Ludwig’s Angina

🧠 Anatomy and Infections of Submental, Submandibular & Sublingual Spaces

This post discusses the three primary mandibular spaces—submental, submandibular, and sublingual—including their boundaries, contents, communication pathways, infections, and Ludwig’s angina, which results from their bilateral involvement.

📍 Submental Space

• Location: Between the mylohyoid (superiorly) and platysma (inferiorly) in the midline under the chin.

• Boundaries:

  • Superior: Mylohyoid muscle
  • Inferior and anterior: Superficial layer of deep cervical fascia
  • Lateral: Anterior belly of digastric (on both sides)
  • Posterior: Hyoid bone

• Contents:

  • Submental lymph nodes
  • Areolar connective tissue
  • Anterior jugular veins

📍 Submandibular Space

• Location: Below the mylohyoid, in the submandibular triangle.

• Boundaries:

  • Superior: Floor of mouth mucosa
  • Lateral: Mandible
  • Antero-inferior: Anterior belly of digastric
  • Postero-inferior: Posterior belly of digastric
  • Posterior: Hyoid bone

• Contents:

  • Submandibular gland
  • Submandibular lymph nodes
  • Hypoglossal nerve
  • Nerve to mylohyoid
  • Facial and lingual artery branches
  • Lingual nerve

📍 Sublingual Space

• Location: Above the mylohyoid.

• Contents:

  • Sublingual gland
  • Wharton’s duct (submandibular duct)

⚠️ Submental Space Infection

• Source: Infection of anterior mandibular teeth (below mylohyoid)

• Presentation:

  • Erythema and induration in submental area
  • Pain and tenderness
  • Fluctuation may be positive

• Treatment:

  • IV fluids, antibiotics, analgesics
  • Submental incision and drainage

⚠️ Submandibular Space Infection

• Source:

  • Infection from 2nd or 3rd mandibular molars (roots below mylohyoid)
  • Mandibular fractures, foreign bodies, malignancies

• Presentation:

  • Swelling starts at inferior lateral mandible border
  • Pain, fever, malaise, toxic look

• Treatment:

  • IV antibiotics and fluids
  • Incision & Drainage

What is the site of incision for I&D in Submandibular Space Infection?

• Complications:
  • Airway obstruction
  • Aspiration pneumonia, lung abscess
  • Ludwig's angina, osteomyelitis, tongue necrosis

What is the Differential Diagnosis of Submandibular Space Infection?

⚠️ Sublingual Space Infection

• Source:

  • Dental caries of premolar/first molar (above mylohyoid)
  • Fractures
  • Malignancy

• Presentation:

  • Intraoral lingual swelling (floor of mouth)
  • Minimal extraoral swelling
  • Dysphagia, odynophagia
  • Floor of mouth edema and induration

• Treatment:

  • IV fluids, antibiotics, analgesics
  • Intraoral incision and drainage if localized

🔥 Ludwig’s Angina

Definition: Rapidly spreading bilateral gangrenous cellulitis of submental, submandibular, and sublingual spaces.

• Source:

  • Dental infections (80% cases)
  • Submandibular sialadenitis
  • Oral injuries, fractures, dental extraction trauma
  • Mandibular malignancy, osteoradionecrosis

• Microbiology:

  • Mixed flora – aerobes and anaerobes
  • Alpha-hemolytic streptococci, staphylococci, bacteroides
  • Occasionally H. influenzae, E. coli, pseudomonas

🩺 Clinical Features of Ludwig’s Angina

• Odynophagia, dysphagia
• Trismus
• Floor of mouth swelling → tongue pushed upward and backward
• Woody hard induration of submandibular area
• Drooling, halitosis, fever, malaise
• Risk of airway obstruction

🛠️ Treatment of Ludwig’s Angina

• IV fluids, IV antibiotics
• Intraoral drainage → if localized to sublingual space
• External drainage → for submandibular involvement
• Tracheostomy

What are the indications of Rapid surgical intervention in Ludwig's Angina?

What are the causes of difficult oral intubation in Ludwig's Angina?

⚠️ Complications of Ludwig’s Angina

• Airway obstruction
• Mediastinitis
• Aspiration pneumonia
• Lung abscess
• Septicemia
• Internal jugular vein thrombosis
• Carotid artery erosion

💡 Pro Tip: Always examine oral cavity and submental/submandibular regions in patients with odontogenic infections, and act early to prevent life-threatening complications.