Advances in antibiotic therapy, surgical drainage, and airway management have markedly reduced mortality from earlier reports exceeding 54% to approximately 4% in recent series (3) . However, in many low- and middle-income countries (LMICs), Ludwig’s angina continues to pose a serious clinical challenge due to delayed presentation, poor access to dental care, and limited surgical and critical care resources (4) . Recent studies from sub-Saharan Africa and South Asia report significant morbidity, prolonged hospitalizations, and preventable complications (3,4) . Patients typically present with a history of untreated dental infections, most often involving the lower second or third molars, where the anatomical relationship to the mylohyoid line facilitates spread into the submandibular space (2, 4) . This can result in severe complications, including parapharyngeal abscess, submandibular sialadenitis, septicemia, and fatal airway obstruction, if not promptly recognized and managed (4) . Bacterial infections are the primary cause of Ludwig’s angina, often involving a polymicrobial mix of pathogens. Management typically includes broad-spectrum antibiotics, along with surgical incision and drainage of abscesses ( 5 ). Severe complications may include aspiration pneumonia, necrotizing fasciitis, mediastinitis, internal jugular vein thrombophlebitis, empyema, and osteomyelitis. If left untreated, Ludwig’s angina frequently leads to respiratory obstruction, which carries a fatality risk of up to 50% ( 6 ). In Somalia, no systematic studies of Ludwig’s angina have been reported despite high burdens of dental disease, fragile oral healthcare infrastructure, and restricted access to preventive services. Moreover, the absence of advanced airway facilities such as endotracheal intubation and tracheostomy in many hospitals underscores the heightened risks of poor outcomes. This study therefore represents the first systematic evaluation of Ludwig’s angina in Somalia, documenting demographic distribution, clinical features, treatment patterns, and outcomes at a tertiary referral hospital. By presenting local data, it not only fills a critical gap in the literature but also provides insights relevant to clinicians in other LMICs facing similar healthcare constraints. Methods Study Population and Data Collection The Somali–Türkiye Recep Tayyip Erdoğan Training and Research Hospital (STRTEH), established in Mogadishu in 2015, is the largest and best-equipped tertiary referral and teaching hospital in Somalia. For this study, we retrospectively reviewed electronic medical records from January 1, 2024, to December 31, 2024. A total of 120 patients diagnosed with Ludwig’s angina were identified. Patients were included if they had a confirmed diagnosis made by emergency physicians based on clinical presentation and imaging. Exclusion criteria were unconfirmed diagnoses and incomplete medical records. Demographic information, etiology, clinical presentation, duration of hospital stay, treatment modality, complications, and outcomes were extracted. Management of the source of infection (such as extraction of the offending tooth or drainage of abscesses) was also recorded. All cases were managed at the Emergency Unit of STRTEH during the study period. Management Protocol Initial treatment included empiric broad-spectrum antibiotics (ceftriaxone plus metronidazole), which were subsequently modified according to microbiological culture and sensitivity results. Source control was achieved through surgical drainage and extraction of the offending tooth when indicated. The small subset of patients classified as having “orthopedic abscesses” were clarified as odontogenic/post-extraction abscesses and were managed surgically with incision, drainage, and antibiotics. Patients presenting with complications such as sepsis or disseminated intravascular coagulation (DIC) received supportive care including intravenous fluids, oxygen therapy, nutritional support, and physician consultation for systemic stabilization, in addition to surgical and antimicrobial therapy. Ethical Approval Approval for this retrospective descriptive study was obtained from the Mogadishu Somali–Türkiye Training and Research Hospital Ethics Committee (Approval No.: 13.05.2024-MSTH/20230). Given the retrospective nature of the study and use of anonymized data, the requirement for informed consent was waived. Data Analysis Data were stored and analyzed using IBM SPSS Statistics for Windows, Version 26.0 (IBM Corp., Armonk, NY, USA). Descriptive statistics were used to summarize frequencies and proportions. Inferential statistics included chi-square tests for categorical variables and linear regression for continuous outcomes. A p-value of <0.05 was considered statistically significant. Results During the review period, 120 patients presented with clinical features of Ludwig’s angina. Of these, 90 cases were included in the analysis; 30 cases with incomplete data were excluded. Among the 90 patients, 70 (77.8%) were male and 20 (22.2%) were female. The mean age was 39.13 ± 21.4 years (range: 11–104 years). The primary cause of Ludwig’s angina was odontogenic infection, observed in 59 patients (65.5%). Dental caries was recorded separately in 15 patients (16.7%), idiopathic infections in 15 patients (16.7%), and trauma in 1 patient (1.1%). Among odontogenic infections, 31 (52.5%) were periodontal abscesses, 19 (32.2%) post-extraction abscesses, 5 (8.5%) orthopedic abscesses, and 4 (6.8%) chronic periodontitis. Symptom duration prior to presentation ranged from 2 to 14 days (mean: 2.7 ± 1.0 days) (Table 1). Surgical decompression via interrupted submandibular and submental incisions with blunt dissection and insertion of povidone-iodine–soaked gauze was performed under local anesthesia in 35 patients (38.9%). Surgical drainage and incision alone were performed in 13 patients (14.4%), and empiric antibiotic therapy alone was administered to 42 patients (46.7%). Source control (e.g., dental extraction or abscess drainage) was achieved in 27 patients (53.3% of those undergoing surgical intervention). All patients were managed with an oropharyngeal airway and supplemental intranasal oxygen. This approach was effective in maintaining airway patency throughout hospitalization. Empiric antibiotics consisted of ceftriaxone and metronidazole, later adjusted according to culture and sensitivity results. Comorbid conditions were systematically assessed and co-managed with physicians, and nutritional support was provided via high-protein diets or peripheral parenteral nutrition. Overall, 44 patients (48.9%) developed complications, including disseminated intravascular coagulation, necrotizing fasciitis, septicemia, and laryngeal spasm. No deaths were recorded. Favorable outcomes may be attributed to the relatively young patient population, early empiric antibiotics, effective conservative airway management, and prompt surgical intervention. Linear regression demonstrated a significant positive relationship between symptom duration and length of hospital stay. Longer symptom duration predicted longer hospitalization (B = 0.500, β = 0.484, t[86] = 5.131, p < 0.001). The model explicitly defined symptom duration as the independent variable and hospital stay as the dependent variable. No causality is implied; the relationship is associative. (Table 2, Table 3). Patients with comorbidities had a higher complication rate compared to those without (p < 0.001). Surgical decompression was associated with faster resolution and fewer secondary complications compared to empiric antibiotics alone (p 5 days), and presence of comorbidities were significant predictors of longer hospital stay (all p < 0.001). (Table 1) Discussion Ludwig’s angina is a rapidly progressive, life-threatening cellulitis of the submandibular, sublingual, and submental spaces that can result in airway compromise and systemic infection if not promptly managed. This study aimed to identify the most affected age groups and gender, common etiologies, and optimal management strategies for Ludwig’s angina. This study provides insight into the demographic distribution, etiology, clinical presentation, management strategies, and outcomes of Ludwig’s angina in Somalia, where data remain scarce. Our findings demonstrated a clear male predominance (male-to-female ratio 3.5:1), consistent with studies from India and Iraq that also reported higher rates in men, though with less disparity (55–65%) [7, 12] . In contrast, some studies have found a more balanced gender distribution [1]. The male excess in our cohort may reflect regional occupational exposures, delayed health-seeking behavior, and cultural factors influencing healthcare access. The majority of cases 58.9% occurred among younger adults (20–39 years), similar to studies from Vietnam and Indonesia where working-age groups were disproportionately affected [6, 13] . This pattern differs from reports in high-income settings, where older, immunocompromised patients predominate, suggesting that local epidemiological and socioeconomic factors shape disease burden in LMICs (4) . Odontogenic infections were the leading cause, with periodontal and postextraction abscesses ( 34.4% , and 21.1% respectively) most frequently identified. This finding is in line with evidence from multiple LMICs, where poor oral hygiene, limited access to preventive dental care, and delayed interventions increase susceptibility [4] . Interestingly, the prevalence of dental caries in our cohort (16.7%) was lower than that reported in India (63.3%) [8], possibly reflecting earlier extractions as a common practice in Somalia. Non-odontogenic causes, such as renal failure, diabetes, or salivary gland infections, frequently documented elsewhere [4] , were uncommon in our study, but dentoalveolar absces s and chronic periodontitis were identified as contributing factors, while 16.7% of the patients had an unclear etiology , though this may reflect limited screening for systemic comorbidities. Our study did not specifically assess systemic risk factors, emphasizing the need for further research on comorbidities associated with Ludwig’s angina. Moreover, the reference study documented rare causes such as insect bites (3.33%), sharp foreign-body ingestion (6.66%), and the use of herbal remedies (3.33%) , none of which were observed in our cohort ( 8 ). Trauma was a minor cause in both studies (1.1% in our study vs. 10% in the reference study). Clinical presentation was dominated by submandibular swelling, trismus, tongue elevation, and airway compromise, consistent with classic descriptions of Ludwig’s angina [9] . Nearly half of our patients developed complications, most notably septicemia, underscoring the systemic spread of infection when care is delayed. Necrotizing fasciitis and disseminated intravascular coagulation, though less common, highlight the potential lethality of advanced disease. Comparable complication rates have been documented in Iraq and India [10, 12] . Odontogenic infections account for 38.8% to 49% of deep neck infections involving soft tissues and 89% of severe multispace infections. These infections spread due to a lack of oral hygiene, inadequate preventive measures, and poor antibiotic therapy (11). Our study revealed that 30% of patients had sepsis, reinforcing the systemic impact of Ludwig’s angina. Other common comorbidities included severe anaemia (13.3%), aspiration pneumonia (2.2%), diabetes mellitus (5.6%), and chronic liver disease (4.4%). Additionally, 41.1% of patients had no underlying conditions, indicating that even otherwise healthy individuals can develop severe infections. Comorbidity profiles varied; while severe anemia and sepsis were common in our setting, diabetes and hypertension frequent in studies from India and Vietnam [12,13] were less prevalent. This may reflect demographic differences, as our cohort included more young adults, but it also points to underdiagnosis of chronic diseases in Somalia. Given the established role of diabetes as a risk factor for Ludwig’s angina, future studies should incorporate routine screening for systemic conditions. Management was primarily conservative, with empiric antibiotics used in nearly half of patients, while surgical decompression and drainage were required for those with airway compromise. Other LMIC series have reported higher rates of surgical intervention, with incision and drainage performed in up to 90% of cases [5] . Our findings suggest that timely antibiotic therapy can be effective when presentation is not severely advanced, but the relatively high rate of surgical decompression underscores the importance of early referral and surgical capacity. Delays in presentation were common, with over three-quarters of patients seeking care after 5–7 days of symptoms. This delay, greater than that reported in India [1] , likely reflects barriers to timely healthcare access in Somalia, including financial constraints, geographic distance, and limited awareness of oral health risks. Hospitalization duration (mean 3–8 days) was comparable to LMIC studies [14 ,15,16] , with relatively few patients requiring intensive care. Limitations of this study include its retrospective design, single-center setting, and lack of long-term follow-up, which limit generalizability and prevent assessment of recurrence or late complications. Moreover, systemic comorbidities were not comprehensively evaluated, potentially underestimating their contribution. In conclusion, Ludwig’s angina in Somalia predominantly affects young men and arises chiefly from odontogenic infections. High complication rates, frequent delays in presentation, and variable access to surgical care highlight the urgent need for improved dental preventive services, early recognition, and strengthened referral systems. Comparative evidence from other LMICs underscores both shared challenges and regional differences. Future multicenter, prospective studies are needed to better characterize comorbidity patterns and long-term outcomes in this population. Conclusion Ludwig’s angina remains a potentially life-threatening infection that requires prompt recognition and timely management. In our cohort from a tertiary hospital in Mogadishu, early access to care, aggressive antibiotic therapy, and surgical intervention contributed to zero mortality , highlighting the importance of timely healthcare delivery even in resource-limited settings. Odontogenic infections were the primary cause, underscoring the critical role of preventive oral hygiene and regular dental care, particularly among high-risk groups such as children and the elderly. Strengthening awareness among healthcare providers, improving early referral systems, and ensuring rapid airway management are essential strategies to further reduce morbidity and prevent severe complications, including airway obstruction, sepsis, and necrotizing fasciitis. These findings provide valuable insights for improving outcomes for Ludwig’s angina in Somalia and similar low-resource settings. Abbreviations L.A. : Ludwig's Angina S.T.T.R.H. : Mogadishu Somali Turkey Training and Research Hospital P.A. : Periodontal Abscess S.D. : Surgical Decompression A.T.T. : Antibiotic Therapy S.C. : Septicemia Declarations Institutional Review Board Statement Ethical Approval and Consent to Participate This study was conducted in accordance with the Declaration of Helsinki (latest revision, 2024). Ethical approval was obtained from the Mogadishu Somali–Türkiye Training and Research Hospital Research Ethics Committee (Approval No.: 13.05.2024‑MSTH/20230). All participants (or their legal guardians, in the case of minors) provided written informed consent to participate. Clinical Trial Number Clinical trial number: not applicable. Consent for Publication Not applicable (no individually identifiable data or images are included). Availability of data and materials The data that support the findings of this study are available in Mogadishu Somali Turkey, the Recep Tayyip Erdogan Training and Research Hospital information system. Data are, however, allowed to the authors upon reasonable request and with permission of the education and research committee. Competing interests Conflicts of interest refer to situations where personal, financial, professional, or other considerations may compromise, or have the appearance of compromising, a person's objectivity, integrity, or judgment in conducting or reporting research, providing reviews, or making decisions. Funding We declare that we have not received any financial support. Author Contributions Abdullahi Ahmed Ahmed: conceptualization, research, resources, writing—original draft, data curation, formal analysis, investigation, writing—review & editing, validation, visualization, study concept/design, and manuscript preparation. Ismail Mohamoud Abdullahi: took part in the design development and data analysis. Hussein Hassan Mohamud: supervision; writing—reviewing and editing. Abdishakur Mohamed Abdirahmanand and Nasteho Mohamed Sheikh Omar: took part in gathering information and creating the design. Sahra Ali Yusuf: contributed to study design, data interpretation, and review & editing of the manuscript. Resul Nusretoğlu: participated in data acquisition, formal analysis, and critical revision of the manuscript. All authors made significant contributions to the work reported—whether in conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; participated in drafting, revising, or critically reviewing the article; gave final approval of the version to be published; agreed on the journal to which the article has been submitted; and agreed to be accountable for all aspects of the work. Acknowledgments We thank Hussein Hassan Mohamud for his supervision and manuscript review. Appreciation is also extended to Ömer Metin provided valuable input in study design and data interpretation, while Resul Nusretoğlu contributed to data acquisition and critical manuscript revisions. Disclosure The authors declare that they have no conflicts of interest. References Ahmed YJ, Younis AG, Tawfeeq BA. Clinical survey for Ludwig’s angina cases presented in the emergency department of Al-Salam Teaching Hospital. Surg Res. 2024;6(4):1–6. Beedkar A, Jadhav SP, Iyer V, Gowda V, Iyer S. Ludwig’s angina to retrosternal abscess: a complication of odontogenic infection. Int Surg J. 2022;9(3):694–8. 10.18203/2349-2902.isj20220445 . Sjamsudin E, Nurwiadh A, Adiantoro S, Muharty A, Nusjirwan R. Ludwig’s angina as an odontogenic infection: management and characteristics of fifteen patients. Int J Clin Med. 2018;8(7):–. Osaghae IP, Adebola AR, Amole IO, Olaitan AA, Salami YA, Kuye O, Ayoub A. Ludwig’s angina in Nigeria: the disease of the poor and health inequality. Surgeon. 2022;20(4):e129–33. 10.1016/j.surge.2021.12.005 . PMID: 35093535. BS R, MB B, Dey D, Unisa T. Ludwig’s angina: analysing clinical profile and microbiology with antibiotic sensitivities at a tertiary care hospital. Egypt J Otolaryngol. 2021;22(22):1–4. Kumari A, Maan AS, Singh S, Saran SK. Diabetes mellitus and odontogenic infections: a life-threatening combination in Ludwig’s angina. Int J Res Med Sci. 2024;12(5):1502–6. 10.18203/2320-6012.ijrms20241335 . Raj LV, Sachdeva K, Shukla A, Kabade MV, Tom SM. Current scenario of suppurative head and neck infections in patients of tertiary care centre in COVID era. Int J Otorhinolaryngol Head Neck Surg. 2022;8(4):314–8. 10.18203/issn.2454-5929.ijohns20220923 . Parmar BD, Joshi KJ, Modi AD, Dave GP, Desai RS. Management of Ludwig’s angina at a tertiary care hospital in Western region of India. Cureus. 2022;14(3):e23278. 10.7759/cureus.23278 . Nguyen CD, Pham HV, Tran AT, Tran PTA, Dao HV, Nguyen KM, et al. Predicting factors for patients with Ludwig’s angina treated at Viet Duc University Hospital. GSC Adv Res Rev. 2022;12(2):69–78. 10.30574/gscarr.2022.12.2.0236 . Pucci R, Cassoni A, Di Carlo D, Della Monaca M, Romeo U, Valentini V. Severe odontogenic infections during pregnancy and related adverse outcomes: case report and systematic literature review. Trop Med Infect Dis. 2021;6(2):106. 10.3390/tropicalmed6020106 . PMID: 34201609. Maiese A, Del Duca F, Ghamlouch A, Treves B, Manetti AC, Napoletano G et al. Sudden death: a practical autopsy approach to unexplained mediastinitis due to fatal untreated neck infections—a systematic review. Diagnostics (Basel). 2024;14(11):1150. 10.3390/diagnostics14111150 . PMID: 38821252. Zhao Z, Ma D, Xu Y, Guo C, Li S, Wang J et al. Surgical therapy and outcome of descending necrotizing mediastinitis in Chinese: a single-center series. Front Med (Lausanne). 2024;10:1337852. 10.3389/fmed.2023.1337852 . PMID: 38206648. Adi ARP, Wibowo MD, Susilo DH. The relationship between metabolic acidosis as a predictive factor of mortality in Ludwig’s angina patients at Dr. Soetomo General Hospital, Surabaya, Indonesia. Bali Med J. 2023;12(1):966–70. 10.15562/bmj.v12i1.4096 . Pluksa P, Piromchai P. Efficacy of rubber tube drain versus Penrose drain to decrease hospital stay in Ludwig’s angina with upper airway obstruction. Thai J Otolaryngol Head Neck Surg. 2024;25(1):3–14. Rowe DP, Ollapallil J. Does surgical decompression in Ludwig’s angina decrease hospital length of stay? ANZ J Surg. 2011;81(3):168–71. 10.1111/j.1445-2197.2010.05496.x . Epub 2010 Oct 1. PMID: 21342390. Dudhe P, Burse K, Kulkarni S, Bhardwaj C, Patel R. Clinical profile and outcome of head and neck abscesses in 68 patients at a tertiary care centre. Indian J Otolaryngol Head Neck Surg. 2023;75(2):668–74. 10.1007/s12070-022-03265-8 . PMID: 37303404. Tables Table 1 This datasets presents the demographic, clinical, and treatment-related characteristics of patients with ludwing angina. Characteristics Description N % Gender Male 70 (77.8%) Female 20 (22.2%) Agegroup 1–14 6 (6.6%) 15–19 4 (4.4%) 20–39 53 (58.9%) 40–59 12 (13.3%) 60–79 10 (11.1%) > 80 5 (5.5%) Etiology Dental caries 15 (16.7) Chronic periodontitis 4 (4.4) Periodontal abscess 31 (34.4%) Post extraction abscess 19 (21.1%) Trauma 1 (1.1%) Dentoalveolar abscess 5 (11.1%) Apical periodontitis 0% Unknown 15 (16.6%) Symptoms and Sign Fever ,Toothache and Submental swelling 32 (35.6%) submandibular swelling ,Trismus ,Elevation of the tongue and Difficulty in breathing 47 (52.2%) Poor Oral Hyigen ,Halitosis ,Submental and submandibular swelling bilateral 11 (12.2%) Comorbidity Sepsis 27 (30%) Severe anaemia 12 (13.3%) Aspiration pneumonia 2 (2.2%) Hypertension 0% Pneumonia 3 (3.3%) Diabetes mellitus 5 (5.5%) Mental retardation 0% Chronic liver disease 4 (4.4%) Nil 37 (41.1%) Complications Dissseminated intravascular coagultion 3 (3.3%) mediastinitis 0% Necrotizing fasciitis 5 (5.5%) septicemia 33 (36.7%) laryngeal spasm 3 (3.3%) asphyxia 0% cardiac arrest 0% non 46 (51.1%) Type of management Antibiotic 42 (46.7%) Surgical decompression 35 (38.9%) Surgical draining and incision 13 (14.4%) Duration of Symptom 3 days 6 (6.7%) 5 days 34 (37.8%) 7 days 36 (40%) 10 days 10 (11.1%) more than 10 days 4 (4.4%) Hospital Stay Time 1–2 days 5 (5.5%) 3–5 days 46 (51.1%) 6–8 days 21 (23.3%) more than 10 days 16 (17.8%) Type of Admitted ward 86 (95.6%) ICU 4 (4.4%) Table 2 Model Summary for Regression Analysis Model R R Square Adjusted R Square Std error of the estimate R Square change F Change df1 Df2 Sig. F Change 1 .484 .234 .225 .779 .234 26.323 1 86 .000 Note. Predictors: (Constant), hospital stay time The regression model was statistically significant, F (1,86) = 26.32, p < .001, suggesting that hospital stay time significantly predicts the duration of symptoms. Table 3 Coefficients for Duration of Symptom Prediction Predictor B Std.error Beta t Sig Constant 1.375 0.262 5.257 .000 Predictor variable 1 0.500 0.097 0.484 5.131 .000 Note: Dependent variable = Duration of symptom Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8062782","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":561173359,"identity":"753185ec-6bc9-44d1-9159-886795acf630","order_by":0,"name":"Abdullahi Ahmed 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09:08:16","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8062782/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8062782/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":98532304,"identity":"17903c00-c9da-467d-82e4-7e16c8d5effb","added_by":"auto","created_at":"2025-12-18 16:06:37","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":39518,"visible":true,"origin":"","legend":"","description":"","filename":"LUDWINGMANUSCRIPTREVISED1.docx","url":"https://assets-eu.researchsquare.com/files/rs-8062782/v1/4163f848b483af387ecd94e4.docx"},{"id":98625713,"identity":"35d842a8-db9b-46fb-9d69-be7180387669","added_by":"auto","created_at":"2025-12-19 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12:21:12","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":803903,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8062782/v1/4c3ea4d7-f6b7-4e58-a1d7-81d6e122ffe2.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Ludwig’s Angina in Somalia: Clinical Characteristics, Management, and Outcomes from a Tertiary Emergency Department Retrospective Study. First report of Ludwig’s angina in Somalia","fulltext":[{"header":"Introduction","content":"\u003cp\u003eLudwig\u0026rsquo;s angina, also known as Angina Ludovici, is a potentially life-threatening infection characterized by rapidly progressive cellulitis involving the floor of the mouth and submandibular spaces bilaterally, which can lead to airway obstruction \u003csup\u003e(1)\u003c/sup\u003e. Although multiple etiologies such as tonsillitis, mandibular fractures, and penetrating injuries of the oral cavity have been reported, the most common cause remains odontogenic infections, particularly periapical and periodontal disease of the mandibular molars \u003csup\u003e(2)\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eAdvances in antibiotic therapy, surgical drainage, and airway management have markedly reduced mortality from earlier reports exceeding 54% to approximately 4% in recent series \u003csup\u003e(3)\u003c/sup\u003e. However, in many low- and middle-income countries (LMICs), Ludwig\u0026rsquo;s angina continues to pose a serious clinical challenge due to delayed presentation, poor access to dental care, and limited surgical and critical care resources \u003csup\u003e(4)\u003c/sup\u003e. Recent studies from sub-Saharan Africa and South Asia report significant morbidity, prolonged hospitalizations, and preventable complications \u003csup\u003e(3,4)\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003ePatients typically present with a history of untreated dental infections, most often involving the lower second or third molars, where the anatomical relationship to the mylohyoid line facilitates spread into the submandibular space \u003csup\u003e(2, 4)\u003c/sup\u003e. This can result in severe complications, including parapharyngeal abscess, submandibular sialadenitis, septicemia, and fatal airway obstruction, if not promptly recognized and managed \u003csup\u003e(4)\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eBacterial infections are the primary cause of Ludwig\u0026rsquo;s angina, often involving a polymicrobial mix of pathogens. Management typically includes broad-spectrum antibiotics, along with surgical incision and drainage of abscesses (\u003csup\u003e5\u003c/sup\u003e). Severe complications may include aspiration pneumonia, necrotizing fasciitis, mediastinitis, internal jugular vein thrombophlebitis, empyema, and osteomyelitis. If left untreated, Ludwig\u0026rsquo;s angina frequently leads to respiratory obstruction, which carries a fatality risk of up to 50% (\u003csup\u003e6\u003c/sup\u003e).\u003c/p\u003e \u003cp\u003eIn Somalia, no systematic studies of Ludwig\u0026rsquo;s angina have been reported despite high burdens of dental disease, fragile oral healthcare infrastructure, and restricted access to preventive services. Moreover, the absence of advanced airway facilities such as endotracheal intubation and tracheostomy in many hospitals underscores the heightened risks of poor outcomes. This study therefore represents the first systematic evaluation of Ludwig\u0026rsquo;s angina in Somalia, documenting demographic distribution, clinical features, treatment patterns, and outcomes at a tertiary referral hospital. By presenting local data, it not only fills a critical gap in the literature but also provides insights relevant to clinicians in other LMICs facing similar healthcare constraints.\u003c/p\u003e"},{"header":"Methods","content":"\u003ch3\u003eStudy Population and Data Collection\u003c/h3\u003e\n\u003cp\u003eThe Somali–Türkiye Recep Tayyip Erdoğan Training and Research Hospital (STRTEH), established in Mogadishu in 2015, is the largest and best-equipped tertiary referral and teaching hospital in Somalia.\u003c/p\u003e\n\u003cp\u003eFor this study, we retrospectively reviewed electronic medical records from January 1, 2024, to December 31, 2024. A total of 120 patients diagnosed with Ludwig’s angina were identified. Patients were included if they had a confirmed diagnosis made by emergency physicians based on clinical presentation and imaging. Exclusion criteria were unconfirmed diagnoses and incomplete medical records.\u003c/p\u003e\n\u003cp\u003eDemographic information, etiology, clinical presentation, duration of hospital stay, treatment modality, complications, and outcomes were extracted. Management of the source of infection (such as extraction of the offending tooth or drainage of abscesses) was also recorded. All cases were managed at the Emergency Unit of STRTEH during the study period.\u003c/p\u003e\n\u003ch3\u003eManagement Protocol\u003c/h3\u003e\n\u003cp\u003eInitial treatment included empiric broad-spectrum antibiotics (ceftriaxone plus metronidazole), which were subsequently modified according to microbiological culture and sensitivity results. Source control was achieved through surgical drainage and extraction of the offending tooth when indicated. The small subset of patients classified as having “orthopedic abscesses” were clarified as odontogenic/post-extraction abscesses and were managed surgically with incision, drainage, and antibiotics.\u003c/p\u003e\n\u003cp\u003ePatients presenting with complications such as sepsis or disseminated intravascular coagulation (DIC) received supportive care including intravenous fluids, oxygen therapy, nutritional support, and physician consultation for systemic stabilization, in addition to surgical and antimicrobial therapy.\u003c/p\u003e\n\u003ch3\u003eEthical Approval\u003c/h3\u003e\n\u003cp\u003eApproval for this retrospective descriptive study was obtained from the Mogadishu Somali–Türkiye Training and Research Hospital Ethics Committee (Approval No.: 13.05.2024-MSTH/20230). Given the retrospective nature of the study and use of anonymized data, the requirement for informed consent was waived.\u003c/p\u003e\n\u003ch3\u003eData Analysis\u003c/h3\u003e\n\u003cp\u003eData were stored and analyzed using IBM SPSS Statistics for Windows, Version 26.0 (IBM Corp., Armonk, NY, USA). Descriptive statistics were used to summarize frequencies and proportions. Inferential statistics included chi-square tests for categorical variables and linear regression for continuous outcomes. A p-value of \u0026lt;0.05 was considered statistically significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eDuring the review period, 120 patients presented with clinical features of Ludwig’s angina. Of these, 90 cases were included in the analysis; 30 cases with incomplete data were excluded. Among the 90 patients, 70 (77.8%) were male and 20 (22.2%) were female. The mean age was 39.13 ± 21.4 years (range: 11–104 years).\u003c/p\u003e\n\u003cp\u003eThe primary cause of Ludwig’s angina was odontogenic infection, observed in 59 patients (65.5%). Dental caries was recorded separately in 15 patients (16.7%), idiopathic infections in 15 patients (16.7%), and trauma in 1 patient (1.1%). Among odontogenic infections, 31 (52.5%) were periodontal abscesses, 19 (32.2%) post-extraction abscesses, 5 (8.5%) orthopedic abscesses, and 4 (6.8%) chronic periodontitis. Symptom duration prior to presentation ranged from 2 to 14 days (mean: 2.7 ± 1.0 days) (Table 1).\u003c/p\u003e\n\u003cp\u003eSurgical decompression via interrupted submandibular and submental incisions with blunt dissection and insertion of povidone-iodine–soaked gauze was performed under local anesthesia in 35 patients (38.9%). Surgical drainage and incision alone were performed in 13 patients (14.4%), and empiric antibiotic therapy alone was administered to 42 patients (46.7%). Source control (e.g., dental extraction or abscess drainage) was achieved in 27 patients (53.3% of those undergoing surgical intervention). All patients were managed with an oropharyngeal airway and supplemental intranasal oxygen. This approach was effective in maintaining airway patency throughout hospitalization.\u003c/p\u003e\n\u003cp\u003eEmpiric antibiotics consisted of ceftriaxone and metronidazole, later adjusted according to culture and sensitivity results. Comorbid conditions were systematically assessed and co-managed with physicians, and nutritional support was provided via high-protein diets or peripheral parenteral nutrition.\u003c/p\u003e\n\u003cp\u003eOverall, 44 patients (48.9%) developed complications, including disseminated intravascular coagulation, necrotizing fasciitis, septicemia, and laryngeal spasm. No deaths were recorded. Favorable outcomes may be attributed to the relatively young patient population, early empiric antibiotics, effective conservative airway management, and prompt surgical intervention.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eLinear regression demonstrated a significant positive relationship between symptom duration and length of hospital stay. Longer symptom duration predicted longer hospitalization (B = 0.500, β = 0.484, t[86] = 5.131, p \u0026lt; 0.001). The model explicitly defined symptom duration as the independent variable and hospital stay as the dependent variable. No causality is implied; the relationship is associative. (Table 2, Table 3).\u003c/p\u003e\n\u003cp\u003ePatients with comorbidities had a higher complication rate compared to those without (p \u0026lt; 0.001). Surgical decompression was associated with faster resolution and fewer secondary complications compared to empiric antibiotics alone (p \u0026lt; 0.001).\u003c/p\u003e\n\u003cp\u003eMultivariate analysis indicated that older age, delayed presentation (\u0026gt;5 days), and presence of comorbidities were significant predictors of longer hospital stay (all p \u0026lt; 0.001). (Table 1)\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eLudwig’s angina is a rapidly progressive, life-threatening cellulitis of the submandibular, sublingual, and submental spaces that can result in airway compromise and systemic infection if not promptly managed. This study aimed to identify the most affected age groups and gender, common etiologies, and optimal management strategies for Ludwig’s angina. This study provides insight into the demographic distribution, etiology, clinical presentation, management strategies, and outcomes of Ludwig’s angina in Somalia, where data remain scarce.\u003c/p\u003e\n\u003cp\u003eOur findings demonstrated a clear male predominance (male-to-female ratio 3.5:1), consistent with studies from India and Iraq that also reported higher rates in men, though with less disparity (55–65%) \u003csup\u003e[7, 12]\u003c/sup\u003e. In contrast, some studies have found a more balanced gender distribution [1]. The male excess in our cohort may reflect regional occupational exposures, delayed health-seeking behavior, and cultural factors influencing healthcare access.\u003c/p\u003e\n\u003cp\u003eThe majority of cases \u003cstrong\u003e58.9%\u003c/strong\u003eoccurred among younger adults (20–39 years), similar to studies from Vietnam and Indonesia where working-age groups were disproportionately affected \u003csup\u003e[6, 13]\u003c/sup\u003e. This pattern differs from reports in high-income settings, where older, immunocompromised patients predominate, suggesting that local epidemiological and socioeconomic factors shape disease burden in LMICs\u0026nbsp;\u003csup\u003e(4)\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eOdontogenic infections were the leading cause, with periodontal and postextraction abscesses (\u003cstrong\u003e34.4%\u003c/strong\u003e\u003cstrong\u003e, and 21.1%\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;respectively)\u003c/strong\u003emost frequently identified. This finding is in line with evidence from multiple LMICs, where poor oral hygiene, limited access to preventive dental care, and delayed interventions increase susceptibility \u003csup\u003e[4]\u003c/sup\u003e. Interestingly, the prevalence of dental caries in our cohort (16.7%) was lower than that reported in India (63.3%) [8], possibly reflecting earlier extractions as a common practice in Somalia. Non-odontogenic causes, such as renal failure, diabetes, or salivary gland infections, frequently documented elsewhere \u003csup\u003e[4]\u003c/sup\u003e, were uncommon in our study, but\u0026nbsp;\u003cstrong\u003edentoalveolar absces\u003c/strong\u003e\u003cstrong\u003es and chronic periodontitis\u003c/strong\u003ewere identified as\u0026nbsp;contributing\u0026nbsp;factors, while \u003cstrong\u003e16.7% of\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003ethe patients had an unclear etiology\u003c/strong\u003e, though this may reflect limited screening for systemic comorbidities.\u003c/p\u003e\n\u003cp\u003eOur study did not specifically assess systemic risk factors, emphasizing the need for further research on comorbidities associated with Ludwig’s angina. Moreover, the reference study documented \u003cstrong\u003erare causes\u003c/strong\u003e such as \u003cstrong\u003einsect bites (3.33%), sharp foreign-body ingestion (6.66%), and the use of herbal remedies (3.33%)\u003c/strong\u003e, none of which were observed in our cohort (\u003csup\u003e8\u003c/sup\u003e). Trauma was a minor cause in both studies (1.1% in our study vs. 10% in the reference study).\u003c/p\u003e\n\u003cp\u003eClinical presentation was dominated by submandibular swelling, trismus, tongue elevation, and airway compromise, consistent with classic descriptions of Ludwig’s angina \u003csup\u003e[9]\u003c/sup\u003e. Nearly half of our patients developed complications, most notably septicemia, underscoring the\u0026nbsp;systemic spread of infection when care is delayed. Necrotizing fasciitis and disseminated intravascular coagulation, though less common, highlight the potential lethality of advanced disease. Comparable complication rates have been documented in Iraq and India \u003csup\u003e[10, 12]\u003c/sup\u003e. Odontogenic infections account for 38.8% to 49% of deep neck infections involving soft tissues and 89% of severe multispace infections. These infections spread due to a lack of oral hygiene, inadequate preventive measures, and poor antibiotic therapy (11).\u003c/p\u003e\n\u003cp\u003eOur study revealed that 30% of patients had sepsis, reinforcing the systemic impact of Ludwig’s angina. Other common comorbidities included severe anaemia (13.3%), aspiration pneumonia (2.2%), diabetes mellitus (5.6%), and chronic liver disease (4.4%). Additionally, 41.1% of patients had no underlying conditions, indicating that even otherwise healthy individuals can develop severe infections.\u003c/p\u003e\n\u003cp\u003eComorbidity profiles varied; while severe anemia and sepsis were common in our setting, diabetes and hypertension frequent in studies from India and Vietnam \u003csup\u003e[12,13]\u003c/sup\u003ewere less prevalent. This may reflect demographic differences, as our cohort included more young adults, but it also points to underdiagnosis of chronic diseases in Somalia. Given the established role of diabetes as a risk factor for\u0026nbsp;Ludwig’s angina, future studies should incorporate routine screening for systemic conditions.\u003c/p\u003e\n\u003cp\u003eManagement was primarily conservative, with empiric antibiotics used in nearly half of patients, while surgical decompression and drainage were required for those with airway compromise. Other LMIC series have reported higher rates of surgical intervention, with incision and drainage performed in up to 90% of cases \u003csup\u003e[5]\u003c/sup\u003e. Our findings suggest that timely antibiotic therapy can be effective when presentation is not severely advanced, but the relatively high rate of surgical decompression underscores the importance of early referral and surgical capacity.\u003c/p\u003e\n\u003cp\u003eDelays in presentation were common, with over three-quarters of patients seeking care after 5–7 days of symptoms. This delay, greater than that reported in India \u003csup\u003e[1]\u003c/sup\u003e, likely reflects barriers to timely healthcare access in Somalia, including financial constraints, geographic distance, and limited awareness of oral health risks. Hospitalization duration (mean 3–8 days) was comparable to LMIC studies \u003csup\u003e[14\u003c/sup\u003e\u003csup\u003e,15,16]\u003c/sup\u003e, with relatively few patients requiring intensive care.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLimitations\u003c/strong\u003e of this study include its retrospective design, single-center setting, and lack of long-term follow-up, which limit generalizability and prevent assessment of recurrence or late complications. Moreover, systemic comorbidities were not comprehensively evaluated, potentially underestimating their contribution.\u003c/p\u003e\n\u003cp\u003eIn conclusion, Ludwig’s angina in Somalia predominantly affects young men and arises chiefly from odontogenic infections. High complication rates, frequent delays in presentation, and variable access to surgical care highlight the urgent need for improved dental preventive services, early recognition, and strengthened referral systems. Comparative evidence from other LMICs underscores both shared challenges and regional differences. Future multicenter, prospective studies are needed to better characterize comorbidity patterns and long-term outcomes in this population.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eLudwig’s angina remains a potentially life-threatening infection that requires prompt recognition and timely management. In our cohort from a tertiary hospital in Mogadishu, early access to care, aggressive antibiotic therapy, and surgical intervention contributed to \u003cstrong\u003ezero mortality\u003c/strong\u003e, highlighting the importance of timely healthcare delivery even in resource-limited settings. Odontogenic infections were the primary cause, underscoring the critical role of preventive oral hygiene and regular dental care, particularly among high-risk groups such as children and the elderly. Strengthening awareness among healthcare providers, improving early referral systems, and ensuring rapid airway management are essential strategies to further reduce morbidity and prevent severe complications, including airway obstruction, sepsis, and necrotizing fasciitis. These findings provide valuable insights for improving outcomes for Ludwig’s angina in Somalia and similar low-resource settings.\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eL.A.\u003c/strong\u003e: Ludwig's Angina\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eS.T.T.R.H.\u003c/strong\u003e: Mogadishu Somali Turkey Training and Research Hospital\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eP.A.\u003c/strong\u003e: Periodontal Abscess\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eS.D.\u003c/strong\u003e: Surgical Decompression\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eA.T.T.\u003c/strong\u003e: Antibiotic Therapy\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eS.C.\u003c/strong\u003e: Septicemia\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cem\u003eInstitutional Review Board Statement\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Approval and Consent to Participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted in accordance with the Declaration of Helsinki (latest revision, 2024). Ethical approval was obtained from the Mogadishu Somali–Türkiye Training and Research Hospital Research Ethics Committee (Approval No.: 13.05.2024‑MSTH/20230). All participants (or their legal guardians, in the case of minors) provided written informed consent to participate.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical Trial Number\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eClinical trial number: not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable (no individually identifiable data or images are included).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAvailability of data and materials\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe data that support the findings of this study are available in Mogadishu Somali Turkey, the Recep Tayyip Erdogan Training and Research Hospital information system. Data are, however, allowed to the authors upon reasonable request and with permission of the education and research committee.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConflicts of interest refer to situations where personal, financial, professional, or other considerations may compromise, or have the appearance of compromising, a person's objectivity, integrity, or judgment in conducting or reporting research, providing reviews, or making decisions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe declare that we have not received any financial support.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAuthor Contributions\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAbdullahi Ahmed Ahmed: conceptualization, research, resources, writing—original draft, data curation, formal analysis, investigation, writing—review \u0026amp; editing, validation, visualization, study concept/design, and manuscript preparation. Ismail Mohamoud Abdullahi: took part in the design development and data analysis. Hussein Hassan Mohamud: supervision; writing—reviewing and editing. Abdishakur Mohamed Abdirahmanand and Nasteho Mohamed Sheikh Omar: took part in gathering information and creating the design. Sahra Ali Yusuf: contributed to study design, data interpretation, and review \u0026amp; editing of the manuscript. Resul Nusretoğlu: participated in data acquisition, formal analysis, and critical revision of the manuscript.\u003c/p\u003e\n\u003cp\u003eAll authors made significant contributions to the work reported—whether in conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; participated in drafting, revising, or critically reviewing the article; gave final approval of the version to be published; agreed on the journal to which the article has been submitted; and agreed to be accountable for all aspects of the work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;We thank Hussein Hassan Mohamud for his supervision and manuscript review. Appreciation is also extended to Ömer Metin provided valuable input in study design and data interpretation, while Resul Nusretoğlu contributed to data acquisition and critical manuscript revisions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDisclosure\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no conflicts of interest.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAhmed YJ, Younis AG, Tawfeeq BA. Clinical survey for Ludwig\u0026rsquo;s angina cases presented in the emergency department of Al-Salam Teaching Hospital. Surg Res. 2024;6(4):1\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBeedkar A, Jadhav SP, Iyer V, Gowda V, Iyer S. Ludwig\u0026rsquo;s angina to retrosternal abscess: a complication of odontogenic infection. Int Surg J. 2022;9(3):694\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.18203/2349-2902.isj20220445\u003c/span\u003e\u003cspan address=\"10.18203/2349-2902.isj20220445\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSjamsudin E, Nurwiadh A, Adiantoro S, Muharty A, Nusjirwan R. Ludwig\u0026rsquo;s angina as an odontogenic infection: management and characteristics of fifteen patients. Int J Clin Med. 2018;8(7):\u0026ndash;.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOsaghae IP, Adebola AR, Amole IO, Olaitan AA, Salami YA, Kuye O, Ayoub A. Ludwig\u0026rsquo;s angina in Nigeria: the disease of the poor and health inequality. Surgeon. 2022;20(4):e129\u0026ndash;33. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.surge.2021.12.005\u003c/span\u003e\u003cspan address=\"10.1016/j.surge.2021.12.005\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 35093535.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBS R, MB B, Dey D, Unisa T. Ludwig\u0026rsquo;s angina: analysing clinical profile and microbiology with antibiotic sensitivities at a tertiary care hospital. Egypt J Otolaryngol. 2021;22(22):1\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKumari A, Maan AS, Singh S, Saran SK. Diabetes mellitus and odontogenic infections: a life-threatening combination in Ludwig\u0026rsquo;s angina. Int J Res Med Sci. 2024;12(5):1502\u0026ndash;6. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.18203/2320-6012.ijrms20241335\u003c/span\u003e\u003cspan address=\"10.18203/2320-6012.ijrms20241335\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRaj LV, Sachdeva K, Shukla A, Kabade MV, Tom SM. Current scenario of suppurative head and neck infections in patients of tertiary care centre in COVID era. Int J Otorhinolaryngol Head Neck Surg. 2022;8(4):314\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.18203/issn.2454-5929.ijohns20220923\u003c/span\u003e\u003cspan address=\"10.18203/issn.2454-5929.ijohns20220923\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eParmar BD, Joshi KJ, Modi AD, Dave GP, Desai RS. Management of Ludwig\u0026rsquo;s angina at a tertiary care hospital in Western region of India. Cureus. 2022;14(3):e23278. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.7759/cureus.23278\u003c/span\u003e\u003cspan address=\"10.7759/cureus.23278\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNguyen CD, Pham HV, Tran AT, Tran PTA, Dao HV, Nguyen KM, et al. Predicting factors for patients with Ludwig\u0026rsquo;s angina treated at Viet Duc University Hospital. GSC Adv Res Rev. 2022;12(2):69\u0026ndash;78. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.30574/gscarr.2022.12.2.0236\u003c/span\u003e\u003cspan address=\"10.30574/gscarr.2022.12.2.0236\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePucci R, Cassoni A, Di Carlo D, Della Monaca M, Romeo U, Valentini V. Severe odontogenic infections during pregnancy and related adverse outcomes: case report and systematic literature review. Trop Med Infect Dis. 2021;6(2):106. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3390/tropicalmed6020106\u003c/span\u003e\u003cspan address=\"10.3390/tropicalmed6020106\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 34201609.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMaiese A, Del Duca F, Ghamlouch A, Treves B, Manetti AC, Napoletano G et al. Sudden death: a practical autopsy approach to unexplained mediastinitis due to fatal untreated neck infections\u0026mdash;a systematic review. Diagnostics (Basel). 2024;14(11):1150. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3390/diagnostics14111150\u003c/span\u003e\u003cspan address=\"10.3390/diagnostics14111150\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 38821252.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhao Z, Ma D, Xu Y, Guo C, Li S, Wang J et al. Surgical therapy and outcome of descending necrotizing mediastinitis in Chinese: a single-center series. Front Med (Lausanne). 2024;10:1337852. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3389/fmed.2023.1337852\u003c/span\u003e\u003cspan address=\"10.3389/fmed.2023.1337852\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 38206648.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAdi ARP, Wibowo MD, Susilo DH. The relationship between metabolic acidosis as a predictive factor of mortality in Ludwig\u0026rsquo;s angina patients at Dr. Soetomo General Hospital, Surabaya, Indonesia. Bali Med J. 2023;12(1):966\u0026ndash;70. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.15562/bmj.v12i1.4096\u003c/span\u003e\u003cspan address=\"10.15562/bmj.v12i1.4096\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePluksa P, Piromchai P. Efficacy of rubber tube drain versus Penrose drain to decrease hospital stay in Ludwig\u0026rsquo;s angina with upper airway obstruction. Thai J Otolaryngol Head Neck Surg. 2024;25(1):3\u0026ndash;14.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRowe DP, Ollapallil J. Does surgical decompression in Ludwig\u0026rsquo;s angina decrease hospital length of stay? ANZ J Surg. 2011;81(3):168\u0026ndash;71. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/j.1445-2197.2010.05496.x\u003c/span\u003e\u003cspan address=\"10.1111/j.1445-2197.2010.05496.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub 2010 Oct 1. PMID: 21342390.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDudhe P, Burse K, Kulkarni S, Bhardwaj C, Patel R. Clinical profile and outcome of head and neck abscesses in 68 patients at a tertiary care centre. Indian J Otolaryngol Head Neck Surg. 2023;75(2):668\u0026ndash;74. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s12070-022-03265-8\u003c/span\u003e\u003cspan address=\"10.1007/s12070-022-03265-8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 37303404.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eThis datasets presents the \u003cspan class=\"Italic\"\u003edemographic, clinical, and treatment-related characteristics of patients with ludwing angina.\u003c/span\u003e\u003c/div\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan class=\"Italic\"\u003eCharacteristics\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan class=\"Italic\"\u003eDescription\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan class=\"Italic\"\u003eN\u003c/span\u003e %\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eGender\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eMale\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e70 (77.8%)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eFemale\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e20 (22.2%)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"6\" align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eAgegroup\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e1\u0026ndash;14\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e6 (6.6%)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e15\u0026ndash;19\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e4 (4.4%)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e20\u0026ndash;39\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e53 (58.9%)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e40\u0026ndash;59\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e12 (13.3%)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e60\u0026ndash;79\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e10 (11.1%)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u0026gt;\u0026thinsp;80\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e5 (5.5%)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"8\" align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eEtiology\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eDental caries\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e15 (16.7)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eChronic periodontitis\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e4 (4.4)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003ePeriodontal abscess\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e31 (34.4%)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003ePost extraction abscess\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e19 (21.1%)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eTrauma\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e1 (1.1%)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eDentoalveolar abscess\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e5 (11.1%)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eApical periodontitis\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0%\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eUnknown\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e15 (16.6%)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eSymptoms and Sign\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eFever ,Toothache and Submental swelling\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e32 (35.6%)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003esubmandibular swelling ,Trismus ,Elevation of the tongue and Difficulty in breathing\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e47 (52.2%)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003ePoor Oral Hyigen ,Halitosis ,Submental and submandibular swelling bilateral\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e11 (12.2%)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"9\" align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eComorbidity\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eSepsis\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e27 (30%)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eSevere anaemia\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e12 (13.3%)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eAspiration pneumonia\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e2 (2.2%)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eHypertension\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0%\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003ePneumonia\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e3 (3.3%)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eDiabetes mellitus\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e5 (5.5%)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eMental retardation\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0%\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eChronic liver disease\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e4 (4.4%)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eNil\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e37 (41.1%)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"8\" align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eComplications\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eDissseminated intravascular coagultion\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e3 (3.3%)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003emediastinitis\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0%\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eNecrotizing fasciitis\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e5 (5.5%)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003esepticemia\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e33 (36.7%)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003elaryngeal spasm\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e3 (3.3%)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003easphyxia\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0%\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003ecardiac arrest\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0%\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003enon\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e46 (51.1%)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eType of management\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eAntibiotic\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e42 (46.7%)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eSurgical decompression\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e35 (38.9%)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eSurgical draining and incision\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e13 (14.4%)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"5\" align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eDuration of Symptom\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e3 days\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e6 (6.7%)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e5 days\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e34 (37.8%)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e7 days\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e36 (40%)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e10 days\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e10 (11.1%)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003emore than 10 days\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e4 (4.4%)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eHospital Stay Time\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e1\u0026ndash;2 days\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e5 (5.5%)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e3\u0026ndash;5 days\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e46 (51.1%)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e6\u0026ndash;8 days\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e21 (23.3%)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003emore than 10 days\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e16 (17.8%)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eType of Admitted\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eward\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e86 (95.6%)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eICU\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e4 (4.4%)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n \u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan class=\"Italic\"\u003eModel Summary for Regression Analysis\u003c/span\u003e\u003c/div\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eModel\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eR\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eR Square\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eAdjusted R Square\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eStd error of the estimate\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eR Square change\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eF Change\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003edf1\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eDf2\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eSig. F Change\u003c/div\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e1\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.484\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.234\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.225\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.779\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.234\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e26.323\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e1\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e86\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.000\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"10\"\u003eNote. Predictors: (Constant), hospital stay time\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"10\"\u003eThe regression model was statistically significant, F (1,86)\u0026thinsp;=\u0026thinsp;26.32, p\u0026thinsp;\u0026lt;\u0026thinsp;.001, suggesting that hospital stay time significantly predicts the duration of symptoms.\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan class=\"Italic\"\u003eCoefficients for Duration of Symptom Prediction\u003c/span\u003e\u003c/div\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003ePredictor\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eB\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eStd.error\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eBeta\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003et\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eSig\u003c/div\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eConstant\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e1.375\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0.262\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e5.257\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.000\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003ePredictor variable 1\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0.500\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0.097\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0.484\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e5.131\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.000\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\"\u003eNote: Dependent variable\u0026thinsp;=\u0026thinsp;Duration of symptom\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-oral-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ohea","sideBox":"Learn more about [BMC Oral Health](http://bmcoralhealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ohea/default.aspx","title":"BMC Oral Health","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Ludwig angina, surgical drainage, submental swelling, odontogenic infection, antibiotics","lastPublishedDoi":"10.21203/rs.3.rs-8062782/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8062782/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground and Objectives\u003c/h2\u003e \u003cp\u003eLudwig\u0026rsquo;s angina is a life-threatening cellulitis of the submandibular space that can rapidly compromise the airway. Despite its clinical importance, data from Somalia are lacking. This study aims to document the demographic distribution of Ludwig\u0026rsquo;s angina, evaluate patients who presented at Mogadishu Somali Turkey Training and Research Hospital over one year, and analyze the causes, complications, length of hospital stay, treatment, outcomes, and management approaches used.\u003c/p\u003e\u003ch2\u003eMaterials and Methods\u003c/h2\u003e \u003cp\u003eA retrospective analysis was conducted on 90 patients diagnosed with Ludwig\u0026rsquo;s angina. Demographic and clinical data, including age, sex, cause, referral source, duration of symptoms, length of hospital stay, clinical presentation, and treatment modality, were recorded and analyzed.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eLudwig\u0026rsquo;s angina was more prevalent in males (77.8%), with a mean patient age of 39.1 years. The leading cause was odontogenic infection (65.5%), most commonly periodontal abscesses (34.4%). Surgical decompression was performed in 38.9% of patients, whereas targeted antibiotic therapy was administered in 46.7%. Complications were observed in 48.9% of cases, with septicemia being the most frequent (36.7%). A statistically significant correlation was found between prolonged hospital stays and the severity of clinical manifestations (B\u0026thinsp;=\u0026thinsp;0.500, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Importantly, no mortality was recorded.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThis study highlights a high complication rate and frequent delayed presentation among Somali patients with Ludwig\u0026rsquo;s angina, although no deaths were reported. Early recognition, timely airway management, and surgical drainage remain crucial to prevent morbidity. Improved access to dental care and early referral could help reduce the burden of this potentially fatal condition in resource-limited settings.\u003c/p\u003e","manuscriptTitle":"Ludwig’s Angina in Somalia: Clinical Characteristics, Management, and Outcomes from a Tertiary Emergency Department Retrospective Study. First report of Ludwig’s angina in Somalia","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-18 16:06:29","doi":"10.21203/rs.3.rs-8062782/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2025-12-28T09:47:00+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-23T11:00:26+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-22T02:38:29+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"304477170122575828608142890836153295374","date":"2025-12-18T08:51:43+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"5195935151461106566824677405887439542","date":"2025-12-18T08:35:14+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"73701305790213711065093468916732264141","date":"2025-12-16T12:22:03+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-12-16T08:07:50+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-11-15T12:02:14+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-11-11T05:30:27+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-11-11T05:26:28+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Oral Health","date":"2025-11-08T09:03:12+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-oral-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ohea","sideBox":"Learn more about [BMC Oral Health](http://bmcoralhealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ohea/default.aspx","title":"BMC Oral Health","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b1258b22-c0ba-484a-b556-e27e7bf296ba","owner":[],"postedDate":"December 18th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-12-18T16:06:30+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-18 16:06:29","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8062782","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8062782","identity":"rs-8062782","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}