Ludwig's Angina ENT

📌 Definition: Infection of the Submandibular space.

Applied Anatomy

The Submandibular space lies between the floor of the mouth and the deep cervical fascia. It is divided by the Mylohyoid Muscle into two compartments:

• Sublingual compartment: Above the mylohyoid.
• Submaxillary/Submental compartment: Below the mylohyoid.

Note: Both compartments communicate around the posterior border of the mylohyoid.

Aetiology

1. Dental Infections (80% of cases)

The spread depends on the relationship of the tooth root to the Mylohyoid Line:

Tooth	Root Position	Space Involved
Premolars	Above Mylohyoid	Sublingual Space
Molars	Below Mylohyoid	Submaxillary Space

2. Other Causes

• Submandibular Sialadenitis.
• Injuries to Oral Mucosa.
• Fractures of Mandible.

Bacteriology: Usually mixed (Aerobes + Anaerobes).
Common: Alpha-haemolytic Strep, Staph, Bacteroides.

Clinical Features

• Odynophagia: Marked difficulty in swallowing.
• Trismus: Varying degrees.
• Sublingual Spread: Floor of mouth swollen; tongue pushed up and back.
• Submaxillary Spread: Submental/Submandibular regions swollen and tender.

Risks:

• Tongue pushed backward → Airway Obstruction.
• Laryngeal Oedema.

Treatment

1. Systemic Antibiotics: Broad coverage.
2. Incision & Drainage (I&D):
   • Intraoral: If localized to Sublingual space.
   • External: If involves Submaxillary space. (Transverse incision angle to angle).
3. Tracheostomy: If airway is endangered.

Note on I&D: Often serous fluid is found rather than frank pus.

Complications

• Spread: Parapharyngeal → Retropharyngeal → Mediastinitis.
• Airway Obstruction / Asphyxia.
• Septicaemia.
• Aspiration Pneumonia.