Submandibular and Sublingual Spaces

Infection of the submandibular and sublingual spaces usually arises from the second and third mandibular teeth. Swelling and minimal trismus are generally present. Sublingual space infection generally originates from the mandibular incisors and is characterized by a brawny erythematous, tender swelling of the floor of the mouth. In the later stages, tongue elevation may also be noted.

The classic Ludwig's angina involves a bilateral infection of both the submandibular and sublingual spaces (53). A dental source of the infection usually can be found, and the second and third mandibular molars are often involved. The infection begins in the mouth floor and spread rapidly, causing indurating cellulitis that often induces lymphatic involvement or abscess formation. The clinical presentation includes a brawny, boardlike non pitting swelling of the mandibular spaces and general toxicity. The mouth is generally held open, and the floor is elevated, which pushes the tongue upward. Eating, swallowing, and breathing may be impaired. Rapid progression can induce neck and glottis edema, which precipitates asphyxiation (54).

A variety of microorganisms has been isolated from cases of Ludwig's angina. In recent years, anaerobic bacteria have predominated, including Fusobacterium spp., AGNB, and Peptostreptococcus spp. Often, one or more of the following also have been found: staphylococci, streptococci, pneumococci, E. coli, Vincent's spirochetes, Haemophilus influenzae, and Candida albicans (4). Management includes high doses of parenteral antibiotics, airway monitoring, early intubation or tracheostomy, soft tissue decompression, and surgical drainage (55).

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