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Submandibular Space Infection

(Ludwig Angina)

By Clarence T. Sasaki, MD, The Charles W. Ohse Professor of Surgery and Director, Yale Larynx Lab, Yale University School of Medicine

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Submandibular space infection is acute cellulitis of the soft tissues below the mouth. Symptoms include pain, dysphagia, and potentially fatal airway obstruction. Diagnosis usually is clinical. Treatment includes airway management, surgical drainage, and IV antibiotics.

Submandibular space infection is a rapidly spreading, bilateral, indurated cellulitis occurring in the suprahyoid soft tissues, the floor of the mouth, and both sublingual and submaxillary spaces without abscess formation. Although not a true abscess, it resembles one clinically and is treated similarly.

The condition usually develops from an odontogenic infection, especially of the 2nd and 3rd mandibular molars, or as an extension of peritonsillar cellulitis. Contributing factors may include poor dental hygiene, tooth extractions, and trauma (eg, fractures of the mandible, lacerations of the floor of the mouth).

Symptoms and Signs

Early manifestations are pain in any involved teeth, with severe, tender, localized submental and sublingual induration. Boardlike firmness of the floor of the mouth and brawny induration of the suprahyoid soft tissues may develop rapidly. Drooling, trismus, dysphagia, stridor caused by laryngeal edema, and elevation of the posterior tongue against the palate may be present. Fever, chills, and tachycardia are usually present as well. The condition can cause airway obstruction within hours and does so more often than do other neck infections.


  • Clinical evaluation and sometimes CT

The diagnosis usually is obvious. If not, CT is done.


  • Maintenance of airway patency

  • Surgical incision and drainage

  • Antibiotics active against oral flora

Maintaining airway patency is of the highest priority. Because swelling makes oral endotracheal intubation difficult, fiberoptic nasotracheal intubation done with topical anesthesia in the operating room or ICU with the patient awake is preferable. Some patients require a tracheotomy. Patients without immediate need for intubation require intense observation and may benefit temporarily from a nasal trumpet.

Incision and drainage with placement of drains deep into the mylohyoid muscles relieve the pressure. Antibiotics should be chosen to cover both oral anaerobes and aerobes (eg, clindamycin, ampicillin/sulbactam, high-dose penicillin).

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