INTRODUCTION
Ludwig’s angina is a bilateral infection of the submandibular space that consists of two compartments in the floor of the mouth, the sublingual space and the submylohyoid (also known as submaxillary) space (figure 1). It was first described by the German physician, Wilhelm Frederick von Ludwig in 1836. This infection most commonly arises from an infected second or third mandibular molar tooth. It is an aggressive, rapidly spreading cellulitis without lymphadenopathy with potential for airway obstruction and requires careful monitoring and rapid intervention for prevention of asphyxia and aspiration pneumonia.
The anatomy, microbiology, clinical manifestations, imaging, and treatment of submandibular space infections (Ludwig’s angina) will be reviewed here. Other deep neck space infections are discussed separately. (See “Deep neck space infections”.)
DEFINITION
Although the term Ludwig’s angina has been loosely applied to a heterogeneous array of infections involving the sublingual and submylohyoid (submaxillary) spaces, this diagnosis should be restricted to the following classical description:
- The infection begins in the floor of the mouth. It is characteristically an aggressive, rapidly spreading “woody” or brawny cellulitis involving the submandibular space.
- The infection is a rapidly spreading cellulitis without lymphatic involvement and generally without abscess formation.
- Both the submylohyoid and sublingual spaces are involved.
- The infection is bilateral.
ANATOMIC CONSIDERATIONS
The submandibular space lies within the submental and submandibular triangles between the mucosa of the floor of the mouth and the superficial layer of the deep cervical fascia. It is subdivided by the mylohyoid muscle into the sublingual space (which contains the sublingual gland, hypoglossal nerve, part of the submandibular gland, and loose connective tissue) and the submylohyoid space (which contains the submandibular salivary gland and lymph nodes) (figure 1). The two divisions communicate posteriorly around the mylohyoid muscle. This accounts for the bilateral involvement by contiguous spread of infection within the submandibular space in Ludwig’s angina.
[Cause]
submental space infection is caused by what the?
space under the chin (submental space) located in the suprahyoid region, the submental triangle within a single space. A small amount of adipose tissue within the gap and lymph nodes, this gap for the mylohyoid muscle, the submental hyoid muscle and the sublingual space apart. Connected with the submandibular space on both sides, the infection spread easily with each other (Figure 1).
Figure 1 submental space anatomy
submental space infections come from the lymph node inflammation. Lower lip, tongue, floor of mouth, sublingual caruncle, mandibular anterior teeth and periodontal tissues of the lymphatic flow can be remitted directly to the submental lymph nodes, it is more than one region of inflammation, mouth ulcers, mouth under the chin can cause go far lymphadenitis and cellulitis secondary to the submental space.
[Symptoms]
submental space infection early symptoms?
submental space as much as the lymph nodes caused by infection, it is generally slow progression, early limited lymph node enlargement, obvious clinical symptoms. When extranodal spread to the lymph node inflammation, the gap was caused by cellulitis tissue inflammation, swelling extended to cover different time to the submental triangle development area, skin redness, pain. Abscess formation after local skin purple, palpable pressure fluctuations have pitting edema, and infection. Back when the infection spread to submandibular space, and can demonstrate the appropriate symptoms.
[Prevention]
submental space infection should be how to prevent?
prevention
lower lip, tongue, floor of mouth, sublingual caruncle, mandibular anterior teeth and periodontal tissue lymphatic drainage can be remitted directly to the submental lymph nodes, so the need to actively treat more than one region of inflammation, oral ulcers, mouth go far, avoid submental lymphadenitis, cellulitis and secondary to the submental space.
[Treatment]
submental space infection precautions before treatment?
abscess formation, swelling in the submental area to do the most prominent transverse skin incision, separated from the submental platysma of the gap and establish drainage.
submental space infection medicine treatment
No information
Western submental space infection treatment
No information
[Check]
submental space infection should be how?
oral examination.
obvious sense of deep abscess fluctuations, sometimes required by the puncture diagnosis.
[Confused]
submental space infection and the diseases easily confused?
detailed analysis of the history, combined with clinical and anatomical features, coupled with the biopsy, etc., is not difficult to make a correct diagnosis.
Abscesses of the second and third mandibular molars may perforate the mandible and spread into the submandibular and submental spaces. Ludwig’s angina is manifested by swelling of the floor of the mouth and elevation and posterior displacement of the tongue. A rapidly spreading gangrenous cellulitis produces a brawny edema of the suprahyoid region of the neck. The infection begins unilaterally but quickly spreads to include the entire neck. The most common presenting symptoms are oral, neck, and dental pain. In addition, there is neck swelling, odynophagia, dysphagia, dysphonia, trismus; and tongue swelling. Airway patency is the main concern. In many of these patients, it is impossible to introduce an endotracheal tube and therefore, tracheotomy under local anesthesia is the only way to ventilate them.
Submental space abscess, secondary to dental disease
Submental Abscess
Ludwig’s Angina.
LUDWIG’S ANGINA is an inflammation of the submandibular space, usually starting in the submaxillary space and spreading to the sublingual space via the fascial planes, not the lymphatics. As the submandibular space is expanded by cellulitis or abscess formation, the floor of the mouth becomes indurated and the tongue is forced upward and backward, causing airway obstruction. Ludwig’s angina does not necessarily mature to form an abscess, it is more likely to produce a cellulitis or a phlegmon. It is typically bilateral and presents with drooling, trismus, pain, dysphagia, submandibular swelling airway obstruction caused by displacement of the tongue. The tongue may protrude outside the mouth. This is a life-threatening condition that requires tracheotomy. Before antibiotics, the mortality rate of Ludwig’s angina was 50%. With modern antimicrobial and surgical therapies, the mortality rate is less than 5%.
This patient developed acute upper respiratory obstruction. The swelling became so severe that the tongue protruded outside the mouth. A tracheotomy was performed to provide an airway. After resolution of the infection, a large stone was found in the submandibular gland duct (Wharton’s duct). The radio-opacity in the occlusal film on the left represents the stone that was removed.
Stages of Infection
I. Cellulitis
II. Abscess
III. Sinus Tract/Fistula
CELLULITIS
A painful swelling of the soft tissue of the mouth and face resulting from a diffuse spreading of purulent exudate along the fascial planes that separate the muscle bundles.
Abscess
Well defined borders
Pus accumulation in tissues
Fluctuant to palpation
Cellulitis – “spreading” infection
Abscess – “localized” infection
FISTULA
A drainage pathway or abnormal communication between two epithelium-lined surfaces due to destruction of the intervening tissue.
Management of Infection
Determine the severity of the infection
Evaluate the host defense
Decide on setting of care
Treat surgically
Support medically
Choose and prescribe antibiotics appropriately
Evaluate patient frequently
Severity of Infection
Rate of progression
Potential for airway compromise or affecting vital organs
Anatomic location of infection
HISTORY
Duration of infectious process.
Sequence of events and changes in symptoms or signs.
Antibiotics prescribed, dosages and responses.
Review of systems with emphasis on neuro-ophthalmologic and cardiopulmonary and immune systems.
Social history – exposure, travel, (fungal or parasitic infections), chemical dependency.
SIGNS OF SEVERITY
Fever
Dehydration
Rapid progression of swelling
Trismus
Marked pain
Quality and/or location of swelling
Elevation of tongue
Difficulty with speech and swallowing
Anatomic Location
Graded in severity by level to which the airway and vital structures are threatened
Low
Buccal, Vestibular, Subperiosteal
Moderate
Masticator space
Severe
Lateral pharyngeal
Retropharyngeal
Danger Space
What are the primary fascial spaces?
The spaces directly adjacent to the origin of the odontogenic infections. Infections spread from the origin into these spaces, which are:
Vestibular Submental
Canine Sublingual
Buccal Submandibular
VESTIBULAR
BUCCAL
Likely from
Upper Premolar
Upper molar
Lower molars
SUBMENTAL SPACE
Anterior mandibular teeth
Deep to mentalis muscle
Submental Space
Most likely caused by lower anterior teeth or mandibular sympysis fracture
SUBLINGUAL SPACE
Presents in floor of mouth
Drained intraorally parallel to Wharton’s duct
Submandibular Space
Likely cause:
Lower molars
SUBMANDIBULAR SPACE
Extra-oral presentation
Deep to mylohyoid
I & D through skin with blunt incision
LUDWIG’S ANGINA
Bilateral submandibular, sublingual, and sub-mental involvement
Rarely fluctuant
Often fatal
Requires early, aggressive intervention
What are the secondary fascial spaces?
Fascial spaces that become involved following spread of infection from the primary spaces.
The secondary spaces are:
Pterygomandibular Infratemporal
Masseteric Lateral pharyngeal
Superficial and deep temporal Retropharyngeal Prevertebral
PHARYNGEAL SPACE INFECTIONS
Lateral pharyngeal
Retro-pharyngeal
(both can lead directly to mediastinum)
What factors influence the spread of odontogenic infection?
Thickness of bone adjacent to the offending tooth
Position of muscle attachment in relation to root tip
Virulence of the organism
Status of patient’s immune system
INCISION AND DRAINAGE
The production of “laudable pus” by:
– mucosal incision
– extraction
– endodontic access
– periodontal curettage
INCISION AND DRAINAGE
Incise in healthy skin
Incise in gravity-dependent, esthetic area – if possible
Explore entire abscess cavity
Non-absorbable drains
PRINCIPLES IN
THE USE OF DRAINS (II)
Drained wounds should be cleansed frequently.
Bacteria can migrate into a wound along the drain surface.
Latex Penrose drains are best used unmodified
INDICATIONS FOR CULTURE
Nonresolving infection in spite of appropriate care
Atypical flora expected
= long term antibiotic treatment
= age extremes (<2 or >65)
= patients with malignancies
Infections with systemic involvement
Immunocompromised or myelosuppressed patients
EMPIRIC THERAPY OF ODONTOGENIC INFECTIONS
Penicillin
Penicillin + metronidazole
PCN allergy —— clindamycin
MANAGEMENT OF ODONTOGENIC INFECTIONS
1. Determine severity Assess history of onset and progression perform physical examination of area:
(1) Determine character and size of swelling
(2) Establish presence of trismus
2. Evaluate host defenses Evaluate:
(1) Diseases that compromise the host
(2) Medications that may compromise the host
3. Perform surgery Remove the cause of infection Drain pus Relieve pressure
4. Select antibiotic
5. Follow up
Determine:
(1) Most likely causative organisms based on history
(2) Host defense status
(3) Allergy history
(4) Previous drug history
Prescribe drug property (route,dose and dosage interval, and duration)
Confirm treatment response
Evaluate for side effects and secondary infections
Patient should be monitored frequently
out-patient should return for f/u in 2-3 days
Patient should have decreased swelling, discharge, airway edema, malaise in 2-3 days
If no improvement consider:
Re-culture
Re-image
Repeat I and D
Sublingual Space Infections
The sublingual space (SLS) is located inferior to intrinsic muscles of the oral tongue, lateral to the genioglossus-geniohyoid complex and superomedial to the mylohyoid muscle. Anteriorly, it is related to the mandible. Posteriorly, the SLS communicates with the submandibular space (SMS) with no fascia separating these spaces.
Sublingual Space Abscess
Abscesses originating in this space are usually due to sublingual or submandibular duct stenosis or calculus disease. Dental infection or mandibular osteomyelitis may also extend into the SLS. The most commonly encountered organisms in SLS abscess formation are S. aureus and Streptococcus viridans.
Clinically, patients with SLS abscess usually present with pain, tenderness and swelling in the anterior floor of the mouth. There may be a history of salivary colic, recent dental disease or dental manipulation. Treatment of an SLS abscess should commence with antibiotic therapy followed by surgical drainage.
CT shows an enhancing mass involving the SLS associated with subcutaneous streaking and thickening of the platysma muscle. The genioglossus-geniohyoid complex is often displaced medially or across the midline (Figure 4). If an SMS component is present, this abscess may track into parapharyngeal space, where further spread can take place in the craniocaudal axis. Infection may also spread to the medial pterygoid or masseter muscles.
Sublingual Space Infections
The sublingual space (SLS) is located inferior to intrinsic muscles of the oral tongue, lateral to the genioglossus-geniohyoid complex and superomedial to the mylohyoid muscle. Anteriorly, it is related to the mandible. Posteriorly, the SLS communicates with the submandibular space (SMS) with no fascia separating these spaces.
Sublingual Space Abscess
Abscesses originating in this space are usually due to sublingual or submandibular duct stenosis or calculus disease. Dental infection or mandibular osteomyelitis may also extend into the SLS. The most commonly encountered organisms in SLS abscess formation are S. aureus and Streptococcus viridans.
Clinically, patients with SLS abscess usually present with pain, tenderness and swelling in the anterior floor of the mouth. There may be a history of salivary colic, recent dental disease or dental manipulation. Treatment of an SLS abscess should commence with antibiotic therapy followed by surgical drainage.
CT shows an enhancing mass involving the SLS associated with subcutaneous streaking and thickening of the platysma muscle. The genioglossus-geniohyoid complex is often displaced medially or across the midline (Figure 4). If an SMS component is present, this abscess may track into parapharyngeal space, where further spread can take place in the craniocaudal axis. Infection may also spread to the medial pterygoid or masseter muscles.
Figure 4.
Sublingual space abscess. Axial contrast-enhanced CT (A) shows an abscess involving the left sublingual space (arrow). The bone algorithm (B) shows that the cause of the abscess is due to a “rotten” tooth (arrow).
MR imaging is rarely used for inflammatory disease involving the floor of the mouth. A floor-of-the-mouth abscess shows the typical enhancing mass on T1W images and high signal intensity on T2W images. In contrast-enhanced images, a central area of no enhancement, indicating pus collection, can readily be demonstrated. Mandibular marrow edema is more readily demonstrated on MR as intermediate signal tissues replacing high signal intensity fat on T1W images.
Sublingual abscess
Localization
Accumulation of pus between the mucosa of the floor of the mouth and the mylohyoid muscle.
Tongue muscles lay medially, the mandible ventrally and laterally.
- elevated floor of mouth
- glass-like reddening of the mucosa of the floor of the mouth
- difficulties speaking due to dislocation of the tongue to the healthy side
Treatment
- Incision in the alveolar ridge near the floor of the mouth, touching the periosteum of the affected tooth.
Caveat! The course of the lingual nerve goes laterally close to the periosteum of the lower wisdom tooth! - Drainage, rinsing
- Elimination of causes
Submandibular abscess
- between mylohyoid muscle and superficial fascia colli and the anterior belly of the digastric muscle
Causes
- Periapical periodontitis of molar teeth
- Periapical periodontitis of premolar teeth
Specific symptoms
- reddening and swelling of the inner mandibular surface
- The floor of the mouth is reddened, swollen and hardened dorsally.
- The margin of the mandible is laterally palpable, contours disappear medially.
- occasional trismus
Treatment
- extraoral incision, approx. width 4 cm, parallel to the margin of mandible
- drainage, rinsing
- elimination of causes
Massetericomandibular abscess
Localization
Causes
periapical periodontitis of molar teet
Specific symptoms
- reddening and pain on pressure in masseter region
- non-movable extraoral swelling
- The margin of mandible can usually not be palpated.
- trismus
Treatment
- intraoral incision in the lateral region of the pterygomandibular plica
- drainage, rinsing
- antibiotic treatment obligatory
- treatment of the affected tooth
Perimandibular abscess
Localization
- accumulation of pus laterally from the mandibular body, which encompasses the mandibular margin medially
Causes
- infection usually originates from the mandibular molars
Specific symptoms
- reddening and pain on pressure in the lower buccal region
- non-movable extraoral swelling
- fluctuation
- mandibular margiot palpable
- trismus
Treatment
- extra oral incision (4 cm width) parallel to and below the edge of the mandible
- drainage
- antibiotic treatment obligatory
- treatment of the affected tooth
Chin abscess
Location
Causes
- Periapical periodontitis of incisors
Specific symptoms
- reddening and pain on pressure of the chin
- non-movable, usually central, extraoral swelling above the chin
- intraoral swelling of the oral vestibule
Treatment
- Isolated chin abscess can be incised from an intraoral access.
- drainage, rinsing
- elimination of causes
Pterygomandibular abscess
Localization
Causes
infections of the lower wisdom teet
Specific symptoms
- extreme trismus
- minor swelling from outside
- collateral edema in the parotid bed (on occasion)
- pain on pressure at the mandibular angle and retromandibular
- difficulties swallowing
- swelling of the soft palate
Treatment
- extraoral incision, approx. width 4 cm, parallel to the margin of mandible (in rare cases intraoral incision)
- drainage, rinsing
- antibiotic treatment obligatory
- secondary tooth restoration
Retromandibular (parotid bed) abscess
Localization
Causes
- usually through an inflammation spreading into the masseterico-mandibular space
- abscess formation of a parotitis
Specific symptoms
- swelling of the parotid region (behind the ascending ramus of the mandible) to the sternocleidomastoid muscle
- A fluffy, purulent discharge from the parotid duct is indicative of parotitis.
Treatment
- intra- or extra-oral incision
- drainage, rinsing
- antibiotic treatment
- necrotizing fasciitis
- mediastinitis (Bräuing et al. 1997)
