Submandibular space infections (Ludwig's angina)
- Anthony W Chow, MD, FRCPC, FACP
Anthony W Chow, MD, FRCPC, FACP
- Professor Emeritus of Medicine
- University of British Columbia
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".)
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.To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Boscolo-Rizzo P, Da Mosto MC. Submandibular space infection: a potentially lethal infection. Int J Infect Dis 2009; 13:327.
- Furst IM, Ersil P, Caminiti M. A rare complication of tooth abscess--Ludwig's angina and mediastinitis. J Can Dent Assoc 2001; 67:324.
- Brook I. Microbiology and principles of antimicrobial therapy for head and neck infections. Infect Dis Clin North Am 2007; 21:355.
- Patel M, Chettiar TP, Wadee AA. Isolation of Staphylococcus aureus and black-pigmented bacteroides indicate a high risk for the development of Ludwig's angina. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009; 108:667.
- Dixon EE, Steele RW. Ludwig Angina Caused by MRSA: A New Syndrome. Clin Pediatr (Phila) 2016; 55:316.
- Reynolds SC, Chow AW. Life-threatening infections of the peripharyngeal and deep fascial spaces of the head and neck. Infect Dis Clin North Am 2007; 21:557.
- Botha A, Jacobs F, Postma C. Retrospective analysis of etiology and comorbid diseases associated with Ludwig's Angina. Ann Maxillofac Surg 2015; 5:168.
- Hurley MC, Heran MK. Imaging studies for head and neck infections. Infect Dis Clin North Am 2007; 21:305.
- Roscoe DL, Hoang L. Microbiologic investigations for head and neck infections. Infect Dis Clin North Am 2007; 21:283.
- Barakate MS, Jensen MJ, Hemli JM, Graham AR. Ludwig's angina: report of a case and review of management issues. Ann Otol Rhinol Laryngol 2001; 110:453.
- Vieira F, Allen SM, Stocks RM, Thompson JW. Deep neck infection. Otolaryngol Clin North Am 2008; 41:459.
- Ovassapian A, Tuncbilek M, Weitzel EK, Joshi CW. Airway management in adult patients with deep neck infections: a case series and review of the literature. Anesth Analg 2005; 100:585.
- Barton ED, Bair AE. Ludwig's angina. J Emerg Med 2008; 34:163.
- Bagul R, Chandan S, Sane VD, et al. Comparative Evaluation of C-Reactive Protein and WBC Count in Fascial Space Infections of Odontogenic Origin. J Maxillofac Oral Surg 2017; 16:238.
- Manasia A, Madisi NY, Bassily-Marcus A, et al. Ludwig's angina complicated by fatal cervicofascial and mediastinal necrotizing fasciitis. IDCases 2016; 4:32.
- Blanchard A, Garza Garcia L, Palacios E, et al. Ludwig angina progressing to fatal necrotizing fasciitis. Ear Nose Throat J 2013; 92:102.